baseline report-evidence based ri, vhnd and imnci service delivery through health system...

EVIDENCE-BASED IMNCI, VHND AND RI SERVICE

DELIVERY THROUGH HEALTH SYSTEM STRENGTHENING

IN ODISHA – AN EXTERNAL MONITORING

DEMONSTRATION PROJECT

Base-line Report

October 2013

Conducted by

Public Health Foundation of India

Indian Institute of Public Health – Bhubaneswar

In collaboration with

Government of Odisha and UNICEF – Odisha

Key Words: Base-line, Routine Immunization, VHND, IMNCI, External Monitoring, Odisha

Evidence-based IMNCI, VHND and RI Service Delivery

through Health System Strengthening in Odisha – An External

Monitoring Demonstration Project

Base-line Report

October 2013

Conducted by


Indian Institute of Public Health – Bhubaneswar

In collaboration with Government of Odisha and UNICEF – Odisha

Key Words: Routine Immunization, VHND, IMNCI, External Monitoring, Odisha

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A research study conducted by:

Indian Institute of Public Health, Bhubaneswar

2nd and 3rd floor, JSS Software Technology Park

E1/1, Infocity Road, Patia, Bhubaneswar - 24

Contact no: 0674 6655601


ISID Campus, 4 Institutional Area

Basant Kunj, New Delhi – 70

www.phfi.org

Corresponding Author:

[email protected]

This work was supported by UNICEF

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Principal Investigator Dr. Bhuputra Panda (PHFI-IIPHB)

Co-Investigators Dr. Shridhar Kadam (PHFI-IIPHB)

Dr. Meena Som (UNICEF)

Dr. A K Sen (UNICEF)

Research Advisory Team Director of Family Welfare, Govt of Odisha

Dr. Subhash Salunke, Sr Advisor PHFI and Director, IIPHB

Dr. Lipika Nanda, Deputy Director, IIPHB

Additional Director, Child Health, Govt of Odisha

Research Support Team Ms. Anindita Pattnaik (PHFI-IIPHB)

Dr. Gyanaranjan Pradhan PT (PHFI-IIPHB)

Dr. Nishitha Ranjan Dash (PHFI-IIPHB)

Dr. Sandeep Kumar Panigrahi (UNICEF)

Dr. Sovesh Das (PHFI-IIPHB)

Mr. Sudeep Kesh (PHFI-IIPHB)

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ACKNOWLEDGEMENT

This study report was a result of three months of incessant hard work on conceptualization, finalization

of study design, development of data collection tools, and then collecting data from the remotest sites of

five far-off districts of Odisha, followed by meticulous data analysis.

The Study was conducted by Indian Institute of Public Health – Bhubaneswar with funding support of

UNICEF between July 2013 and September 2013. We are thankful to the UNICEF team for

commissioning this study to IIPH-Bhubaneswar and for providing timely support throughout the course

of data collection, data analysis and report writing.

The department of health and family welfare (DoH& FW), government of Odisha provided all necessary

support and cooperation during data collection phase, for we are thankful to the state, district and sub-

district level officials. Specific mentions may be made of the chief district medical officers, additional

district medical officers and block programme managers of all the five intervention districts.

The crisp support provided by Dr Ajit Basanta Ray and Ms Padmavathi Yedla was useful for finalization

of the tools and writing the report. We thank them all for their contribution.

Last, but not the least, the efforts and enthusiasm of field investigators, all staff associated with this

work in data collection from the field was instrumental in completion of this study on time.

Dr Shridhar Kadam Dr Bhuputra Panda

Co-Investigator Principal Investigator

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ABBREVIATIONS

ANM: Auxiliary Nursing and Midwifery

MPHW (F): Multi Purpose Health Worker (Female)

AWW: Anganwadi Workers

BPO: Block Program Organizer

CHC: Community Health Centre

ICDS: Integrated Child Development Scheme

ILR: Ice Line Refrigerator

IMR: Infant Mortality Rate

LHV: Lady Health Visitor

MCH: Maternal & Child Health

MMR: Maternal Mortality Ratio

MO: Medical Officers

NRHM: National Rural Health Mission

PHC: Primary Health Centre

SC: Sub Centre

RI: Routine Immunization

VHND: Village Health & Nutrition Day

IMNCI: Integrated Management of Neonatal & Childhood Illness

AVD: Alternate Vaccine Delivery

PRI: Panchayati Raj Institutions

GKS: Gaon Kalyan Samiti

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CONTENTS

EXECUTIVE SUMMARY ........................................................................................................................................1

BACKGROUND ........................................................................................................................................................5

REVIEW OF LITERATURE .....................................................................................................................................7

AIMS & OBJECTIVES OF THE STUDY ................................................................................................................9

MATERIALS AND METHODS .............................................................................................................................10

RESULTS - BOLANGIR .........................................................................................................................................14

RESULTS - NUAPADA ..........................................................................................................................................37

RESULTS - KORAPUT...........................................................................................................................................58

RESULTS - NABRANGPUR ..................................................................................................................................79

RESULTS - MALKANGIRI ..................................................................................................................................101

DISCUSSION ........................................................................................................................................................123

CONCLUSION & RECOMMENDATIONS .........................................................................................................126

ETHICAL ISSUES AND QUALITY ASSURANCE ............................................................................................128

STUDY LIMITATIONS ........................................................................................................................................128

BIBLIOGRAPHY ..................................................................................................................................................129

ANNEXURES ........................................................................................................................................................130

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TABLES

Tables

Page No(s).

Bolan

gir

Nuapa

da

Kora

put

Nabar

angpur

Malka

ngiri

Table-1: Availability of vaccines at routine

immunization session sites

15 38 59 80 102

Table-2: Availability of logistics at routine immunization

session sites

15 38 59 80 102

Table-3: Quality indicators-I at RI session sites 16 39 60 81 103

Table-4: Quality indicators-II at RI session sites 17 40 61 82 104

Table-5: Health supervisors visited in last three months

v/s 4 key messages delivered to caregivers

18 40 62 83 105

Table-6: Availability of logistics at VHND sites 19 42 63 84 106

Table-7: Session site of VHND 20 43 64 85 107

Table-8: Availability of health workers at VHND sites 21 44 64 86 108

Table-9: Maternal health service delivery at VHND sites 21 44 65 86 108

Table-10: Child health & family planning service

delivery at VHND session sites

22 45 66 87 109

Table-11: Quality attributes of VHND services 23 46 67 88 110

Table-12: Review of IMNCI records 24 47 68 89 111

Table-13: Assessment of skills of IMNCI trained

workers

24 47 68 89 111

Table-14: Availability of logistics at AWC 25 48 69 90 112

Table-15: Skill assessment of IMNCI trained workers on

assessment, classification & management of sick

neonates

26 49 70 91 113

Table-16: Skill assessment of IMNCI trained workers on

assessment, classification & management of sick children

of 2 months to 5 years

27 50 71 92 114

Table-17: Profile of supervisors 30 52 73 94 116

Table-18: Supervisory visits made by internal

supervisors in last one month

30 52 73 94 116

Table-19: Frequency, method and place of feedback

received on IMNCI from higher officials

31 53 74 95 117

Table-20: Programme management of IMNCI by the

supervisors

31 53 74 96 118


received on RI from higher officials

32 54 75 97 119

Table-22: Programme management of RI by the

supervisors

33 55 76 97 119


received on VHND from higher officials

34 56 77 99 121

Table-24: Programme management of VHND by the

supervisors

35 57 78 99 122

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EXECUTIVE SUMMARY

Background

Over the past decades continued efforts are being made to improve under five and maternal survival in

the country. Notwithstanding a continuous improvement in the key maternal and child health indicators

(U5MR reduced from 166 in 1980 to 55 in 2011 and MMR declined from 398 in 1998 to 212 in 2011;

SRS 2011) more focused interventions need to be undertaken. Consequently, maternal and child

survival initiatives continue to remain a priority for government of India and, in turn, the state

government of Odisha. Of the various initiatives taken up by the government, this project focuses on

assessment of implementation status of three community based child survival programmes, such as,

routine immunization (RI), village health and nutrition day (VHND) and integrated management of

neonatal and childhood illnesses (IMNCI). The project also focuses upon the need for providing regular

handholding support to the frontline functionaries for continued reinforcement of skills and knowledge.

It is estimated that early diagnosis, timely referral & management and regular supervision and

monitoring by internal monitors can ensure sustainability of community based interventions and quality

of services. Thus, Indian Institute of Public Health, Bhubaneswar with the support of UNICEF,

undertook this study, based on which further interventions could be planned in order to improve the

quality of the services. The purpose is to identify high risk mothers among population who are

accessing the health system, and to reduce under-five mortality.

Materials & Methods

We conducted the base-line in five intervention districts of Odisha to assess the existing quality of

services, and to explain the knowledge, opinions and skills of the supervisory workforce on programme

supervision. Thirty clusters were selected as sample, based on the WHO thirty cluster sampling, wherein

each cluster represented a sector. The allocation of number of clusters to each sample district was done

using the PPS technique. Primary and secondary data were collected during June to August, 2013, using

the standardized supervision checklists of Government of India, adopted by Government of Odisha, for

RI, VHND and IMNCI programmes. We administered a semi-structured questionnaire (designed and

field-tested by IIPHB) for the supervisors. The data was subsequently analyzed qualitatively and

quantitatively, the results of which are discussed in the next section of the report.

Results & Discussion

In general, availability of logistics, frequency of supervisory visits and quality assurance mechanisms

across three most sought after community based maternal and child health interventions were found to

be unsatisfactory. For RI programme, we found that vaccines were not available in all the sites,

supervision frequency was very less and kind of support provided by the supervisors to the service

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providers was inadequate. With respect to IMNCI programme, there was remarkable loss of skills

among health workers. Consequently, the workers were not confident in classification, assessment,

management and referral of infants and young children, using IMNCI protocol. Availability of IMNCI

drugs, especially Cotrimoxazole, Paracetamol and Zinc, was found to be an important barrier to

successful IMNCI implementation. With regard to VHND services, we found that quality of ANC was

very poor. For instance, abdominal palpation, urine examination, haemoglobin testing and BP

measurement was not done in all the sites. Availability of examination table and provision of privacy

during examination were grossly inadequate. Even in sites wherein examination tables were available,

abdominal palpations were not done. On child health services, weight recording of infants, ORS

demonstration and communicating danger signs of newborns to parents was found to be done in less

than 40% sites. Involvement of male members in family planning meetings was virtually non-existent.

With regard to the nature and quality of support the supervisors were getting from their supervisors (who

are mostly district level officials), most of the supervisor respondents mentioned that they got vehicles

and handholding support from their supervisors for providing services in hard to reach areas. Few of

them also mentioned about the incentives and logistics support that they received from their supervisors.

When asked to identify and name the stakeholders for RI, IMNCI and VHND programmes, most of

them mentioned about health workers and ICDS workers as the key stakeholders, while some of them

also stated that beneficiaries, PRI members and GKS members were stakeholders.

When asked about the special steps which they had taken to address the issues of high left-outs and

drop-outs in RI, about one-third of respondents agreed to answer this question and most of them gave

importance to home visits and follow-up visits as the main strategies to improve upon the situation of

high left-outs and dropouts. Some of them also mentioned about the importance of community

sensitization programmes.

Conclusion

Bolangir:

With respect to RI programme, vaccine availability was satisfactory but functional hub-cutters were

available in 81% sites, while counterfoils in 72% sites; availability of red and black bags and delivery of

four key messages on RI was found in 81% sites, each. In VHND sessions, ICDS supervisors were

available in just 3% sites; urine examination was done in 12% sites; male involvement in family

planning was almost non-existent; weight recording of infants was found in 25% sites only; logistic

items, such as, screen for privacy, availability of pregnancy testing kits, IFA tab (small), test tubes and

red bags for disposal were available in less than 50% VHND sites; with respect to services, abdominal

palpations, foetal heart sound recording and privacy during examination was ensured in less than 50%

sites. Dietary counseling, danger signs of newborns and ORS demonstration was also found in less than

50% sites. For IMNCI component, we found that home visits were conducted by 12% IMNCI trained

workers. Assessment sheets were correctly filled up in 25% instances. Skills on assessment,

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classification and management were found in less than 50% workers. Similarly, availability of IMNCI

board, jar, cup and spoon and zinc tablets were found in less than 50% instances; only 22% of

supervisors had received feedback on IMNCI from their supervisors; comparable figures for RI was

30%, and for VHND at 26%; transportation support was found to be an important systemic barrier; use

of supervisory checklists was just 26% for IMNCI, 56% for RI and 52% for VHND.

Nuapada:

With regard to RI, we found that though the availability of logistics was good, functional hub-cutters

and counterfoils were available in just 45% RI sites; MCP cards were available in 82% sites. In VHND,

zinc tablets, foetoscopes, test-tubes, due list of beneficiaries were available in less than 50% sites. We

didn’t find any ICDS supervisor attending any of the VHND sites; urine examination and abdominal

palpation was not done in any site, while foetal health sounds recorded and danger signs communicated

to pregnant women in 17% sites; danger signs of newborns were not communicated in any of the sites;

recording of weight of infant (17%) and demonstration of ORS (42%) were two key short-comings on

VHND services. For IMNCI, management of sick neonates, classification and management of young

infants was in less than 50% instances; Paracetamol was also found to be available in less than 50%

sites.

Koraput:

Availability of OPV, DPT and TT was found in less than 90% sites; tracking bags were available in less

than 50% RI session sites; counterfoils were available in 85% sites. For VHND services, we found

examination table, screen for privacy, foetoscope, zinc tablets, gentian violet, test tubes, hand gloves and

red bags for disposal were found in less than 50% sites; ICDS supervisors were available in 6% sites and

health supervisors were present in just 25% sites; abdominal palpation, foetal heart sound recording and

PPTCT counseling was done in less than 50% sites; danger signs of newborns recording, weight of

infant recording and ORS demonstration was done in <50% sites. On IMNCI, assessment, classification

and management was done in <50% instances; IMNCI board, jar, cup, spoon, cotrimoxazole,

paracetamol, gentian violet and zinc tablets were found to be available in <50% instances.

Nabarangpur:

In RI sessions, vaccines were available in around 90% sites; tracking bags were available in only 33%

sites; red and black bags were available in 71% sites; four key messages were delivered in 58% sites.

Under VHND programme, screens for privacy, foetoscopes, baby weighing scales, hemoglobin testing

kits, zinc tablets, cotrimoxazole, paracetamol, IFA (small) tablets, IFA syrup, test tubes, hand gloves,

gentian violet and red bags for disposal were found in less than 50% sites; we didn’t find ICDS

supervisors attending any of the VHND sites and the health supervisors were found attending only in

21% of the VHND session sites; abdominal palpation, foetal heart sound recording, PPTCT counseling

and communicating danger signs to pregnant women were found to be done in less than 30% sites; with

respect to child health service delivery, communicating danger signs of newborns to parents, weighing

of infants, ORS demonstration and advice on hand washing/hygiene was being done in less than 40%

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sites. On IMNCI, assessment, classification and management was done in <50% instances. IMNCI

board, one litre jar, cup, spoon, cotrimoxazole tablets, paracetamol tablets, zinc tablets, IFA tablets and

gentian violet were found to be available in <50% instances.

Malkangiri:

With respect to RI, in one site vaccines were found in frozen state; vaccines without label and with

unreadable label were also found in one site; Measles, OPD and TT were available in 93% sites only;

MCP cards were found in 64% sites, while counterfoils in 79% sites; tracking bags were found in just

7% sites; only in 50% sites we found four key messages were delivered. In VHND, screens for privacy,

foetoscope, paracetamol tablets, urine testing kits, test tubes and duelist of beneficiaries were found to

be available in less than 50% sites; we didn’t find ICDS supervisors attending any of the VHND sites;

with respect to the maternal health service delivery, relevant history recording, ensuring privacy during

examination, urine examination, abdominal palpation and PPTCT counseling was found to be done in

less than 50% sites; foetal sound recording was not being done in any of the sites; ORS demonstration

and advice on hand washing/hygiene was found to be done in less than 25% sites. With regard to skills

of IMNCI trained health workers, we found that assessment, classification & management of sick

neonates and assessment & counseling of sick children were done in less than 50% instances; IMNCI

board, paracetamol tablets, IMNCI chart booklets, IMNCI modules and IMNCI photo booklets were

found to be available in less than 50% instances.

Recommendations

Improving availability of drugs and other logistics, across districts, is a major challenge which will have

direct effect on quality of services. Logistics and supply chain management practices may be improved

by piloting an indenting mechanism from sub centre level to the district store. Erratic supply of

materials and drugs could be reduced to a great extent through improvement of indenting system.

Periodic training of both front-line workers and supervisors is essential for skill upgradation and

motivation. Refresher on IMNCI would cement the gaps in knowledge and practices with regard to

implementation of IMNCI as a child survival strategy. Involvement of RKS and GKS members may be

envisaged to institutionalize community participation and local decision making for quality

improvement. Skill enhancement of supervisory cadre would help strengthen supportive supervision.

Regular review at block and district level would be critical for long-term sustainability of service

delivery. The reporting mechanism of VHND, IMNCI and RI may be made regular and authentic which

could be relied upon by the state and district officials to take strategic and operational decisions,

respectively.

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BACKGROUND

Provision of and access to essential healthcare services including immunization is one of the key public

health goals of India. Recent data indicate that complete immunization coverage is 59.5% (Coverage

evaluation survey, 2009). Moreover, malnutrition and low birth weight (LBW) contributes to about

50% of deaths among infants and children under five. Bringing down under five mortality rates and

improving child health & survival has been an important goal of the family welfare programmes in

India. The under five mortality rate (U5MR) of the country has come down significantly over the years

from 166 in 1980 to 55 in 2011 (SRS, 2011); one of the recent surveys reveals that the same for Odisha

is 78 (AHS, 2011). Of the 100 worst-performing districts, 40 are in Uttar Pradesh, 22 in Bihar, 15 in

Jharkhand, 12 in Madhya Pradesh, 10 in Rajasthan and five in Odisha (Naandi Survey).

Reports from routine health management information system (HMIS) of NRHM for 2010-11 indicate

that the eleven KBK Plus Districts report maximum number of under-five deaths in Odisha. The data of

AHS 2011 also confirms this finding (Bolangir – 115/1000 live births; Nabarangpur – 81/1000 live

births; Malkangiri – 79/1000 live births; Nuapada – 75/1000 live births; Koraput – 72/1000 live births)-

our intervention districts and Kandhamal with a highest of 145/1000 live births.

Failure to recognize warning signs owing to poor knowledge, delayed referral of sick children, lack of

supportive supervision, provision of prompt and appropriate care at the facility, etc. are identified as the

key factors behind such high mortalities. Thus, Public Health Foundation of India (PHFI) through its

constituent institution Indian Institute of Public Health Bhubaneswar (IIPHB) recognized the needs and

priorities of the state and proposed to contribute to the reduction of mortalities and morbidities amongst

under-five children by strengthening implementation & monitoring of IMNCI, VHND and RI through

hand-holding support to the internal monitors & facilitating regular visit of the system supervisors to the

field for programme monitoring.

We propose to facilitate in the capacity building efforts of district and sub-district functionaries on the

above issues. The project would comprise a baseline survey, followed by a series of interventions at

sector, block, district and state levels and culminate in an endline survey after about one year of

intervention. The results would provide a comprehensive understanding of the relative and attributable

improvement in the quality of service delivery which could be due to the interventions done during the

intervention phase.

The summary of interventions proposed under the project are:

1. Monitoring the quality of RI and IMNCI trainings being conducted at district and sub-district

level for the front-line health and WCD workers, such as, the ANM, AWW, LHV, BPOs, MOs

etc.

2. Facilitate in development of an integrated supervisory plan at sector and block level to monitor

the quality of service delivery

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3. Conduct regular field visits along with internal supervisors to monitor IMNCI, RI and VHND

sessions and report the findings in the prescribed formats on a monthly basis

4. Facilitate block and district level meetings with inter-departmental officials to ensure

intersectoral coordination

5. Provide hand-holding support to sector and block level officials in monitoring the programme

implementation, documenting best practices and conducting periodic reviews

6. Document case-studies, success stories and best practices from the field

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REVIEW OF LITERATURE

Supportive supervision in health care has proved to be an effective strategy to improve quality of

services and drive the programme towards its core objective. In supportive supervision regular

handholding support and capacity building of grass root level workers and solving the issues by

addressing the bottlenecks really strengthen the system as well as the programme. The most important

observation is to improve the motivation level of workers at all levels and increase their skills and

competencies. Small issues having greater effect on programmes can be identified and addressed easily

as well as effectively through supportive supervision.

Although convergence between nutrition and health has long been recognized as a barrier to improving

child under nutrition in India, actual convergence has been limited and somewhat ineffective. Some

factors underlying limited convergence include a range of multiple and diverse stakeholders; complexity

of the technical issue; determinants of under nutrition that lie outside technical domains; and the view,

based on an experiential understanding among implementers, that convergent action is an almost

insurmountable barrier. We postulate that three factors lie at the heart of this incomplete convergence

process: failure to include convergence in policy formulation, lack of attention to institutional

modifications to facilitate convergence, and lack of monitoring mechanisms to assess convergence of

programs on an ongoing basis. (Rajani Ved et al., 2012)

External monitoring for streamlining supportive supervision and capacity building of internal

supervisors has also been a proven strategy to combat the issues of poor supervision. Despite repeated

trainings, there is a lack of ability among supervisors to address the day to day issues and the underlying

causes to strengthen the system & programme effectively towards its goal. In such cases external

monitoring to strengthen the internal monitors/supervisors has proved to be an effective measure in

various programs.

Any project’s effectiveness must be evaluated simultaneously to ensure effective performance,

achievement of the objectives, visualize robust concurrent monitoring and course correction where ever

required. To achieve this, M & E is an efficient and effective tool, which helps in identifying problems

and its causes; suggests possible solutions to problems; raises questions about risks or assumptions and

strategy; encourages reflection on the progress and its directions; provides information and insight into

the programme; stimulates action on information and finally enhances the likelihood of positive and

sustainable impact.

Cornerstone of supportive supervision is working with health staff to establish goals, monitor

performance, identify and rectify problems, and proactively improve the quality of services. The

supervisor and health care personnel together identify and address weaknesses within the health care

service delivery system. Supervisory visits (external processes) also provide the opportunity to identify

and acknowledge best practices and successful approaches to motivating, training and enabling health

care personnel to effectively conduct self-assessment and peer assessment (internal processes). The

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supervisory process explores how self and peer assessment with the inclusion of community input can

contribute to effective results-oriented supportive supervision (Government of the kingdom of Lesotho

Millennium challenge account. Supportive supervision system for district health management teams: a

guide to primary health care supervision. Health systems strengthening, technical assistance, HS-A-

012-09. 2010).

Supportive supervision by an external agent can lead to substantial improvement in the performance of

ASHAs as related to IMNCI. Under the current supervisory system, many line supervisors lack a clear

understanding of their roles and responsibilities as supervisors. In addition, they lack sufficient time and

training to provide supervisory support to ASHAs under IMNCI. We find that supportive supervision

has the greatest effect in improving ASHAs’ capacity, and hence their performance under IMNCI in the

following areas: record keeping, motivation, and knowledge and skills, such as the use of IMNCI

reference materials and techniques in home visit assessments. However, while external supportive

supervisors were effective in providing IMNCI materials, registers, and case sheets, we find less

evidence that they can improve access to medicine. Regardless of the presence of supportive

supervision, ASHAs continue to face resistance from their communities against institutional deliveries,

immunization, health checks for newborns, and referral to hospital facilities. (Martin Abel et. al. Effect

of Supportive Supervision on ASHAs’ Performance under IMNCI in Rajasthan. 2009)

Supervisory activities need to be budgeted and prioritized for community based project: Improving the

coverage and quality of village health and nutrition day. (USAID, Vistar project report).

Developing robust monitoring and evaluation methodologies can support performance improvement and

enable officials to better understand and advocate the contribution that convergence can make to

improved delivery of services.

Supportive supervision is a process that promotes quality at all levels of the health system by

strengthening relationships within the system, focusing on the identification and resolution of problems

and helping to optimize the allocation of resources, promoting high standards, teamwork and better two-

way communication.

