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Naya Savera - integrated F W Program |
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Population Foundation of India
NAYA SAVERA
Integrated Family Welfare Programme
JK Lakshmi Cement Ltd.,
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Contributors:
Mr. Bhagirath Gope
Dr. Kumudha Aruldas
Dr. Sharmila Neogi
Dr. Vikram Gupta
Mr. Debabrata Bhuniya
Dr. Lalitendu Jagatdeb
Mr. Nihar Ranjan Mishra
Ms. Sona Sharma
Assistance:
Ms. Prema Ramesh
Mr. Shailendra Singh Negi
Acknowledgements:
Mr. Sushil Kumar Wali, Whole Time Director, JKLC
Mr. Ganpat Singh Rajawat, Chief Executive Project Director, JKLC
Mr. Dinesh Pandya, Project Coordinator, JKLC
Dr. R.C. Sharma, Medical Officer, Naya Savera
Ms. Vijay lakhsmi, ANM, Naya Savera
Mr. Chetan Rawal, Naya Savera
Mr. Kishore Rawal, Naya Savera
© Copyright Population Foundation of India, 2008
Foreword
Naya Savera is an integrated Family Welfare project implemented
by JK Lakshmi Cement Ltd, Sirohi in technical and financial
collaboration with Population Foundation of India. The 4 year pilot
project (2004-2008) covers 10 revenue villages of Pindwara tehsil of
Sirohi district in Rajasthan. The aim is to improve the maternal and
child health and family planning in the area by increasing access to
health services through an outreach programme in partnership with
the local people and building capacity of the community in the
process. JK Lakshmi Cement Ltd has been well aware of the
government efforts in the area and has worked closely with the
government, thus complementing and supplementing the government
efforts.
Success of the programme was possible since both the Population
Foundation of India and JK Lakshmi Cement Ltd believe in designing
and implementing the programmes that is gender sensitive, right
based and quality oriented. JK Lakshmi Cement Ltd is a recipient of
'Golden Peacock Award' in 2007.
The Population Foundation of India is committed to work with JK
Lakshmi Cement Ltd to make the right to reproductive and child health
and family planning a reality.
November, 2008
A R Nanda
Executive Director
Population Foundation of India
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From the desk of Managing Director
It gives me great pleasure to pen down my thoughts on the special occasion of the
release of the book capturing the four year journey of our “NAYA SAVERA” project. This
project has served as a real awakening for the poor and needy tribal population
inhabiting the vicinity of JK Lakshmi Cement Ltd., bringing a ray of hope for ladies
deprived of basic medical care and modern know-how of health and hygiene.
Naya Savera is very close to my heart and whenever I have got a chance I have
attended the innumerable Health Melas, Immunization Camps, Growth Monitoring
Camps being organized by the focussed, dedicated and energetic Naya Savera project
team. I always found the response to be overwhelming and was immensely touched by
the affection showered by ladies and children when I was in their midst.
Our association with Population Foundation of India has been really strong and we
have grown richer in experience by the technical expertise they have provided over the
period of four years. The project review meetings which I have attended with PFI have
been intense and thought provoking and the contribution of the PFI team has been
integral to the success of this project.
Our success story will never be complete without due recognition to the District
Administration which have appreciated and provided motivation and support for
fulfilling the targets set by our team. I render my heartfelt appreciation to the
authorities who have helped make this project special.
My best wishes to all for ensuring that this small beginning will be stepping stone for
better women health and empowerment in the times to come.
VINITA SINGHANIA
Managing Director,
J.K. Lakshmi Cement Ltd.
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Table of Contents
Acknowledgements
Foreword
Acronyms
1. Setting the Context
2. Project area
2.1 Settlements
2.2 Housing
2.3 Family Structure
2.4 Locating women and children
2.4.1 Female Literacy
2.4.2 Women work in home and outside
2.4.3 Nutritional Status
2.5 Health infrastructure in the area
3. Maternal and Child Health
3.1 Problems in Pregnancy and their redressal
3.2 Where do women deliver?
4. Naya Savera - Basic Intervention
4.1 Guiding Principles
4.2 Project Objectives & Strategy
4.2.1 Objectives
4.2.2 Strategy
4.3 Basic Model
5. Project Roll-Out
5.1 Building Block
5.1.1 Information
5.1.2 Human Resource, equipment et al
5.2 First Step Forward
5.3 The real magnet- Curative services!
5.3.1 Understanding these services
5.3.2 What have these camps achieved over the project period?
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5.3.3 ANC- only injection TT?
5.3.4 Delivery
5.3.4.1 Existing mixture of providers
5.3.4.2 Home or out of home?
5.3.5 Post Natal Care
5.3.6 Contraception
5.3.7 Child Vaccination
6. Communication Channels for Village Women
6.1 How to communicate?
6.2 Channels to talk with people
6.2.1 Mass Community Meetings
6.2.2 Kala Jattha
6.2.3 And Others…
6.3 Health Mela
7. Child growth monitoring
8. Collaboration with the Government
9. Making of the Women Village level motivator
10. Community's overwhelming faith
11. Learnings
12. Limitations
13. The Change Agents
14. Findings from qualitative assessment and way forward
15. Annexures
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SETTING THE CONTEXT
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Nestled in Southwest Rajasthan is Sirohi; the third northeast, Udaipur in the east, Jalore in the west
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smallest district in the state. The southern extent of and Banaskantha district of Gujarat in the south. It
the Aravali range of hills can be viewed in their accounts for a mere 1.52% of the state's total area.
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entire splendor here. Sirohi is home to the only hill The district is further sub divided into three
station of Rajasthan, the Mount Abu with the highest subdivisions and five sub-districts or tehsils.
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peak of Aravali at Guru Shikhar. Sirohi is landlocked Pindwara is one among five tehsils of Sirohi.
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by three districts of Rajasthan - Pali in the
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RAJASTHAN
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35
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41
43
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1. In a district RCH survey in 2002-03, half (50.9%) of the sample households were found to have low standard of living index.
2. Source- www.sirohi.nic.in (social development indicators, 2000-06)
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Sirohi was a state founded by the Deoras, one
branch of the Chauhan clan of Rajputs. With the
independence of India in 1947, the process of
integration of princely states of India started and
that is when 16th November 1949 Sirohi state was
merged with Rajasthan State.
Sirohi has a dry climate with a maximum
temperature of 47°C and an average temperature of
23°C. The average rainfall of the district is 665 mm.
The main rivers are Jawai, Sukhadi, Khari, Bodi,
Krishnavati, Kapalganga, and Banas. Agriculture is
the main source of income. Millets (bajra, jowar,
maize), Pulses, Sesame and red chilly are cultivated
alongside wheat and oilseeds. Majority of the
agriculture is rain fed assisted by wells and tube
wells. Most of the people live on difficult hilly
terrains and the houses are scattered. Primarily, the
people are cultivators and only lately have they
started migrating to cities for work.
A large proportion, nearly 44%, of the population
in the district comprise scheduled caste (SC) and
scheduled tribe (ST). The predominant scheduled
castes are Meghwals, Koli and the Sargara. Garasia
(excluding the Rajput Garasia) is the largest
scheduled tribe besides Bhil and Mina. The tribals
continue to live in their traditional way. Their
houses are scattered along the hillocks and they
rear animals. Their traditions and customs continue
to prosper in their unadulterated original form.
Quite an atmosphere is created by the rejoicing
tribals, singing folk songs and dancing in colouful
attires during fairs and festivals. Sirohi has the
fragrance and colour of three cultures- Mewar,
Marwar and Gujarat and therefore, folk songs, folk
dances and cultural and religious fairs are found
aplenty here and are famous. Each tehsil of the
district has its preferred set of fairs.
Large proportions of the population have low
standard of living.1 Nearly a third (31.01%) is below
the poverty line.2 Hinduism is the predominant
religion in the area. Muslims and Jains, the other
two religions together constitute approximately 5%
of the population.
SC and ST population in Sirohi
SC
19%
All Others
56%
Soure : Census 2001
ST
25%
Table 1 : Sirohi at a glance3
Total area
5139 or 5136 sq km
Total Population
8,51,107
Density of Population (person/ sq km)
166
Proportion of rural: urban population
82:18
Sex Ratio (females per 1000 males)
943
Sex Ratio (0-6 years)
918
Literacy Rate
53.94
Major crops
Jowar, Bajra, maize, Wheat, Barley, Oilseeds-
rapeseed, mustard
3. Source: Census 2001
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THE PROJECT AREA
2.1 Settlements
Naya Savera project is being implemented as a
pilot in 10 revenue villages of Pindwara tehsil of
Sirohi. Although the number of the villages is small,
there is wide variation amongst them. The
population covered under the project is roughly
27,000. People live in scattered hamlets, a
characteristic feature of tribal habitation. Thus,
one village could typically have more than one
habitation/ hamlets/phali such as is seen in Valoria
and Basantgarh, two of the ten project villages
which have several hamlets or phalli besides the
main village, unlike other villages of the project
which have at the most one or two hamlets besides
the main village. Valoria has 13 hamlets and
Basantgarh 21 (including the main village). Further,
even amongst these two villages there are
differences. While nearly all hamlets of Valoria have
at least 100 people residing in each, the same is not
true of Basantgarh, where at least a quarter of the
hamlets have population less than a hundred each
(Table 2 ).
Table : 2 Villages with hamlets show varying features
Hamlets with at least
100 population
Hamlets within 5 kms of the
main village
Valoria= 13 hamlets
All except 1
Only 3 of 13
Basantgarh= 21 hamlets
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All except 3
Not only is the size of a habitation of each village
hamlet a concern but also their spread or distance
from the main village. In Valoria, the majority of the
hamlets lie at a radial distance greater than 4.5 kms
from the main village. The farthest is approximately
15-16 kms. In stark contrast, majority of the
hamlets of Basantgarh are located within a radial
distance of five kms from the main village.
It is important to understand this scatter of the
population in the village because different groups
inhabit different areas in the village. Two worlds
exist in the project area - one lives in the main
villages and the other in the hamlets. The main
village is home to non- tribals (Scheduled Castes,
Other Backward Castes and other castes) while the
scattered hamlets are predominantly tribal. This is
one explanation for the difference in the health and
other socio economic indicators between the two
groups; usually the tribal area is worse than non
tribal on most indicators. In the hilly terrain of the
project area, some of the hamlets are located in
such remote places that access to them round the
year is limited. These furthest inhabitants are
imaginably the poorest with the worst health
indices. The project makes earnest attempt to
cover all the hamlets of the identified villages.
2.2 Housing
Majority (at least two-third) of the houses in the
project area are Kuchcha. However, in the main
villages relatively more houses are pucca. While one
wanders through the hamlets, eyes strain to see a
pucca house however, survey of the area reveals
that three to four percent houses in the hamlets are
indeed pucca, the rest are either kuchcha or semi-
pucca. When it pours during the monsoon some of
the tribal houses crumble. The roof is made up of
kabelu tiles or khaprail, walls and the floor made
out of mud. The tribal habitation is usually two
roomed. In tribal families either the brothers build
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home next to each other with a shared common wall
enclosed within a common boundary wall or they
build at a distance on another hillock. Animals are
quintessential in tribal houses, usually goats but
also cattle (cows and buffaloes). The tribals
consume goat milk unlike the non-tribals who prefer
cattle milk. Non-tribals too own animals, in fact
animal rearing is specific to some castes like the
kalvis, rebari and the ghanthi. It is not difficult to
identify a tribal with their characteristic dressing
style and language. While the costume of the tribals
and the non-tribals is similar, the design, material
and the style of adorning marks the difference. The
language is different as bhil and the garasiyas speak
nearly similar language called locally as the “adivasi
bhasha”, distinct from that spoken by the non-
tribals.
“Our village does not have electricity supply then
how we would have light in our house” 4
Majority of the houses in the main village and
probably all in the hamlets do not have electricity
connection. The forest is the source of fuel and
women are responsible for collecting fuel wood.
2.3 Family structure
Majority of the families are nuclear families. The
nuclear families and scattered population
especially among tribals go hand in hand. In the
project area, on an average family size is 6 to 7
while for the district it is 5 per household9. Nearly
one third of the girls are married before 18 years of
age however the mean age at marriage for girls in
the area is 18.7 years5 and that for boys 22.4 years.
The district has a high Total Fertility Rate (TFR) of
Age wise distribution of population in Sirohi.
Source Census 2001
7%
14%
3.3 (source DLHS, round 2 phase 1 for Sirohi) The
TFR for the district shows a downward trend over
the past decades, 5.80 in 1981 and 4.73 in 1991.6
The majority of the population in the district is in
the age group of 15-59 years. This has implications
not only for population growth which grew at 30%
over the last decade but also in terms of services for
this age group, specially the reproductive age
group.
Nearly half of the women (52.2%)7 have children
with birth order 3 and above. As one tries to
acquaint with the area, its people, the one question
that crosses the mind is -Do women desire to have so
many children? The answer is found in the secondary
data itself, a resounding “No”. A district level
survey revealed that at least 15.4% of women would
have preferred not to have too many children and
another 5% would have, if possible, preferred to
delay their last child. Thus, at least 20% of the
women in the survey mentioned how they would
want to restrict the size of their families. This could
be an underestimation as some who are aware of the
survey methodologies would know that these are at
best average figures in a sample and the actual
proportions could be larger and when translated
into number of women this would turn out to be a
substantial number. So, what do the women do to
restrict their family size? The DLHS has the answer.
Most women resort to female sterilization rather
than adopt a spacing method. 75% of those women
currently using any modern method of family
planning have undergone female sterilisation8.
These are decisions made and choices expressed.
The inclination of the Naya Savera project was to
explore why these decisions were made and
whether these were made out of choice of women or
not? In the following pages, the journey of the
project informs us more on these questions.
2.4 Locating women and children
Sirohi is entangled in the high fertility and high
0-4 y
mortality web. Nearly one in every ten children born
5-14 y
27% 15-59 y
>=60 y
in a year die before reaching his/her first birthday
(IMR=91, year 2006). This rate of infant death is
nearly 50 % more than the state average (IMR,
52%
Rajasthan=67 (SRS, 2006). While the infants die
more than they should in the district another
4. Statement of a woman during a FGD
5. Source: District level household survey round 2, phase 1
6. Source: Census of the respective decades
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Integrated Family Welfare Programme
7.
DLHS, 2002-03. Sirohi.
8.
Full ANC=3 ANC checkups, 100 IFA tablets and at least one
dose of injection Tetanus Toxoid.
9.
For mother with children aged <=24 months*
disturbing trend while prevalent in the more
prosperous areas is visible here too. Over the past
few years, fewer girls were born in Sirohi. The child
sex ratio over the past two census periods has been
falling consistently, from 961 in 1991 census to 918
in 2001 census. The sex ratio of the district pari
parsistantly declined over the past 3 decades from
963 (1981), 949 (1991) to 943 (2001). No wonder
that the district was ranked a poor 23rd in the
Human Development Index (HDI) and 26th in Gender
Related Development Index among all then 32
districts in the state (HDR, Rajasthan 1999).
Indicator
Gender Ratio- All
Juvenile Sex Ratio (0-6 years)
Table 3: Sex Ratio
1991 census
949
961
2001 census
943
918
2.4.1 Female literacy
The available RCH communication strategies by
design are dependant on the literacy status of
women. IEC/BCC activities are ubiquitously found
on the menu of each RCH programme. However,
illiterate women are unable to read IEC/BCC
messages by themselves. Besides, they are unable
to teach their children and are obviously aloof from
the events in the world since they do not read
newspapers, magazines. In the project area, the
ownership of radio and television is limited and
moreover there is no or limited supply of electricity.
New knowledge thus, cannot be spread through the
printed material targeted at women. In this area,
unless people have had experience, any practice or
behaviour does not become a part of life. One
cannot logically articulate in favour of a practice or
behaviour based on experience and success
elsewhere as the cycle of experiencing and then
adopting has to be undergone to make any change.
In their traditional lifestyle, change is not welcome
or easily acceptable. There is not enough
conventional wisdom on most of the preferred
practices or behaviour. Only a miniscule proportion
of the women in the district or the block are
literate. In the project area, a sample (n=287)
survey revealed a very high illiteracy level of nearly
88% amongst married women aged 15-49 years. Only
four women had studied upto middle school (8th
standard) and only two were graduates. Even within
the state, the women of Pindwara block are poorly
placed. (See table below).
Sex indicators
Person
Male
Female
Literacy Rate 7 years and above Census 2001
Rajasthan
Sirohi district
60.41
53.94
75.70
69.89
43.85
37.15
Pindwara block
52.03
67.99
35.35
2.4.2 Women work in the home and
outside
Women work in the house and keep the hearth
burning and “Do they work outside home?” is the
legitimate question to know the scope of their work.
One finds that they work in the fields during sowing
and harvest season. There is a new dimension to
women's work seen now in the project area. With
men folk opting to migrate to the cities in search of
work, women take on the responsibilities of the
family left behind - elders and children. In the
project area, however, majority of women work
outside as cultivators or agricultural labour besides
their home.
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“The best thermometer to the progress of a
nation is its treatment of its women”
— Swami Vivekananda
2.4.3 Nutritional Status of women and
children
Are these women who take care of the home and
the fields, work in employment sites, undergo
repeated pregnancies, healthy? Or simply, as a first
step of enquiry, what is their nutritional status?
There is no secondary district level data to
comment on the nutritional status of women of the
district. Malaria is highly prevalent (1368 per 100,
000 population, Source= DLHS, 2004) as is
Tuberculosis (549 per 100, 000 population). The
DLHS however, informs that only 16% or less than
one fifth of the women reported having received
100 IFA tablets when pregnant and worse, only 12.7
% women reported consuming 2 or more IFA tablets
regularly.
Children's nutritional status is no better; majority
is under-nourished. The weight of approximately
1900 children in the project area aged less than 5
years were measured. Their nutritional status was
expressed as “weight for age” for the child. The
survey revealed a very high level of malnutrition.
Besides poor nutrition, the status of
immunisation is found wanting. Only one in nine
children are fully immunized! Newborns, as a
practice, do not receive colostrum or the first milk
of the mother. Exclusive breast-feeding, even for an
abbreviated four months is practiced by a mere
twenty percent of all mothers. The co-existence of
poor nutrition and low or no immunisation is adding
to the number of infants dying before reaching their
first birthday. Thus both mother and child are in
poor health.
2.5 Health infrastructure in the project
area
While the picture of health is not rosy, there is no
absolute lack of public health facilities in the area.
The project area is served by 7 Sub-centers (SCs)
and 3 Primary health centers (PHCs). Deliveries are
conducted in four of the seven sub-centers. ANMs
reside in three (Vasa, Kodarla, Dhanari) of the seven
sub-centers. In two sub-centers, Kodarla and
Dhanari, the ANM offers round the clock delivery
services. In another two Basantgarh & Rampura sub-
centers the ANM resides in the day and her services
including delivery services are therefore restricted
to the day time. All three PHCs have resident
doctors and conduct deliveries. Pindwara is the
block PHC and majority of the deliveries in the
project area are conducted there. The ANMs are
primarily engaged in identifying clients for family
planning in the field areas. There is scope for
strengthening the antenatal and the postnatal
services and the routine primary childhood
immunisation. However, it would be unfair to ignore
the limitations within which the ANM works like
unavailability of transport.
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MATERNAL AND CHILD HEALTH
3.1 Problems in pregnancy and their
redressal
On the background of poor nutritional status,
poverty and repeated pregnancies, it is not
surprising to find nearly one third of the pregnant
women had complications when pregnant (Source
DLHS, 2002-03). Only 16% of the pregnant women
received adequate IFA tablets and less than 10%
women received full8 ANC coverage. Nearly two-
third women in the district (64% to be precise)
either did not receive any antenatal care or
received fewer than the recommended three ante-
natal checkups. This is likely to be worse in tribal
predominant areas where settlements are scattered
and access is limited. On the face of this limited
recourse to care and support during pregnancy, it is
likely that a woman who developed a problem
during pregnancy would quietly suffer? This is
evident in the health seeking behaviour of women;
only one in two (50.2%) pregnant women sought any
treatment for pregnancy related complication.
With the prevalent illiteracy, poverty and poor
access it is not hard to imagine that the women
would only delay seeking care till the time the
problems are either advanced or life threatening for
which the treatment is expensive.
Key Indicators
3 ANC check-ups9
Safe Delivery8
Institutional Delivery
Complete child immunization10
Use of any modern FP methods
Table 4 : Health Profile
Sirohi
(Source: DLHS-2)
36.2
55.0
34.2
18.0
33.7
Project area
(Baseline Survey Estimate,2004)
35.9
43.5
27.2
25.4
13.4
3.2 Where do women deliver?
Delivering at home with the help of a traditional
birth attendant, relative, ANM or doctor is the norm
in the project area. The rates of institutional
deliveries are abysmally low; more than 85% women
deliver at home. However, this has changed rapidly
with the introduction of Janani Suraksha Yojna
scheme of the government of India. Delivering at
home is fraught with danger. If the woman or her
newborn develops any complication then their life
could be threatened unless the condition is
identified early and the mother or the child rushed
to a facility where they could be treated. With poor
access, the danger is even more pronounced. The
maternal mortality ratio of the state is 445 per
100,000 live births, the third highest in the country.
It appears that equilibrium of high morbidity and
mortality has been created in the area.
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8. Full ANC=3 ANC checkups, 100 IFA tablets and at least one dose of injection Tetanus Toxoid.
9. For mother with children aged <=24 months*
10. For children aged 12-23 months
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You can tell the condition of a nation by
looking at the status of its women
— Jawahar lal Nehru
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4
NAYA SAVERA - BASIC INTERVENTION
Concerted action was required to reduce the
status of morbidity, mortality and fertility that exist
in the project area. In that direction JK Lakshmi
Cement Limited (JKLC) with the support of
Population Foundation of India initiated a pilot
intervention in 10 selected villages of Pindwara
tehsil of Sirohi District in Rajasthan covering a
population of 27272.
4.1 Guiding principles
Shri Harishankar Singhania, chairman of the JK
group of industries nurtured a vision for socio-
economic development. He identified four focus
areas for action:
1. Women Empowerment
2. Population Stabilization
3. Vocational Training and
4. Adult Education
Of these four areas, JKLC initiated work in two
areas- Adult Education and Population Stabilization
in the area surrounding the plant at Pindwara.
Since the inception of the plant, JKLC has
engaged in construction of roads, water tanks,
school buildings among other activities in and
around the factory. It was quickly realized that long
lasting change could be ushered only by working
closely with people through a structured approach.
In the beginning of 2004, JKLC and PFI together
designed a reproductive health project. This was a
pilot initiative and the work would be expanded if
the pilot was successful. In addition to its
experience in designing, providing technical
assistance to reproductive and child health
projects, PFI also decided to partly fund the pilot.
Besides meeting the remaining funds, JKLC donned
the mantle of direct implementation of the project.
This marked a shift from an unstructured to a
structured response by the company to community's
need. Additionally, this brought with it the
challenge of maintaining accountability and
realizing the objectives and goal of the project.
4.2 The project objectives and strategy
Naya Savera, the name of the project was coined
while designing the project. Oblivious to the shape
the project would finally take, the emphasis was to
design something that would mark a new beginning
for the health of the people in the area, perhaps
signal the arrival of a new and better future and
what better way to express this feeling than Naya
Savera or a new dawn.
Although the area around the factory required
improvement in the overall health status; however,
being a pilot both JKLC and PFI decided to prioritize
and chose to work with women and children. This
selection was based on the understanding that
women and children suffer disproportionately from
ill health and deprivation. Therefore, the basic
thrust of the programme was on enabling women to
attain and maintain optimal health and nutrition for
themselves and their children.
The goal of the programme was to improve health
and reduce disease and deaths among women and
children. However, to achieve this goal a multi
pronged approach was required. With an
understanding of the socio cultural location of the
women and children, working with them alone was
unlikely to yield much.
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4.2.1 Three objectives were identified to
achieve the goal:
Ÿ Building capacity at the community level
Ÿ Promoting health seeking behaviour
Ÿ Increasing access to basic RCH and family
planning services.
Service delivery was a key intervention for
addressing the felt need of the community. To
achieve the objectives, the following strategy was
adopted:
4.2.2 Strategy:
Ÿ Build capacity of community level volunteers
on issues related to general health and
hygiene, reproductive and child health issues
to ensure their involvement in making services
available on a sustainable basis at the
grassroots level;
Ÿ Raise awareness and knowledge of the
community stakeholders such as school
teachers, anganwadi workers, local
representative, opinion makers, RMPs and
other members on general health and RCH
issues through Information Education and
Communication (IEC) and Behavioural Change
Communication (BCC) programmes; and
Ÿ Provide basic quality Reproductive and Child
Health Services in the target areas through
Mobile Van.