In three of our national flagship programmes, such as, RI, VHND and IMNCI that aim to improve the

maternal and child health indicators in low performing areas, streamlining of supportive supervision has

received priority. Though there is a lack of related literature in the support of this strategy but the

findings from other programs indicate it might be effective in these programs. A recent study conducted

by IIPH-Bhubaneswar found that supportive supervision would be most effective when there is an

enabling policy environment at district and sub-district level to involve the supervisory cadre of health

workforce at work.

9

AIMS & OBJECTIVES OF THE STUDY

Keeping the above findings in mind, we proposed the project, titled, “Evidence-based IMNCI, VHND

and RI service delivery through health system strengthening in Odisha – an external monitoring

demonstration project”, under which we would externally monitor services at session sites and

strengthen the health system preparedness. The overall purpose of this demonstration project is to assess

and compare the quality of maternal and child health services provided through community-based

service delivery programmes, such as, village health and nutrition day (VHND), integrated management

of neonatal and childhood illnesses (IMNCI) and routine immunization (RI) in Odisha.

1. In the first step, we proposed to conduct a baseline survey with respect to quality of VHND,

IMNCI & RI services. We will also assess the knowledge and opinion of supervisory cadre of

health workforce, namely, the medical officer (MO), AYUSH MO, lady health visitor (LHV),

ICDS supervisor and male health supervisors on these three key community-based MCH

programmes.

2. Over next one year, we will facilitate provision of a basket of interventions at session sites, block

levels, district and state level: monitoring of sessions, providing hand-holding support, assessing

quality of training programmes on IMNCI and RI, facilitating preparation of micro-plans and

integrated supervision plans and providing inputs in the block and district level meetings to

strengthen the service delivery of these three programmes.

3. At the end of one-year of intervention, we will conduct an end-line from the same sample

clusters, using same data collection tools for comparative analysis.

The specific objectives of this base-line study are:

I. To assess the coverage and quality of health and nutrition related services provided under the

VHND programme in Odisha.

II. To assess the skills of frontline health and ICDS workers trained in IMNCI, with respect to

assessment, classification, management and referral of sick neonates and children up till the age

of five years.

III. To assess the quality of RI services with respect to important quality parameters, such as,

coverage, logistics management, bio-waste management, behavior change communication and

interpersonal communication, etc.

IV. To assess the existing level of knowledge, opinions and skills of the supervisory staff at the

district and sub-district levels, with regard to VHND, IMNCI and RI services.

10

MATERIALS AND METHODS

Study Design and Setting

The land area of Odisha is 155,707 Sq. kms., which is 4.74 per cent of the total land area of India. In

terms of physical size, it is the 10th largest state in India. Amongst the districts in the state, Mayurbhanj

with the land area of 10,418 sq. kms ranks first position (6.69 per cent to the total area of the state) while

Jagatsinghpur with the land area 1,668 sq. kms ranks the lowest position - 1.70 per cent to the total area

of the state (Govt of Odisha).

It is one of the least urbanized states in India. As per the 2001 census, the rate of urbanization is 14.97%,

which is only higher than Assam and Bihar among the major States. Amongst the districts in the state,

the lowest degree of urbanization (having less than 5% urban population) is in the district of Nayagarh

4.29% and the highest degree of urbanization is in the district of Khurda 42.93 %. 15 districts have

urban population below 10% and 5 districts have urban population above 25% (Govt. of Odisha).

The state has been one of the most natural disaster-prone in India. Floods and droughts regularly

devastate the state and cyclones are common. Frequent occurrences of natural calamities stand as a

barrier to economic progress of the state. Agriculture sector absorbs about 80 per cent of the total work

force and contributes 50% of state’s domestic product. Paddy is the “principal” crop. Its cultivation is

the main occupation of 75% of the people. This is against all India average annual rate of growth of

7.4% in GDP during this period. The net state domestic product (NSDP) commonly known as state

income increased from Rs. 16,184.30 crores in 1993-94 to Rs. 25,178.31 crores in 2004-05. The per

capita income has increased to Rs. 6555 in 2004-05.

As per Census 2011 reports, the actual population of the state is 4.19 crores with a decadal growth rate

of 13.97 percent. Sex ratio of Odisha is 978 i.e. for each 1000 male, which is above national average of

940 as per census 2011. In 2001, the sex ratio of female was 972 per 1000 males in Odisha (Odisha

Population Census Data 2011, Provisional Population Totals 2011). Administratively, the state has 3

revenue divisions (also termed as revenue divisional commissioners or RDCs, 30 districts, 58 Sub-

divisions, 171 tehsils and 314 community development blocks. Out of total of 30 districts in the State,

broadly, the KBK category of districts (total =11) belong to the southern and western belt of the State,

while the non-KBK districts (total 19) are mostly from the coastal and northern belt. The State has

about 22% tribal population most of them residing in these KBK districts. The vital health indicators,

such as, infant mortality and maternal mortality data are skewed in favour of non-KBK districts. In

terms of health services delivery, the state has 6688 sub centres, 314 block PHCs, 310 24/7 facilities and

131 first referral units (FRU).

11

Sampling

We selected five sample districts on the basis of priorities of the state government and UNICEF –

Odisha. In the second step, we adopted the WHO recommended thirty-cluster sampling technique for

data collection. Administratively, each district comprises of blocks; each block constitutes about 1.5 to

2 lac populations; and a block PHC, also termed as community health centre or CHC, caters to the health

needs of the block population as well as controls the functions of the PHCs-New. The block is further

divided for convenience of service delivery, into sectors. Each sector has a sector level primary health

centre - New (PHC-New) and about three to five sub centers. This way, one block usually has about

four to five PHCs-New and about 20 to 25 sub centres. For the purpose of our sampling a cluster

constituted a sector. Since thirty clusters were to be allocated to five districts, the number of clusters to

be assigned to each of the districts was decided on the basis of probability proportionate to size (PPS)

technique.

From each sample cluster (or sector), we focused on data collection for continuous six days. This

included observation of about 4 RI sessions, about 4 VHND sessions, about 8 IMNCI sessions; and

interviewing of about 4 supervisory staff. Therefore, the total number of events planned for observation

from each sector was 20. Given that there were thirty sample clusters, the events summed up to 600.

Against this, the achievement was 547 (Exhibit - 1).

Exhibit – 1: Summary of samples of RI sites, IMNCI sites, VHND sites, and supervisors, five

districts, Odisha

Sl.

No

District Name No of

clusters

allocated

RI sessions

observed

AWCs

observed

for IMNCI

VHND

sessions

observed

Supervisors

interviewed

P A P A P A P A

1 Bolangir 8 32 32 64 64 32 32 32 27

2 Nuapada 3 12 11 24 24 12 12 12 11

3 Koraput 8 32 27 64 64 32 32 32 23

4 Nabrangpur 7 28 24 56 52 28 28 28 14

5 Malkangiri 4 16 14 32 34 16 14 16 8

Total 30 120 108 240 238 120 118 120 83

(P=Planned; A=Achieved)

Data collection tools

For objective I, we used the government of Odisha recommended supervisory tool for collection of data

from the VHND site while the session was on. The tool comprised key quality parameters of VHND

programme, such as, availability of logistics, coverage and quality of services; and assessment of

children for growth monitoring.

12

For objective II, we used the IMNCI supervisory tool as recommended by government of Odisha. This

comprised a check-list on issues like coverage of services; skill level of IMNCI trained health providers

in assessment, management and referral of sick neonates and children under five. It also included

questions related to facility support, including availability of logistics.

For objective III, we used the government of India recommended supervisory format for data collection

from the RI session sites. It contained questions related to basic parameters of holding RI sessions,

quality of services, including availability of logistics, quality of vaccines, cold chain, waste management

and behavior change communication.

For objective IV, we developed a semi-structured interview schedule, field-tested it and used for data

collection from the supervisory cadre of health workforce working at sub-district level. It comprised of

questions on all three above mentioned community based child health service delivery programmes,

such as, the level of their involvement in planning and implementation of these programmes, the nature

and extent of support received from their supervisors, the kind of communication used in monitoring,

familiarity with the check-lists, the challenges and opportunities they face in supervising the sessions,

etc.

The baseline study was conducted over a period of three months; and data was collected from the

intervention districts through direct observation and interview. We also reviewed the existing literature

on external monitoring from the following databases: google, google scholar, PubMed Central and

Health Policy & Planning websites. The findings are reflected under literature review section.

13

Exhibit – 2: Matrix of objective-wise data collection tools

Sl

No

Objective Research Question Stakeholders Data Collection

Tool

I To assess the coverage and

quality of health and nutrition

related services provided under

the VHND programme in Odisha.

What is the coverage and

quality of the health and

nutrition services

provided under VHND

in Odisha?

Beneficiaries

Service Providers

Standardized

checklist for VHND

supervision, Govt. of

India, adapted by

Govt. of Odisha

II To assess the skills of frontline

health and ICDS workers trained

in IMNCI, with respect to

assessment, classification,

management and referral of sick

neonates and children up till the

age of five years.

How skilled are the

frontline workers in

implementation of

IMNCI programme?

Beneficiaries

Trained MPHW (F)

Trained AWW

Internal supervisors

Standardized

checklist for IMNCI


India, adapted by

Govt. of Odisha

III To assess the quality of RI

services with respect to important

quality parameters, such as,

coverage, logistics management,

bio-waste management, behavior

change communication and

interpersonal communication, etc.

What is the quality of

services provided under

routine immunization

programme?

Beneficiaries

ASHA

AWW

ANM

Internal supervisors

Standardized

checklist for RI


India

IV To assess the existing level of

knowledge, opinions and skills of

the supervisory staff at the district

and sub-district levels, with

regard to VHND, IMNCI and RI

services.

What are the knowledge

& opinions of the

supervisory cadre on

programme

implementation and

supervision?

How skilled are the

supervisors in

programme supervision?

Supervisory health workers,

like

MPHS-M

MPHS-F

ICDS Supervisor

AYUSH-MO

Sector-MO

Semi-structured

questionnaire

designed and field

tested by IIPHB

RESULTS - BOLANGIR

15

ROUTINE IMMUNIZATION (RI)

Table 1- Availability of vaccines at routine immunization session sites, Bolangir, Odisha

Vaccine availability Bolangir (N=32) Total (N=108)

No. % No. %

BCG 31 97 105 97

BCG diluents 31 97 105 97

Measles 32 100 105 97

Measles diluents 32 100 106 98

tOPV 32 100 98 91

Hepatitis B 32 100 104 96

DPT 32 100 101 93

TT 32 100 97 90

With respect to availability of vaccines at immunization session sites in Bolangir district, we found that all

antigens except BCG and BCG diluents were available in 100 percent sites, while the later were available in 97%

sites.

Table 2-Availability of logistics at routine immunization session sites, Bolangir, Odisha

Logistics availability Bolangir (N=32) Total (N=108)

No. % No. %

AD (0.1ml) syringes 32 100 106 98

AD (0.5ml) syringes 32 100 107 99

5ml reconstitution syringes 30 94 104 96

Vitamin A solution 32 100 105 97

Blank RI card 30 94 92 85

Counterfoils 23 72 83 77

ORS packet 32 100 105 97

Paracetamol 31 97 95 88

Plastic spoon/cap for Vitamin A 31 97 100 93

Tracking bag 23 72 56 52

Functional hub-cutter 26 81 91 84

AD syringes, Vit. – A solution and ORS packets were found to be available in all the sites visited for data

collection. Tracking bags and counterfoils was in less than 75% of the sites visited. In about 80% sites,

functional hub-cutters were found to be available. Blank RI cards (MCP cards) and reconstitution syringes were

found to be available in more than 94% sites. In 31 out of 32 sites, paracetamol tablets were available.

16

Table 3-Quality indicators-I at RI session site, Bolangir, Odisha

Bolangir (N=32) Total (N=108)

No. % No. %

Vaccines without label 0 0 1 1

Vaccines with unreadable label 0 0 1 1

Expired vaccine vial 0 0 0 0

Vaccines at VVM stage III or IV 0 0 1 1

Frozen vaccines 0 0 0 0

BCG/Measles reconstituted for more than 4 hrs 0 0 0 0

Sessions held as per plan 32 100 94 87

Vaccines brought to site by AVD 16 50 59 55

Vaccines brought to site by ANM 6 19 33 31

Vaccines brought to site by supervisor 0 0 1 1

Vaccines brought to site by others* 9 28 12 11

Vaccines & diluents kept in vaccine carrier 31 97 94 87

Vaccines & diluents kept in zipper bag 30 94 84 78

Four ice packs in the vaccine carrier 31 97 101 93

Vaccine batch no. recorded 28 87 89 82

Vaccine expiry date recorded 28 87 87 81

Diluent batch no. recorded 28 87 87 81

Diluent expiry date recorded 28 87 88 81

*Others=HW (M &F), MPW (M), Malaria Worker, MPHS (M)

We found that in all the session sites vaccines were correctly labeled and in readable form. There were no expired

vaccines or vaccines in stage III/IV of VVM or in frozen state. In all the sites, the sessions were held as per plan.

In 97% of the sites, we found that the vaccines were kept in vaccine carriers and zipper bags. Further, the

appropriate use of four ice packs was also found in 97% sites. In 50% sites, vaccines were brought by AVD, while

in 19% sites, it was brought by the ANM and in 28% sites other health workers delivered the vaccines to the

session sites. In more than 85% sites, the batch number and expiry date of both the vaccines and the diluents were

found to have been properly mentioned.

17

Table 4-Quality indicators-II at RI session sites, Bolangir, Odisha

Quality Indicators Bolangir (N=32) Total (N=108)

No. % No. %

Due list available with ANM 32 100 106 98

Due list available with mobilize 29 91 100 93

Reconstitution time written on vials by ANM 31 97 101 93

AD syringe used by ANM to inject vaccines 32 100 107 99

DPT vaccine given on antero lateral aspect of mid thigh 32 100 105 97

Route of measles (sub-cutaneous) 32 100 102 94

Measles given on right upper arm 32 100 101 93

ANM touching any part of needle while injecting 5 16 8 7

ANM following no recapping procedure 32 100 66 61

Syringe cut with hub cutter after use 26 81 91 84

Red & black bags used to segregate immunization waste 26 81 92 85

Tally sheet used to keep record after vaccinating each child 15 47 80 74

4 key messages delivered to caregivers 26 81 79 73

Beneficiaries ask to wait for 30 mins after vaccination by ANM 10 31 48 44

Vaccinate a child with mild fever 24 75 85 79

Vaccinate a child with loose motion 26 81 75 69

Immunization waste carried to PHC 23 72 88 81

Health supervisor visited you in last three months 18 56 85 79

MO visited you in last three months 7 22 15 14

Availability of due list, correct use of AD syringe by the ANM and correct site of administration of

measles and DPT was found in 100% sites. Also, ANMs followed no recapping procedure in all the

sites. In about 80% sites the syringes were being cut with hub cutter after use, red and black bags were

used to segregate immunization waste, four key messages were delivered to caregivers and ANMs said

that they would vaccinate a child with loose motion. Tally sheets were used to keep record after

vaccination in 47% sites. In 30% of the sites, beneficiaries were asked by ANMs to wait for 30 minutes

after vaccination. In the last three months, health supervisors had visited to 56% sites whereas MOs had

visited to 22% sites.

18

Table 5-Health supervisors visited in the last three months v/s 4 key messages delivered to caregivers,

Bolangir, Odisha

Health supervisor visited you in last three months

Bolangir Total

Yes No Yes No

All 4 key messages delivered to

caregivers

Yes 15 11 61 18

No 3 2 21 2

With respect to delivery of four key messages and its relationship with the frequency of supervisory

visits, we found that out of 18 sites where the supervisors had made visits in the last three months, in 15

sites all four key messages were being delivered to the caregivers by the front-line health workers.

19

VILLAGE HEALTH & NUTRITION DAY (VHND)

Table 6-Availability of logistics at VHND site, Bolangir, Odisha

Logistics Availability

Bolangir

(n=32)

Total

(N=118)

No. % No. %

Examination table 21 66 69 58

Screen for privacy 10 31 35 30

BP Instrument 29 91 106 90

Stethoscope 29 91 108 91

Foetoscope 1 3 16 14

Inch tape 17 53 76 64

MUAC tape 31 97 113 96

Weighing scale (adult) 29 91 105 90

Weighing scale (baby) 30 94 86 73

Haemoglobin testing 30 94 86 73

Needle/Lancet 31 97 81 69

Nischay kit 3 9 71 60

ORS sachets 30 94 112 95

Zinc tablets 0 0 31 26

Albendazole tablets / Syrup 29 91 91 77

Anti-malarial tablets / Syrup 28 87 89 75

Cotrimoxazole tablets 26 81 81 69

Paediatric Paracetamol 24 75 64 54

IFA tablets (large) 26 81 94 80

IFA tablets (small) 14 44 58 49

IFA syrup 21 66 68 58

Urine testing kit / Uristix 17 53 69 58

RDK kit 20 62 79 67

Condoms 19 59 88 75

Oral contraceptives 17 53 74 63

Emergency contraceptive pills 18 56 87 74

Gentian violet lotion 25 78 62 52

Test tubes 1 3 18 15

Hand gloves 20 62 42 36

Toilet 4 12 17 14

Water supply 17 53 37 31

20


Bolangir

(n=32)

Total

(N=118)

No. % No. %

Soap 26 81 71 60

Red bag for disposal 11 34 36 30

Cotton bandage 13 41 50 42

Absorbent cotton 23 72 64 54

IMNCI chart booklet 31 97 93 79

Blank MCP cards 27 84 99 84

Referral cards 30 94 100 85

Monthly topic calendar 23 72 87 74

Duelist of beneficiaries 20 62 81 69

Reporting format 28 87 102 86

BP instrument, stethoscope, haemoglobin testing kit, weighing scale (adult and baby), MUAC tape,

referral cards, IMNCI chart booklets and needles were found to be available in more than 90% sites.

Foetoscope & test tubes, and pregnancy testing kits were available in just 1 and 3 sessions respectively.

Zinc tablets were conspicuous by their non availability in any of the sample sessions. Examination

tables and screens for privacy were available in 66% and 31% sites, respectively. IFA tab – large and

small were available in 81% and 44% sites, respectively. Availability of RDK kits was found in 62%

sites and contraceptives were available in about 60% sites.

Table 7-Session site of VHND, Bolangir, Odisha

Session Site Bolangir (N=32) Total (N=118)

Sub center 2 10

AWC 24 87

Others 6 15

Total 32 112

24 out of 32 sessions visited were conducted at AWCs, while only 2 were being held at sub centres. 6

sessions were held in other places including school buildings, community halls etc.

21

Table 8- Availability of health workers at VHND site, Bolangir, Odisha

*Others=BPO, AYUSH MO, PHEO, etc.

With respect to availability of different types of health workers at VHND session sites, we found that in

66% sessions the MPHW (F) also known as the ANMs were present while the session was on. The

comparable percentages for male health workers, AWW and ASHAs were found to be 31%, 78% and

91%, respectively. Further, the presence of supervisory cadre of health workforce at session sites was

found to be ranging from 3% (ICDS supervisor) to 37% (health supervisors). The sessions where the

ANMs were not present were being conducted by the MPHW (M) and LHV.

Table 9-Maternal health service delivery at VHND sites, Bolangir, Odisha

Maternal Health Service Delivery

Bolangir

(N=32)

Total

(N=118)

No. % No. %

Relevant history taken 23 72 91 77

Privacy during examination ensured 12 37 54 46

BP recorded 30 94 103 87

Hemoglobin test done 26 81 93 79

Urine examination done 4 12 54 46

Pregnant women weighed 29 91 101 86

Abdominal palpation done 12 37 26 22

Fetal heart sound recorded 12 37 26 22

IFA for antenatal woman provided 30 94 112 95

Relevant counseling done 27 84 80 68

Danger signs communicated 18 56 51 43

PPTCT counseling done 29 91 61 52

Health workers at site

Bolangir

(N=32)

Total

(N=118)

No. % No. %

MPHW(F) 21 66 103 87

MPHW(M) 10 31 62 52

Health supervisors 12 37 42 36

AWW 25 78 107 91

ASHA 29 91 102 86

ICDS supervisors 1 3 3 2

AWH 22 69 75 64

GKS/PRI members 5 16 7 6

Others* 9 28 17 14

22

Weighing of pregnant women, their BP recording, availability of IFA for ANC and PPTCT counseling

was found to be done in more than 90% sites. Hemoglobin testing was done in about 80% sites.

However, privacy during examination, fetal heart sound recording and abdominal palpation was done

only in 37% sites. Urine examination was done in as low as 12% sites.

Table 10-Child health & family planning service delivery at VHND session sites, Bolangir, Odisha

Child Health Service Delivery & Family Planning

Bolangir

(N=32)

Total

(N=118)

No. % No. %

Advice on breast feeding given 17 53 88 75

Dietary counseling on children done 14 44 71 60

Need for supplementation with IFA communicated 26 81 86 73

Danger signs of new born communicated 13 41 41 35

Weight of infants recorded 8 25 40 34

ORS demonstration done 13 41 42 36

Advice on hand washing /hygiene given 22 68 58 49

FP counseling provided 25 78 108 91

Contraceptives provided 25 78 101 86

ANM & ASHA conduct meeting with women 26 81 70 59

ANM & ASHA conduct meeting with men 0 0 1 1

With regard to delivery of child health & family planning services, we found that ANM and ASHA

conducted meeting with the lactating mothers in about 80% instances. But meeting with their husbands

was not found in any of the sessions. Advice on breastfeeding, dietary counseling to mothers, weighing

of infants and assessment of danger signs of newborns was done in less than 50% samples. Family

planning counseling was found to be done in 78% sites and contraceptives were provided in an equal

percentage of sites.

23

CROSS-TABULATIONS

Table 11- Quality attributes of VHND services, Bolangir, Odisha

Bolangir Total

ICDS supervisors present at site

Yes No Yes No

Beneficiaries mobilized to site

by ICDS workers

Yes 1 17 3 79

No 0 14 0 36

Beneficiaries mobilized to site by ASHA

Health Supervisors present at

site

Yes 10 2 36 7

No 14 6 64 11

Examination table present at site

GKS/PRI members present at

site

Yes 5 0 5 2

No 16 11 65 46

Abdominal palpation done and recorded

Screen for privacy present at

site

Yes 3 7 10 17

No 9 12 25 63


Abdominal palpation done and

recorded

Yes 6 6 16 11

No 15 4 53 35

Cross tabulation of key attributes of quality of services revealed that only in one session wherein the

ICDS Supervisor was present in the session site were the beneficiaries mobilized by the ICDS workers.

In 12 sessions the health supervisors were present out of which in 10 sites the beneficiaries were

mobilized by the ASHAs. Examination tables were available in 21 sites out of which in five sites the

GKS/PRI members were present. Abdominal palpations were carried out in 12 sites though the screens

for privacy were available only in 10 sites. On the other hand, examination tables were available in 21

sites against which only in 12 sites abdominal palpations were carried out. In other words, in 9 sites

despite of availability of an examination table, abdominal examinations were not carried out.

24

INTEGRATED MANAGEMENT OF NEONATAL &

CHILDHOOD ILLNESSES (IMNCI)

Table 12-Review of IMNCI records, Bolangir, Odisha

Record review Bolangir

(N=64)

Total

(N=238)

Total no. of live birth in last 3 months 484 1830

Total no. of newborns in last 3 months who have received home visits 462 1533

Average no. of newborns per AWC/SC in last 3 months who have received home visits 7.2 6.4

Home visits conducted as per IMNCI guidelines 8 (12%) 41 (17%)

IMNCI assessment sheets correctly filled up 16 (25%) 55 (23%)

All sick cases referred 12 (19%) 30 (13%)

Referral Slips filled up 12 (19%) 27 (11%)

IMNCI monthly reporting formats filled up 17 (27%) 42 (18%)

On an average, 7 newborns had received home visits in last three months. The study found that all key

parameters of IMNCI implementation, such as, home visits as per IMNCI guidelines, filling-up of

assessment sheets, filling-up of referral slips and reporting formats were abysmally low, lesser than

30%.