Several factors influenced the selection of the
above strategy - First and perhaps the most
important was the poor utilisation of the present
health services. The people were caught in a time
wrap due to their physical inaccessibility & socio
economic backwardness which in turn only
reinforced the grips of age old myths and
misconceptions creating a self perpetuating circle.
In their world where outside interference was
limited and often viewed with suspicion, changing
habits was never going to be an easy task. Outsiders,
no matter how respected could only go a particular
distance to usher change and not beyond. The
journey to good health could only be completed
with the assistance of one among them and who
could be better than their own daughters and
daughters in law? The project therefore chose at the
outset to work through women as change agents.
They were christened - Village Level Motivators.
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Integrated Family Welfare Programme
4.3 Basic Model
NAYA SAVERA
Goal: Improve health of women and children by reducing disease and death
Objective: Building
sustainable resource at grass
roots- Village Level Motivators
Objective: Increasing
knowledge and demand for
services
Objective: Increasing
access to RCH services in
underserved areas
• Selecting VLMs in
consultation with
community
• Capacity building of the
VLMs
• Arranging awareness
generation meetings
• Arranging special camps
• Selection of the sites in
consultation with the
community
• Informing the
community about the
date and timings of the
camps
• ANM services through
household visits
• Providing services at
the camp
Activities:
• Acting as bridge between
Naya Savera and
Community
• Informing people about
the camps and special
programs
• Accompany ANM during
household visits
• Follow-up services
• Identifying new ANCs
• Motivating the
community for
immunisation, family
planning services, etc.
• Health Melas
• Growth monitoring
• Puppet shows
• Film shows
• Healthy Baby Shows
Type of Services:
• Primary Immunisation
• Growth monitoring upto
5 yrs age
• ANC and PNC
• Community based
contraceptive supplies
• Referral services
Treatment of RTI/STI
cases
• General health check-ups
• Counseling services
• Awareness generation on
RCH issues and HIV/AIDS
Collaboration with government
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M&E framework for the project.
— Baseline, Midline and Endline by external agency,
— Structured data recording and reporting formats (MIS formats)
— Review & oversight by Project Implementation Committee (PIC) and Project Steering Committee (PSC)
— Cross validation of the work of various staff
— Process documentation
Outcome Indicators
— Increased awareness about appropriate RCH practices,
— Reduction in maternal and infant mortality rates
— Greater access and utilization of RCH, general health and welfare services by the target groups
— Improved ability of women to make decision and increased responsibility of men with regard to
maternal health, delivery, birth spacing, childcare, etc
— % of children fully immunized
— % increase in safe deliveries
— % of eligible couples adopting any modern method of family planning
— No. of VLMs sustaining the services
— No. of Stakeholders actively supporting the programme
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Integrated Family Welfare Programme
5
PROJECT ROLL OUT
Naya Savera was officially launched on 17 August,
2004.
5.1 Building Blocks
— awareness and experience of signs and
symptoms of RTI/STI, HIV/AIDS
— Practice of child rearing, child immunization
amongst others.
5.1.1 Information
A baseline survey was conducted in the 10 project
villages. It informed on the status of reproductive
health of married women and health of their
children, information related to RCH focused on:
— the experience during a woman's previous
pregnancy- receipt of ANC, place of delivery,
birth attendance, post natal care,
immunization, IFA tablets, etc
— awareness, knowledge and preference of
family planning method
The purpose of the baseline sample survey was to
gather information on the area and provide
estimates of broad health indicators. These
indicators would provide the pre project status and
help gauge the difference made by the project
(amongst other factors) in the health situation of
the area when compared by another similar survey
at the end of the project duration. A house listing
was done and a sample frame selected using
probability proportion to size (PPS) method. A
structured questionnaire was administered. The
respondents were married women, 15-49 years of
age.
Table 5 : The major findings of the baseline survey are presented in the table below:
Key Indicators
Knowledge of all modern FP methods
Use of any modern FP methods
Safe Delivery (children aged <=24 months)*
Institutional Delivery (children aged <=24 months)*
3 ANC check-ups (children aged <=24 months)*
First ANC check-up in Ist trimester (children aged <=24 months)*
Complete child immunization (12-23 months old)**
Baseline Estimates (%)
26.3
13.4
43.5
27.2
35.9
20.5
25.4
5.1.2 Human resource
The “Naya Savera” project team comprised of
one MBBS doctor, one Nurse Midwife, one Social
Worker and one Multi-purpose Worker. The team
was selected and they underwent 5 day induction
training at Action Research & Training in Health, an
technical support agency in at Udaipur.
The initial days were spent in meeting the
villagers including opinion makers, Doctors at PHC,
ANMs at Sub Centers and field workers. The
necessary instruments and equipments and other
requirements for running a mobile clinic was
procured. The project decided to hire a vehicle for
use as a mobile clinic. This proved to be a wise
decision since a hired vehicle could neither be
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exploited for personal use nor did one have to worry
about its maintenance. A white coloured TATA SUMO
was hired. Each of the ten project villages was to be
visited by the mobile health team at least once a
week as per a fixed schedule. Little was any one
aware that this vehicle would become a symbol, a
visiting card for the Naya Savera team.
5.2 First Step Forward
Work was initiated from village Adarsh, closest to
the factory. During the inauguration, JKLC had
invited 30 select stakeholders representing the
project area. They were informed on the objectives
and the strategy of the Naya Savera project. They
were requested that the word be spread in the
villages on the project so that the people are aware
of the project and utilise its services. The district
administration and the elected representatives
(PRI, MLA) were present alongside the JKLC
management. Through this one meeting a large
constituency was informed on the project. Besides,
mass awareness programmes also called group
meetings were conducted to inform people on the
project.
Introductory meeting was held in all villages for
rapport building. Team did not face difficulty in
introducing themselves because of the initial
meeting by JKLC, besides JKLC is well known in the
area. There were employees of the company
amongst the villagers who helped the team set its
feet in the project villages. The brand name and the
employees helped the team to stand and talk about
the 'Naya Savera' project.
5.3 The real magnet- Curative medical
services
“Dava Leva Avjiyo Dava Leva Avjiyo”-
These simple words in Marwari language mean
“come and take medicine”, announce the arrival of
the project team of NAYA SAVERA to the village.
5.3.1 Understanding Curative services
The project team reaches a village/hamlet and
set up a camp - health camp. Each day the health
team visits two villages thereby covering all the ten
villages in 5 days time. The last day of the week is
kept for office work to maintain records and for
other purpose. Since the project area villages have
hamlets, in addition to the main village, the health
camps are held in the hamlets as well. The visits are
as per a fixed schedule prepared each month. The
dates are then communicated to the village through
the VLM.
Mobile Clinic and household visits are the two
ways through which pregnant women receive Ante
Natal Care (ANC), Post natal care and other RCH
services. Identification of pregnant women, follow
up and community distribution of contraceptives is
mostly done by VLMs who hail from the same
locality.
Mobile sites for the mobile camps
Camps are set up at sites which are decided in one
to one or group meetings with the Stakeholders and
Opinion Makers. In view of scattered population
living in hamlets, the camps sites have been
extended to them. This has led to an increase in the
number of the sites. Earlier there were 11 sites;
slowly they were increased to 23. The scattered
villages have more number of sites to cover more
households and population. The site in a village is
changed every week and a new place selected. The
team shifts the sites to cover more population and
increase the catchment of the camps. While the
sites are increased, the team ensures that each site
is visited at least once a month. Majority of the sites
are either anganwadi center, sub center, panchayat
building or in some cases government schools.
In these camps, facilities like outdoor medical
consultation, including treatment for RTI/STI,
ANC/PNC, Child Immunisation, routine health
check-up, growth monitoring, counseling - on family
planning, adolescent health, etc, awareness
generation on RCH issues provision of
contraceptives, referral services, first aid and
limited range of laboratory tests- hemoglobin
estimation, urine pregnancy determination test,
urine test for proteins and sugar are provided. While
the doctor and the social worker are involved in
providing medical care to the people collected in
the camp, the project Nurse-midwife escorts the
VLM to meet the clients, pregnant women, recently
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Integrated Family Welfare Programme
delivered women and those taking or thinking of
adopting a family planning method, in the
village/hamlet. Till she returns the camp continues.
Token money
During the camp, medical consultation is
provided by the doctor. The project maintains ready
stock of medicines based on local disease pattern.
On the prescription of the project doctor, the
medicines are dispensed free of cost. Rarely,
medicines are prescribed to be purchased from
outside. A small token amount is charged from the
client. Rs 2 are charged for examination of a mother
or for a person less than 19 years and Rs 4 is charged
for those above 19 years including non pregnant
women. Token money was initiated after the initial
2-3 months of the project. A receipt is issued against
the token money. Over the last two years of the
project, Rs 1500 per month is the usual token money
collection from the entire project area. Till date,
the project has collected approximately Rs 50,000
as token money. Village wise accounts are
maintained for the collection. The collected money
is ploughed back into the project.
People don't hesitate to pay the token amount.
However, not all had agreed to pay. Questions were
asked on our intention of collecting money,
however, with time all skepticism has been laid to
rest. The rationale for charging a small but
insignificant amount is encourage ownership. Time
and again people communicated that “free” must
be poor in quality. Additionally, it was thought that
misuse would be prevented by a small fee, however,
mindful of the poverty levels of the area, the
amount was kept as token.
Mohabbat Singh- man transformed
Few people questioned the token amount collected by the project. Mohabbat Singh, resident of
Richadi village, a retired army man aged 68 years was an exception. In the group meetings he would
tell the project team "what are you teaching these people, they know everything?" He would refuse
to give token money-"the factory is paying for the medicines, why then are you charging? I shall
inform the factory management of this malpractice". He was often told that this was a token amount
and all services including medicines were free of cost. On few occasions, he would even seek
treatment but not pay the token fee; the staff then paid from their pockets. One day, he fell sick and
suffered a severe attack of Bronchial Asthma. Luckily the team was visiting. Treatment was
immediately initiated and he responded. Later, the team followed up on him. He recovered rapidly
with the treatment, but was moved by this gesture of the team who he often disturbed and
questioned their intentions. Since then Mohabbat Singh is a changed man. Dr Sharma jokingly
remarks- "Now we receive mohabbatein (love and affection) of Mohabbat Singh". His family is the
first to deposit token money, sometimes they even send tea for the project team. He has become an
important stake holder for the project. The team calls upon him whenever there is a health mela in
the village. He comes forward and speaks in favor of the project and their work. Mohabbat singh is
now a good friend of the project and a spokesperson.
Announcement
The team announces their arrival using loud
speakers (fixed in the vehicle) in the scattered
settlements and moves the mobile vehicle all round
the village before settling at the selected place.
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Duration
The duration of the camps are flexible and well
planned. The duration is completely dependent on
the patient turnout and coverage of the households
by the Nurse and the VLM. This freedom gives the
team to serve more people.
“At the initial camps people would not trust us,
but slowly as they started receiving medical
services and observed our Nurse doing Hb and urine
test, measuring weight and doing physical
examination for the pregnant women, they felt
that there was something concrete going on. The
free medicines and treatment brought a slow
change.” Dr RC Sharma, doctor, Naya Savera.
Home Visits
Vijay Lakshmi, the project nurse-midwife visits 6
10 households in each campsite village/ hamlet. Her
household visit strengthens Naya Savera's out reach
program. ANM is able to reach each individual,
provide RCH services and improve health awareness
among families. She carries a kit containing Blood
Pressure measuring instrument, weighing machine,
Hemoglobinometer, Uristix (for Urine examination),
measuring tape, Oral contraceptive Pills, Condoms,
Saheli ( non steroidal contraceptive) Pills, Copper T
(for Demonstration) and Iron folic acid tablets (for
adults and children). Since 2005, the frequency of
the house visits was increased.
In addition to providing treatment and
counselling to the women, the house visits serve as
the opportunity for the VLMs to learn by observing
the Nurse. They had, in the first place, agreed to
join as VLM because it would involve going around
the village with behanji (project nurse).
Activities conducted by the ANM during
household visit
1. Complete ANC Check up
2. PNC Check up of mother and newborn.
3. Meeting with the Individual & Family
members,
4. Counseling, follow-up of women adopting
family planning, & Distribution of FP
methods
5. Follow-up of sterilization cases.
6. Informing people who are ill to reach the
medical camp.
7. Sharing information with the local ANMs &
Anganwadi Teachers and also meets ASHA,
Sahyogini, TBAs and Mahila Ward
Members.