Table 13-Assessment of skills of IMNCI trained workers, Bolangir, Odisha

A. NEW BORN (0-2 months)

Bolangir

(N=64)

Total

(N=238)

No. % No. %

Correctly assessed a young infant 27 42 70 29

Correctly classified the young infant 25 39 98 41

Correctly treated the young infant 27 42 83 35

Correct counseled the infant 22 34 59 25

Infant needing referral is referred 18 28 41 17

Correctly assessed the immunization of infant 17 27 54 23

25

B. CHILD (2 months – 5 yrs)

Bolangir

(N=64)

Total

(N=238)

No. % No. %

Correctly assessed a child 28 44 71 30

Correctly classified the child 18 28 46 19

Correctly treated the child 12 19 35 15

Correctly counseled the child 14 22 39 16

Child needing referral is referred 4 6 30 13

Correctly assessed the immunization of child 33 52 75 31

With respect to the skills of IMNCI trained workers on key parameters of IMNCI programme

implementation we found that both in the case of 0-2 months and 2 months-5 yrs age group of infants

and young children the assessment skills were poor, a little over 40%. On correct classification,

counseling, management and referral their skills were also equally poor. It ranged from 6% to 42%.

Table 14-Availability of logistics at AWC, Bolangir, Odisha

FACILITY SUPPORT

Bolangir

(N=64)

Total

(N=238)

No. % No. %

IMNCI board 3 5 35 15

Salter scale / child weighing scale 62 97 196 82

One litre jar, cup and spoon 12 19 40 17

Ped Cotrimoxazole tab/syp 39 61 92 39

Ped Paracetamol tab/syp 38 59 90 38

ORS 50 78 188 79


IFA tablets 44 69 155 65

Gentian violet paint/ powder 34 53 73 31


IMNCI module 64 100 212 89

IMNCI photo booklet 62 97 206 87

IMNCI forms for 0-2 mon 52 81 217 91

IMNCI forms 2 mon to 5 yrs 52 81 217 91

Referral slips 46 72 208 87

Reporting forms 42 66 175 73

With respect to availability of various logistics at AWCs on the days of conducting this survey, we

found that certain key components of the programme, such as, IMNCI chart booklets and IMNCI

modules were available in all the sites. Photo booklet and Salter scales were available in 97% sites.

26

Among IMNCI drugs, ORS was found to be available in most of the sites (78%) and Zinc tablets were

available in the least (2%). Availability of other drugs, such as, Cotrimaxazole, Paracetamol, IFA

tablets, Gentian violet ranged from 53% to 69%.

Table 15-Skill assessment of IMNCI trained workers on assessment, classification & management of sick

neonates, Bolangir, Odisha

Bolangir

(N=64)

Total

(N=238)

No. % No. %

Assessing possible serious bacterial infection

Convulsion 19 30 89 37

Fast breathing 31 48 117 49

Chest in-drawing 24 37 109 46

Nasal flaring 23 36 95 40

Pustule 10 16 74 31

Temperature 44 69 138 58

Decreased movement 22 34 83 35

Assessing diarrhea

Blood in stool 32 50 96 40

Lethargic or unconscious 17 27 78 33

Restlessness/irritability 21 33 84 35

Sunken eyes 26 41 118 50

Skin pinch 32 50 128 54

Assessing breastfeeding

Difficulty feeding 34 53 110 46

Not able to feed 20 31 70 29

Less than 8 breastfeeds in 24 hours 34 53 109 46

Received other foods or drinks 21 33 74 31

Attachment 22 34 92 39

Suckling 25 39 97 41

Oral thrush 29 45 99 42

Assessing immunization 40 62 117 49

Assessing other problems 11 17 41 17

Classification 23 36 80 34

Treatment/Management

Referral of severe cases 16 25 60 25

Given antibiotic for local infection 13 20 32 13

Given ORS solution in facility 15 23 51 21

27

Bolangir

(N=64)

Total

(N=238)

No. % No. %

Advise on home care 39 61 86 36

Explained signs for when to return immediately 20 31 34 14

Advised follow-up care 24 37 65 27

Counseled on breastfeeding 42 66 80 34

Next date for immunization 23 36 65 27

Checking mother’s/caretaker’s understanding 5 8 18 8

The survey assessed the skills of IMNCI trained health workforce on assessment, classification and

management of sick neonates by using the state government advocated format. We found that with

regard to assessment of sick neonates the skills of health workers ranged from 16% to 69%. On

classification aspect, 36% respondents had the correct skills, while effective management skills ranged

from 8% (checking understanding of mothers) to 66% (counseling on breastfeeding).


children of 2 months to 5 years, Bolangir, Odisha

Bolangir

(N=64)

Total

(N=238)

No. % No. %

Assessed general danger signs

Not able to drink or breastfeed 9 14 17 7

Vomit everything 8 12 17 7

Convulsion 3 5 14 6


Asked for cough or difficult breathing


Chest indrawing 8 12 40 17

Asked for diarrhea

Restless and irritable 10 16 33 14


Able/ not able to drink/ drinking eagerly/ thirsty 6 9 15 6

Skin pinch 10 16 43 18

Diarrhoea for 14 days or more 9 14 21 9


28

Bolangir

(N=64)

Total

(N=238)

No. % No. %

Assessed fever

Stiff neck 8 12 17 7

Fever present for more than 7 day 9 14 26 11

Assessed malnutrition

Visible severe wasting 8 12 28 12

Oedema of both feet 8 12 23 10

Grade of malnutrition (red/ yellow/ green) 8 12 38 16

Assessed anaemia

Severe palmar pallor 9 14 21 9

Some palmar pallor 7 11 20 8

Assessed immunization 9 14 40 17

Assessed feeding

Not Exclusive breastfeeding (for less than 6 month infant) 9 14 31 13

Using bottle to feed to child 8 12 19 8

Child is not fed actively 9 14 25 10

Child is fed less frequently 8 12 20 8

Child is fed less quantity of food 7 11 9 4

During illness child is fed less quantity of food 7 11 9 4

Assessed other problems 8 12 21 9




Given antibiotic for pneumonia 8 12 20 8


Advise home care 10 16 34 14




Counseling on feeding 11 17 34 14


29

With regard to the technical skills of health workers on implementation of IMNCI programme for 2

months to 5 years children, the assessment skills ranged from 5 to 17%. About 16% of respondents

could correctly classify. About 5% workers were confident in checking the understanding of

mothers/caretakers as against 17% workers who could correctly counsel the mothers on appropriate

feeding practices.

30

INTERVIEW OF SUPERVISORS

Table 17 – Profile of supervisors, Bolangir, Odisha


No. % No. %

Designation of

supervisor

MPHS-F 8 30 21 25

MPHS-M 2 7 17 20

ICDS supervisor 7 26 20 24

AYUSH MO 7 26 22 26

Sector MO 3 11 3 4

The table above reflects the profile of our respondents. Out of the total 27 supervisors interviewed, 30%

were lady supervisors (LHV), 7% were male supervisors, 26% were ICDS supervisors, 26% were

AYUSH MOs and 11% were Sector MOs.

Table 18 – Supervisory visits made by internal supervisors in last one month, Bolangir, Odisha


Total Avg Total Avg.

No. of supervisory visits made last month on IMNCI 48 2 149 2

No. of filled in supervisory checklists submitted to block level on

IMNCI last month 8 0 32 1

No. of supervisory visits made last month on RI 101 4 287 3


RI last month 52 2 161 2

No. of supervisory visits made last month on VHND 95 3 313 4


VHND last month 43 2 127 2

Support from supervisors while providing services in hard

to reach areas 13 48 (%) 41 49 (%)

With reference to all the three programmes, the number of supervisory visits made during last one

month was found to be maximum for RI, followed by VHND. For IMNCI the supervisory visits were

the least. The supervisors were filling up on an average 2 supervisory checklists, each for VHND and

RI programmes; whereas, for IMNCI, the comparable figures were close to nil. When asked whether

they were getting support from their supervisors for providing services in hard to reach areas, 13 (48%)

respondents gave an affirmative answer.

31

Table 19 – Frequency, method and place of feedback received on IMNCI from higher officials, Bolangir,

Odisha

IMNCI Bolangir (N=27) Total (N=83)

No. % No. %

Frequency of feedback

from supervisors on

IMNCI

Always 6 22 26 57

Sometimes 18 67 32 39

Never 3 11 22 26

Method of feedback from

supervisors on IMNCI

Verbal 7 26 31 37

Written 11 41 25 30

Both verbal & written 6 22 7 8

Place of getting feedback

from supervisors on

IMNCI

Sector meeting 1 4 18 22

Block meeting 6 22 9 11

OJ training 4 15 4 5

Block meeting & OJ training 3 11 3 4

Sector meeting & block

meeting 0 0 2 2

Sector meeting, block meeting

& OJ training 0 0 2 2

22% supervisors received feedback on IMNCI from their higher officials, regularly, while 11% of them

never received it at all. The method of feedback was in written form (41%), followed by verbal (26%)

and both verbal and written (22%). Block meetings (22%), followed by OJ training (15%) and both

block meetings & OJ trainings (11%) were the platform of getting the feedback. Only 4% respondents

said that they received feedback from their higher officials in sector meetings also.

Table 20 – Programme management of IMNCI by the supervisors, Bolangir, Odisha


No. % No. %

Familiar with IMNCI supervision checklist 13 48 33 40

Role in preparing integrated supervision plan 10 37 21 25

Aware of reporting system under IMNCI 16 59 48 58

Aware of referral services under IMNCI 21 78 54 65

Transportation support for IMNCI supervision 6 22 11 13

Instances of IMNCI drug stock out during last 3 months 14 52 41 49

Regular indenting for IMNCI in your sector 5 18 19 23

Verifying centers supervised v/s planned in the sector 8 30 19 23

32


No. % No. %

Weekly review at sector level meetings 25 93 54 65

Monthly review at block level meetings 25 93 44 53

Received FUS training on IMNCI 10 37 28 34

Use of supervisory checklist

Always 7 26 14 17

Sometimes 4 15 5 6

Rarely 0 0 3 4

Never 16 59 50 60

Components of programme

supervised during visits

Registers 12 44 46 55

Assessment forms 15 56 54 65


Drugs 13 48 44 53

Other logistics* 8 30 26 31

*Other logistics like booklets, IMNCI board, weighing machine, home visits, etc.

93% supervisors informed that they were conducting weekly and monthly reviews on IMNCI. Regular

indenting of IMNCI drugs was done by the supervisors only in 18% cases. 22% Supervisors received

transportation support. 37% of them were involved in preparing the integrated supervision plans. Equal

percentage of them was trained on FUS training. 48% of supervisors were familiar with the IMNCI

supervision checklist; whereas, 26% supervisors always used IMNCI supervisory checklist against 59%

who never used it. While supervising, they most often check the assessment forms (56%), while other

logistics (booklets, IMNCI board, weighing machine, home visits, etc) were being supervised the least

(30%).

Table 21 - Frequency, method and place of feedback received on RI from higher officials, Bolangir, Odisha

RI Bolangir (N=27) Total (N=83)

No. % No. %


from supervisors on RI

Always 8 30 47 57


Never 4 15 5 6

Method of feedback


Verbal 3 11 37 45

Written 11 41 27 32


33


No. % No. %

Place of getting

feedback from

supervisors on RI

Sector Meeting 0 0 28 34

Block Meeting 4 15 10 12

OJ Training 2 7 2 2

Block Meeting & OJ training 9 33 10 12

Sector Meeting & Block Meeting 1 4 3 4

Sector Meeting, Block Meeting &

OJ Training 1 4 3 4

30% supervisors received feedback on RI from their higher officials, regularly, while 15% of them never

received it at all and 48% said that they receive feedback from their higher officials sometimes. The

method of feedback was in written form (41%), followed by both verbal and written (30%) and only

verbal (11%). 33% of supervisors said that block meetings & OJ training were the most common

platform of getting feedback from higher officials. Sector meetings were not used as a platform for

giving feedback to the supervisors.

Table 22- Programme management of RI by the Supervisors, Bolangir, Odisha


No. % No. %

Involvement in preparation of micro plan 15 56 53 64

Providing OJ training to ANM on micro plan preparation 17 63 50 60

Verifying sub centre level RI micro plan during final compilation 18 67 51 61

Verifying sessions planed v/s held in your sector 19 70 69 83

Monitoring counterfoils in the session site 24 89 68 82

Verifying session logbook of ANM at the session site 19 70 51 61

Regular indenting in the sector for RI 15 56 44 53

Conducting review meetings at block level 27 100 68 82

Conducting review meetings at district level 18 67 37 45

Monitoring cold chain maintenance system at session site 21 78 57 69

Monitoring cold chain maintenance system at ILR point 14 52 38 46

Transportation support for supervision 15 56 27 32

Financial incentives for supervision 3 11 10 12

Left out/drop out cases of RI 7 26 30 36

Vaccine/Equipment stock out in last 3 months 4 15 10 12

34


No. % No. %


Always 15 56 42 51


Rarely 0 0 2 2

Never 7 26 13 16

Familiarity with RI

supervision checklist

Poorly 5 18 8 10

Somewhat 2 7 7 8

Fairly 5 18 21 25

Very Well Familiar 15 56 39 47

Factor for drop out

Illiteracy 1 4 11 13

Improper programme planning 0 0 3 4

Poor quality services 0 0 1 1

Cultural barrier 1 4 5 6

Others* 17 63 42 51

*Other factors majorly include migration, lack of communication, poor awareness, etc.

100% supervisors informed that they were conducting RI review meetings on block level against 67%

who conducted review meetings at district level. 78% supervisors monitored cold chain maintenance

system at session site and 52% at ILR points. 56% Supervisors received transportation support and 11%

received financial incentives for supervision. 56% of them were involved in preparing of micro plan.

26% supervisors informed that there were left out/drop out cases of RI and 63% of them agreed that the

major factors for drop out were migration, lack of communication, poor awareness, etc. 56% of them

always used the supervision checklist and were very familiar with the same, while 26% never used the

checklist and 18% were poorly familiar with the RI supervision checklist.

Table 23- Frequency, method and place of feedback received on VHND from higher officials, Bolangir,

Odisha

VHND Bolangir (N=27) Total (N=83)

No. % No. %


from supervisors on

VHND

Always 7 26 37 45


Never 5 18 8 10

Method of feedback

from supervisors on

VHND

Verbal 10 37 52 63

Written 4 15 10 12


35


No. % No. %

Place of getting

feedback from

supervisors on VHND



OJ Training 1 4 1 1

Block Meeting & OJ

training 7 26 9 11

Sector Meeting & Block

Meeting 3 11 6 7

Sector Meeting, Block

Meeting & OJ Training 0 0 2 2

26% supervisors received feedback on VHND from their higher officials, regularly, while 18% of them

never received it at all and 52% said that they receive feedback from their higher officials sometimes.

The method of feedback was in verbal form (37%), followed by both verbal and written (18%) and only

written (15%). 30% of supervisors said that block meetings were the most common platform of getting

feedback from higher officials followed by 26% who agreed that block meetings and OJ training were

used as a platform for giving feedback on VHND by their higher official. Only 4% of respondents said

that OJ training was used as a platform for feedback.

Table 24- Programme management of VHND by the supervisors, Bolangir, Odisha


No. % No. %

Availability of VHND micro plan at sector level 22 81 60 72

Training to ANM/AWW on VHND micro plan preparation 20 74 53 64

Verifying sub center level VHND plan & guiding as per need 22 81 55 66

Compiling & finalizing VHND micro plan at sector level 20 74 53 64

Reviewing VHND reports in the sector 23 85 69 83

Verifying sessions planed v/s held 20 74 68 82

Transportation support for monitoring 10 37 22 26

Weekly review of programme at sector level review meetings 26 96 75 90

Monthly review of programme at block level review meetings 26 96 56 67

Familiarity with supervision checklist

Not aware at all 5 18 15 18

Somewhat familiar 2 7 17 20

Fairly familiar 2 7 17 20

Very well familiar 16 59 31 37

36


No. % No. %

Use of supervision checklist

Always 14 52 29 35


Rarely 0 0 10 12

Never 8 30 20 24

Components of VHND supervised

Registers/records 23 85 74 89

Availability of drugs 17 63 61 73

Availability of other logistics 22 81 72 87

Others* 15 56 45 54

*Other components include due list, equipment, MCP cards, Danger signs in mothers, adolescent health, etc.

96% supervisors informed that they were conducting weekly & monthly reviews on VHND and 85% of

them reviewed the VHND reports in the sector. 81% supervisors were involved in verifying the sub

center level VHND plan and 74% trained the ANM on VHND micro plan preparation. 74% of

supervisors also verified the sessions planned v/s the sessions held. Only 37% supervisors received

transportation support for monitoring. 59% of supervisors were very well familiar with the VHND

supervision checklist against 18% who were not aware of it at all. 52% supervisors always used the

VHND supervisory checklist against 30% who never used it. While supervising, they most often

checked the registers/records (85%), while other components (due list, equipment, MCP cards,

adolescent health, danger sign in mothers, etc) were being supervised the least (56%).

37

RESULTS - NUAPADA

38


Table 1- Availability of vaccines at routine immunization session sites, Nuapada, Odisha

Vaccine availability Nuapada (N=11) Total (N=108)

No. % No %

BCG 11 100 105 97

BCG diluent 11 100 105 97

Measles 11 100 105 97

Measles diluent 11 100 106 98

tOPV 11 100 98 91


DPT 11 100 101 93

TT 11 100 97 90

With respect to availability of vaccines at immunization session sites in Nuapada district, we found that

all antigens were available in 100 percent sites.

Table 2-Availability of logistics at routine immunization session sites, Nuapada Odisha

Logistics availability Nuapada (N=11) Total (N=108)

No. % No %

AD (0.1ml) syringes 11 100 106 98

AD (0.5ml) syringes 11 100 107 99





ORS packets 11 100 105 97





AD syringes, reconstitution syringes, Vit. – A solutions and ORS packets were found to be available in

all the sites visited for data collection. In about 45% sites, functional hub-cutters and counterfoils were

found to be available. Blank RI cards (MCP cards) were found to be available in 82% sites. Zinc tablets

were available in 27% and Paracetamol in 64% sites.

39

Table 3-Quality indicators-I at RI session site, Nuapada, Odisha

Nuapada (N=11) Total (N=108)

No. % No. %







Session as per plan 11 100 94 87





Vaccines & Diluents kept in vaccine carrier 11 100 94 87

Vaccines & Diluents kept in zipper bag 11 100 84 78







We found that in all the session sites vaccines were correctly labeled and in readable form. There were

no expired vaccines or vaccines in stage III/IV of VVM or in frozen state. In all the sites, the sessions

were held as per plan. In 100% of the sites, we found that vaccines were kept in vaccine carriers and

zipper bags. Further, the appropriate use of four ice packs was also found in 100% sites. In 54% sites,

vaccines were brought by AVD, while in 18% sites, it was brought by the ANM and in 27% sites other

health workers delivered the vaccines to the session sites. In more than 100% sites, the batch number

and expiry date of both the vaccines and the diluents were found to have been properly mentioned.

40

Table 4-Quality indicators II at RI session sites, Nuapada, Odisha

Quality Indicators Nuapada (N=11) Total (N=108)

No. % No. %


Due list available with mobilizer 11 100 100 93




Route of measles (Sub-cutaneous) 11 100 102 94










Vaccinate a child with loose motions 11 100 75 69


Health Supervisor visited you in last three months 10 91 85 79


The following indicators were found to be available in all the sites: due list available with ANM,

reconstitution time written on vials by ANM, AD syringe used to inject vaccines, DPT vaccines given

on anterolateral aspect of thigh, route of Measles administration, Measles given on the right site, ANM

following no recapping procedure, red and black bags used to segregate immunization wastes,

vaccinating child with loose motion. 27% of respondents asked the beneficiaries to wait for about 30

minutes after vaccination. In 45% sites, syringes were found to be cut with hub-cutter. In 73% sites,

tally sheets were used for record keeping. On the other hand, in none of the sites we found the medical

officers visited the session in last three months.

41


Nuapada, Odisha


Nuapada Total

Yes No Yes No


caregivers

Yes 8 1 61 18

No 2 0 21 2




42


Table 6-Availability of logistics at VHND site, Nuapada, Odisha


Nuapada

(N=12)

Total

(N=118)

No. % No. %

Examination table 11 92 69 58.


BP instrument 12 100 106 90



Inch tape 8 67 76 64

MUAC tape 12 100 113 96














IFA syrup 11 92 68 58


RDK kit 9 75 79 67

Condoms 10 83 88 75






Toilet 1 8 17 14


Soap 11 92 71 60

43


Nuapada

(N=12)

Total

(N=118)

No. % No. %










BP instrument, stethoscope, haemoglobin testing kit, weighing scale (adult and baby), MUAC tape, ORS

sachets, Albendazole, Cotrimaxazole, IFA tab (large), IMNCI chart booklets, blank MCP cards,

reporting formats and needles were found to be available in 100% sites. Test tubes and Zinc tabs were

found in one site, while foetoscope in two sites, and pregnancy testing kits were available in just 4 sites.

Zinc tablets were conspicuous by its availability in only one site. Paracetamol and IFA (small) were

available in 58% sites. Urine testing kits were found in 50% sites. Examination tables and screens for

privacy were available in 92% and 58% sites, respectively. Availability of RDK kits was found in 75%

sites and contraceptives were available in about 80% sites.

Table 7-Session site of VHND, Nuapada, Odisha

Session Site Nuapada (N=12) Total (N=118)

Sub Center 0 10

AWC 9 87

Others 3 15

Total 12 112

9 out of 12 sessions visited were conducted at AWCs, while no sessions were being held at sub centres.

3 sessions were held in other places including in school buildings, community halls etc.

44

Table 8- Availability of health workers at VHND site, Nuapada, Odisha

*Others=AYUSH MO, BPM, PRI members



comparable percentages for Male health workers, AWW and ASHAs were found to be 67%, 75% and


found to be ranging from 0% (ICDS Supervisor) to 42% (Health supervisors).

Table 9-Maternal health service delivery at VHND sites, Nuapada, Odisha


Nuapada

(N=12)

Total

(N=118)

No. % No. %














Nuapada

(N=12)

Total

(N=118)

No. % No. %

MPHW(F) 12 100 103 87

MPHW(M) 8 67 62 52


AWW 9 75 107 91

ASHA 9 75 102 86


AWH 10 83 75 64

GKS /PRI members 0 0 7 6

Others* 5 42 17 14

45

Weighing of pregnant women was done in 50% sites. Their BP recording, relevant counseling and

availability of IFA for ANC was found in 100% sites. PPTCT counseling and haemoglobin testing was

found to be done in more than 90% sites. However, privacy during examination, fetal heart sound

recording were done in 67% and 17%, respectively. Urine examination and abdominal palpation was

done in none of the sites.

Table 10-Child health & family planning service delivery at VHND session sites, Nuapada, Odisha


Nuapada

(N=12)

Total

(N=118)

No. % No. %

Advice on breastfeeding given 11 92 88 75











With regard to delivery of child health and family planning services, we found that ANM and ASHA

conducted meeting with the lactating mothers; availability of contraceptives; counseling on family

planning and the need for supplementation with IFA in about 100% instances. But meeting with their

husbands and describing danger signs of newborns was not found in any of the sessions. Advice on

breastfeeding and on hand washing was found in 92% sites; dietary counseling to mothers was found in

83% sites, while ORS demonstration in 42%, and weighing of infant in 17% sites.

46

CROSS-TABULATIONS

Table 11-Quality attributes of VHND services, Nuapada, Odisha

Nuapada Total

ICDS supervisor present at site

Yes No Yes No

Beneficiaries mobilized to site by

ICDS worker

Yes 0 11 3 79

No 0 1 0 36


Health Supervisor present at site Yes 3 2 36 7

No 6 1 64 11

GKS/PRI member present at site

Examination table present at site Yes 0 11 5 2

No 0 1 65 46


Screen for privacy present at site Yes 0 7 10 17

No 0 5 25 63



No 0 1 53 35

Cross tabulation of key attributes of quality of services revealed that in 11 out of 12 sites, the beneficiaries were

mobilized by the ICDS workers, though in none of the sites the ICDS supervisors were present. In 5 sessions the

health supervisors were present, whereas in 9 sites the beneficiaries were mobilized by the ASHAs. Examination

tables were available in 11 sites, whereas GKS/PRI members were present in none of the sites. Abdominal

palpations were carried out in none of the sites, though the screens for privacy were available only in 7 sites. On

the other hand, examination tables were available in 11 sites but no abdominal palpations were carried out in any

of those sites.