Not surprisingly, curative medical services were
the prime attraction of the project. Importantly,
this was only a means to an end and not the end
itself. As expressed earlier, the clinical services
were meant to serve two purposes - first, to address
the felt need of people and second, to introduce
additional aspects like BP measurement during ANC,
hemoglobin estimation (quantitative) among
others. While pursuing the objectives, there were
other outcomes like the increase in the frequency of
visits of the government ANMs and sharing of data
amongst project staff and the govt. ANMs. These
collaborative efforts would definitely contribute to
the improvement in the health status of people.
Series of activities in a typical Medical Camp:
— Patients first register themselves with the
Social Worker and pay the token fee. " The
doctor evaluates the patient in the serial
order of their registration. A prescription is
written handed to the patient.
— Prescription is brought back to Social
Worker.
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Integrated Family Welfare Programme
— Once a few patients collect, a group
awareness meeting is organised wherein
the doctor/ social worker discuss
common health topics.
— After the group meeting, the social
worker dispenses medicines to the client.
5.3.2 What have these camps achieved
over the project period?
In a short period, the project has made its
presence in the project area. Clinics were
consistently held year after year. The gap between
the ANC and the PNC clients was slowly reduced and
presently the project provides PNC to every woman
who delivers in the project area within a week of
delivery. A drastic increase in the number of clients
seeking care for RTI/STI was observed. Household
visits were also increased since 2005.
Table 6: Beneficiaries of the Naya Savera program
Type of Services
Number of camps
Households Visited
General Cases Treated
RTI/STI
ANC
PNC
Contraceptives Distributed
Children<5 yrs Treated
2005
478
1553
4949
100
532
376
375
1508
2006
460
2261
6175
61
450
453
817
1163
2007
451
2142
5328
495
440
423
423
1457
Total
1389
5956
16452
656
1422
1252
1615
4128
The graph shows that over the project duration
there has been a drastic increase in the RTI/STI
cases seen at the health camps. The team thinks
600
500
400
300
200
100
0
2005
2006
2007
RTI/STI
treated
Menu of services availed in the camps
RTI/STI
3%
ANC
7%
PNC
6%
General
cases
84%
that this is largely due to awareness efforts that
have been strengthened and has resulted in
increase demand for cure.
ANC and PNC clients over the
project period
600
500
400 532
450
440
ANC
300
200
376
453
423
PNC
100
0
2005 2006 2007
5.3.3 Antenatal Care- only injection TT !
"Pregnant women should not be examined again
and again…, Injection (TT) has been given so her
checkup is complete…"
Provision of ante natal care is an essential
component of the essential obstetric service
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18
package under the RCH programme of the
government. The aim of the ante natal care is to
ensure that the outcome of pregnancy is a healthy
mother and newborn. It therefore involves health
education, counseling, medical and laboratory
examination of the mother and her foetus.
In the project area, the baseline survey showed
that at least half of the women had not received
ANC during their previous pregnancy. This is worse
as compared to the overall figures for the district
Sirohi where a third of the women did not receive
ante natal care during their previous pregnancy.11 In
hamlets which are far away from the main project
villages, nearly two-third of the women did not ever
receive ANC. The women equated ANC with tetanus
injection. 36.8% of women in the district did not
receive any tetanus toxoid injection during their
previous pregnancy, worse only 16% of the pregnant
women received 100 tablets of Iron folic acid. The
project made a conscious effort to provide a
package of ANC services.
It is a common belief in the field that women
develop an understanding of the features of a
service such as antenatal care package largely
based on their past experience of the services
received. Little surprise, elderly mothers in law and
in some cases even the pregnant women object to
the antenatal examination, especially examination
of the abdomen. According to them pregnant
woman should not be examined repeatedly. They
were even suspicious of the nurse examining the
abdomen of the pregnant woman. If the woman
received Injection TT , her ANC was complete.
The initial days therefore were very difficult but
for the free medical OPD services. When people
responded well to the treatment they started
coming in the camp. This opportunity was utilised to
hold group meetings with them and counsel them on
the benefit of ANC including the components that
constitute complete ANC. Individually, pregnant
woman were counseled on the merit of each
component of ANC- abdomen examination, Hb test,
urine test, BP measure, etc.
Running away!
Lakshmi, the project Nurse-midwife recalls that
11. DLHS 2004, Sirohi.
Integrated Family Welfare Programme
in early days, pregnant women in Valoria used to run
away on seeing her. Slowly as the community
realized the benefit of medical OPD and gained
information through meetings, they were less
hesitant and welcomed the project staff to their
houses. Thus, house visits for conducting check-ups
started. Initially, each day only 2-3 houses were
visited because considerable time was spent in
allaying apprehensions and counselling. The
presence of the VLM helped matters. Today, each
day 5-6 houses are visited. People have opened the
door of not only their houses but also their heart to
the project team. They are convinced that the
project works for their good.
ANC Package
For the pregnant women visiting the camp,
Lakshmi conducts antenatal checkup in privacy,
either in a neighbouring Anganwadi center or any
other close-by house. An ante natal examination
involves physical examination, BP Measurement, Hb
estimation (using Sahli's method), Urine test for
proteins, sugar (using dipstick method), Weight
Measurement, IFA distribution- prophylactic or
therapeutic and listening to the heart sounds of the
foetus.
She records all details in her daily dairy and later
updates the ANC register at Project office. She takes
the government ANMs cooperation and uses her
records to verify on Immunisation and ANC clients. If
Government ANM is present, she looks after child
immunization, distributes IFA tablets while Lakshmi
does the remaining tasks.
Quality ANC
The ANC provided includes clinical examination,
laboratory examination alongside counselling.
While high blood pressure induced by pregnancy
(Pregnancy induced hypertension or PIH) is among
the leading cause of maternal mortality. A dreaded
complication of high blood pressure in pregnancy
leads to convulsions and even death of pregnant
women. Simple measurement with training has
been proven of great value in identifying pregnant
women at risk of severe complications. Efforts can
then be instituted in time to prevent or minimise
the consequences of PIH.
Pricking the finger
Recent evidence from National Family Health
Survey-2005, a nation wide health survey, shows
that the iron deficiency anaemic among pregnant
women has increased. Anaemia in women is a
leading cause of death and disability in pregnant
women on its own. Further still, it compromises the
survival chances of pregnant women from other
complication- anaemic women are more at risk of
death from bleeding either during pre or post
delivery. 100 IFA tablets given to pregnant women is
only prophylactic and will not treat anaemic in
pregnant women for which additional dose of IFA is
required. Thus, not only should the 100 IFA tablets
be given as a precaution but accurate estimate of
the Haemoglobin (Hb) status of the pregnant women
be done to treat underlying anaemia.
Vijaylakshmi uses the Sahli's method to estimate
the Hb in addition to the colorimetry and clinical
screening. This enables her to get a good estimate
of the (in) adequacy of the Hb of the woman. The
table below shares the results of the Hb tests done
between March 06 to December 07:
Indicator
No. of Hb tests done
Mean Hb value
Range of Hb value
Proportion of total women who are anaemic12
Women in their first pregnancy who were anaemic
Women in their second or more pregnancies who were anaemic
Value
777
10.75 gm%
5-15.2 gm%
436 (56.11%)
56 / 149 (37.58%)
380 / 628 (60.50%)
Iron deficiency between tribal and non tribal
women
Clearly, the levels of iron deficiency anemia are
very high among pregnant women. As revealed in
the table below anemia is more amongst women
who were pregnant for the second time or more.
Across the tribals and the non tribals there is hardly
any difference in the values compared.
Indicator
No. of Hb tests done
Mean Hb value (gm%)
Range of Hb value (gm%)
Proportion of total women who are anemic (%)13
Of the Women in their first pregnancy, anemic (%)
Women in their second or more pregnancies who
were anemic (%)
Sample Tribal village
Valoria
Basantgarh
Sample Non
tribal village
Dhanari
112
119
72
10.51
10.8210.65
5-19
7.2-15
6-14.2
62.50
55.46
54.16
8/17 (47.05) 4/15 (26.66) 3/13 (23.06)
62/95 (65.26) 62/104 (59.61) 36/59 (61.01)
Dietary intake during pregnancy
In the tribals, a commonly held belief is if a
pregnant woman eats more during pregnancy then
she would have difficult delivery owing to the large
size of the head of the child. Conforming to the
belief, their diet does not increase during
pregnancy. In the non tribals however the total
intake increases.
12. Using WHO cut off for anemia in pregnant women, Hb= less than 11 gm%
13. Using WHO cut off for anemia in pregnant women, Hb= less than 11 gm%
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Diet before pregnancy, during pregnancy
and immediately after pregnancy
Non tribal woman
Diet post delivery:
1st 5 days- consume preparation locally called
TEJI , prepared of liberal quantity of ghee,
jaggery, wheat flour, edible resin (goondh) and
ajwain (carum seeds or bishop's weed). This
mixture is prepared to semi solid almost liquid
consistency and given to the pregnant woman for
the first 5 days post delivery. It is believed that
this mixture specially the ajwain helps removal
of clots from uterus and prevents or reduces
flatulence.
From the 5th day to eight days post delivery:
Chapati, porridge and milk is allowed from the
5th day onwards.
8th day onwards- special laddoo are eaten.
These are made of large quantities of ghee,
coconut, cashew, jaggery, pistachio, wheat flour
or pulses, goondh, saunth (sweet date). These
are made in ghee and shaped to round balls
(laddoo). Women are encouraged to eat as many
as she can for another 15 days.
The tribal woman on the other hand begins
with the traditional TEJI for the first 5 days.
Thereafter, she resumes her normal diet which is
chapati eaten with red chilly (grounded to a
paste) admixed with rock salt. Meat is a part of
the diet in this period. The red chilly
interestingly is not cultivated but bought from
the local market.
Diet change during pregnancy:
In non tribals- quantity of food intake
increases
In tribals- the quantity of intake remains the
same and in some cases could reduce.
Common food avoided during
pregnancy and the associated reasons
Papaya
Abortifacient, owing to its hot
nature
Curd
Gets deposited on the outer
surface of child
Brinjal
Will cause dark complexion (of
baby)
Edible resin Creamy, gets deposited on the
(goondh) body
Ghee
Same as goondh
Any greasy item is supposed to deposit on the
body of baby (white deposition on the baby is the
vernix caseosa)
The project has introduced the lab examination
of Hb for pregnant women. The roots of anaemia
are multiple and IFA supplementation alone is not
sufficient. To supplement the IFA, the project staff
counsel the pregnant, lactating women on the food
they should consume to boost their iron stores and
other micro nutrients
Reaching them early- Timing the first antenatal
contact
VLM is entrusted to identify pregnant women in
their village/ hamlet as early as in the pregnancy as
possible. Early identification allows early initiation
of a relationship with the pregnant woman and
provides a longer window of opportunity to work
with her to understand and improve her and her
unborn child's health. Usually women received ANC
in the last three months of her pregnancy. The table
below shows the shift induced by the project. Track
the orange colour boxes in the table to see that the
proportion of women received ANC early in their
pregnancy as the project progressed. The success is
attributed to the VLMs. They periodically meet up
with the women and find out whether there was any
new pregnant woman in the village/hamlet. She
then communicates the news to the team which
visits each village at least once a month. This high
frequency of visits and community level reporting
by the VLM enables early initiation of pregnancy
care. Consequently, early identification of
pregnancy has been achieved in the project. This
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Integrated Family Welfare Programme
further enables completion of at least 3 ANC
checkups and the opportunity to raise the Hb levels
of the pregnant women in the area besides a deep
knowledge of her living environment.
Table 7 : Identification of Pregnancy
Year No. of pregnancies identified
Total
1st 3 months Middle three last three
of pregnancy months of months of
pregnancy pregnancy
2005
143
202
189
534
2006
194
171
85
450
2007
264
161
70
495
Total
601
534
344 1479
ANC registration & Duration of pregnancy
300
250
264
200
150
194
100
143
50
0
1st three
months
202
171
161
189
85
70
M iddle thre e Last three
months
months
Pregnancy duration
2005
2006
2007
Cost
5.3.4.1 Existing mixture of providers
Each health camp cost the project on an average
between Rs 1600 and Rs 1800. The variation is on
account of the travel involved and the medicines
consumed. On an average the project provided
medicines worth rupees thirteen per beneficiary.
The cost of providing one antenatal checkup with all
investigation is on an average Rs 55.35 per ANC per
woman. Three ANC checkups are provided at an
average cost of Rs 133.55 per woman.
5.3.4 Delivery
Women preferred to deliver at home; often
attended by unqualified personnel. According to the
DLHS-2004, nearly half of the deliveries (45%) were
unsafe. Institutional deliveries, an important
indicator of the status of maternal health care, was
only 34.2%; 19.9% in government health facility.
Women are happy if deliveries are conducted at
home since they do not have to go to the hospitals.
Going to the hospitals is expensive and one has to
leave the family behind. The dai and in some cases
ANM or doctor conducts delivery at home. Only in
the case of any complication, recourse to a hospital
is solicited. With the introduction of Janani
Suraksha Yojna scheme of the government of India,
however, there has been an increase in the number
of institutional deliveries, mainly because of the
attraction of the financial incentive given to the
woman as part of the scheme.
The service providers providing delivery services
in the project area are doctors (govt and private),
nurses (govt and private) and traditional birth
attendant or dai maa as she is locally known. In one
of the project village, Swaroopganj, few nurses
have set up private practice, one of them is famous
for conducting deliveries and clients come from far
and wide. Besides in the government health service
delivery system deliveries are conducted at all the 3
Primary Health Centers serving the area and in 3 of
the 7 Sub-centers. In fact, in two of the sub centers,
the resident Auxiliary Nurse Midwives provide round
the clock delivery service, while in two other Sub
Centers, ANMs conduct deliveries in the day when
they are present. Some of the government staff also
conduct deliveries at home. In two of the villages-
Adarsh and Rampura, a private doctor conducts
home deliveries. In a pregnant women's maternity
cycle, the delivery is the period where she receives
some external help from a trained or an untrained
provider. Few of these providers however provide
ante natal or post natal care.
5.3.4.2 Home or out of home?
In some of the villages however the shift to
institutional delivery has not yet taken place.
Women continue to prefer delivering at home. The
project VLMs enquires the place of delivery of each
woman. Their data tells a story of its own- the
proportion of home deliveries has not changed by
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much over the three years. The increase in
institutional deliveries is largely because of a shift
from private institutions to the government system
as given in in the table below.
Table 8 : Place of Delivery
Year
Home
Institution
Total
Trained
Untrained
Private
Government
2005
80
88
152
51
371
2006
119
100
132
94
445
2007
82
93
77
240
492
Total
281
281
361
385
1308
5.3.5 Post natal Care (PNC)
There is very little post natal contact of the
mother and her newborn. The high contribution of
newborn deaths has reiterated the importance/
significance of post natal contacts. A good PNC
improves the survival chances of both the mother
and her newborn. In the project emphasis was laid
on post natal care. The VLM makes note of the
outcome of each delivery in her register. Post natal
contact by the VLM is provided within the first week
of delivery. Initially, the project Nurse did the post
natal contacts but later the VLMs were trained to
conduct basic screening for the post natal visit. The
project MIS provides information whether all the
recently delivered women were provided with PNC
care and this is confirmed by the team during their
field visit.
Table 9 : Provision of Post Natal Care
Year
Pregnant
Women
Live Births
Women provided PNC
women
identified
within 7 days of delivery
identified
ANC
2005
534
534
362*
371
2006
450
450
440
449
2007
495
495
482
492
Total
1479
1479
1284
1312
* In the first year of operation, the tracking by the VLM was not complete, thus the difference between
the women provided ANC and the live births recorded by the project.
Myths, Misconceptions and traditional beliefs
—
Consumption of IFA tablets leads to complication during delivery".
—
"It is difficult for the new born to digest it"(Referring to Colostrum feeding)
—
"Since the fist milk is nine month old it is not good for the new born baby"
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Integrated Family Welfare Programme
5.3.6 Contraception
Salient features of Family Planning Services in
Naya Savera:
— Team holds awareness meetings at camp site
and during household visits by Nurse.
— Team supplies Mala N tablets, Nirodh to the
people who desire spacing methods.
— They refer for Copper-T and sterilisation to
government facilities.
— They inform and give women the freedom to
choose the family planning method.
The acceptance of spacing methods is poor in the
project area whether tribal or non tribal. In spite of
persistent attempts there has been no drastic
improvement. When the project initiated work,
there were only 1-2 women in the project area who
used Copper T. Today, there are approximately 21.
Many myths are still prevalent for each method of
family planning.
Are people not aware?
Remarkably, awareness is not low on family
planning methods but this is not translated to
adoption of a method. The baseline survey showed
the following levels of awareness of Family Planning
methods
Female Sterilization
Male Sterilization
IUD
OP
Condom
Safe Periods
Aware of all modern methods
Aware of all spacing methods
Aware of all spacing methods
Total
Aware
Not aware
Aware
Not aware
Aware
Not aware
Aware
Not aware
Aware
Not aware
Aware
Not aware
Number
284
3
264
23
187
100
219
68
155
132
8
279
156
109
130
287
Average
Percentage (%)
99.0
1.0
92.0
8.0
65.2
34.8
76.3
23.7
54.0
46.0
2.8
97.2
54.4
38.0
45.3
100.0
What do they choose for family planning?
The choice of family planning methods is skewed in favour of Female Sterilization, which is usually the case
in Rajasthan
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Pattern of adoption of Family Planning method among married
women in Sirohi
3%
8%
10%
Female Sterilisation
Male Sterilisation
5%
IUD
Pills
1%
Condom
73%
Any traditional method
Source: DLHS, 2002-03, Sirohi
Low adoption of spacing methods was a concern
in the project. The role of VLM in distributing the
family planning methods has received a good
response but it is not in proportion to the
counselling done by both the staff and the VLM.
Anxieties on family planning
Women in their turn have own anxieties regarding
the use of family planning method. Some of them
share their anxieties with the project team. Some
are worried whether they would conceive again if
they used OCP, others are more worried about the
side effects specially associated bleeding. Some
even believe that OCPs would spoil/ damage their
uterus. These anxieties have been repeatedly
addressed by the team. There have been some
success stories, of some women who have been
using OCP consistently now for a long time and those
who have opted for Copper-T and are satisfied. They
were not only counselled but also heard the same
messages repeatedly from various quarters doctors
in the health mela, from their trainers during
training. This helped reinforce the messages. The
breakthrough came when some of the VLMs started
using oral pills. Satisfied, they were convinced. Only
then they started actively motivating other women
of their village to consider modern method of FP.
The earliest adopters were therefore the VLM
themselves.
The Copper-T is referred to as “sui”, a local term
for needle. Women feel that the copper T will
ascend to their stomach and cause great
discomfort. Male sterilisation is believed to produce
weakness (sexual, physical) in men. Therefore
women instead opt for sterilisation sparing the
males. “Kinara”- a documentary film produced by
Population Foundation of India is regularly screened
in the project area. The movie dispels the
commonly held myths and misconceptions
associated with non scalper vasectomy. The
screening is interspersed with question answer
sessions. While the prevalent myths and
misconceptions are thus addressed, the service side
is also covered by the project. They have mapped
and listed health facilities in the government health
system where Non scalpel vasectomy is conducted
round the year (besides the winter camps). Liaison
with the operating doctors ensures that the clients
coming from the project villages are counseled and
operations done as per the convenience of the
client. This effort has been strengthened since late
2007 and it is hoped that in times to come there will
be a larger proportion of men adopting NSV.
However, the project has an unfinished agenda of
increasing the acceptance and adoption of the
modern methods of family planning and help
families decides the size of their families.
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Integrated Family Welfare Programme
Year
2005
2006
2007
Total
Table 10 : Family Planning Services :
Temporary Method Users
Permanent Method Adopted
IUD
OCP Condoms
Male Sterilisation
Female Sterilisation
2
254
130
1
51
19
248
97
0
37
13
247
155
1
64
34
749
382
2
152
Use of modern family planning methods in the project area over time
300
254
248
247
250
200
155
150
130
97
100
50
2
64
51
37
19
13
1
0
1
0
2005
2006
2007
IUD
OCP
Condoms
M ale ste rilisation
Female
5.3.7 Child Vaccination
Salient features of Naya Savera's work on Child
Immunisation are:
— Naya Savera team create awareness
regarding immunization services and inform
local Govt. ANMs regarding the same.
— The project Nurse extends her help to
Government ANMs to immunize whenever
there is an opportunity.
Status of routine child immunisation
The findings from the baseline survey reveal the
poor immunisation status of the children in the
project area. Overall, only 25 percent of the
children were found to be immunized against all the
six deadly diseases. In the far away hamlets a large
percentage of the children, 58 percent, were not
immunized against any disease. The same in the
main village was 25 percent.
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Table 11 : reproduced from the Baseline report showing the Immunisation
status of children <2 years in the project area.
Total
Number
Percentage (%)
Do you have immunization card
No
148
87.6
Yes
21
12.4
BCG received
No
64
37.9
Yes
105
62.1
DPT1 received
No
86
50.9
Yes
83
49.1
DPT 2 received
No
105
62.1
Yes
64
37.9
DPT 3 received
No
118
69.8
Yes
51
30.2
OPV 1 received
No
94
55.6
Yes
75
44.4
OPV 2 received
No
110
65.1
Yes
59
34.9
OPV 3 received
No
117
69.2
Yes
52
30.8
Measles received
No
108
63.9
Yes
61
36.1
Vitamin A received
No
112
66.3
Yes
57
33.7
Pulse Polio received
No
22
13.0
Yes
147
87.0
Total
169
100.0
A few reasons for poor immunisation
People are not aware of the schedule of the
immunization (source-Baseline report). Sometimes
inconvenience and inaccessibility of the vaccination
session was a barrier to child vaccination. The
project team does not vaccinate children. They
facilitate the government ANMs in doing so.
However the VLM and the project nurse keeps a
track of each child's immunisation status.
The project has adorned the role of explaining the
role of the vaccines to the people and dispelling
myths. The explanation on the role of vaccines uses
common language and common symbols located in
the context with which people are familiar with. As
an illustration, the importance of the protective
benefit of vaccination is explained allegorically
using agricultural practices- Vaccination protects
the child from disease just as “baad” or fencing
protects the newly sown seeds from the grazing
animals. Messages such as these messages are an
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Integrated Family Welfare Programme
attempt to help people understand the importance
of child vaccination. “Hamara kaam unko jagana
hai- Jaago!!!” (Our work is to awaken them, wake
up!!!), Dr Sharma states explaining the role of the
project in child vaccination. As a part of the growth
monitoring of children their immunisation status is
also noted. Whenever the project organises such
camps, it coordinates with the government ANM and
pending vaccination of children are given.
BCG and Sooraj Puja
The protection from TB provided by BCG is explained in context of the Sooraj Puja- a prayer performed
one month after the birth of new born. A function marks this occassion where friends and relatives greet
the child and care him. This exposes the child to many infections and if there happens to be someone with
TB, the child is at risk of contacting the disease. BCG provides protection to the child against TB and should
be given before the Sooraj Puja is performed. This clearly locates BCG in the social context of the people
and improves compliance.
Polio kya hai???
During a group meeting, Dr Sharma (the project doctor) asked a mother whether she had given her child
polio drops during the pulse polio round. She replied in affirmative but did not know what polio was. It is
the "name of medicine" she said as did many others except for one person who said that polio is a disease.
Earlier there were many cases of 'Rentiya” (those who creep), do you see as many children now? No, the
mother replied. This was because the polio vaccine protected the child from Rentiya.
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Integrated Family Welfare Programme
6
COMMUNICATION CHANNELS FOR VILLAGE WOMEN
6.1 How to communicate?
The following table shows from the baseline women exposed to different mass media
Media Exposure
— Do you usually read newspaper/
magazine at least once a week
Total
— Do you usually listen to radio at
least once a week
Total
— Do you usually watch television at
least once a week
Total
Total
N
%
No
273
95.1
Yes
14
287
No
261
4.9
100.0
90.9
Yes
26
287
No
264
9.1
100.0
92.0
Yes
23
287
8.0
100.0
The modern means of communicating messages-
radio, TV, print media do not work in the project
area for various reasons. The majority of women are
illiterate and cannot read. The electricity supply is
poor and therefore, TV does not work. The street
plays and cultural shows are the live and active
media of communication. People are familiar and
readily accept them. They engage and involve the
audience unlike the one sided communication of the
S.No.
Activity
(July 2004-Jan 08)
1
Mass Meetings
2
Kishor-kishori Meetings
3
Nav Yuvak Mandal meetings
4
Mahila Mandal Meetings
5
Health Mela
6
Kala Jatha Shows
radio, TV or newspaper. Inter personal
communication is used as the main communication
strategy. The project team reaches out to people
through various meetings and directly engages with
them. These efforts are supplemented by audio
visual show that sometimes the team also organises.
Organising these shows is no mean tasks since the
TV, CD/DVD player, generator all have to be carried
to the field.
No. of events
People participated
897
34358
16
2551
12
468
445
8568
15
4457
11
1557
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Some of the modes of communication used in the
project are:
— Mass community meetings.