47

INTEGRATED MANAGEMNT OF NEONATAL &

CHILDHOOD ILLNESS (IMNCI)

Table 12-Review of IMNCI records, Nuapada, Odisha

Record Review Nuapada

(N=23)

Total

(N=238)










parameters of IMNCI implementation, such as, home visits as per IMNCI guidelines, filling-up of

referral slips and reporting formats were abysmally low, lesser than 25%, while filling up of assessment

sheets were found in about 60% sites.

Table 13-Assessment of skills of IMNCI trained workers, Nuapada, Odisha

A. NEW BORN

Nuapada

(N=23)

Total

(N=238)

No. % No. %




Correctly counseled the young infant 3 13 59 25



48

B. CHILD

Nuapada

(N=23)

Total

(N=238)

No. % No. %

Correctly assessed the child 15 65 71 30








and young children the assessment skills were poor, a little over 65%. On correct classification,

counseling, management and referral their skills were also equally poor, figures ranged from 4% to 56%.

Table 14-Availability of logistics at AWC, Nuapada, Odisha

FACILITY SUPPORT

Nuapada

(N=23)

Total

(N=238)

No. % No. %






ORS 19 83 188 79












found that certain key components of the programme, such as, IMNCI chart booklets, IMNCI photo

booklets and IMNCI modules were available in all the sites. Referral slips and reporting formats were

49

available in 96% sites. Among IMNCI drugs, ORS was found to be available in most of the sites (83%)

and Zinc tablets were available in none of the sites. Availability of other drugs, such as, Cotrimaxazole,

Paracetamol, IFA tablets, Gentian violet ranged from 39% to 78%.


neonates, Bolangir, Odisha

Nuapada

(N=23)

Total

(N=238)

No. % No. %






Pustule 10 43 74 31



Assessing diarrhoea





Skin pinch 14 61 128 54







Suckling 6 26 97 41









50











from nil (giving antibiotic for local infection and ORS solution in facility) to 74% (counseling on

breastfeeding).


children of 2 months to 5 years, Nuapada, Odisha

Nuapada

(N=23)

Total

(N=238)

No. % No. %




Convulsion 1 4 14 6





Asked for diarrhoea







Assessed fever

Stiff neck 0 0 17 7


51

Nuapada

(N=23)

Total

(N=238) No. % No. % Assessed malnutrition




Assessed anaemia




Assessed feeding

Not exclusive breastfeeding (for less than 6 month infant) 1 4 31 13



















months to 5 years children, the assessment skills ranged from nil to 4%. None of the respondents could

correctly classify. About 5% workers were confident in checking the understanding of


feeding practices.

52


Table 17-Profile of supervisors, Nuapada, Odisha

Nuapada (N=11) Total (N=83)

No. % No. %

Designation of

supervisor

MPHS-F 2 18 21 25

MPHS-M 2 18 17 20


AYUSH MO 3 27 22 26

Sector MO 0 0 3 4

The above table reflects the profile of our respondents. Out of the total 11 supervisors interviewed, 36%

were ICDS supervisors, 27% were AYUSH MOs, 18% were lady supervisors (LHV) and the rest 18%

were male supervisors.

Table 18-Supervisory visits made by internal supervisors in last one month, Nuapada, Odisha

Nuapada

Total Avg. Total Avg.





No. of filled in supervisory checklists submitted to block level on RI last

month 4 0 161 2


No. of filled in supervisory checklists submitted to block level on VHND

last month 5 0 127 2

Support from supervisors while providing services in hard to

reach areas 6 54 (%) 41 49 (%)


month was found to be maximum for VHND, followed by IMNCI. For RI the number of supervisory

visits made was comparatively low. The supervisors were filling up on an average 3 supervisory

checklists, each for IMNCI and RI programmes; whereas, for VHND, the average was found to be 4.

When asked whether they were getting support from their supervisors for providing services in hard to

reach areas, 6 (54%) respondents gave an affirmative answer.

53

Table 19-Frequency, method and place of feedback received on IMNCI from higher officials, Nuapada,

Odisha

IMNCI Nuapada (N=11) Total (N=83)

No. % No. %


from supervisors on

IMNCI

Always 11 100 26 57

Sometimes 0 0 32 39

Never 0 0 22 26



Verbal 0 0 31 37

Written 11 100 25 30



from supervisors on

IMNCI



OJ Training 0 0 4 5



meeting 0 0 2 2

Sector meeting, block

meeting & OJ training 0 0 2 2

All the supervisors received feedback on IMNCI from their higher officials regularly and the method of

feedback was always in written form. None of the supervisors mentioned about the place of receiving

feedback.

Table 20-Programme management of IMNCI by the supervisors, Nuapada, Odisha

IMNCI Nuapada (N=11)

Total (N=83) % No. %











54

IMNCI Nuapada (N=11) Total (N=83)

No. % No. %



Always 3 27 14 17

Sometimes 0 0 5 6

Rarely 1 9 3 4

Never 7 64 50 60






Drugs 5 45 44 53




indenting of IMNCI drugs was done by the supervisors only in 36% cases. None of the supervisors

received transportation support. 18% of them were involved in preparing the integrated supervision

plans. 36% of them were trained on FUS training. 54% of supervisors were familiar with the IMNCI

supervision checklist; whereas, 27% supervisors always used IMNCI supervisory checklist against 64%

who never used it. While supervising, they most often check the assessment forms (56%), while other

logistics (booklets, IMNCI board, weighing machine, home visits, etc) were being supervised the least

(36%).

Table 21-Frequency, method and place of feedback received on RI from higher officials, Nuapada, Odisha

RI Nuapada (N=11) Total

(N=83) %

No. %



Always 7 64 47 57


Never 0 0 5 6


supervisors on RI

Verbal 2 18 37 45

Written 9 82 27 32






OJ training 0 0 2 2

Block meeting & OJ

training 0 0 10 12


meeting 0 0 3 4



55

64% supervisors received feedback on RI from their higher officials, regularly and 36% said that they

receive feedback from their higher officials sometimes. The method of feedback was mostly in written

form (82%), followed by verbal (18%). 9% supervisors said that block meetings were the most common

platform of getting feedback from higher officials.

Table 22- Programme Management of RI by the Supervisors, Nuapada, Odisha

RI Nuapada (N=11) Total

(N=83) %

No. %

















Always 5 45 42 51


Rarely 0 0 2 2

Never 3 27 13 16

Familiarity with RI supervision

checklist

Poorly 2 18 8 10

Somewhat 0 0 7 8

Fairly 1 9 21 25


Factor for drop out





Others* 11 100 42 51


100% supervisors informed that they were conducting RI review meetings at block level and district

level. 82% supervisors monitored cold chain maintenance system at session site and 36% at ILR points.

18% supervisors received transportation support and an equal percentage received financial incentives

56

for supervision. 36% of them were involved in preparing of micro plan. 73% supervisors informed that

there were left out/drop out cases of RI and 100% of them agreed that the major factors for drop out

were migration, lack of communication, poor awareness, etc. 45% of them always used the supervision

checklist and 73% were very familiar with the same, while 27% never used the checklist and 18% were

poorly familiar with the RI supervision checklist.

Table 23- Frequency, method and place of feedback received on VHND from higher officials, Nuapada,

Odisha

VHND Nuapada (N=11) Total

(N=83) %

No. %

Frequency of feedback from

supervisors on VHND

Always 1 9 37 45


Never 3 27 8 10


supervisors on VHND

Verbal 9 82 52 63

Written 0 0 10 12


Place of getting feedback from

supervisors on VHND



OJ training 0 0 1 1



meeting 1 9 6 7

Sector meeting, block meeting

& OJ training 0 0 2 2


never received it at all and 64% said that they receive feedback from their higher officials sometimes.

The method of feedback was mostly verbal (82%). 36% of supervisors said that block meetings were

the most common platform of getting feedback from higher officials.

57

Table 24- Programme management of VHND by the Supervisors, Nuapada, Odisha

VHND Nuapada (N=11) Total

(N=83) %

No. %
















Always 3 27 29 35

Sometimes 1 9 22 26

Rarely 1

10 12

Never 6 54 20 24





Others* 10 91 45 54


100% supervisors informed that they were conducting weekly & monthly reviews on VHND and 82%

of them reviewed the VHND reports in the sector. 45% supervisors were involved in verifying the sub

center level VHND plan and 45% trained the ANM on VHND micro plan preparation. 91% of

supervisors also verified the sessions planned v/s the sessions held. Only 18% supervisors received

transportation support for monitoring. 45% of supervisors were very well familiar with the VHND

supervision checklist against 36% who were not aware of it at all. 27% supervisors always used the

VHND supervisory checklist against 54% who never used it. While supervising, they most often

checked the registers/records and availability of other logistics & components like due list, MCP cards,

equipment, etc. (91%), while availability of drugs was being supervised the least (36%).

58

RESULTS - KORAPUT

59


Table 1- Availability of vaccines at routine immunization session sites, Koraput, Odisha

Vaccine availability Koraput (N=27) Total (N=108)

No. % No. %

BCG 27 100 105 97


Measles 27 100 105 97


tOPV 22 81 98 91


DPT 24 89 101 93

TT 22 81 97 90

With respect to availability of vaccines at immunization session sites in Koraput district, we found that

all antigens except tOPV, Hepatitis B, DPT and TT were available in 100 percent sites, while the later

were available in about 90% sites. Hepatitis B vaccines were found to be available in 96% sites.

Table 2-Availability of logistics at routine immunization session sites, Koraput, Odisha

Logistics availability Koraput (N=27) Total (N=108)

No. % No. %

AD (0.1ml) syringes 27 100 106 98

AD (0.5ml) syringes 27 100 107 99










AD syringes were found to be available in all the sites visited for data collection. Reconstitution

syringes, vitamin A solution and ORS packets were found in 96% sites. In 93% sites, functional hub-

cutters, Paracetamol and plastic spoon for vitamin-A were found to be available. Tracking bags were

found to be available about 50% sites. In 23 out of 27 sites, we found blank RI cards and counterfoils to

be available.

60

Table 3-Quality indicators-I at RI session site, Koraput, Odisha

Koraput (N=27) Total (N=108)

No. % No. %












Vaccines & Diluents kept in vaccine carrier 21 78 94 87

Vaccines & Diluents kept in zipper bag 16 59 84 78








no expired vaccines or vaccines in stage III/IV of VVM or in frozen state. In 85% sites, the sessions

were held as per plan. We found that vaccine carriers and zipper bags were in use in 78% and 59% sites

respectively. Further, the appropriate use of four ice packs was found in 100% sites. In 59% sites,

vaccines were brought by AVD, while in 33% sites, it was brought by the ANM and in 4% sites

supervisors delivered the vaccines to the session sites. In about 85% sites, the batch number and expiry

date of both the vaccines and the diluents were found to have been properly mentioned.

61

Table 4-Quality indicators II at RI session site, Koraput, Odisha

Quality Indicators Koraput (N=27) Total (N=108)

No. % No. %














Beneficiaries ask to wait for 30 mins after vaccination by

ANM 20 74 48 44






In 100% sites it was found that the ANM used AD syringes to inject vaccines. The following indicators

were found to be available in more than 90% sites: due list available with ANM, DPT vaccines given on

anterolateral aspect of thigh, red and black bags used to segregate immunization waste, immunization

waste carried to PHC, health supervisor visited in last three months and vaccinate a child with mild

fever. Route of Measles administration, Measles given on the right site and reconstitution time written

on vials by ANM was found to be followed in about 90% sites. 74% of respondents asked the

beneficiaries to wait for about 30 minutes after vaccination. In 85% sites, syringes were found to be cut

with hub-cutter. In 89% sites, tally sheets were used for record keeping. The medical officers visited

the session in last three months in just 22% sites.

62


Koraput, Odisha


Koraput Total

Yes No Yes No


caregivers

Yes 21 2 61 18

No 3 0 21 2




63


Table 6-Availability of logistics at VHND site, Koraput, Odisha


Koraput

(N=32)

Total

(N=118)

No. % No. %

Examination table 15 47 69 58





Inch tape 20 62 76 64

MUAC tape 30 94 113 96














IFA syrup 19 59 68 58


RDK kit 24 75 79 67

Condoms 25 78 88 75

Oral Contraceptives 23 72 74 63





Toilets 8 25 17 14


Soap 19 59 71 60




64

Logistics Availability Koraput

(N=32)

Total

(N=118) No. % No. %





Due list of beneficiaries 23 72 81 69


Stethoscope, MUAC tape and ORS sachets were found to be available in 94% sites. Screens for privacy

were available in just 4 sessions while examination tables were found in 15 sessions out of the total 32

sessions visited. Weighing scale (adult), IFA (large), blank MCP cards, referral cards and reporting

formats were found to be available in more than 80% sites. Zinc tablets and red bags for disposal were

available in around 30% sites. Cotrimoxazole and Paracetamol tablets were available in 69% and 62%

sites, respectively. Availability of RDK kits was found in 75% sites and contraceptives were available

in about 80% sites.

Table 7-Session site of VHND, Koraput, Odisha

Session Site Koraput (N=32) Total (N=118)

Sub Center 7 10

AWC 22 87

Others 1 15

Total 30 112

22 out of 32 sessions visited were conducted at AWCs, while 7 were being held at sub centres. Only 1

session was held in another place, viz. school buildings, community halls etc.

Table 8- Availability of health workers at VHND site, Koraput, Odisha



Koraput

(N=32)

Total

(N=118)

No. % No. %

MPHW(F) 30 94 103 87

MPHW(M) 20 62 62 52


AWW 32 100 107 91

ASHA 29 91 102 86


AWH 18 56 75 64


Others* 2 6 17 14

65



comparable percentages for Male health workers, AWW and ASHAs were found to be 62%, 100% and


found to be ranging from 6% (ICDS Supervisor) to 25% (Health supervisors).

Table 9-Maternal health service delivery at VHND sites, Koraput, Odisha


Koraput

(N=32)

Total

(N=118)

No. % No. %













In 100% sites, relevant history was being taken during maternal health service delivery, followed by

97% sites where IFA was being provided to ante natal women. Weighing of pregnant women was found

to be done in 94% sites. However, abdominal palpation and foetal sound recording was being done in

only 9 sites. In 50% sites privacy was being ensured during examination and danger signs were being

communicated. Urine examination was found to be done in 81% sites. Relevant counseling and PPTCT

counseling was found to be done in 37% sites

66

Table 10-Child health & family planning service delivery at VHND session sites, Koraput, Odisha

Child Health Service Delivery & Family Planning Koraput

(N=32)

Total

(N=118)

No. % No. %

Advice on breastfeeding given 26 81 88 75



Danger signs of newborn communicated 14 44 41 35






ANM & ASHA conducted meeting with women 15 47 70 59

ANM & ASHA conducted meeting with men 1 3 1 1

With regard to delivery of child health and family planning services, we found that family planning

counseling was being provided in 97% sites, followed by 87% sites where contraceptives were being

provided. ANM & ASHA conducted meeting with women in 47% sites whereas with men it was seen to

be conducted in only 3%. ORS demonstration, recording weight of infants and communicating danger

signs of new born was observed in about 40% sites. Advice on breastfeeding was found to be given in

81% sites.

67

CROSS-TABULATIONS

Table 11- Quality attributes of VHND services, Koraput, Odisha

Koraput Total

ICDS supervisors present at site

Yes No Yes No

Beneficiaries mobilized to site

by ICDS workers

Yes 2 19 3 79

No 0 11 0 36


Health supervisors present at

site

Yes 7 1 36 7

No 24 0 64 11

GKS/PRI members present

Examination table present at

site at site

Yes 0 15 5 2

No 0 17 65 46

Screen for privacy present at site


recorded

Yes 4 5 10 17

No 0 22 25 63



recorded

Yes 5 4 16 11

No 10 12 53 35

Cross tabulation of key attributes of quality of services revealed that only in two sessions wherein the

ICDS supervisor was present in the session site was the beneficiaries mobilized by the ICDS workers.

In 8 sessions the health supervisors were present out of which in 7 sites the beneficiaries were mobilized

by the ASHAs. Examination tables were available in 15 sites however the GKS/PRI members were not

present in any of the sites. Abdominal palpations were carried out in 9 sites though the screens for

privacy were available only in 4 sites. On the other hand, examination tables were available in 15 sites

against which only in 9 sites abdominal palpations were carried out. In other words, in 6 sites despite of

availability of an examination table, abdominal examinations were not carried out.

68



Table 12-Review of IMNCI records, Koraput, Odisha

Record Review Koraput

(N=64)

Total

(N=238)







Referral slips filled up 7 (9%) 27 (11%)



parameters of IMNCI implementation, such as, home visits, filling-up of assessment sheets, filling-up of

referral slips and reporting formats were abysmally low, lesser than 20%.

Table 13-Assessment of skills of IMNCI trained workers, Koraput, Odisha

A. NEW BORN

Koraput

(N=64)

Total

(N=238)

No. % No. %




Correctly counseled the young infant 12 19 59 25



69

B. CHILD

Koraput

(N=64)

Total

(N=238)

No. % No. %




Correct counseled the child 1 2 39 16





and young children the assessment skills were poor, about 20%. On correct classification, counseling,

management and referral their skills were also equally poor. It ranged from 2% to 31%.

Table 14-Availability of logistics at AWC, Koraput, Odisha

FACILITY SUPPORT

Koraput

(N=64)

Total

(N=238)

No. % No. %






ORS 47 73 188 79












found that IMNCI assessment forms for 0-2 months were available in all sites. Certain key components

of the programme, such as, IMNCI chart booklets, IMNCI modules, IMNCI photo booklets, IMNCI

70

assessment forms for 2months to 5 years age group and referral slips were available in more than 90%

sites. Reporting forms and Salter scales were found to be available in 80% sites. Among IMNCI drugs,

ORS was found to be available in most of the sites (73%) and Zinc tablets were available in the least

(14%). Availability of other drugs, such as, Cotrimaxazole, Paracetamol, IFA tablets, Gentian violet

ranged from 20% to 56%.


neonates, Koraput, Odisha

Koraput

(N=64)

Total

(N=238)

No. % No. %






Pustule 22 34 74 31



Assessing diarrhoea





Skin pinch 28 44 128 54












71

Koraput

(N=64)

Total

(N=238) No. % No. %















from 2% (given antibiotic for local infection) to 8% (advising on home care and next date for

immunization).


children of 2 months to 5 years, Koraput, Odisha

Koraput

(N=64)

Total

(N=238)

No. % No. %




Convulsion 2 3 14 6





Asked for diarrhoea







72

Koraput

(N=64)

Total

(N=238) No. % No. % Assessed fever

Stiff neck 3 5 17 7






Assessed anaemia



Assessed immunization

Assessed feeding 1 2 32 13









Treatment/Management 3 5 31 13





Explained signs for when to return immediately. 0 0 12 5






months to 5 years children, the assessment skills ranged from 0 to 6%. About 8% of respondents could

correctly classify. About 2% workers were confident in checking the understanding of

mothers/caretakers and 3% workers could correctly counsel the mothers on appropriate feeding

practices.

73


Table 17 – Profile of supervisors, Koraput, Odisha

Koraput (N=23) Total

(N=83)

%

No. %

Designation of

supervisor

MPHS-F 6 26 21 25

MPHS-M 5 22 17 20


AYUSH MO 5 22 22 26

Sector MO 0 0 3 4

The table above reflects the profile of our respondents. Out of the total 23 supervisors interviewed, 26%

were lady supervisors (LHV), 22% were male supervisors, 30% were ICDS supervisors and 22% were

AYUSH MOs.

Table 18 – Supervisory visits made by internal supervisors in last one month, Koraput, Odisha

Koraput



No. of filled in supervisory checklists submitted to block level on IMNCI




month 40 4 161 2





reach areas 12 52 (%) 41 49 (%)


month was found to be maximum for VHND, followed by RI. For IMNCI the supervisory visits were

the least. The supervisors were filling up on an average 4 supervisory checklists for RI followed by

VHND (2) and IMNCI programmes (1). When asked whether they were getting support from their

supervisors for providing services in hard to reach areas, 12 (52%) respondents gave an affirmative

answer.

74

Table 19 – Frequency, method and place of feedback received on IMNCI from higher officials, Koraput,

Odisha

IMNCI Koraput (N=23) Total

(N=83) %

No. %



Always 5 22 26 57


Never 7 30 22 26



Verbal 12 52 31 37

Written 0 0 25 30


Place of getting feedback from




OJ training 0 0 4 5

Block meeting & OJ

training 0 0 3 4


meeting 1 4 2 2



22% supervisors received feedback on IMNCI from their higher officials, regularly, while 30% of them

never received it at all. The method of feedback was mostly in verbal form (52%). 39% supervisors

commented that sector meeting was the most often platform of receiving feedback from their higher

officials. 4% supervisors also mentioned about block meetings being a platform for feedback.

Table 20 – Programme management of IMNCI by the supervisors, Koraput, Odisha

IMNCI Koraput (N=23) Total (N=83)

No. % No. %










75

IMNCI Koraput (N=23) Total (N=83)

No. % No. %




Always 2 9 14 17

Sometimes 1 4 5 6

Rarely 0 0 3 4

Never 12 52 50 60






Drugs 12 52 44 53




indenting of IMNCI drugs was done by the supervisors only in 22% cases. 17% Supervisors received

transportation support. 26% of them were involved in preparing the integrated supervision plans. 39%

of them were trained on FUS training. 39% of supervisors were familiar with the IMNCI supervision

checklist; whereas, 9% supervisors always used IMNCI supervisory checklist against 52% who never

used it. While supervising, they most often check the assessment forms (61%), while other logistics

(booklets, IMNCI board, weighing machine, home visits, etc) were being supervised the least (30%).

Table 21 - Frequency, method and place of feedback received on RI from higher officials, Koraput, Odisha

RI Koraput (N=27) Total

(N=83) %

No. %



Always 14 61 47 57


Never 0 0 5 6


supervisors on RI

Verbal 18 78 37 45

Written 0 0 27 32






OJ training 1 4 2 2

Block meeting & OJ

training 1 4 10 12


meeting 1 4 3 4



76

61% supervisors received feedback on RI from their higher officials, regularly, while 35% of them

received feedback sometimes. The method of feedback was mostly verbal (78%). 61% of supervisors

said that sector meetings were the most common platform of getting feedback from higher officials.

Table 22- Programme management of RI by the supervisors, Koraput, Odisha

RI Koraput (N=23) Total

(N=83) %

No. %

















Always 10 43 42 51


Rarely 2 9 2 2

Never 3 13 13 16


checklist

Poorly 1 4 8 10

Somewhat 4 17 7 8

Fairly 3 13 21 25


Factor for drop out





Others* 5 22 42 51


61% supervisors informed that they were conducting RI review meetings on block level against 17%

who conducted review meetings at district level. 52% supervisors monitored cold chain maintenance

system at session site and 43% at ILR points. 13% Supervisors received transportation support and 9%

received financial incentives for supervision. 74% of them were involved in preparing of micro plan.

77

35% supervisors informed that there were left out/drop out cases of RI and 22% of them agreed that the

major factors for drop out were migration, lack of communication, poor awareness, etc. 43% of them

always used the supervision checklist and 26% were very familiar with the same, while 13% never used

the checklist and 4% were poorly familiar with the RI supervision checklist.

Table 23- Frequency, method and place of feedback received on VHND from higher officials, Koraput,

Odisha

VHND Koraput (N=23)



supervisors on VHND

Always 16 70 37 45


Never 0 0 8 10


supervisors on VHND

Verbal 18 78 52 63

Written 0 0 10 12



from supervisors on VHND



OJ training 0 0 1 1



meeting 1 4 6 7




received it sometimes. The method of feedback was mostly in verbal form (78%). 61% of supervisors

said that sector meetings were the most common platform of getting feedback from higher officials

followed by 9% who agreed that block meetings alone and block meetings & OJ training were used as a

platform for giving feedback on VHND by their higher official.