— Meetings with special target groups - men,
women, adolescent boys and girls mother
in laws, etc.
— Flip charts, posters, pamphlets and
banners etc.
— Street plays ( Natak Mandali / Kala Jathas )
— Video shows
— Need based IEC for individuals
— Influencing through opinion makers.
6.2 Channels used to talk with people
6.2.1 Mass Community Meetings
Salient features of awareness meetings are:
— Team waits till the maximum number is
gathered for the day at the camp site
— Team decides the topic according to the
group's perceived need (Family Planning
methods, sex selective abortions,
Tuberculosis, Immunisation, etc.)
— Meetings are held at camp site and also at
household level by Nurse
— Most of the meetings are talks/lectures
They are also called social meetings, they are one
of the most common methods used to create
awareness on reproductive and child health in the
project area. Regular meetings feature talks on
particular tropic followed by question & answer
sessions. Flip charts, pamphlets, posters, boards,
are used to emphasise and clarify topics. Team also
conducts smaller group meetings, family meetings
and individual meetings in the Mohallas and phalis
(Hamlets) of the villages. Meeting proceedings are
recorded by the social worker or sometimes ANM in
"proceeding register". Attendance of each
participant is noted by the Assistant in the register.
The attendance helps us to calculate how many new
persons attended these meetings.
Meetings are held at different location- Mass
Meetings in campsite, Kishor -Kishori meetings in
schools, Mahila Mandal Meeting in Anganwadi
centers or Mohallas or during growth monitoring
camps and also during Video Shows. Family Meetings
and Individual Meetings are held by the project
Nurse and sometimes by other team members also
during the household visits.
In the initial phase of the project, social meetings
were conducted with the clients in the medical
camp prior to dispensing medicines. These patients
who were seen by the doctor would not disperse
without taking the medicines and this was utilised
to build their knowledge on various RCH issues. It
helped building rapport and clarified the purpose of
the project. However, now that a relationship is
established, the group meetings are not held in the
camp. Instead, the team tries to reach very small
pockets (hamlets, Mohallas, etc.) and hold meetings
with smaller groups. The aim is to reach out to those
who are not able to gather or come for receiving
treatment.
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Integrated Family Welfare Programme
6.2.2 Kala Jattha
Blending entertainment with information adds
the palatability and acceptance of the latter. The
project commissioned a private artist group
"Bharatiya Lok Kala Mandal, Udaipur" to conduct a
series of theme based Puppet shows, Folk Dance,
Nukkad Nataks and Songs in the project area. The
group has rich past experience and has travelled far
and wide with its performance. It is not only
experienced but also innovative. The project team
provided the concept and theme (based on RCH) and
the group would create a show. For Naya Savera the
group decided to perform at one fifth of their usual
cost. The feed back from the community on these
shows was encouraging. People wanted these shows
to be repeated in future.
6.2.3 And others…
Besides the mass meetings or mass shows, door to
door visits are made both for mobilizing the people
to attend the clinics and also for distribution of
contraceptives. Video shows are held in the project
villages. Documentary films on the role of TBA and
Contraceptive choices titled "Dai Maa" and "Vikalp"
respectively have been screened. A documentary
film produced by PFI on Non scalpel Vasectomy
titled "Kinara" was screened in addition to other
videos.
The video shows and the kala jatha were screened
in the evening when people specially men returned
from work. In the relaxed atmosphere, discussion on
concepts and resolution of queries was easier. For
the team however this meant working beyond the
office hours and reaching home late.
The focus of awareness is mainly on the following
issues:
— Causes, symptoms, community based
treatment and prevention of common
illness and conditions.
— Immunization for prevention of major
childhood killer diseases.
— Water, sanitation, environment and
education.
— Special emphasis on RTI/STI and HIV/AIDS.
— Benefits and law on right age of marriage.
— Awareness on different health care
facilities available in the vicinity.
— Special focus on educating newly married
couples about delaying the first
pregnancy.
— Family Planning - to increase the spacing
between two children to at least 3 years,
terminal methods for limiting the desired
size of the family etc.
— Gender, reproductive rights, male
responsibilities, community
responsibilities, birth registration, female
feticide etc.
— Substance abuse and related issues.
6.3 Health Mela
Besides the medical camps, mass meetings, the
project organizes Health Mela once in every quarter.
These are called "mela" since people assemble in
large numbers in a joyous mood to seek health. The
structure of a typical health mela is in the text box
below:
Health Mela
Components:
1. Inaugural function- govt representatives,
CMHO, JKLC management representative
2. Medical consultation by specialists- lady
specialist (Obstetrician), child specialist
(Paediatrician)
3. Immunisation by the ANM
4. Healthy Baby show
5. Exhibition
6. Prize distribution
7. Snacks
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Preparation
The preparation for the mela starts four days in
advance. Dates are fixed in consultation with the
community and the visiting resource people and a
site identified. Announcements are made and
leaflets are distributed ahead of the health mela for
greater participation of community. The timings are
usually 10 A.M to 5 P.M. The Chief Medical and
Health Officer of the district has always attended
these melas. In his key address, he usually informs
on the available government health schemes and
invites participation in Naya Savera project. The
star attraction of the Health Mela, however is the
Healthy baby competition.
Star attraction- Healthy baby show
Healthy Baby Show is organised for children in the
age group 0 - 2 years. Children are divided into two
groups 0 - 1 yrs and 1 - 2 yrs. Every participant is
given an attractive toy. Three healthiest babies in
each group are selected by a jury which includes the
Paediatrician. The jury makes its judgement based
on an objective point system. The three winners are
given special toys. Poster exhibitions are organised
on health and hygiene, common diseases, RCH and
family planning issues, HIV/AIDS, Female Foeticide,
Child Marriage, Female Child Education among
others. On an average, a health mela is attended by
200-300 people. All are served snacks. Each health
mela costs us Rs 14910 on an average. The Naya
Savera team is now more cognizant of the concerns
that plague people affecting their health and have
learnt how to communicate with them over time.
7
CHILD GROWTH MONITORING
Growth monitoring of children was planned to be
a regular activity of the project. But
implementation problems meant that it was limited
to special camps. It was envisaged that the growth
monitoring would be done through the agency of the
anganwadi centres measuring the weight of the
children enrolled. The exercise would be done
alongside the health camp in the village/ hamlet.
However, it was soon discovered that the time of
health camps would not match with those of the
Anganwadi centers. Further, limited children were
enrolled in the anganwadi and not all of those
enrolled attended it. Thus, all children in a
particular village/hamlet could not be captured via
the anganwadi. Therefore, growth monitoring was
done as a special time bound activity at special
camps.
Growth Monitoring was started in April 2007. Over
23 camps were held for all children in the 10 project
villages and their hamlets were covered. The
special camps were all held at the anganwadi
centres of the village. It was decided that these
camps would be used to assess immunisation status
of children and vaccinate them if incomplete or
unvaccinated. The local ANM was thus consulted and
the schedule of the camp aligned with the date of
her visit to the anganwadi. As the team wanted to
attract maximum number of children and were
aware of the poor turnout at the anganwadis, they
publicised the camps. The dates of the camps were
advertised in the villages. Additionally, small
encouragement was given- a packet of biscuit to the
woman bringing the child and 4 sweets (toffee) to
the child. This proved to be a major crowd puller
and on an average each camp witnessed a gathering
of 70-80 children. The cost of one camp on an
average is Rs 3,332 or approximately Rs 48 per child.
Activities during the Growth monitoring camp
are:
1. Weight of every participant child (0 - 5yr.)
was measured.
2. Mid arm circumference was measured by
Shakir's tape. Malnourished / under weight
children thus identified were listed out
separately. The angawadi centre was given
the list of these children and asked to enrol
them for regular supply of supplementary
nutrition to the child.
3. Mass Immunisation -
i. Immunisation status of Children (0 - 5)
yrs. was assessed and suitably
vaccinated.
ii. Pregnant mothers were immunised for
T.T.
4. Mothers Meetings - Discussion meetings with
Mothers who accompanied their children
were held on the importance of Mother's
Milk especially Colostrum feeding,
nutritional requirements of a child, diet
planning, weaning and malnutrition in
children.
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Integrated Family Welfare Programme
8
COLLABORATION WITH GOVERNMENT
The aim of the project was to improve the health
status of the people it works for. In doing so,
collaborations were done at various levels with the
government health system. While the project was
required to collaborate with the higher echelons of
health administration and also with the frontline
workers, the most definite interaction was with the
ANMs deployed in the field. Most of our work was
actually their work. Going frequently to the field
meant that much truth about the health services
was known. Some new facts emerged and all of
these helped us define an understanding with the
govt health staff specially the ANMs.
Initially, the Government Health Department was
unsure of JKLC's ability to implement the project.
However, instead of being despondent, the team
proactively engaged with the health system. They
made several visits to the Block PHC, attended
monthly review meeting of Block PHC and invited
government staff including the District Chief
Medical and Health Officer to health Melas, Puppet
shows and other programmes. In one such
programme, seeing the congregation of people and
their involvement, CMHO's perception underwent a
sea change. He became a friend of Naya Savera and
supported our activities. Today, the project sources
IEC materials, supplies like IFA, condoms, oral pills,
ORS packets from the CMHO office. CMHO supports
in posting/deputing staff during the Health Mela.
The project on its end shares all the information
with the government. The presence of Dr RC Sharma
(Naya Savera doctor) who had retired from the
government services and knew the system and
helped JKLC liaison with the government. To build
relationship with the ground staff- ANMs, Anganwadi
workers, Teachers, Janmangal couples, ASHA, team
organized village level meetings.
Rapport with ANMs
Some of the ANM's (in four villages) husbands had
worked in the JKLC factory and they were very
cooperative in the project. Since the project did not
conduct immunisation services, it was required by
the project team to share data on new ante natals,
post natals, child immunisation (information
collection on this was started by the team), family
planning requirements of the various clients, etc
with Govt. ANMs. This led to increasing the
collaborative actions.
Restricted mobility was one of the major
challenges that the ANM faced in making her
services available to scattered areas. This was
addressed to an extent by presence of a vehicle in
the project. The team would happily give a ride to
the ANM to their village. Later the visit schedules
were shared and some ANMs hitched a ride with the
team. There was another advantage that many of
the young ANMs were less afraid to venture out
alone. They also acquired a helping hand. A direct
result of this was an increase in the frequency of
ANM visits to the project villages. Once the ANMs
participated in the project awareness program they
felt more confident. The outcome was better
service delivery to the area. The ANMs have started
identifying themselves as part of the team, they get
support of team in their work and vice versa.
Routinely, in most camps organised by the
project, the govt ANM vaccinates children while the
doctor and the project ANM examines patients, ante
natals and post natals. The VLM provides valuable
community link. The role of the latter has been
institutionalized by the govt in ASHA. The ANM
however, is still alone and in absence of a mobile
team, her access to villages especially in
inaccessible areas will continue to be limited- a
food for thought for the planners and
administrators.
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Today I am confident…
One of the ANM working in the village where Naya Savera project is implemented feels very strong
and confident today. She says-"the hamlet in which we are visiting today was not accessible for me
3-4 years earlier. I was feeling unsafe in moving in these areas. Community people were not ready to
hear any thing from me".
She was not able to extend any services in these areas."But now I am confident and ready to move
to any part of the village. I feel safe and people also listen to me and receive services. The
immunization rates has changed drastically after Naya Savera's intervention. People are accepting
family planning services. The awareness program run by Naya Savera helps us in extending the
services. I feel like part of the team. I receive support from local VLMs in following up of the cases.
Things have changed today, all due to Naya Savera's intervention and support".
9
VLMs
VLMs
"Pehle Pagli Thee, Ab Mujhe Kayee Cheejo Pe
Gyan Bada Hai. Mujhe ghar mai aur bahar bhi log
puchte hai- dava aur elaj kee jarroraton ke bare
me."
(Earlier I was ignorant, now I have knowledge on
various things. People ask for me both in my house
and outside for opinion on health and other
matters)
Search for VLMs
After every village came to know of the project
and its objectives, search for VLMs was started. The
team met several individuals in the community
(stakeholders and opinion makers) and collected
information about educated daughters-in-law of
the community including their rapport with people.
Identifying daughters-in-law for the post of VLM was
a conscious decision since the project wanted to
work with women and having a woman VLM would
make matters easier. A daughter-in-law was likely to
stay in the village as a sustainable resource
compared with the daughters who would generally
leave after marriage.