78

Table 24- Programme management of VHND by the supervisors, Koraput, Odisha

VHND Koraput (N=23) Total

(N=83) %

No. %
















Always 7 30 29 35


Rarely 6 26 10 12

Never 3 13 20 24





Others* 10 43 45 54


74% supervisors informed that they were conducting weekly & 35% conducted monthly reviews on

VHND. 74% of them reviewed the VHND reports in the sector. 56% supervisors were involved in

verifying the sub center level VHND plan and 61% trained the ANM on VHND micro plan preparation.

78% of supervisors also verified the sessions planned v/s the sessions held. Only 26% supervisors

received transportation support for monitoring. 26% of supervisors were very well familiar with the

VHND supervision checklist against 13% who were not aware of it at all. 30% supervisors always used

the VHND supervisory checklist against 13% who never used it. While supervising, they most often

checked the registers/records, availability of drugs and other logistics (87%), while other components

(due list, equipment, MCP cards, adolescent health, danger sign in mothers, etc) were being supervised

the least (43%).

RESULTS - NABRANGPUR

80


Table 1- Availability of vaccines at routine immunization session sites, Nabarangpur, Odisha

Vaccine availability Nabarangpur (N=24) Total (N=108)

No. % No. %

BCG 22 92 105 97


Measles 22 92 105 97


tOPV 20 83 98 91


DPT 20 83 101 93

TT 19 79 97 90

With respect to availability of vaccines at immunization session sites in Nabrangpur district, we found

that all antigens except tOPv, Hepatitis B, DPT and TT were available in 92 percent sites, while the later

was available in 83%, 87%, 83% and 79% sites respectively.

Table 2-Availability of logistics at routine immunization session sites, Nabarangpur, Odisha

Logistics availability Nabarangpur (N=24) Total (N=108)

No. % No. %

AD (0.1ml) syringes 22 92 106 98

AD (0.5ml) syringes 23 96 107 99










AD syringes, Vit – A solutions and reconstitution syringes were found to be available in 96% sites

visited for data collection. Availability of tracking bags was in less than 35% of the sites visited. In

more than 80% sites, blank RI cards and counterfoils were found to be available. In 92% sites,

functional hub cutter, Paracetamol and ORS packets were found to be available. IFA tablets were

available in 71% sites.

81

Table 3-Quality indicators-I at RI session site, Nabarangpur, Odisha

Nabarangpur (N=24) Total (N=108)

No. % No. %





















no expired vaccines or vaccines in stage III/IV of VVM or in frozen state. In 92% sites, the sessions

were held as per plan. In more than 83% of the sites, we found that vaccine carriers and zipper bags

were in use. Further, the appropriate use of four ice packs was found in 100% sites. In 58% sites,

vaccines were brought by AVD, while in 37% sites, it was brought by the ANM. In more than 83%

sites, the batch number and expiry date of both the vaccines and the diluents were found to have been

properly mentioned.

82

Table 4-Quality indicators II at RI session site, Nabarangpur, Odisha

Quality Indicators Nabarangpur (N=24) Total (N=108)

No. % No. %





DPT vaccine given on antero-lateral aspect of mid-thigh 23 96 105 97













Health Supervisor visited you in last three months 19 79 85 79


The following indicators were found to be available in 96% sites: due list available with ANM, due list

available with mobilize, reconstitution time written on vials by ANM, DPT vaccines given on

anterolateral aspect of thigh. In 92% sites, AD syringes were used to inject vaccines, route of Measles

administration was subcutaneous, Measles was given on the right site, syringes were being cut with hub

cutter after use and tally sheet was found to be used to keep record after vaccinating each child. In none

of the sites, the ANM was found to be touching any part of the needle while injecting. 42% of

respondents asked the beneficiaries to wait for about 30 minutes after vaccination. The Medical Officers

visiting the session in last three months was found in just 8% of sites. In 79% sites, the health supervisor

visited the sessions in the last three months. Red and black bags used to segregate immunization waste

were found in 71% of the sites visited.

83


Nabarangpur, Odisha


Nabarangpur Total

Yes No Yes No


caregivers

Yes 11 3 61 18

No 7 0 21 2




84


Table 6-Availability of logistics at VHND site, Nabarangpur, Odisha


Nabarangpur

(N=28)

Total

(N=118)

No. % No. %






Inch tape 23 85 76 64

MUAC tape 26 96 113 96









Anti-malarial tablets/ Syrup 16 59 89 75





IFA syrup 10 37 68 58


RDK kit 16 59 79 67

Condoms 25 93 88 75

Oral Contraceptives 19 70 74 63





Toilet 4 15 17 14


85


Nabarangpur

(N=28)

Total

(N=118)

No. % No. %

Soap 10 37 71 60





Blank MCP Cards 26 96 99 84





BP instrument, pregnancy testing kit, ORS sachets, MUAC tapes, blank MCP cards, referral cards,

monthly topic calendar, duelist of beneficiaries and reporting formats were found to be available in more

than 90% sites. Foetoscope, test tubes and hand gloves were available in about 10% sites. Zinc tablets

were available in just 6 sites out of the 28 session sites visited. Examination tables and screens for

privacy were available in 67% and 48% sites, respectively. IFA tab – large and small were available in

78% and 26% sites, respectively. Availability of RDK kits was found in 59% sites and contraceptives

were available in about 85% sites. While adult weighing scale was found in 81% sites, baby weighing

scales were available in just 48% sites. Cotrimoxazole and paracetamol were found to be available in

33% and 26% sites, respectively.

Table 7-Session site of VHND, Nabarangpur, Odisha

Session Site Nabarangpur (N=28) Total (N=118)

Sub center 1 10

AWC 22 87

Others 0 15

Total 23 112

22 out of 23 sessions visited were conducted at AWCs, while only one was conducted at the sub center.

86

Table 8- Availability of health workers at VHND site, Nabarangpur, Odisha




comparable percentages for male health workers, AWW and ASHAs were found to be 64%, 96% and


found to be ranging from 0% (ICDS Supervisor) to 21% (health supervisors).

Table 9 -Maternal health service delivery at VHND sites, Nabarangpur, Odisha


Nabarangpur

(N=28)

Total

(N=118)

No. % No. %












PPTCT counseling 6 22 61 52


Nabarangpur

(N=28)

Total

(N=118)

No. % No. %

MPHW(F) 26 93 103 87

MPHW(M) 18 64 62 52


AWW 27 96 107 91

ASHA 23 82 102 86


AWH 16 57 75 64


Others* 1 4 17 14

87

Weighing of pregnant women was found to be done in all the sites visited. Their BP recording,

hemoglobin testing and provision of IFA was observed in more than 90% sites. Communicating danger

signs and PPTCT counseling was found to be done in 26% and 22% sites, respectively. Hemoglobin

testing was done in about 80% sites. Privacy during examination was being ensured in 63% of the sites.

Fetal heart sound recording and abdominal palpation was done only in 11% sites. Urine examination and

relevant counseling was done in 74% sites.

Table 10-Child health & family planning service delivery at VHND session sites, Nabarangpur, Odisha


Nabarangpur

(N=28)

Total

(N=118)

No. % No. %












With regard to delivery of child health services, we found that ANM and ASHA conducting meeting

with the lactating mothers in about 44% instances. But meeting with their husbands was not found in

any of the sessions. Advice on breastfeeding and providing contraceptives was found to be done in 85%

sites. In 26% sites, weight of infants was being recorded, danger signs of newborns were being

communicated and advice on hand washing/hygiene was being given. ORS demonstration was being

done in just 30% sites.

88

CROSS-TABULATIONS

Table 11-Quality attributes of VHND services, Nabarangpur, Odisha

Nabarangpur Total


Yes No Yes No


ICDS worker

Yes 0 21 3 79

No 0 6 0 36


Yes No Yes No

Health Supervisor present at site Yes 5 1 36 7

No 18 3 64 11


Yes No Yes No


No 0 9 65 46


Yes No Yes No


recorded

Yes 2 1 10 17

No 10 13 25 63


Yes No Yes No


recorded

Yes 3 0 16 11

No 15 9 53 35

Cross tabulation of key attributes of quality of services revealed that in 21 out of 28 sites, the

beneficiaries were mobilized by the ICDS workers, though in none of the sites the ICDS supervisors

were present. In 6 sessions the health supervisors were present, whereas in 23 sites the beneficiaries

were mobilized by the ASHAs. Examination tables were available in 18 sites, whereas GKS/PRI

members were present in none of the sites. Abdominal palpations were carried out in 3 sites, though the

screens for privacy were available 12 sites. On the other hand, examination tables were available in 18

sites but abdominal palpations were carried out in only 3 sites.

89

INTEGRATED MANAGEMENT OF NEONATAL AND


Table 12-Review of IMNCI records, Nabarangpur, Odisha

Record Review Nabarang

pur

(N=53)

Total

(N=238)




Home visits conducted as per IMNCI guidelines 1 (2%) 41

(17%) IMNCI assessment sheets correctly filled up 9 (17%) 55

(23%) All sick cases referred 5 (9%) 30

(13%) Referral Slips filled up 5 (9%) 27

(11%) IMNCI monthly reporting formats filled up 4 (7%) 42

(18%)


parameters of IMNCI implementation, such as, home visits, filling-up of referral slips and reporting

formats were abysmally low, lesser than 18%.

Table 13-Assessment of skills of IMNCI trained workers, Nabarangpur, Odisha

A. NEW BORN

Nabarangpur

(N=53)

Total

(N=238)

No. % No. %




Correctly counseled 13 24 59 25



90

B. CHILD

Nabarangpur

(N=53)

Total

(N=238)

No. % No. %






Correctly assessed the immunization of the child 0 0 75 31



and young children the assessment skills were poor, 6% and 21% respectively. On correct classification,

counseling, management and referral their skills were also equally poor, figures ranged from 0% to 47%.

Table 14-Availability of logistics at AWC, Nabarangpur, Odisha

FACILITY SUPPORT

Nabarangpur

(N=53)

Total

(N=238)

No. % No. %






ORS 40 75 188 79












found that certain key components of the programme, such as, IMNCI chart booklets, IMNCI photo

booklets, IMNCI modules and IMNCI assessment forms for 0-2months & 2 months-5 years age group

91

were available in 98% sites. Referral slips and reporting formats were available in 92% and 81% sites,

respectively. Among IMNCI drugs, ORS was found to be available in most of the sites (75%) and Zinc

tablets were available in 6% of the sites. Availability of other drugs, such as, Cotrimaxazole,

Paracetamol, IFA tablets, Gentian violet ranged from 13% to 45%.


neonates, Nabarangpur, Odisha

Nabarangpur

(N=53)

Total

(N=238)

No. % No. %






Pustule 19 36 74 31



Assessing diarrhea





Skin pinch 26 49 128 54









Assessing immunization



92

Nabarangpur

(N=53)

Total

(N=238) No. % No. %















from 6% (explained signs for when to return immediately) to 53% (assessed temperature).


children of 2 months to 5 years, Nabarangpur, Odisha

Nabarangpur

(N=53)

Total

(N=238)

No. % No. %




Convulsion 1 2 14 6





Asked for diarrhea







93

Nabarangpur

(N=53)

Total

(N=238) No. % No. % Assessed fever

Stiff neck 1 2 17 7






Assessed anaemia




Assessed feeding




















months to 5 years children, the assessment skills ranged from 0 to 2%. None of the respondents could

correctly classify or effectively manage the assessed children.

94


Table 17-Profile of supervisors, Nabarangpur, Odisha

Nabarangpur (N=14) Total

(N=83)

%

No. %

Designation of

supervisor

MPHS-F 5 36 21 25

MPHS-M 3 21 17 20


AYUSH MO 5 36 22 26

Sector MO 0 0 3 4

The above table reflects the profile of our respondents. Out of the total 14 supervisors interviewed, 36%

were lady supervisors (LHV), 36% were AYUSH MOs, 21% were male supervisors and 7% were ICDS

supervisors.

Table 18-Supervisory visits made by internal supervisors in last one month, Nabarangpur, Odisha

Nabarangpur






No. of filled in supervisory checklists submitted to block level on RI




VHND last month 24 3 127 2


reach areas

6 43 (%) 41 49 (%)


month was found to be maximum for RI followed by VHND. For IMNCI the number of supervisory

visits made was comparatively low. The supervisors were filling up on an average 4 supervisory

checklists for RI and 3 for VHND programme; whereas, for IMNCI, no supervisory checklists were

found to be filled up. When asked whether they were getting support from their supervisors for

providing services in hard to reach areas, 6 (43%) respondents gave an affirmative answer.

95

Table 19-Frequency, method and place of feedback received on IMNCI from higher officials,

Nabarangpur, Odisha

IMNCI Nabarangpur (N=14) Total (N=83)

No. % No. %


from supervisors on

IMNCI

Always 2 14 26 57


Never 7 50 22 26



Verbal 9 64 31 37

Written 0 0 25 30



from supervisors on

IMNCI



OJ training 0 0 4 5

Block meeting & OJ

training 0 0 3 4


meeting 0 0 2 2



14% of the supervisors received feedback on IMNCI from their higher officials regularly against 50%,

who never received any feedback. The method of feedback was in verbal form as mentioned by 64%

supervisors. Sector meetings were found to be the most often platform of receiving feedback (57%)

followed by block meetings (7%).

96

Table 20-Programme management of IMNCI by the supervisors, Nabarangpur, Odisha

IMNCI Nabarangpur (N=14)














Always 0 0 14 17

Sometimes 0 0 5 6

Rarely 1 1 3 4

Never 10 5 50 60



Registers 7 8 46 55



Drugs 8 6 44 53



43% supervisors informed that they were conducting weekly reviews and just 7% supervisors conducted

monthly reviews on IMNCI. Regular indenting of IMNCI drugs was done by the supervisors only in

14% cases. 7% supervisors received transportation support. Equal percentage of them was involved in

preparing the integrated supervision plans. 21% of them were trained on FUS training. 21% of

supervisors were familiar with the IMNCI supervision checklist; whereas, only 1% of them rarely used

the IMNCI supervisory checklist against 5% who never used it. While supervising, they most often

check the assessment forms, registers and referral slips (8%), while other logistics (booklets, IMNCI

board, weighing machine, home visits, etc) were being supervised the least (5%).

97

Table 21-Frequency, method and place of feedback received on RI from higher officials, Nabarangpur,

Odisha

RI Nabarangpur (N=14) Total

(N=83) %

No. %


supervisors on RI

Always 11 79 47 57


Never 0 0 5 6


supervisors on RI

Verbal 14 100 37 45

Written 0 0 27 32






OJ training 0 0 2 2

Block meeting & OJ

training 0 0 10 12

Sector meeting &

block meeting 0 0 3 4



79% supervisors received feedback on RI from their higher officials, regularly and 21% said that they

receive feedback from their higher officials sometimes. The method of feedback was always in verbal

form. 86% supervisors said that sector meetings were the most common platform of getting feedback

from higher officials and 7% mentioned that block meeting were also used as a platform for the same.

Table 22- Programme management of RI by the supervisors, Nabarangpur, Odisha

RI Nabarangpur (N=14) Total (N=83)

No. % No. %









98

RI Nabarangpur (N=14) Total (N=83)

No. % No. %









Always 6 43 42 51


Rarely 0 0 2 2

Never 0 0 13 16


checklist

Poorly 0 0 8 10

Somewhat 0 0 7 8

Fairly 7 50 21 25


Factor for drop out





Others* 4 29 42 51


100% supervisors informed that they were verifying the sessions planned v/s sessions held in their

sector. 57% of them conducted RI review meetings at block level and 7% at district level. 50%

supervisors monitored cold chain maintenance system at session site and 43% at ILR points. 43%

supervisors received transportation support and 21% received financial incentives for supervision. 64%

of them were involved in preparing of micro plan. 7% supervisors informed that there were left out/drop

out cases of RI and 29% of them agreed that the major factors for drop out were migration, lack of

communication, poor awareness, etc.; whereas 7% mentioned that cultural barriers could be a possible

factor for drop outs. 43% of them always used the supervision checklist and 29% were very familiar

with the same.

99

Table 23- Frequency, method and place of feedback received on VHND from higher officials, Nabrangpur,

Odisha

VHND Nabarangpur (N=14)



supervisors on CHND

Always 7 50 37 45


Never 0 0 8 10


supervisors on VHND

Verbal 14 100 52 63

Written 0 0 10 12






OJ training 0 0 1 1



meeting 0 0 6 7




never received it sometimes. The method of feedback was always in verbal form. 86% of supervisors

said that sector meetings were the most common platform of getting feedback from higher officials

while 7% of them also mentioned about block meetings.

Table 24- Programme Management of VHND by the Supervisors, Nuapada, Odisha

VHND Nabarangpur (N=14) Total (N=83)

No. % No. %










100

VHND Nabarangpur (N=14) Total (N=83)

No. % No. %

Familiarity with supervision

checklist






Always 2 14 29 35


Rarely 2 14 10 12

Never 2 14 20 24




Availability of other

logistics 14 100 72 87

Others* 4 29 45 54


93% supervisors informed that they were conducting weekly reviews on VHND and an equal percentage

of them reviewed the VHND reports in the sector as well as verified the sessions planned v/s held. 50%

supervisors were involved in verifying the sub center level VHND plan and 50% trained the ANM on

VHND micro plan preparation. Only 21% supervisors received transportation support for monitoring.

14% of supervisors were very well familiar with the VHND supervision checklist against 14% who were

not aware of it at all. Similarly, 14% supervisors always used the VHND supervisory checklist against

14% who never used it. While supervising, all the supervisors checked the registers/records and

availability of drugs & other logistics. Other components like due list, MCP cards, equipment, etc. were

being checked by 29% supervisors.

101

RESULTS - MALKANGIRI

102


Table 1- Availability of vaccines at routine immunization session sites, Malkangiri, Odisha

Vaccine availability Malkangiri (N=14) Total (N=108)

No. % No. %

BCG 14 100 105 97


Measles 13 93 105 97


tOPV 13 93 98 91


DPT 14 100 101 93

TT 13 93 97 90

With respect to availability of vaccines at immunization session sites in Malkangiri district, we found that all

antigens except BCG and BCG Diluents were available in 100 percent sites, while the later was available in 97%

sites. As there are some IRI sessions included in the sample survey, so availability was found to be little lesser

than in 100% sites, but as per the requirement of session sites under regular outreach plan, availability of vaccine

was found to be satisfactory.

Table 2-Availability of logistics at routine immunization session sites, Malkangiri, Odisha

Logistics availability Malkangiri (N=14) Total (N=108)

No. % No. %

AD (0.1ml) syringes 14 100 106 98

AD (0.5ml) syringes 14 100 107 99










103

AD syringes, Vit. – A solution and ORS packets were found to be available in all the sites visited for data

collection. Availability of tracking bags and counterfoils was in 100%, 7% and 79% sites, respectively. In

about 93% sites, functional hub-cutters were found. Blank RI cards (64%) and reconstitution syringes (100%)

were found in various proportions in the session sites. In 10 out of 14 sites (71%), we found paracetamol to be

available.

Table 3-Quality indicators-I at RI session site, Malkangiri, Odisha

Malkangiri (N=14) Total (N=108)

No. % No. %







Sessions held as per plan** 14 100 108 100













** 6 out of 14 sessions were as per routine microplan, while 8 were under IRI plan.

We found that in 13 out of 14 sites (93%) of sites, we found vaccines were correctly labeled and in

readable form. Expired vaccine vials were not found in any session, but vaccines in stage III/IV of VVM

were found in one session (7%). In all the sites, the sessions were held as per the plan (either routine or

IRI). We found that vaccines were kept in vaccine carriers in 71% sites and in zipper bags in 50% sites.

Further, the appropriate use of four ice packs was also found in only 57% sites. In 50% sites, vaccines

were brought by AVD; while in rest 50% of session sites, it was brought by the ANM. In only 43%

sites, the batch numbers were recorded and expiry date was found to have been recorded in 36% sites.

104

Table 4-Quality indicators II at RI session site, Malkangiri, Odisha

Quality Indicators Malkangiri (N=14) Total (N=108)

No. % No. %




















The due list was available with ANMs in 100% sites, but with the mobilisers only in 79% sites. In 14 %

(2 sites out of 14 observed) of sites the time of reconstitution was not recorded as per the instruction. In

3 places (21%) we found that Measles vaccine was not administered through proper route and in 2 sites

(14%), it was not administered in the proper place. In around 93 % places red bags and black bags were

properly used for waste disposal. In 93 % sites the syringes were cut with hub cutters as the hub cutters

were available also in 93% sites. In 3 places out of 14 the tally sheets were not used properly (i.e. either

not properly filled-up or real time filling-up by ANM after each vaccination was not done). In 50 % of

session sites 4 key messages were delivered but and in only 36 % sites beneficiaries were asked to stay

for 30 minutes. Out of 14 sessions visited, in 13 sites health supervisors had visited in last 3 month at

least once. But visit of Medical Officer was not found in any site. In 86% session sites, immunization

waste was carried to PHC /CHC.

105

Table 5 - Health supervisors visited in the last three months v/s 4 key messages delivered to caregivers,

Malkangiri, Odisha


Malakngiri Total

Yes No Yes No


caregivers

Yes 6 1 61 18

No 6 0 21 2


visits, we found that out of 12 sites where the supervisors had made visits in the last three months only

in 7 sites all four key messages were being delivered to the caregivers by the front-line health workers. It

indicated that the supervisors’ visits to session sites were not directly related to the messages being

delivered. It may also be owing to poor quality of supervision.

106


Table 6-Availability of logistics at VHND site, Malkangiri, Odisha


Malkangiri

(N=14)

Total

(N=118)

No. % No. %






Inch tape 8 57 76 64

MUAC tape 14 100 113 96














IFA syrup 7 50 68 58


RDK kit 10 71 79 67

Condoms 9 64 88 75






Toilet 0 0 17 14


Soap 5 36 71 60


107


Malkangiri

(N=14)

Total

(N=118)

No. % No. %




Blank MCP Cards 7 50 99 84



Due list of beneficiaries 7 50 81 69


Stethoscopes were found in 100 % of palces whereas BP instruments were found in only 79 % sites.

Haemoglobin testing kits were available in 86% sites. Though adult weighing scales & MUAC tapes

were present in 100% places, the baby weighing scales were found only in 86 % places. The referral

cards, IMNCI chart booklets and needles were found to be available in about 60 % places. Foetoscope,

test tubes, and pregnancy testing kits were available in just 7%, 27% and 77% session sites, respectively.

Zinc tablets were available in 100% sites. Examination tables and screens for privacy were available in

29% and 7% sites, respectively. IFA tab – large and small were available in 57% and 50% sites,

respectively. Availability of RDK kits was in 71% sites, while oral contraceptives were available in

about 43%% sites, condoms and ECPs in 64% sites.

Table 7-Session site of VHND, Malkangiri, Odisha

Session Site Malkangiri(N=14) Total (N=118)

Sub Ccnter 0 10

AWC 9 87

Others 5 15

Total 14 112

9 out of 14 sites were held at AWC and rest sessions were held in other places, such as, school, public

varanda or any health workers’ house.

108

Table 8- Availability of health workers at VHND site, Malkangiri, Odisha




same for male health workers was 43%, for AWWs was 100% and for ASHAs it was 85%. Further,

with respect to the presence of supervisory cadre of health workforce at session sites we found that no

session was monitored by ICDS supervisors, while 80% session were monitored by health supervisors.

In only 2 places PRI members were present while the VHND session was on.

Table 9-Maternal health service delivery at VHND sites, Malkangiri, Odisha


Malkangiri

(N=14)

Total

(N=118)

No. % No. %






Pregnant women weighed & recorded in MCPC card 9 64 101 86








Malkangiri

(N=14)

Total

(N=118)

No. % No. %

MPHW(F) 14 100 103 87

MPHW(M) 6 43 62 52


AWW 14 100 107 91

ASHA 12 85 102 86


AWH 9 64 75 64


Others* 0 0 17 14

109

Weighing of pregnant women, their BP recording and hemoglobin testing were done in 64% sites.

Availability of IFA was found in 100% sites. PPTCT counseling was found to be done in 21% sites.

Privacy during examination was maintained in 7% sites, while abdominal palpation was done in 14%

sites. Fetal heart sounds were not recorded in any site. Urine examination was done in as low as 29%

sites. Counseling on family planning and contraceptive distribution was done in 93% sites.

Demonstration of ORS preparation and hand washing was done in 21% and 14% sites, respectively.

Table 10-Child health & family planning service delivery at VHND session sites, Malkangiri, Odisha


Malkangiri

(N=14)

Total

(N=118)

No. % No. %





Weight of infants recorded in MCPC card 9 64 40 34







With regard to delivery of child health services, we found that ANM and ASHA conducting meeting

with the lactating mothers in 36% instances. But meeting with their husbands was not found in any of

the sessions. We found advice on breastfeeding given in 79%, dietary counseling done to 60% mothers.

Weighing of infants and assessment of danger signs of newborns was done in 64% and 60% sites,

respectively.

110

CROSS TABULATIONS

Table 11-Presence of ICDS supervisor at VHND site v/s beneficiaries mobilized to site by ICDS worker,

Malkangiri, Odisha

Malkangiri Total

Yes No Yes No



ICDS worker

Yes 0 11 3 79

No 0 3 0 36


Health supervisor present at site Yes 11 0 36 7

No 2 1 64 11


GKS/PRI member present at site Yes 0 2 5 2

No 4 8 65 46



recorded

Yes 0 2 10 17

No 1 11 25 63



recorded

Yes 1 1 16 11

No 3 9 53 35

In 11 out of 14 sites the beneficiaries were found to be mobilized by the ICDS workers, though in none

of the sites the ICDS supervisors were present. In 13 sites the beneficiaries were being mobilized by the

ASHAs as against presence of health supervisors in 11 sites only. GKS members were present in two

sites against availability of examination tables in four sites. Screen for privacy was available in only one

place, while abdominal palpation was done in two places. On the other hand, examination table was

present in four sites, while abdominal palpation was being conducted in two places only.

111


CHILDHOOD ILLNESSES (IMNCI)

Table 12-Review of IMNCI records, Malkangiri, Odisha

Record Review Malkangiri

(N=34)

Total

(N=238)



Average no. of newborns per AWC/SC in last 3 months who have received home

visits 3.0 6.4






Review of records at AWC revealed that the average number of newborns who received home visits by

IMNCI trained workers was found to be 3 for Malkangiri district. However, home visits conducted as

per IMNCI guidelines was found to be done only in 35% sites. Correct filling-up of IMNCI assessment

sheets was found to be done in 15% sites, while referral of all sick cases was done in 9% sites and in all

of these places the referral slips were filled-up.

Table 13-Assessment of skills of IMNCI trained workers, Malkangiri, Odisha

A. NEW BORN

Malkangiri

(N=34)

Total

(N=238)

No. % No. %




Correctly counseled the infant 9 26 59 25



112

B. CHILD

Malkangiri

(N=34)

Total

(N=238)

No. % No. %

Correctly assessed a young child 10 29 71 30

Correctly classified the young child 19 56 46 19

Correctly treated young child 18 53 35 15


Child needing referral was referred 24 71 30 13




and young children the assessment skills were poor, at 44% and 30%, respectively. On correct

classification, counseling, management and referral their skills were also equally poor. It ranged from

18% to 71%.

Table 14-Availability of logistics at AWC, Malkangiri, Odisha

FACILITY SUPPORT

Malkangiri

(N=34)

Total

(N=238)

No. % No. %






ORS 32 94 188 79




MNCI chart booklet 13 38 210 88








found that certain key components of the programme, such as, IMNCI chart booklets and IMNCI

113

modules were available in 38% sites, each. Photo booklets and Salter scales were available in 23% and

73% sites, respectively. Among IMNCI drugs, ORS was found to be available in most of the sites

(94%), followed by Zinc tablets (91%). Availability of other drugs was found in the following

percentages: Cotrimaxazole (53%), Paracetamol (38%), IFA tablets (97%), Referral slips (82%),

Gentian violet was not found in any site.


neonates, Malkangiri, Odisha

Malkangiri

(N=34)

Total

(N=238)

No. % No. %






Pustule 13 38 74 31



Assessing diarrhea





Skin pinch 28 82 128 54












114

Malkangiri

(N=34)

Total

(N=238)

No. % No. %

Treatment 17 50 64 27














from 12% (checking understanding of mothers) to 82% (given ORS solutions).


children of 2 months to 5 years, Malkangiri, Odisha

Malkangiri

(N=34)

Total

(N=238)

No. % No. %









Asked for diarrhea







115

Malkangiri

(N=34)

Total

(N=238) No. % No. %

Assessed fever

Stiff neck 5 15 17 7






Assessed anaemia




Assessed feeding 23 68 32 13









Treatment











months to 5 years children, the assessment skills ranged from 3% to 91%. About 65% of respondents

could correctly classify. About % workers were confident in checking the understanding of


feeding practices. Treatment skills ranged from 12% to 82%.

116


Table 17 – Profile of supervisors, Malkangiri, Odisha

Malkangiri (N=8) Total

(N=83)

%

No. %

Designation of

supervisor

MPHS-F 0 0 21 25

MPHS-M 5 62 17 20


AYUSH MO 2 25 22 26

Sector MO 0 0 3 4

The table above reflects the profile of our respondents. Out of the total 8 supervisors interviewed, there

were no were lady supervisors (LHV), 62% were male supervisors, 12% were ICDS supervisors, 25%

were AYUSH MOs and no Sector MO was present.

Table 18 – Supervisory visits made by Internal Supervisors in last one month, Malkangiri, Odisha

Malkangiri



No. of filled in supervisory checklists submitted to block level on IMNCI




month 19 2 161 2




Support from supervisors while providing services in hard to reach

areas 4 50 (%) 41 49 (%)


month was found to be the maximum for VHND, followed by IMNCI. For RI the supervisory visits

were relatively the least. The supervisors were filling up on an average 6 supervisory checklists for

VHND and 3 checklists for RI and IMNCI programmes, each. When asked whether they were getting

support from their supervisors for providing services in hard to reach areas, 4 (50%) respondents gave

an affirmative answer.

117

Table 19 – Frequency, method and place of feedback received on IMNCI from higher officials, Malkangiri,

Odisha

IMNCI Malkangiri (N=8) Total

(N=83) %

No. %


from supervisors on

IMNCI

Always 2 25 26 57


Never 5 62 22 26



Verbal 3 37 31 37

Written 3 37 25 30



from supervisors on

IMNCI



OJ training 0 0 4 5

Block meeting & OJ

training 0 0 3 4

Sector meeting & Block

meeting 1 12 2 2



25% supervisors received feedback on IMNCI from their higher officials, regularly, while 62% of

supervisors never received it at all. 12% supervisors mentioned that they received feedback sometimes.

The method of feedback was in written form (37%), followed by verbal (37%) and both verbal and

written (0%). Block meetings (12%), followed by both block meetings & OJ trainings (12%) were the

platforms of getting the feedback. Another12% respondents said that they received feedback from their

higher officials in sector meetings, block meetings and OJ trainings all together.

118

Table 20 – Programme management of IMNCI by the supervisors, Malkangiri, Odisha

IMNCI Malkangiri (N=8) Total

(N=83) %

No. %













Always 2 25 14 17

Sometimes 0 0 5 6

Rarely 1 12 3 4

Never 5 62 50 60






Drugs 6 75 44 53



12% supervisors informed that they were conducting weekly reviews while 25% respondents were

conducting monthly reviews on IMNCI. Regular indenting of IMNCI drugs was done by the

supervisors only in 37% cases. None of the supervisors received transportation support. 25% of them

were involved in preparing the integrated supervision plans. Equal percentage of them was trained on

FUS training. 25% of supervisors were familiar with the IMNCI supervision checklist; whereas, 25%

supervisors always used IMNCI supervisory checklist against 62% who never used it. While

supervising, all the supervisors checked on all the key components of IMNCI programme, such as,

assessment forms, registers and referral slips (100%). Other logistics (booklets, IMNCI board, weighing

machine, home visits, etc) were being supervised the least (62%).

119

Table 21 - Frequency, method and place of feedback received on RI from higher officials, Malkangiri,

Odisha

RI Malkangiri (N=8) Total

(N=83) %

No. %



Always 7 87 47 57

Sometimes 0 0 28 34

Never 1 12 5 6


supervisors on RI

Verbal 0 0 37 45

Written 7 87 27 32






OJ training 0 0 2 2

Block meeting & OJ

training 0 0 10 12


meeting 1 12 3 4



87% supervisors received feedback on RI from their higher officials, regularly, while 12% of them never

received it at all, and none of them said that they received feedback from their higher officials

sometimes. The method of feedback was in written form (87%). 37% of supervisors said that block

meetings; 25% supervisors said sector meetings were the platforms and 12%, each, said both sector &

block meetings, and sector meeting-block meeting-OJ training as the commonly used platforms for

giving feedbacks.

Table 22- Programme Management of RI by the Supervisors, Malkangiri, Odisha

RI Malkangiri (N=8) Total (N=83)

No. % No. %










120

RI Malkangiri (N=8) Total (N=83)

No. % No. %








Always 6 75 42 51


Rarely 0 0 2 2

Never 0 0 13 16


checklist

Poorly 0 0 8 10

Somewhat 1 12 7 8

Fairly 5 62 21 25


Factor for drop out





Others* 5 62 42 51


100% supervisors informed that they were conducting RI review meetings at block level, involved in

preparation of micro-plans, verified sessions planned v/s held, monitored counterfoils, verified session

log books of ANMs and monitoring cold chain maintenance systems at session sites. 37% said they

conducted review meetings at district level. 12% Supervisors received transportation support and none

of them received financial incentives for supervision. 75% supervisors informed that there were left

out/drop out cases of RI and 62% of them agreed that the major factors for drop out were migration, lack

of communication, poor awareness, etc. Half of the supervisors cited illiteracy as an important factor,

while one-fourth of the respondents indicated improper programme planning as a factor for drop-outs.

75% of supervisors always used the supervision checklist and 25% of them were very familiar with the

same; while 0% never used the checklist.

121

Table 23- Frequency, method and place of feedback received on VHND from higher officials, Malkangiri,

Odisha

VHND Malkangiri (N=8)



supervisors on VHND

Always 6 75 37 45


Never 0 0 8 10


supervisors on VHND

Verbal 1 12 52 63

Written 6 75 10 12






OJ Training 0 0 1 1

Block Meeting & OJ training 0 0 9 11

Sector Meeting & Block

Meeting 1 12 6 7

Sector Meeting, Block

Meeting & OJ Training 1 12 2 2

75% supervisors received feedback on VHND from their higher officials, regularly and 25% said that

they received feedback from their higher officials sometimes. The method of feedback was in written

form (75%), followed by verbal form (12%). 37% of supervisors said that block meetings were the most

common platform of getting feedback from higher officials followed by 25% who agreed that sector

meetings were used as a platform for receiving feedback on VHND by their higher official. 12% of

respondents said both sector and block meetings were used for receiving feedback; equal percentage of

them cited all – sector, block and OJ trainings – as the platforms for receiving feedback from their

higher officials.

122

Table 24- Programme management of VHND by the supervisors, Malkangiri, Odisha

VHND Malkangiri (N=8) Total

(N=83) %

No. %










Familiarity with supervision

checklist






Always 3 37 29 35


Rarely 1 12 10 12

Never 1 12 20 24




Availability of other logistics 6 75. 72 87

Others* 6 75 45 54


100% supervisors informed that they were conducting weekly & monthly reviews on VHND, verified

sub centre level VHND plans and checked availability of VHND micro-plans at sector level. 87% of

them reviewed the VHND reports in the sector. 87% supervisors were involved in imparting training to

the ANM on VHND micro-plan preparation. Equal percentage of supervisors also verified the sessions

planned v/s held. Only 12% supervisors received transportation support for monitoring. 25% of

supervisors were very well familiar with the VHND supervision checklist against 12% who were not

aware of it at all. 37% supervisors always used the VHND supervisory checklist against 12% who never

used it. While supervising, they most often checked the registers/records (87%), while other

components (due list, equipment, MCP cards, adolescent health, danger sign in mothers, etc),

availability of drugs and other logistics were being supervised the least (75%).

123

DISCUSSION

With respect to Routine Immunization programme, the study revealed that in an average of 55%

sessions the alternate vaccine delivery (AVD) is being implemented (Koraput – 59% and Malkangiri –

50%). Availability of all vaccines in session sites ranged from 79% (Nab) to 100% (Nua, Bol, Kor,

Mal). Record keeping was not appropriate in 20% of the sites. The availability and functionality of

hub-cutters ranged from 45% (Nua) to 93% (Mal and Kor). RI cards (MCP cards) were available at

85% sites. Consumable and logistics, such as, IFA, Vit-A and paracetamol tablets were not available in

100% of sites.

Time of reconstitution was not recorded in 7% sites. Administration of vaccines (route and site) was not

correctly practiced in 3% of session sites. Only in 61% of sites, waste disposal procedure was followed

properly. Overall, counseling skills among front-line workers were found to be poor. Only 44% of

mothers were asked to wait for half an hour after immunizing the child. Four key messages were given

in three-fourth (73%) sites.

With regard to VHND services, availability of examination tables was 66%, availability of screens was

31%, availability of due lists was 69%. 15% of the sessions were held in ‘other places’ and not in a Sub

centre or Anganwadi centre. Only in 22% instances abdominal palpation was done and in 90% sites BP

examination was carried out. 22% of sites conducted recording of foetal heart sounds.

36% of sites received supervisory visits from health department officials, while 2% of sites were visited

by ICDS supervisors. Involvement of PRI/GKS members was also very minimal (6%). Relevant

counseling was given in 62% sites. Weight of infants was recorded in 34% sites only. Participation of

husbands was negligible (<1%).

With regard to IMNCI services, 17% AWWs and health workers conducted home visits as per IMNCI

guidelines and 23% correctly filled the IMNCI assessment sheets, while 18% correctly maintained the

IMNCI reporting formats. This reflects very poor state of knowledge and skills of front-line workers on

IMNCI implementation. 29% could correctly assess a new born and 41% could correctly classify. 35%

could correctly identify cases for treatment. Proper counseling skills were present in 25% cases. For

assessment of young children we found that correct assessment was done by 30% respondents, correct

classification was done by 19%, correct identification for treatment in 15% cases and proper counseling

skills were found in 16% cases.

Availability of logistics was a great concern. IMNCI board (15%), jar / spoon (17%). On the other

hand, IMNCI chart booklets, forms and modules and referral forms were available in 85% instances.

Drugs like Cotrimoxazole, Paracetamol were present in only 38% cases. Availability of ORS (79%),

Gentian violet (31%), Zinc (18%) and IFA (65%) were of equal concern. The overall assessment skills

were found to be correct in less than 50% respondents.

124

With regard to the nature and quality of support the supervisors were getting from their supervisors (who

are mostly district level officials), most of the supervisor respondents mentioned that they got vehicles

and handholding support from their supervisors for providing services in hard to reach areas. Few of

them also mentioned about the incentives and logistics support that they received from their supervisors.

When asked to identify and name the stakeholders for RI, IMNCI and VHND programmes, most of

them mentioned about health workers and ICDS workers as the key stakeholders, while some of them

also stated that beneficiaries, PRI members and GKS members were stakeholders.

When asked about the special steps which they had taken to address the issues of high left-outs and

dropouts in RI, about one-third of respondents agreed to answer this question and most of them gave

importance to home visits and follow-up visits as the main strategies to improve upon the situation of

high left-outs and dropouts. Some of them also mentioned about the importance of community

sensitization programmes.

In view of the high instances of logistics stock-outs, we asked as to what were the key factors for

repetition of such occurrences. Almost all the supervisors mentioned about insufficient and erratic

supply of logistics as the key factor. They categorically highlighted the need for meeting up the

indenting requirements. One of them also indicated that indenting not being done on time contributes to

frequent stock-outs.

On further probing, we found that most of the supervisors informed about the stock-out situations to

their higher officials as the only step they took to address this.

When asked about the kind of role they were playing in preparation of integrated supervisory plans, 38

supervisors said that they were not playing any roles in the preparation of the integrated supervision plan

and only 15 of them said that they were involved in the preparation of such plans in coordination with

the WCD department officials.

On IMNCI reporting flow mechanism, 41 of 71 respondents who answered this question, were confident

of the correct flow of IMNCI reporting system, whereas the other 30 supervisors were not sure of the

same.

About referral under IMNCI, almost all the supervisors said that they referred the sick children to the

nearest hospital, as needed, after initial assessment of the child as per the IMNCI protocol.

About the composition of IMNCI kit, all the supervisors interviewed recommended of Paracetamol,

Cotrimoxazole, IFA, ORS and Gentian violet as the drugs that should be available in the IMNCI kit.

Three respondents also emphasized on the need to include Zinc tablets in the IMNCI kit.

With regard to VHND reporting mechanism, 51 of the 78 respondents answered correctly about the flow

of VHND reporting whereas the other 27 were not very sure of the same. All supervisors mentioned

about the need to have BP measuring instrument, hemoglobinometer, weighing machine and stethoscope

at VHND sites. In case of drugs, majority of the supervisors believed ORS, Paracetamol, Cotrimoxazole

125

and IFA tablets were essential. A few of the respondents also mentioned about Albendazole,

Contraceptives, Metronidazole, anti-malarial drugs, Vitamin - A and Gentian violet as essential for

conducting VHND programme.

When asked about the way they addressed VHND drug stockouts in last three months, about 50% of the

supervisors revealed that they indented immediately in such situations, while almost equal number of

respondents mentioned that they only informed their higher officials about the same.

With regard to the key indicators that they used for monthly programme review of VHND, most of the

supervisors opined that they focused on ‘sessions planned v/s sessions held’, ‘no. of beneficiaries’ and

‘availability of logistics’. Some of the supervisors also mentioned about the ‘no. of referrals’ and ‘other

meetings’ as important indicators.

126

CONCLUSION & RECOMMENDATIONS

Logistics & supply chain management

Availability of logistics was found to be of great concern across all five districts with respect to IMNCI

programme implementation. Thus, indenting must improve and supply chain management should be

ensured from the lowest facility (Sub centre) to the State headquarters. We propose to pilot an indenting

system in one block of Malkangiri, the results of which will be shared. The indenting system would be

piloted at three levels: from field level to the CHC, from CHC to the district and from the district to the

state. At the sub centre level, a register would be maintained with the ANM for the stock, issue and

indenting of drugs; where the ASHAs and AWWs can fill in their requirements. The list of drugs shall

be as per the sub centre drug list and the indenting shall be done on a quarterly basis.

Decentralization of purchasing of IMNCI drugs may be brought forth with immediate effect. Monthly

review on this could be utilized to examine the status. Instances of mismanagement of drugs, wrongful

allocation or disproportionate allocation, etc may be discussed at length in such meetings in order to

strengthen the supply chain.

Capacity building & skill development

Skill enhancement of health workers and Anganwadi workers need to be taken up with immediate

priority. A cascading model of capacity building of supervisory cadre may be followed, or alternatively

the entire potential workforce may be inducted for a five days capsular refresher in batches. The main

areas would be: waste disposal, counseling, BCC, administration of vaccines, indenting, appropriate

handling of vaccines at session site and record maintenance.

The findings indicate that availability of certain basic logistics to conduct a quality VHND session was

poor. Instructions may be given to the district and sub-district officials to follow the order to purchase

the necessary furniture and equipments for conducting VHND in letter and spirit.

Issues related to proper waste disposal practices need urgent attention, especially in view of the danger

to the lives of people and environmental degradation that the bio-wastes pose to. A separate extensive

training may be planned for both front-line workers and supervisory cadres to inculcate a habit of

ensuring appropriate bio-waste disposal in every RI / VHND session.

Skill up-gradation of IMNCI workers should be done with utmost urgency and importance in view of the

finding that most workers are not confident in practicing IMNCI. Each worker may be imparted a

refresher course in pairs with their supervisors to improve synergy in the field.

127

Monitoring & supervision

The quantum and quality of supervision was found to be an important gap in the delivery of services.

Supervisory visits must increase and that should be monitored by the higher officials. An in-built

mechanism may be developed to ensure that the supervisor signs in the records of RI and IMNCI

sessions. Regular updates of the supervisory visits must be encouraged at block and district level. The

district must disseminate the incentive provisions with the supervisory cadre which may be monitored

by the in-charge medical officers. The supervisory formats need to be kept ready in sufficient quantity

with the block PHC (BPO’s office).

The involvement of ICDS supervisors in VHND session monitoring was very negligible. Therefore,

immediate attention of the DSWO may be sought to this and instructions should be passed on to the

peripheral workforce of WCD department to work hand-in-hand with the health department workers for

the provision of quality VHND session. This could be strengthened with the involvement of ICDS

supervisors. This component may be reviewed at JCC meetings / other district meetings by the District

Collector.

The means of verification of the number of visits conducted by the AWWs and ANMs should be strictly

monitored at sector, block and district level meetings.

The AYUSH MO at the block must also be involved in the programme review as well as monitoring &

supervision of the individual programmes so as to increase adherence to supervision by the internal

monitors.

Community participation

Very minimal community participation, especially of the GKS/PRI members in VHND sessions, is

indicative of the need to strengthen this component. GKS/PRI members’ presence in a site could

invariably improve the quality of services. However, they themselves may be trained on their roles and

responsibilities vis-à-vis VHND sessions.

Male members in the family play decisive roles about family welfare activities, including planning for

the family. Therefore, their involvement is crucial to the success of family planning services provided in

the VHND platforms. In order to increase their participation, the ASHAs/AWWs may be instructed to

invite the male members of the family to VHND session whenever they make home-visits to mobilize

community members. Incentives may also be piloted to understand the relative efficacy.

128

ETHICAL ISSUES AND QUALITY ASSURANCE

Informed consent was obtained from all participants under the study. Ethical approval for the study was

obtained from the Research Ethics Committee of IIPH-Bhubaneswar. In order to ensure quality of data,

the Principal Investigator was constantly monitoring the activities of the field investigators. Weekly

updates were shared by the field staffs which were cross-checked with their trip reports. During data

entry, steps were taken to clean the data. All quality related issues were cross-verified by thorough

discussion with the field investigators.

STUDY LIMITATIONS

Sample of the study was limited. Results need to be interpreted accordingly. Five districts were

covered in the sample. Generalization for the state may be difficult. Cross-sectional surveys were

conducted. Attributing to systemic factors is difficult.

129

BIBLIOGRAPHY

1. National Rural Health Mission. Ministry of Health and Family Welfare. Government of India.

http://mohfw.nic.in/NRHM.htm; accessed on 6th

January, 2012

2. Donabedian, A. Evaluating the quality of medical care. Milbank memorial quarterly, 44: 166-203

(1966).

3. Smith WA. Consumer demand and satisfaction. The hidden key to successful privatization.

Washington, DC, Academy for Educational Development, HealthCom, Communication for

Child Survival, 1989.

4. L. J. Opit, The Measurement of Health Service Outcomes, Oxford Textbook of Health Care, 10,

OLJ, London, UK, 1993.

5. Ranived & Purnima Menon. Analyzing Intersectoral Convergence to Improve Child Under

nutrition in India. IFPRI report. 2012

6. Shree Roy, Biswamitra Sahu. Can ASHA be the ray of hope for providing MCH services in

Odisha, India? Exploring through a qualitative study. The Journal of Global Health Care

Systems, Vol 3, No 2 (2013)

7. Nirupam Bajpai and Ravindra H. Dholakia. Improving the Integration Of Health And Nutrition

Sectors In India. Working Paper No. 2May 2011Columbia global center

8. Sanghamitra Pati, Bhuputra Panda. Assessment of Supportive Supervision Strategy of Routine

Immunization in Odisha - A Randomized Post-Test Study. IIPHB-2012.