As per the project design, VLM would be selected
in consultation with the community. Some criterions
were fixed cognizant of exigencies of her work. A
VLM was expected to be literate, could be a
traditional birth attendant or a woman panchayat
member or even wife of a paramedical practitioner
of the village. Till date the project has identified 27
VLMs all of whom are literate (could read and write
their name). Savita Devi , VLM of Dhanari village is
class 10 pass. On an average, the VLMs are class 8
pass. Currently, there are 18 VLMs in the project.
The projects expansion to the scattered hamlets
necessitated more VLMs specific for the hamlets.
Additional VLMs were thus recruited and were
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christened "Assistant VLMs". Assistant VLMs perform
the same task as the VLMs but they cover more
interior and remote area. The reason for appointing
them was to extend the services to other parts in
the villages which were missed out due to shortage
of staff. Basantgarh (with several hamlets) has 3
VLMs, Rampura 2 and Valoria (scattered hamlets)
has 6 VLMs.
Quick progress
An initial three day induction training was
organised for VLMs at JK Lakshmi Cement Ltd. They
were given a fixed honorarium, Rs 200 each month.
After a year the honorarium was increased to Rs
250. Nearly two years into the project, it showed
that the VLM's knowledge had increased
tremendously and so was the commitment of these
VLMs to their work. The honorarium of the VLMs was
reviewed against the performance of the project
and was doubled to Rs 500 per month. Although it is
understood that money alone cannot compensate
for the work put in, it did have a positive effect on
the morale of the VLMs.
On another occasion on Feb 6, 2008 in front of the
collector, Sirohi and other prominent office bearers
of the government and the JK Lakshmi Cement Ltd,
Madhu Devi, VLM of Kodarla village shared her
experiences as VLM over the past three and a half
years. "I was very nervous, thought I will not be able
to say anything, but slowly as I started speaking I
gained confidence….", Madhu Devi recalls. Madhu
Devi had never seen the collector so close neither
addressed any public gathering of strangers.
Friends left on the way
Bina, VLM of Adarsh was one among the group of
VLMs who attended a training programme in Ajmer
organised by another PFI partner NGO. This training
programme was for a select few who were
identified as potential leaders or master trainers for
the fellow village level workers. There were similar
health workers from 4 other organisations. The
learning from 3 days of residential training has
stayed with Bina till date. Importantly, the VLMs
met other women and men who were working in
similar capacity but in other project area. For many
of these women it was first opportunity to go out of
their homes and responsibilities - for themselves,
their learning.
While some of the VLMs were recognized for their
work and selected as ASHA, not all VLMs associated
functioned as desired. 9 VLMs were replaced for
various reasons- some could not maintain records,
others could not attend the mobile clinic camps or
mobilise women. The recognition as a VLM feels
great but is hard to sustain as it comes with a lot of
hard work and motivation.
"it is a service to your own village"
Most of the VLMs are young women in their 20s
and 30s. They have young children and shoulder
most of the household work like any other woman in
the village. They also have caste affiliations like any
other woman in the village. Then, why did these
women agree to take on an extra job with no real
financial bonanza. The secret lies in what they were
told during recruitment.
Firstly, the Naya Savera team mapped houses with
educated women in each village. This was done with
active cooperation of the villagers. They then met
these women. "It is a service to your own village"-
these words, recalls Vijaylakshmi (NM of the
project), when told to women in their first meeting
convinced them to take the decision in favour of
accepting the position of VLM. All agreed to serve
their own village. The project team did not initially
put these VLMs under work pressure but spent
considerable time taking them along during their
daily routine, mainly accompanying the NM. This
accosting the project NM did two wonders- First,
VLMs learnt from direct observation and second,
rigid caste barriers were dissolved by free
movement of the VLMs across castes alongside the
project staff.
The twin wonders
Escorting the Nurse, the VLMs had first hand
experience of the services delivered- abdominal
examination of pregnant women, measurement of
hemoglobin and blood pressure, weight
measurement, listening to the heart sounds of the
foetus, etc. This was a valuable learning. Like a
thirsty traveller in the desert sighting water, the
VLMs lapped up this knowledge, they started picking
38
Integrated Family Welfare Programme
up from the counselling that the Nurse would give to
pregnant women, new mother on care of the
newborn, etc. Speaking in key health phrases to the
village women was the first skill they acquired. The
project team was witness to this slow acquisition of
knowledge and slowly added more responsibility.
They were asked to follow up pregnant women,
newborns and maintain information in a register.
Of more importance was the second wonder. The
village is a closed unit with rigid caste boundaries.
The VLMs of one caste were skeptical to go to the
households of "other" caste women. This problem
of reaching to "other "caste women had two
dimensions- of the "lower" caste women going and
advising the "higher" caste women and on the other
hand "higher" caste women going to the house of the
"lower" caste women. Either ways these movements
were difficult for these women. Savita Devi, VLM of
village Dhanari is a Meghwal, a scheduled caste was
skeptical of reaching out to the houses of Brahmins,
traders and other high caste. Her worry was shared
by Prakash kunwar, VLM of Basantgarh who was a
Rajput and was unsure whether she could go to
houses of the "lower" caste women. So then how did
these boundaries dissolve? Surely, an external
factor was required to break the status quo and in
this the project Nurse was the unintentional
catalyst. Routinely, she went to every house where
there was an eligible woman or a child. VLM's job
demanded that she accompany the nurse thus
taking her to the house of "other "caste women.
Slowly, the women discovered that women of the
"other" caste were in need of the service and
information just as much as women of their own
caste. They also discovered that there was little
resistance from the other caste (woman and family)
whether higher or lower to their suggestions than
women of their caste. Was this a reflection of an
underlying appreciation and respect of the value
attributed to the VLMs role or her transformed
identity as a professional (and therefore casteless)
woman who accompanies the NM to every house
providing health care? All these factors in varied
proportions worked for different VLMs and the caste
barriers were permeated to provide services and
information. The VLMs have thus bridged the various
worlds in the village created around caste
identities.
Husbands- the hidden support
While the women were toying with the idea of
accepting the responsibility of the VLM, there was
support forthcoming from their husbands. This was
universal to all VLMs. Men felt that as VLM all that
their wife had to do was accompany the nurse and
not go "ALONE". They were therefore ready and did
not discourage their wife in spite of the small
honorarium.
What is the contribution of the VLMs to the
project?
VLMs played an important role - providing the
team, an entry point to the village. While on one
hand a local person (VLM) in the team gave
confidence to the team, increased their credibility,
on the other hand associated with a team of
qualified people from the factory enhanced the
respect of the VLM. The trust on the VLM is a
reflection on the mobile teams' work and vice versa.
The VLM played a pivotal role in gathering people in
the initial part of the project. She also promoted
the acceptance of modern medicine and care during
conditions considered not called for any
intervention - ANC care during pregnancy is a prime
example besides immunisation, family planning
methods, institutional deliveries, and other
changes that the Naya Savera brought to the village.
VLMs feel that people were not aware about
immunization/family planning/HIV/AIDS but after
Naya Savera project things are changing. Earlier no
one visited these villages to give information on the
above issues. The remote hamlets were untouched
for several reasons till the entry of Naya Savera
rectified the situation.
VLM Ms. Kamla
Kamla is working as VLM since last three years.
She is enthusiastic and active in her community.
Every week she assists the ANM in extending
reproductive and child health services to the
door step. Kamla feels knowledgeable on various
health issues which was not so three years ago.
“Pehle pagli thee ab mujhe kayee cheejo pe gyan
bada hai. Mujhe Ghar me or Bahar be log puchte
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hai Dava aur eelaj ke jaroorathon ke bare
mein”. Kamla has benefited personally from the
program. She was able to know about the spacing
methods and used them to space her pregnancy.
She understood the importance of immunization
and got her children vaccinated first and now
advocates immunisation among village women.
Today, the VLM is an important resource of the
community. She has basic knowledge and awareness
on immunisation, family planning, care during
pregnancy among others. People approach her for
support and advice on health issues. The VLMs
associated with the project have received
recognition in other forms as well - majority are
employed with the government in different
capacities.- 6 are now ASHA-SHAYOGINI and 5 are
anganwadi workers. All the VLMs who today are
ASHAs were selected in recognition for their work
with the project. That they were educated was
indeed an essential qualification. The ANMs of these
villages made recommendations for these VLMs.
The monitoring of the VLMs is done by the project
team. While there is no compromise with the work,
there is both technical and emotional support to
these women. Ultimately, it is the team work that is
reflected in the achievements.
10
COMMUNITY REPOSED OVERWHELMING FAITH
The project design stated that active cooperation
would be solicited from the various stake holders.
There was an inherent intention to involve this
category of people to believe that they have role in
the success of the project. Meetings with the
members of the local government (panchayat
members), village secretary, school teachers,
anganwadi workers, ANMs, etc was a routine part of
the project. Mostly, we were never disappointed in
our call for support. The teachers granted
permission to hold camps in the schools, sometimes
helped in mobilizing the the clients to the clinic.
Magan lal Meghwal, all of 32 years, and a teacher in
secondary school of village Vasa is very creative. He
seized the opportunity to participate in the project.
He wrote and directed a role play on HIV/AIDS. His
students performed the role play in a mass meeting
in front of an audience of 300 people.
Members of the panchayat
On the whole the response from the PRI members
was satisfactory although we hoped that it was
better. However, a few of them like to Sarpanch of
Valoria was very supportive. He would urge the
people to attend the camps and helped resolve any
problem we faced. There has been other benefit to
the village. The village secretary of one project
village informed that prior to the project there
were hardly 50 births or death registered in a year
and since the project started this number has gone
up to 300.
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Stakeholder in Silva Hamlet
Stakeholder in Silva hamlet feels that today they are happy to receive the health services from the
Naya Savera project implemented by JK Lakshmi Cements Ltd. Earlier they used to face many hurdles
in reaching a health center or hospital. The transportation facilities were not available. If a person fell
ill they used to carry the patients in a cot “Hame logo ko khaat par utta kar le jana padta tha, ab ham
mobile unit ke intejar me rehte hai aur yahin par ilaj karva lete hain” (earlier we used to take patients
on a stretcher to the nearest facility, now we wait for the health team and receive treatment here in
the village). He feels that the intervention changed their life. The expenses on health have come
down. He also said that this kind of intervention needs to be continued till the community doesn't get
proper medical services and accessibility doesn't improve.
The stakeholders are satisfied with the
treatment and are happy that quality treatment is
available at their door step. It was not always like
this. Up Sarpanch of one of the villages adds that
tribal areas need such projects and these should be
sustained for long. He feels that if the mobile unit is
withdrawn then health services will again become
inaccessible to them. These stakeholders
participate in health melas, video shows,and other
mass awareness programmes. They provide space
for camps, help call people to meetings and try to
motivate the participants.
What is the key point in the Naya Savera project?
— Key players: VLM : In her absence
acceptance by the community would be
hard, follow-up and information regarding
the services and campaign would be
difficult, information about the village
would be difficult especially if they are
scattered
— Key services: Treatment and household
visits by project Nurse-midwife;
— People recognize JKLC and due to its
rapport in the local area, they also heard us
during village meetings.
11
LEARNINGS
— Strong team: For a program to achieve
success and attain its objectives, a strong
committed team is mandatory. The staff
turnover of the team affects the program.
The project was lucky that the team was
focused; all the members were committed
towards achieving its objectives. There has
been no staff turnover since the beginning
of the project. The team has received
support and guidance from the JKLC
management which has helped solve some
of the problems faced in project
implementation.
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12
LIMITATION
The major reason some of the hamlets while in
the project area cannot be reached consistently is
their distance from the main village. In Valoria, all
hamlets beyond 8 kms from the main village are not
covered since there are no motorable roads, only
small lanes (pagdandi) which would not
accommodate vehicles. Chetan the project social
worker did try to reach out to Khila Fali (a far off
hamlet of village Basantgarh not covered under the
project) from another hamlet of Basantgarh, a
distance of 5 kms. It took him 5 hours of walk
through mountains to reach the hamlet. There was
no alternative route. What Chetan could do, the
vehicle and the project staff cannot, and how often
could even Chetan do it? Thus, in the interest of the
health of the staff some of such hamlets were
dropped. Several hamlets and one or two villages in
our project area are cut off in the monsoons.
Chawarli, Basantgarh, and some hamlets of Valoria
are cut off by seasonal water bodies that spring to
life rendering the approach routes inaccessible.
Vasa and Dhanari are the most populous villages of
the project area with a population of approximately
3500 and 2500 respectively.
13
THE CHANGE AGENTS
The Project Team
Dr RC Sharma had spent 35 years of his career
working mainly in the government PHC. At Naya
Savera, Dr Sharma was given the overall
responsibility of patient medical care (outdoor),
community education through Behaviour Change
and Communication activities, and overall
supervision including validity and accuracy of data.