9. Sameen Almas, Martin Abel. Effect of Supportive Supervision on ASHAs’ Performance under

IMNCI in Rajasthan. KCCI-2009

10. Dr. Narendra K. Arora. Evaluation of Integrated Management of Neonatal and Childhood

Illnesses (IMNCI) Program in India: An IPEN study. 2006-07

11. Health & Family Welfare Department. Improving the Coverage and Quality of Village Health

and Nutrition Day. Operational guidelines. Govt of Odisha.

12. Davidson R Gwatkin. Integrating the management of childhood illness. The Lancet, Volume

364, Issue 9445, 30 October–5 November 2004, Pages 1557-1558

http://mohfw.nic.in/NRHM.htm

ANNEXURES

Annexure – 1: Findings of all five districts at a glance

ROUTINE IMMUNIZATION

Table 1- Availability of vaccines at routine immunization session sites, five districts, Odisha

Vaccine availability Total (N=108) Bolangir (N=32) Nuapada (N=11)

Koraput (N=27)

Nabarangpur (N=24)

Malkangiri (N=14)

No. % No. % No. % No. % No. % No. %

BCG 105 97 31 97 11 100 27 100 22 92 14 100

BCG Diluent 105 97 31 97 11 100 27 100 22 92 14 100

Measles 105 97 32 100 11 100 27 100 22 92 13 93

Measles Diluent 106 98 32 100 11 100 27 100 22 92 14 100

tOPV 98 91 32 100 11 100 22 81 20 83 13 93

Hepatitis B 104 96 32 100 11 100 26 96 21 87 14 100

DPT 101 93 32 100 11 100 24 89 20 83 14 100

TT 97 90 32 100 11 100 22 81 19 79 13 93

131

Table 2-Availability of logistics at routine immunization session sites, five districts, Odisha

Total (N=108) Bolangir (N=32)

Nuapada (N=11)

Koraput (N=27) Nabarangpur

(N=24) Malkangiri

(N=14)

No. % No. % No. % No. % No. % No. %

AD (0.1ml) syringes 106 98 32 100 11 100 27 100 22 92 14 100

AD (0.5ml) syringes 107 99 32 100 11 100 27 100 23 96 14 100

5ml Reconstitution syringes 104 96 30 94 11 100 26 96 23 96 14 100

Vitamin A solution 105 97 32 100 11 100 26 96 23 96 13 93

Blank RI card 92 85 30 94 9 82 23 85 21 87 9 64

Counterfoils 83 77 23 72 5 45 23 85 21 87 11 79

ORS packet 105 97 32 100 11 100 26 96 22 92 14 100

Paracetamol 95 88 31 97 7 64 25 93 22 92 10 71

Plastic Spoon/Cap for Vitamin A 100 93 31 97 11 100 25 93 20 83 13 93

Tracking Bag 56 52 23 72 11 100 13 48 8 33 1 7

Functional Hub-Cutter 91 84 26 81 5 45 25 93 22 92 13 93

132

Table 3-Quality indicators-I at RI session site, five districts, Odisha

Total (N=108) Bolangir (N=32)

Nuapada (N=11)

Koraput (N=27) Nabrangpur

(N=24) Malkangiri

(N=14)

No. % No. % No. % No. % No. % No. %

Vaccines without label 1 1 0 0 0 0 0 0 0 0 1 7

Vaccines with unreadable label 1 1 0 0 0 0 0 0 0 0 1 7

Expired Vaccine Vial 0 0 0 0 0 0 0 0 0 0 0 0

Vaccines at VVM stage III or IV 1 1 0 0 0 0 0 0 0 0 1 7

Frozen Vaccines 0 0 0 0 0 0 0 0 0 0 0 0

BCG/Measles reconstituted for more than 4 hrs

0 0 0 0 0 0 0 0 0 0 0 0

Session held as per plan 94 87 32 100 11 100 23 85 22 92 6 43

Vaccines brought to site by AVD 59 55 16 50 6 54 16 59 14 58 7 50

Vaccines brought to site by ANM 33 31 6 19 2 18 9 33 9 37 7 50

Vaccines brought to site by Supervisor

1 1 0 0 0 0 1 4 0 0 0 0

Vaccines brought to site by Others* 12 11 9 28 3 27 0 0.0 0 0 0 0

Vaccines & Diluents kept in Vaccine Carrier

94 87 31 97 11 100 21 78 21 87 10 71

Vaccines & Diluents kept in Zipper Bag

84 78 30 94 11 100 16 59 20 83 7 50

Four ice packs in the Vaccine Carrier

101 93 31 97 11 100 27 100 24 100 8 57

Vaccine Batch No. recorded 89 82 28 87 11 100 23 85 21 87 6 43

Vaccine expiry date recorded 87 81 28 87 11 100 23 85 20 83 5 36

Diluent Batch no. recorded 87 81 28 87 11 100 23 85 20 83 5 36

Diluent expiry date recorded 88 81 28 87 11 100 23 85 21 87 5 36


133

Table 4-Quality indicators-II at RI session sites, five districts, Odisha

Quality Indicators Total

(N=108) %

Bolangir (N=32) Nuapada

(N=11) Koraput (N=27)

Nabrang-pur (N=24)

Malkangiri (N=14)

No. % No. % No. % No. % No. %

Duelist available with ANM 106 98 32 100 11 100 26 96 23 96 14 100

Duelist available with Mobilizer 100 93 29 91 11 100 26 96 23 96 11 79

Reconstitution time written on vials by ANM

101 93 31 97 11 100 24 89 23 96 12 86

AD syringe used by ANM to inject vaccines

107 99 32 100 11 100 27 100 22 92 14 100

DPT vaccine given on antero lateral aspect of mid thigh

105 97 36 112 11 100 26 96 23 96 13 93

Route of measles (Subcutaneous) 102 94 32 100 11 100 24 89 22 92 11 79

Measles given on right upper arm 101 93 32 100 11 100 24 89 22 92 12 86

ANM touching any part of needle while injecting

8 7 5 16 1 9 2 7 0 0 0 0

ANM following no recapping procedure

66 61 32 100 11 100 7 26 5 21 11 79

Syringe cut with hub cutter after use

98 91 32 100 8 73 23 85 22 92 13 93

Red & Black Bags used to segregate immunization waste

92 85 26 81 11 100 25 93 17 71 13 93

Tally sheet used to keep record after vaccinating each child

80 74 15 47 8 73 24 89 22 92 11 79

4 key messages delivered to caregivers

79 73 26 81 9 82 23 85 14 58 7 50

Beneficiaries ask to wait for 30 mins after vaccination by ANM

48 44 10 31 3 27 20 74 10 42 5 36

Vaccinate a child with mild fever 85 79 24 75 9 82 25 93 18 75 9 64

134

Table 4-Quality indicators-II at RI session sites, five districts, Odisha

Quality Indicators Total

(N=108) %



Nabrang-pur (N=24)

Malkangiri (N=14)

No. % No. % No. % No. % No. %

Vaccinate a child with loose motions

75 69 26 81 11 100 17 63 11 46 10 71

Immunization waste carried to PHC

88 81 23 72 8 73 25 93 20 83 12 86

Health Supervisor visited you in last three months

85 79 18 56 10 91 25 93 19 79 13 93

MO visited you in last three months

15 14 7 22 0 0 6 22 2 8 0 0

Table 5-Health supervisors visited in the last three months v/s 4 key messages delivered to caregivers, five districts, Odisha


Bolangir Nuapada Koraput Nabrangpur Malkangiri Total

Yes No Yes No Yes No Yes No Yes No Yes No

All 4 key messages delivered to caregivers

Yes 15 11 8 1 21 2 11 3 6 1 61 18

No 3 2 2 0 3 0 7 0 6 0 21 2

135

VILLAGE HEALTH AND NUTRITION DAY

Table 6-Availability of logistics at VHND site, five districts, Odisha


Bolangir (N=32)

Nuapada (N=12)

Koraput (N=32)

Nabarangpur (N=28)

Malkangiri (N=14)

Total (N=118)

No. % No. % No. % No. % No. % No. %

Examination table 21 66 11 92 15 47 18 67 4 29 69 58

Screen for Privacy 10 31 7 58 4 12 13 48 1 7 35 30

BP Instrument 29 91 12 100 29 91 25 93 11 79 106 90

Stethoscope 29 91 11 92 30 94 24 89 14 100 108 91

Foetoscope 1 3 2 17 9 28 3 11 1 7 16 14

Inch tape 17 53 8 67 20 62 23 85 8 57 76 64

MUAC tape 31 97 12 100 30 94 26 96 14 100 113 96

Weighing scale (adult) 29 91 12 100 28 87 22 81 14 100 105 90

Weighing scale (baby) 30 94 12 100 19 59 13 48 12 86 86 73

Haemoglobin testing 30 94 12 100 19 59 13 48 12 86 86 73

Needle/Lancet 31 97 12 100 17 53 13 48 8 57 81 69

Nischay kit 3 9 4 33 27 84 26 96 11 79 71 60

ORS Sachets 30 94 12 100 30 94 26 96 14 100 112 95

Zinc tablets 0 0 1 8 10 31 6 22 14 100 31 26

Albendazole tablets / Syrup 29 91 12 100 23 72 14 52 13 93 91 77

Anti-malarial tablets / Syrup

28 87 11 92 21 66 16 59 13 93 89 75

Cotrimoxazole tablets 26 81 12 100 22 69 9 33 12 86 81 69

Paediatric Paracetamol 24 75 7 58 20 62 7 26 6 43 64 54

IFA Tablets (large) 26 81 12 100 27 84 21 78 8 57 94 80

IFA Tablets (small) 14 44 7 58 23 72 7 26 7 50 58 49

136

Table 6-Availability of logistics at VHND site, five districts, Odisha


Bolangir (N=32)

Nuapada (N=12)

Koraput (N=32)

Nabarangpur (N=28)

Malkangiri (N=14)

Total (N=118)

No. % No. % No. % No. % No. % No. %

IFA syrup 21 66 11 92 19 59 10 37 7 50 68 58

Urine testing kit / Uristix 17 53 6 50 21 66 20 74 5 36 69 58

RDK kit 20 62 9 75 24 75 16 59 10 71 79 67

Condoms 19 59 10 83 25 78 25 93 9 64 88 75

Oral Contraceptives 17 53 9 75 23 72 19 70 6 43 74 63

Emergency contraceptive 18 56 10 83 25 78 25 93 9 64 87 74

Pills 17 53 10 83 23 72 25 93 9 64 84 71

Gentian violet lotion 25 78 11 92 14 44 9 33 3 21 62 52

Test tubes 1 3 1 8 10 31 2 7 4 29 18 15

Hand gloves 20 62 6 50 10 31 2 7 4 29 42 36

Toilet 4 12 1 8 8 25 4 15 0 0 17 14

Water Supply 17 53 6 50 7 22 7 26 0 0 37 31

Soap 26 81 11 92 19 59 10 37 5 36 71 60

Red bag for disposal 11 34 7 58 11 34 2 7 5 36 36 30

Cotton bandage 13 41 7 58 17 53 6 22 7 50 50 42

Absorbent cotton 23 72 9 75 19 59 5 18 8 57 64 54

IMNCI chart booklet 31 97 12 100 24 75 19 70 7 50 93 79

Blank MCP Cards 27 84 12 100 27 84 26 96 7 50 99 84

Referral cards 30 94 8 67 28 87 26 96 8 57 100 85

Monthly topic calendar 23 72 10 83 24 75 25 93 5 36 87 74

Due list of beneficiaries 20 62 5 42 23 72 26 96 7 50 81 69

Reporting format 28 87 12 100 26 81 26 96 10 71 102 86

137

Table 7-Session site of VHND, five districts, Odisha

Session Site Bolangir Malkangiri Koraput Nabarangpur Nabarangpur Total

(n=32) (N=14) (N=32) (N=28) (N=28) (N=118)

Sub center 2 0 7 1 1 10

AWC 24 9 22 22 22 87

others 6 5 1 0 0 15

Total 32 14 30 23 23 112

Table 8- Availability of health workers at VHND site, five districts, Odisha

Health workers at site Bolangir (n=32)

% Nuapada

(N=12)

%

Koraput (N=32)

% Nabrangpur

(N=28)

%

Malkangiri (N=14)

% Total

(N=118) %

MPHW(F) 21 66 12 100 30 94 26 93 14 100 103 87

MPHW(M) 10 31 8 67 20 62 18 64 6 43 62 52

Health supervisors 12 37 5 42 8 25 6 21 11 79 42 36

AWW 25 78 9 75 32 100 27 96 14 100 107 91

ASHA 29 91 9 75 29 91 23 82 12 85 102 86

ICDS supervisors 1 3 0 0 2 6 0 0 0 0 3 2

AWH 22 69 10 83 18 56 16 57 9 64 75 64

GKS/PRI members 5 16 0 0 0 0 0 0 2 14 7 6

others 9 28 5 42 2 6 1 4 0 0 17 14

138

Table 9-Maternal health service delivery at VHND sites, five districts, Odisha

Maternal Health Service Delivery Bolangir (N=32)

% Nuapada

(N=12)

%

Koraput (N=32)

% Nabrangpur

(N=28)

%

Malkangiri (N=14)

% Total

(N=118) %

Relevant history 23 72 6 50 32 100 26 96 4 29 91 77

Privacy during examination 12 37 8 67 16 50 17 63 1 7 54 46

BP recorded 30 94 12 100 27 84 25 93 9 64 103 87

Hemoglobin test done 26 81 11 92 22 69 25 93 9 64 93 79

Urine Examination done 4 12 0 0 26 81 20 74 4 29 54 46

Pregnant women weighed 29 91 6 50 30 94 27 100 9 64 101 86

Abdominal Palpation done 12 37 0 0 9 28 3 11 2 14 26 22

Fetal Heart Sound Recorded 12 37 2 17 9 28 3 11 0 0 26 22

IFA for Anti Natal Woman Provided 30 94 12 100 31 97 25 93 14 100 112 95

Relevant counseling done 27 84 12 100 12 37 20 74 9 64 80 68

Danger signs communicated 18 56 2 17 16 50 7 26 8 57 51 43

PPTCT counseling 29 91 11 92 12 37 6 22 3 21 61 52

Table 10-Child health & family planning service delivery at VHND session sites, five districts, Odisha

Child Health Service Delivery & Family Planning Bolangir (n=32)

% Nuapa

da (N=12)

%

Koraput

(N=32) %

Nabrangpur

(N=28)

%

Malkangiri

(N=14) %

Total (N=118)

%

Advice on breast feeding 17 53 11 92 26 81 23 85 11 79 88 75

Dietary counseling on children 14 44 10 83 21 66 18 67 8 57 71 60

Need for supplementation with IFA 26 81 12 100 19 59 17 63 12 86 86 73

Danger signs of new born 13 41 0 0 14 44 7 26 7 50 41 35

Weight of infants recorded 8 25 2 17 14 44 7 26 9 64 40 34

ORS demonstration done 13 41 5 42 13 41 8 30 3 21 42 36

Advice on hand washing /hygiene 22 68 11 92 16 50 7 26 2 14 58 49

FP counseling provided 25 78 12 100 31 97 27 100 13 93 108 91

Contraceptives provided 25 78 12 100 28 87 23 85 13 93 101 86

ANM & ASHA conduct meeting with women 26 81 12 100 15 47 12 44 5 36 70 59

ANM & ASHA conduct meeting with men 0 0 0 0 1 3 0 0 0 0 1 1

139

Table 11- Quality attributes of VHND services, five districts, Odisha

Bolangir Nuapada Koraput Nabarangpur Malkangiri Total

Yes No Yes No Yes No Yes No Yes No Yes No



ICDS worker

Yes 1 17 0 11 2 19 0 21 0 11 3 79

No 0 14 0 1 0 11 0 6 0 3 0 36


Health Supervisor present at site

Yes 10 2 3 2 7 1 5 1 11 0 36 7

No 14 6 6 1 24 0 18 3 2 1 64 11



Yes 5 0 0 0 0 0 0 0 0 2 5 2

No 16 11 11 1 15 17 18 9 4 8 65 46



Yes 3 9 0 0 4 5 2 1 0 2 10 17

No 7 12 7 5 0 22 10 13 1 11 25 63



Yes 6 6 0 0 5 4 3 0 1 1 16 11

No 15 4 11 1 10 12 15 9 3 9 53 35

140

INTEGRATED MANAGEMENT OF NEONATAL & CHILDHOOD ILLNESSES

Table 12-Review of IMNCI records, five districts, Odisha

Record Review Balangir (N=64)

%

Nuapada (N=23)

%

Koraput (N=64)

%

Nabarangpur (N=53)

%

Malkangiri (N=34)

%

Total (N=238)

%


390

553

172

1830

Total no. of newborns in last 3 months who have received home visits

462 203 342 427 104 1533

Average no. of newborns in last 3 months who have received home visits per AWC/SC

7.2 8.8 5.3 8.0 3.0 6.4

Home visits conducted as per IMNCI guidelines 8 (12%) 3 (13%) 17 (27%) 1 (2%) 12 (35%) 41 (17%)

IMNCI assessment sheets correctly filled up 16 (25%) 14 (61%) 11 (17%) 9 (17%) 5 (15%) 55 (23%)

All sick cases referred 12 (19%) 5 (22%) 5 (8%) 5 (9%) 3 (9%) 30 (13%)

Referral Slips filled up 12 (19%) 0 (0%) 7 (9%) 5 (9%) 3 (9%) 27 (11%)

IMNCI monthly reporting formats filled up 17 (27%) 0 (0%) 9 (14%) 4 (7%) 12 (35%) 42 (18%)

Table 13-Assessment of skills of IMNCI trained workers, five districts, Odisha

A. NEW BORN Balangi

r (N=64)

% Korapu

t (N=64)

% Malkangi

ri (N=34)

% Nuapad

a (N=23)

% Nabarang

pur (N=53)

% Total (N=23

8) %

Correctly assessed a young infant 27 42 10 16 15 44 15 65 3 6 70 29

Correctly classified the young infant 25 39 20 31 15 44 13 56 25 47 98 41

Correctly treated young infant 27 42 17 27 7 21 10 43 22 41 83 35

Correctly counseled 22 34 12 19 9 26 3 13 13 24 59 25

Child needing referral is referred 18 28 4 6 6 18 7 30 6 11 41 17

Correctly assessed the immunization of infant

17 27 14 22 17 50 0 0 6 11 54 23

141

Table 13-Assessment of skills of IMNCI trained workers, five districts, Odisha

B. CHILD Balangi

r (N=64)

% Nuapad

a (N=23)

% Korapu

t (N=64)

% Nabaran

gpur (N=53)

% Malkang

iri (N=34)

% Total (N=238)

%

Correctly assessed a child 28 44 15 65 7 11 11 21 10 29 71 30

Correctly classified the child 18 28 3 13 5 8 1 2 19 56 46 19

Correctly treated the child 12 19 1 4 4 6 0 0 18 53 35 15

Correct counseled 14 22 8 35 1 2 0 0 16 47 39 16

Child needing referral is referred 4 6 0 0 2 3 0 0 24 71 30 13

Correctly assessed the immunization of child

33 52 12 52 4 6 0 0 26 76 75 31

Table 14-Availability of logistics at AWC, five districts, Odisha

FACILITY SUPPORT Balangir (N=64)

% Nuapada (N=23)

% Koraput (N=64)

% Nabarangpur (N=53)

% Malkangiri (N=34)

% Total (N=238)

%

IMNCI board 3 5 17 74 6 9 4 7 5 15 35 15

Salter scale / child weighing scale 62 97 18 78 51 80 40 75 25 73 196 82

One litre jar, cup and spoon 12 19 3 13 5 8 3 6 17 50 40 17

Ped Cotrimoxazole tab/syp 39 61 12 52 13 20 10 19 18 53 92 39

Ped Paracetamol tab/syp 38 59 9 39 17 27 13 24 13 38 90 38

ORS 50 78 19 83 47 73 40 75 32 94 188 79

Zinc tablets 1 2 0 0 9 14 3 6 31 91 44 18

IFA tablets 44 69 18 78 36 56 24 45 33 97 155 65

Gentian violet paint/ powder 34 53 16 70 16 25 7 13 0 0 73 31

IMNCI chart booklet 64 100 23 100 58 91 52 98 13 38 210 88

IMNCI Module 64 100 23 100 60 94 52 98 13 38 212 89

IMNCI photo booklet 62 97 23 100 61 95 52 98 8 23 206 87

IMNCI forms for 0-2 mon 52 81 19 83 64 100 52 98 30 88 217 91

IMNCI forms 2 mon to 5 yrs 52 81 20 87 62 97 52 98 31 91 217 91

Referral slips 46 72 22 96 63 98 49 92 28 82 208 87

Reporting forms 42 66 22 96 51 80 43 81 17 50 175 73

142

Table 15-Skill assessment of IMNCI trained workers on assessment, classification & management of sick neonates, five districts, Odisha

Balangir (N=64)

% Koraput (N=64)

% Malkangiri

(N=34) %

Nuapada (N=23)

% Nabarangpur

(N=53) %

Total (N=238)

%


Convulsion 19 30 25 39 5 15 16 70 24 45 89 37

Fast breathing 31 48 26 41 25 73 9 39 26 49 117 49

Chest in-drawing 24 37 25 39 25 73 9 39 26 49 109 46

Nasal Flaring 23 36 24 37 17 50 8 35 23 43 95 40

Pustule 10 16 22 34 13 38 10 43 19 36 74 31

Temperature 44 69 29 45 19 56 18 78 28 53 138 58

Lethargic or unconscious 20 31 28 44 7 21 0 0 26 49 81 34

Decreased movement 22 34 26 41 10 29 0 0 25 47 83 35

Assessing Diarrhoea

Blood in stool 32 50 20 31 5 15 20 87 19 36 96 40


Restlessness/irritability 21 33 21 33 20 59 3 13 19 36 84 35

Sunken eyes 26 41 28 44 30 88 10 43 24 45 118 50

Skin pinch 32 50 28 44 28 82 14 61 26 49 128 54

Assessing Breastfeeding

Difficulty feeding 34 53 18 28 17 50 19 83 22 41 110 46

Not able to feed 20 31 19 30 11 32 3 13 17 32 70 29

Less than 8 breastfeeds in 24 hours

34 53 18 28 23 68 13 56 21 40 109 46

Received other foods or drinks

21 33 18 28 5 15 9 39 21 40 74 31

Attachment 22 34 26 41 13 38 5 22 26 49 92 39

Suckling 25 39 27 42 16 47 6 26 23 43 97 41

Oral thrush 29 45 22 34 12 35 12 52 24 45 99 42

Assessing Immunization 40 62 15 23 23 68 20 87 19 36 117 49

Assessing other problems

11 17 7 11 7 21 7 30 9 17 41 17

143

Balangir (N=64)

% Koraput (N=64)

% Malkangiri

(N=34) %

Nuapada (N=23)

% Nabarangpur

(N=53) %

Total (N=238)

%

Classification 23 36 9 14 17 50 16 70 15 28 80 34


Referral of severe cases 16 25 2 3 27 79 6 26 9 17 60 25

Given antibiotic for local infection

13 20 1 2 14 41 0 0 4 7 32 13

Given ORS solution in facility

15 23 3 5 28 82 0 0 5 9 51 21

Advise on home care 39 61 5 8 24 71 13 56 5 9 86 36

Explained signs for when to return immediately

20 31 2 3 5 15 4 17 3 6 34 14

Advised follow-up care 24 37 2 3 23 68 10 43 6 11 65 27

Counseled on breastfeeding

42 66 1 2 16 47 17 74 4 7 80 34

Next date for immunization

23 36 5 8 24 71 2 9 11 21 65 27

Checking mother’s/caretaker’s understanding

5 8 3 5 4 12 0 0 6 11 18 8

144

Table 16-Skill assessment of IMNCI trained workers on assessment, classification & management of sick children of 2 months to 5 years,

five districts, Odisha

Balangi

r (N=64)

% Nuapad

a (N=23)

% Korapu

t (N=64)

% Nabarangpur (N=53)

% Malkan

giri (N=34)

% Total

(N=238) %

Assessed General danger signs

Not able to drink or breastfeed 9 14 0 0 1 2 1 2 6 18 17 7

Vomit everything 8 12 1 4 2 3 1 2 5 15 17 7

Convulsion 3 5 1 4 2 3 1 2 7 21 14 6


Asked for Cough or difficult breathing

Fast breathing 10 16 1 4 3 5 1 2 31 91 46 19

Chest indrawing 8 12 0 0 3 5 1 2 28 83 40 17

Asked for Diarrhoea

Restless and irritable 10 16 0 0 2 3 1 2 20 59 33 14

Sunken eyes 11 17 0 0 3 5 1 2 31 91 46 19

Able/ Not able to drink/ Drinking eagerly/ Thirsty

6 9 0 0 1 2 1 2 7 21 15 6

Skin pinch 10 16 0 0 4 6 1 2 28 82 43 18

Diarrhoea for 14 days or more 9 14 1 4 3 5 1 2 7 21 21 9

Blood in stool 7 11 1 4 3 5 1 2 2 6 14 6

Assessed Fever

Stiff neck 8 12 0 0 3 5 1 2 5 15 17 7

Fever present for more than 7 day 9 14 0 0 3 5 1 2 13 38 26 11

Assessed Malnutrition

Visible severe wasting 8 12 0 0 0 0 1 2 19 56 28 12

Oedema of both feet 8 12 1 4 1 2 1 2 12 35 23 10

Grade of malnutrition (red/ yellow/ green)

8 12 1 4 0 0 1 2 28 82 38 16

145

Assessed Anaemia

Severe palmar pallor 9 14 1 4 2 3 1 2 8 23 21 9

Some palmar pallor 7 11 0 0 4 6 1 2 8 23 20 8

Assessed Immunization 9 14 0 0 5 8 1 2 25 73 40 17

Assessed Feeding 8 12 0 0 1 2 0 0 23 68 32 13

Not Exclusive breastfeeding (for less than 6 month infant)

9 14 1 4 0 0 0 0 21 62 31 13

Using bottle to feed to child 8 12 1 4 0 0 0 0 10 29 19 8

Child is not fed actively 9 14 0 0 0 0 0 0 16 47 25 10

Child is fed less frequently 8 12 0 0 0 0 0 0 12 35 20 8

Child is fed less quantity of food 7 11 1 4 0 0 0 0 1 3 9 4

During illness child is fed less quantity of food

7 11 1 4 0 0 0 0 1 3 9 4

Assessed other problems 8 12 0 0 2 3 0 0 11 32 21 9

Classification 10 16 0 0 5 8 0 0 22 65 37 15


Referral of severe cases 10 16 0 0 0 0 0 0 28 82 38 16

Given antibiotic for pneumonia 8 12 0 0 0 0 0 0 12 35 20 8

Given ORS solution in facility 8 12 0 0 0 0 0 0 27 79 35 15

Advise home care 10 16 0 0 0 0 0 0 24 71 34 14

Explained signs for when to return immediately.