Dr. Sharma has taken the assignment with utmost
dedication and energy. JKLC has given him company
accommodation. Having a house near the office
meant that late evening returns from the field did
not act as a burden. He is the father figure for the
team. The feeling of getting the task done no matter
whose responsibility it is runs among all the project
team members. Therefore there are no barriers of
hierarchy in the team.
Vijaylakshmi Tanwar had just passed (in 2004) as a
trained Auxiliary Nurse Midwife from ANM training
center, Sirohi. She did not have any prior work
experience. A resident of Pali, she was recruited
from campus interview by the management of JKLC
for the project. Lakshmi was selected from amongst
12 of her batch mates who appeared for an
interview. She was totally unaware of the daily field
visits, and household visits that she would do in the
future. In the first few days on the job, she thought
that the tasks she was doing were those of the
government ANM. While talking to her friends
posted as government ANMs, she was often
discouraged from doing that much work. Initial
difficulties were overcome by encouragement from
the team.
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Others in the dedicated team are Chetan is a local
person from Asau village working as a social worker
and Kishore kumar Rawal native of village Vasa who
is the multi-purpose worker.
Supportive Supervision
A key aspect of this team work is the monitoring
by the senior staff. Lakshmi recalls that in the initial
days, Dr Sharma accompanied her to the house visits
to make sure that she conducted the examination
correctly, was well behaved and counselled the
women well. Similarly, Lakshmi oversees the work
of the VLM by accompanying them to the house and
enquiring from the women what was told to them by
the VLM. This helps in two ways - the staff is
attentive since they are monitored and secondly
when there is some difficulty then the superior can
help out. Jaanta (VLM) shares her experience - "I
learnt a lot from Lakshmi behanji because I went
with her to house visits". Thus a chain has been
created for two way information from top to
bottom, cultivation of skills under supervision and
at times helps in problems solving.
The project team, including the VLMs was trained
in maintaining the records. All the records are
maintained and updated weekly. Once filled, the
doctor checks all the formats and registers, this is
the first level of validation. In the monthly meeting
the data for the month is presented; second level of
validation and at the end of the quarter when the
data is sent to PFI a final level of validation is done
to make sure that we are accurate in our reports and
figures.
Additional to the above process the Project
Implementation Committee (PIC) and Project
Steering Committee (PSC) is constituted to review
the project from time to time. The PIC is headed by
Full Time Director of the JKLC, CEO, Project Officer
and Project Team. Every fortnight the committee
reviews the performance of the project. PSC consist
of three people Director, CEO and Project Officer.
This committee reviews the program in every
quarter or as felt necessary.
14
FINDINGS FROM THE QUALITATIVE ASSESSMENT AND WAY FORWARD
Some of the key achievements of the first phase
of the programme are:
The capacity building of the grassroots level
volunteer emerged as an important component of
this project. Village level motivator's role in terms
of mobilizing the people, providing prior
information about the various project related
activities, was found remarkable.
Household visits by project nurse under the
project were an important feature specially for
maternal health services. The skills of the project
ANM can be further enhanced on aspects like CuT
insertion. There is also scope for her to do
counselling more effectively and consequently the
number of contraceptive acceptors can be
increased.
A significant linkage between Govt. ANMs and the
project nurse was established in terms of execution
of services. Besides, logistical linkages were also
established with PHCs/SC. These can be to be
strengthened further. The participation of Project
ANM/ Doctor in the monthly meeting at the PHCs
would be fruitful.
Overall, this project has left a good impact in the
project area especially in improving the awareness,
ANC, PNC and child immunization coverage.
Besides, an improvement in terms of contraceptive
accepters/users was also noticed.
Establishment of more logistical and technical
linkages with governments, inculcating community
ownership and removal of myths from tribal
community specially in relation to acceptance of
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contraception and improvement in the quality of
services emerged in areas which needed focus.
Based on the learning's of this programme a
second phase of the project that focuses on
repositioning of the basket of choice approach to
family planning methods has been designed.
Addressing the myths, misconceptions through
effective behavior change communication is
another important feature of the project. The
programme also aims to increase knowledge of
adolescent boys and girls on RH/FP issues.
Sustainability, with the aim of transferring the
ownership of the programme to the community is an
issue which the second phase is aiming to address.
With this in view attempts are being made to make
the interventions sustainable by engaging the
community through mechanisms mandated by with
National Rural Health Mission (NRHM).
48
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ANNEXURE - 1
Annex 1- Project villages and their hamlets Population and House Hold of 10 Villages
S. Name of Fali
No. Village
H.H. Population Total
Number
HH
1 Basantgarh Proper
252
Markundeshwar (not covered) 32
Bilawato ki fali
43
Boriwada
31
Movlio,Damro,Raydron
93
Piplia
19
Dhanawato
16
Voeo ki fali, Buti fali
41
Vavrli fail
14
Bhateshwar fali
85
Dalavato ki fali
36
Karnavato ki fali
56
Guie, Khara fali
2
Puravato ki fali
127
Pichawania,Kalimagri, movlio 110
Kahria, damro
20
Khila fali (not covered)
41
Silva fali (not covered)
17
Matvera (not covered)
4
Khara,Damro
92
Lon vav
4
986 1135
167
192
116
481
91
79
203
79
498
203
288
9
675
566
115
215
115
22
419
23
Total
Population
5542
Distance
from
proper
village
4 km
1.5 km
1 km
1 km
0.5 km
0.5 km
0.7km
0.5 km
1.5 km
2.5 km
3 km
4 km
3.5 km
4.5 km
4.5km
10 km
11 km
8 km
3.5 km
1.5 km
2 Valoria
Buta fail
161
Pagara fali
189
Silva fali Upala & Nichala
165
Uba gara, Vanda fali
160
Paniya
119
Siga ki Pawati (not covered) 93
Jod fali (not covered)
29
Arua fali (not covered)
104
Dala pura
29
Kamboi
101
579 1441
941
792
580
563
345
191
362
87
392
5907
1.5 km
6.5 km
8 km
6 km
10 km
9 km
16 km
4 km
5.5 km
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S. Name of Fali
No. Village
Bhamariya (not covered)
Kankarli
Bori fali (not covered)
3 Rampura/ Rampura
Banas
Banas
Pawata
4 Vasa
Proper
Jabaji fail
Dhakela fali (not covered)
Kamboi fali (not covered)
5 Adarsh - Adarsh proper
Dungri
Dungri
6 Kodarla
Proper
Futela
7 Richadi
-
8 Dhanari
-
9 Goliya
-
10 Chawarli Proper
Bhilwas
H.H. Population Total
Number
HH
53
35
203
143
58
25
1042
70
83
74
305
36
157
15
106
257
124
98
12
5181
217
109
749
1737
467
137
3318
375
682
500
1439
300
1272
108
900
2356
1137
1015
80
27272
226
1269
341
172
106
257
124
110
5181
Total
Population
2341
4875
1739
1380
900
2356
1137
1095
27272
Distance
from
proper
village
13 km
6 km
15 km
3 km
4 km
4 km
7 km
6 km
3 km
3 km
3 km
S.No.
1
2
3
4
Data for the period july 04- Jan 2008.
Event
No. of clinics held
No. of beneficiaries attended clinics
Household visits by the project NM
Number of benefeciaries met during the household visits
ANNEXURE - 2
Number
1567
28448
6220
11466
S.No.
1
2
3
4
5
6
7
8
9
10
11
Cost for some of the activities
Event
Cost per health camp in Basantgarh village (tribal village)
Cost per health camp in Valoria village (another tribal village)
Cost per health camp in Kodarla village (non tribal village)
Cost per Health Mela , Average cost
Cost per Health mela, Valoria village (tribal village)
Cost per Health mela, Chawarli village, (non tribal village)
Cost per Beneficiary
Cost per Complete ANC package
Cost per one VLM training programme
Cost per one growth monitoring camp
Cost per child in the Growth monitoring camp
ANNEXURE - 3
Cost (Rs)
1598.26
1763.40
1701.50
14910
15144
10593
98
56
5191
3332
48
50
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4 Pages 31-40 |
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4.1 Page 31 |
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lefUor iz;klks ls]
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tYnh ugh djuk gS]
vPNk [kk,] vPNk igus]
[kwc i<+s] [kwc fy[ks]
LoLFk vkSj l;uh cus]
rc gh yxu djuk gS!
vBkjg dh gksus ij]
tc C;kg gks tkos]
nksuks dks le>kosa]
Bgjks nks lky]
le>ks ,d nwts dks]
tYnh D;k gS vHkh]
vHkh rks rqe gks] ;g gS]
u;k&u;k gS esy]
^vU;^ D;ks tYnh vkdj]
fcxkM+s rqEgkjk [ksy\\
52
Integrated Family Welfare Programme
dfork
u;k losjk
tc eu iqjh rjg fey tkos]
nks tho ,d tku gks tkos]
rc uhao iM+s igys dh
,slk u;k losjk vkos]
u;s egseku dh rS;kjh es]
xHkZorh ekrk dks] de ls de rhu ckj]
tk¡p vo”; djkuh gS]
[kku&iku vkSj nok] Vh0Vh0 dh]
mfpr [kqjkd fnykuh gS]
izlo iwoZ dk le; dfBu gks]
;k izlo le; tfVy gks]
?kj okyksa dks psrk dj]
lgh le; ij cryk dj]
lgh txg fHktokuk gS]
utnhdh vLirky gks tgk¡]
lksp le> djds mldks]
cl ogha fHktokuk gS!
nkbZ ek¡ dks f”kf{kr dj]
mfpr jkg nsuh gS]
LoPN gok] ?kj lkQ]
txg lkQ] gkFk lkQ]
Mksjk ¼dksMZ VkbZ½ vkSj CysM dks]
djds ckWby] fQj ysoks dke]
cl FkksM+h lh lko/kkuh]
ugh yxrk dksbZ nke!
xk¡o dh C;kgrk ,d] ^^oh0,y0,e^^
¼foyst ysoy eksVhosVj½ cukuh gS]
^^iztUu vkSj cky LokLF;^^ esa]
f”kf{kr mldks djuk gS]
Øe'k%---
Vhe ds lkFk&lkFk gj ?kj og tk,xh]
Vhe ds gj lnL; dk lcls ifjp; djok,xh]
tPpk cPpk dk LokLF; lgh gks]
,slh jkg fn[kk,xh]
nks cPpks es j[kks nwjh]
,slk ea= i<+k,xh]
rktk Qwy xqykc tSlk]
cPpk gks cl f[kyk f[kyk]
ekrk dk psgjk gks tSls]
iwue dk pk¡n fudyk!
cPpk tc tUes rc gh ls]
Vhds mls yxkuk gS]
Ng Ng tkuysok jksxksa ls]
ns[kks mls cpkuk gS!
ve`r gS ekrk dk nw/k]
LoLFk jgsxk mldk iwr]
tc rd fi;s] fiykrh jguk]
ckr ;gh le>kuk gS!
cPpk ;fn Nhads [kkals]
Toj ls ihfM+r gks tkos]
“kwa&”kwa&”kwa&”kwa “okl pys]
“kh?kz ges crykuk gS!
nLr ;fn mldks yx tkos]
futZfydj.k ;fn gks tkos]
vk¡[ks x<~<s es /kal tkos]
vks0vkj0,l fiykuk gS]
fQj gedks fn[kykuk gS!
NksVh&NksVh ckrksa ij]
/;ku lh nsos ekrk]
?kj esa [ksy jgh gS fcfV;k]
HkS;k >wys esa eqldkrk]
uUgs ds eEeh MsMh gksa]
;k fofM;ks “kks vkelHkk gks]
ckr ;gh fl[kykuk gS]
vkaxu okMh] tueaxy]
rqe Hkh vkvks lkFk pysa]
vkvks dp:] vkvks /kkew
tYnh ls ckgj vkvks]
,dhd`r dk u;k losjk]
nl xk¡oksa dh gj pkS[kV ij]
u;k jax ys vk;k gS]
u;k losjk vk;k gS]
u;k losjk&Vhe ns[kdj]
lcdk eu g’kkZ;k gS]
u;k losjk vk;k gS!
Mk0 vkj0 lh0 “kekZ
esfMdy vkQhlj] u;k losjk ifj;kstuk
¼,dhd`r ifjokj dY;k.k dk;Zdze½
ts0 ds0 y{eh lhesUV
ts0 ds0 iqje ¼ft0 fljksrh] jkt½
Integrated Family Welfare Programme
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