8 12 0 0 0 0 0 0 4 12 12 5

Advised follow-up care 10 16 1 4 0 0 0 0 18 53 29 12

Next date for immunization 8 12 0 0 2 3 0 0 22 65 32 13

Counseling on feeding 11 17 1 4 2 3 0 0 20 59 34 14

Checking mother’s/caretaker’s understanding

3 5 0 0 1 2 0 0 4 12 8 3

146


Table 17 – Profile of Supervisors, five districts, Odisha

Total

(N=83) %

Bolangir (N=27)

Nuapada (N=11) Koraput (N=23) Nabarangpur

(N=14) Malkangiri (N=8)

No. % No. % No. % No. % No. %

Designation of supervisor

MPHS-F 21 25 8 30 2 18 6 26 5 36 0 0

MPHS-M 17 20 2 7 2 18 5 22 3 21 5 62

ICDS Supervisor

20 24 7 26 4 36 7 30 1 7 1 12

AYUSH MO 22 26 7 26 3 27 5 22 5 36 2 25

Sector MO 3 4 3 11 0 0 0 0 0 0 0 0

Table 18 – Supervisory visits made by Internal Supervisors in last one month, five districts, Odisha

Total Avg. Bolangir Nuapada Koraput Nabarangpur Malkangiri

Total Avg. Total Avg. Total Avg. Total Avg. Total Avg.

No. of supervisory visits made last month on IMNCI

149 2 48 2 32 3 42 3 4 1 23 3

No. of filled in supervisory checklists submitted to block level on IMNCI last month

32 1 8 0 2 0 10 1 0 0 12 1

No. of supervisory visits made last month on RI

287 3 101 4 31 3 79 4 54 4 22 3

No. of filled in supervisory checklists submitted to block level on RI last month

161 2 52 2 4 0 40 4 46 4 19 2

No. of supervisory visits made last month on VHND

313 4 95 3 44 4 85 4 39 3 50 6

No. of filled in supervisory checklists submitted to block level on VHND last month

127 2 43 2 5 0 15 2 24 3 40 5

Support from supervisors while providing services in hard to reach areas

41 49% 13 48% 6 54% 12 52% 6 43% 4 50%

147

Table 19 – Frequency, method and place of feedback received on IMNCI from higher officials, five districts, Odisha

IMNCI Total (N=8

3) %

Bolangir (N=27) Nuapada (N=11) Koraput (N=23) Nabarangpur (N=14) Malkangiri (N=8)

Number % Number % Number % Number % Number %

Frequency of feedback from supervisors on IMNCI

Always 26 57 6 22 11 100 5 22 2 14 2 25

Sometimes 32 39 18 67 0 0 9 39 4 29 1 12

Never 22 26 3 11 0 0 7 30 7 50 5 62

Method of feedback from supervisors on IMNCI

Verbal 31 37 7 26 0 0 12 52 9 64 3 37

Written 25 30 11 41 11 100 0 0 0 0 3 37

Both verbal & written

7 8 6 22 0 0 1 4 0 0 0 0

Place of getting feedback from supervisors on IMNCI

Sector Meeting

18 22 1 4 0 0 9 39 8 57 0 0

Block Meeting

9 11 6 22 0 0 1 4 1 7 1 12

OJ Training 4 5 4 15 0 0 0 0 0 0 0 0

Block Meeting & OJ training

3 4 3 11 0 0 0 0 0 0 0 0

Sector Meeting & Block Meeting

2 2 0 0 0 0 1 4 0 0 1 12

Sector Meeting, Block Meeting & OJ Training

2 2 0 0 0 0 1 4 0 0 1 12

148

Table 20 – Programme Management of IMNCI by the Supervisors, five districts, Odisha

IMNCI Total

(N=83) %

Bolangir (N=27) Nuapada (N=11) Koraput (N=23) Nabarangpur

(N=14) Malkangiri (N=8)

No. % No. % No. % No. % No. %

Familiar with IMNCI supervision checklist

33 40 13 48 6 54 9 39 3 21 2 25

Role in preparing integrated supervision plan

21 25 10 37 2 18 6 26 1 7 2 25

Aware of reporting system under IMNCI

48 58 16 59 10 91 14 61 5 36 3 37

Aware of referral services under IMNCI

54 65 21 78 11 100 15 65 3 21 4 50

Transportation support for IMNCI supervision

11 13 6 22 0 0 4 17 1 7 0 0

Instances of IMNCI drug stock out during last 3 months

41 49 14 52 10 91 9 39 3 21 5 62

Regular indenting for IMNCI in your sector

19 23 5 18 4 36 5 22 2 14 3 37

Verifying centers supervised v/s planned in the sector

19 23 8 30 0 0 7 30 2 14 2 25

Weekly review at sector level meetings

54 65 25 93 11 100 11 48 6 43 1 12

Monthly review at block level meetings

44 53 25 93 11 100 5 22 1 7 2 25

Received FUS training on IMNCI 28 34 10 37 4 36 9 39 3 21 2 25


Always 14 17 7 26 3 27 2 9 0 0 2 25

Sometimes 5 6 4 15 0 0 1 4 0 0 0 0

Rarely 3 4 0 0 1 9 0 0 1 7 1 12

Never 50 60 16 59 7 64 12 52 10 71 5 62

Components of programme supervised during visits

Registers 46 55 12 44 6 54 13 56 7 50 8 100

Assessment forms 54 65 15 56 9 82 14 61 8 57 8 100

Referral slips 43 52 10 37 8 73 13 56 4 29 8 100

Drugs 44 53 13 48 5 45 12 52 8 57 6 75

Other logistics* 26 31 8 30 4 36 5 22 4 29 5 62

149

Table 21 - Frequency, method and place of feedback received on RI from higher officials, five districts, Odisha

RI Total

(N=83) %

Bolangir (N=27)

Nuapada (N=11) Koraput (N=23) Nabarangpur (N=14) Malkangiri (N=8)

No. % No. % No. % No. % No. %

Frequency of feedback from supervisors on RI

Always 47 57 8 30 7 64 14 61 11 79 7 87

Sometimes 28 34 13 48 4 36 8 35 3 21 0 0

Never 5 6 4 15 0 0 0 0 0 0 1 12

Method of feedback from supervisors on RI

Verbal 37 45 3 11 2 18 18 78 14 100 0 0

Written 27 32 11 41 9 82 0 0 0 0 7 87


10 12 8 30 0 0 2 9 0 0 0 0

Place of getting feedback from supervisors on RI

Sector Meeting

28 34 0 0 0 0 14 61 12 86 2 25

Block Meeting

10 12 4 15 1 9 1 4 1 7 3 37

OJ Training 2 2 2 7 0 0 1 4 0 0 0 0


10 12 9 33 0 0 1 4 0 0 0 0


3 4 1 4 0 0 1 4 0 0 1 12


3 4 1 4 0 0 1 4 0 0 1 12

150

Table 22- Programme Management of RI by the Supervisors, Bolangir, Odisha

RI Total (N=8

3) %



Nabarangpur (N=14)

Malkangiri (N=8)

No. % No. % No. % No. % No. %

Involvement in preparation of micro plan 53 64 15 56 4 36 17 74 9 64 8 100

Providing OJ training to ANM on micro plan preparation

50 60 17 63 5 45 14 61 8 57 6 75

Verifying sub centre level RI micro plan during final compilation

51 61 18 67 4 36 13 56 9 64 7 87

Verifying sessions planed v/s held in your sector 69 83 19 70 8 73 20 87 14 100 8 100

Monitoring counterfoils in the session site 68 82 24 89 8 73 16 70 12 86 8 100

Verifying session logbook of ANM at the session site 51 61 19 70 6 54 9 39 9 64. 8 100

Regular indenting in the sector for RI 44 53 15 56 6 54 10 43 7 50 6 75

Conducting review meetings at block level 68 82 27 100 11 100 14 61 8 57 8 100

Conducting review meetings at district level 37 45 18 67 11 100 4 17 1 7 3 37

Monitoring cold chain maintenance system at session site

57 69 21 78 9 82 12 52 7 50 8 100

Monitoring cold chain maintenance system at ILR point

38 46 14 52 4 36 10 43 6 43 4 50

Transportation support for supervision 27 32 15 56 2 18 3 13 6 43 1 12

Financial incentives for supervision 10 12 3 11 2 18 2 9 3 21 0 0

Left out/drop out cases of RI 30 36 7 26 8 73 8 35 1 7 6 75

Vaccine/Equipment stock out in last 3 months 10 12 4 15 0 0 1 4 1 7 4 50


Always 42 51 15 56 5 45 10 43 6 43 6 75

Sometimes 18 22 5 18 3 27 3 13 5 36 2 25

Rarely 2 2 0 0 0 0 2 9 0 0 0 0

Never 13 16 7 26 3 27 3 13 0 0 0 0

Familiarity with RI supervision checklist

Poorly 8 10 5 18 2 18 1 4 0 0 0 0

Somewhat 7 8 2 7 0 0 4 17 0 0 1 12

Fairly 21 25 5 18 1 9 3 13 7 50 5 62

Very Well Familiar 39 47 15 56 8 73 10 43 4 29 2 25

Factor for drop out

Illiteracy 11 13 1 4 0 0 6 26 0 0 4 50

Improper programme planning 3 4 0 0 0 0 1 4 0 0 2 25

Poor quality services 1 1 0 0 0 0 1 4 0 0 0 0

Cultural barrier 5 6 1 4 0 0 2 9 1 7 1 12

Others* 42 51 17 63 11 100 5 22 4 29 5 62

151

Table 23- Frequency, method and place of feedback received on VHND from higher officials, five districts, Odisha

VHND Total

(N=83) %

Bolangir (N=27) Nuapada (N=11) Koraput (N=23) Nabrangpur (N=14) Malkangiri (N=8)

No. % No. % No. % No. % No. %

Frequency of feedback from supervisors on VHND

Always 37 45 7 26 1 9 16 70 7 50 6 75

Sometimes 38 46 14 52 7 64 6 26 7 50 2 25

Never 8 10 5 18 3 27 0 0 0 0 0 0

Method of feedback from supervisors on VHND

Verbal 52 63 10 37 9 82 18 78 14 100 1 12

Written 10 12 4 15 0 0 0 0 0 0. 6 75


7 8 5 18 0 0 2 9 0 0 0 0

Place of getting feedback from supervisors on VHND

Sector Meeting

28 34 0 0 0 0 14 61 12 86 2 25

Block Meeting

18 22 8 30 4 36 2 9 1 7 3 37

OJ Training 1 1 1 4 0 0 0 0 0 0 0 0


9 11 7 26 0 0 2 9 0 0 0 0


6 7 3 11 1 9 1 4 0 0 1 12


2 2 0 0 0 0 1 4 0 0 1 12

152

Table 24- Programme Management of VHND by the Supervisors, five districts, Odisha

VHND Total

(N=83) %

Bolangir (N=27)

Nuapada (N=11)

Koraput (N=23)

Nabrangpur (N=14) Malkangiri

(N=8)

No. % No. % No. % No. % No. %

Availability of VHND microplan at sector level

60 72 22 81 5 45 15 65 10 71 8 100

Training to ANM/AWW on VHND microplan preparation

53 64 20 74 5 45 14 61 7 50 7 87

Verifying sub center level VHND plan & guiding as per need

55 66 22 81 5 45 13 56 7 50 8 100

Compiling & finalizing VHND microplan at sector level

53 64 20 74 6 54 13 56 8 57 6 75

Reviewing VHND reports in the sector 69 83 23 85 9 82 17 74 13 93 7 87

Verifying sessions planed vs held 68 82 20 74 10 91 18 78 13 93 7 87

Transportation support for monitoring 22 26 10 37 2 18 6 26 3 21 1 12

Weekly review of programme at sector level review meetings

75 90 26 96 11 100 17 74 13 93 8 100

Monthly review of programme at block level review meetings

56 67 26 96 11 100 8 35 3 21 8 100


Not aware at all 15 18 5 18 4 36 3 13 2 14 1 12

Somewhat familiar 17 20 2 7 2 18 6 26 4 29 3 37

Fairly familiar 17 20 2 7 0 0 7 30 6 43 2 25

Very well familiar 31 37 16 59 5 45 6 26 2 14 2 25


Always 29 35 14 52 3 27 7 30 2 14 3 37

Sometimes 22 26 4 15 1 9 6 26 8 57 3 37

Rarely 10 12 0 0 1

6 26 2 14 1 12

Never 20 24 8 30 6 54 3 13 2 14 1 12


Registers/records 74 89 23 85 10 91 20 87 14 100 7 87

Availability of drugs 61 73 17 63 4 36 20 87 14 100 6 75

Availability of other logistics

72 87 22 81 10 91 20 87 14 100 6 75.

Others* 45 54 15 56 10 91 10 43 4 29 6 75


153

Annexure – 2: List of sectors used for baseline and number of events observed

BOLANGIR Sl.

No. Sectors BLOCKS VHND(Nos.)

IMNCI (Nos.)

RI(Nos.) Supervisory

Questionnaire(Nos.)

1 LUISINGHA LUISINGHA 4 8 4 3

2 BELGAON SAINTALA 4 8 4 4

3 JAMGAON PUINTALA 4 8 4 2

4 DEOGAON DEOGAON 4 8 4 4

5 GHASIAN PATNAGARH 4 8 4 4

6 AGALPUR AGALPUR 4 8 4 3

7 GAMBHARI BELPARA 4 8 4 4

8 KHOLAN TITLAGARH 4 8 4 3

TOTAL DONE 32 64 32 27

TOTAL PLANNED 32 64 32 32

% ACHIEVED 100 100 100 84.375

NUAPADA

Sl. No.

Sectors BLOCKS VHND(Nos.) IMNCI(No

s.) RI(Nos.)

Supervisory Questionnaire(Nos.)

1 BIRAMAL NUAPADA 4 8 3 3

2 KHARIAR KHARIAR 4 8 4 4

3 KOMNA KOMNA 4 8 4 4



% ACHIEVED 100 100 91.67 91.67

MALKANGIRI Sl. No.

Sectors BLOCKS VHND(Nos.) IMNCI (Nos.)


Questionnaire(Nos.)

1 KHAIRPUT/ MUDULIPADA

KHAIRPUT 1 6 3 1

2 KALIMELA KALIMELA 3 11 3 1

3 CHALNGUDA KORKUNDA 5 9 4 1

4 MATHILI MATHILI 5 8 4 5



% ACHIEVED 87.5 106.25 87.5 50

154

KORAPUT Sl.

No. Sectors BLOCKS VHND (Nos.)

IMNCI (Nos.)


Questionnaire(Nos.)

1 POTTANGI-CH II POTTANGI 4 11 3 2

2 PANCHADA LAKHMIPUR 5 5 3 2

3 DASMANTHAPUR DASMANTHAPUR 2 4 2 3

4 MATHALPUT/ MALIPONDI

KORAPUT 6 9 6 4

5 KOTPAD S B NUAGAON 4 11 5 3

6 BANDHUGAON BANDHUGAON 4 8 3 4

7 NARAYANPATNA NARAYANPATNA 4 8 2 3

8 BALLEL LAMPTAPUT 3 8 3 2



% ACHIEVED 100 100 84.375 71.875

NABRANGPUR

Sl. No.

Sectors BLOCKS VHND(Nos.) IMNCI (Nos.)


Questionnaire(Nos.)

1 TARAGAON NABRANGPUR 4 5 3 2

2 NANDAHANDI NANDAHANDI 4 5 3 3

3 ANCHALGUMMA TENTULIKHUNTI 3 5 2 2

4 KOSAGUMDA KOSAGUMDA 3 10 3 2

5 PAPDAHANDI PAPDAHANDI 6 18 6 3

6 DABUGAON DABUGAON 6 6 5 1

7 UMERKOTE UMERKOTE 2 3 2 1



% ACHIEVED 100 92.86 85.71 50

155

Annexure – 3: Data Collection Tools

Session Monitoring Format for Routine Immunization (for data entry personnel)

For (*) marked questions multiple responses may be

applicable; “NOB” means “Not Observed”

Form No: (_) _ _ / _ _ _ / MMM / YY /_ _ _ _

+

Name of Monitor: Organization: † Govt. † WHO/NPSP † UNICEF † Others Designation: ….………………..

Date : dd / mm / yy Time:…….. Day: † Wed † Others …………….……………….…

Last Polio SIA date…………………….…….

State code (see back)

District

Block/ Urban Local Body

Planning Unit

Sub Center / Urban Health Post

Setting:

† Rural † Urban

Name of session site

Polio HRA : †Yes † No

*Reason for monitoring1 †HR †MG †SL †XR †VS Type of † Fixed site † Outreach

this session site: †MOB †VDPV †WPV †OTH Session Site: †Sub Centre †Others †Sub Centre †ICDS Centre †Others

T

Q1 to Q 24: Observe and ; Tick, whichever is applicable

a) Is session held : †Yes †No

b) If session is not held, reason for session not

held2 : † A2 † B2† C2† D2 ……………..……..

1 If session is not held,

please stop session monitoring and go for house‐to‐house monitoring

c) If session is held, is session as per plan :

† Yes † No

2 Is the session happening with Village Health & Nutrition Day (VHND)?

† Yes † No

3 Who has brought vaccines & logistics to this session site: † Alternate Vaccine Delivery (AVD) † ANM † Supervisor † Others ………

4

a) Vaccines & diluents kept in Vaccine Carrier (VC) : † Yes † No

b) Vaccines & diluents in zipper bag: †Yes † No

c) How many icepacks are in the Vaccine Carrier : † Four † Less than four

Which of the following vaccines/diluents are available at session site

5*

BCG ‐ †Yes †No BCG Diluent ‐ †Yes †No DPT ‐ †Yes †No JE ‐ †Yes †No

Measles ‐ †Yes

†No

Measles Diluent ‐

†Yes †No

DT

‐ †Yes

†No

J E Diluent ‐ †Yes †No

tOPV ‐ †Yes †No Hepatitis B ‐ †Yes †No TT ‐ †Yes †No Pentavalent ‐ †Yes †No

6* Has ANM recorded the following

† Vaccine Batch No † Vaccine Expiry date † Diluent batch † Diluent Expiry date

Observe vaccines vials ANM is using † Without label…………………….………... † Unreadable label …………………………………….……..

or going to use (unopened vials in

† VVM Stage III or IV (Unusable)……….. † Expired Vaccine Vial ………………...................

7* VC). Is any vial found in the † Frozen Vaccine (DPT, TT, Hepatitis–B,

DT) ……………………………………………

mentioned condition?

if ‘Yes’, † BCG/ † Measles vaccine reconstituted

more than 4 hours back………….

Tick ; and record vaccine details † JE vaccine reconstituted more than 2 hours back…………………………..

Which of the mentioned Logistics are

adequately available (if unavailable or inadequate, tick no)

8*

AD (0.1ml) Syringes ‐ †Yes †No 5ml Reconstitution Syringes ‐ †Yes †No Blank RI Card ‐ †Yes †No

AD (0.5 ml) Syringes ‐

†Yes †No Vitamin‐A Solution

‐ †Yes †No Counterfoils ‐ †Yes †No

Which of the mentioned Logistics are available

9* ORS Packet ‐ †Yes †No Plastic Spoon/cap for Vit‐A †Yes †No Nutritional Supplements : †Yes †No Weighing

Paracetamol ‐ †Yes †No

Tracking Bag ‐ †Yes †No

Zinc Tablet : †Yes †No

machine:

B P Apparatus ‐

†Yes †No Functional Hub Cutter ‐ †Yes †No IFA Tablet : †Yes †No †Yes †No

156

10 Is due list available with the ANM † Yes † No † NOB

11 Is due list available with the Mobiliser † Yes † No † NOB

12

Has ANM written time of reconstitution on reconstituted vial/s † Yes † No † NOB

13* Which kind of syringe Is ANM using to inject vaccines † AD syringe †Glass syringe † Disposable Syr † NOB

14 Is DPT vaccine given on outer (anterolateral) aspect of mid thigh † Yes †Others site…………………………………….…… †NOB

15

Route of Measles vaccine given † Sub Cutaneous † Intra Muscular † Intra Dermal † NOB

16 Site of Measles vaccine given † Right Upper Arm † Others † NOB

17 Is ANM touching any part of the needle while giving injection † Yes † No † NOB

18 Is ANM following “no recapping” procedure after giving injection † Yes † No † NOB

19 Is ANM cutting each syringe with hub cutter just after use † Yes †No † NOB If No,Why

3:†A3 †B3 †C3 †D3

20 How is ANM segregating immunization waste † Red & Black bag † others † Not done † NOB

21 How is ANM recording after vaccinating each child † No record † Tally sheet † Others________ † NOB

22 Is ANM delivering all 4 Key Messages to the care‐givers (see

back) † Yes † No † NOB

23* If 4 Messages are not delivered, the most commonly missed message † Message 1 † Message 2 † Message 3 † Message 4

24 Is ANM advising the care‐givers to wait for 30 mins after vaccination † Yes † No † NOB

Q 25: Interview three caregivers

25 Who has mobilized you to this session site4? Caregiver 1 Caregiver2 Caregiver 3

Q26 to Q 29: Ask the ANM/ Vaccinator following questions and Check the records, if needed

26 a) Will you vaccinate,

If a child comes with mild fever ? † Yes † No

b) Will you vaccinate, If a child comes with loose motions ?

† Yes † No

27 How do you dispose off the immunization‐waste 5 ? † A5 † B5 †C5 †D5

28* Has any supervisor visited you in last 3 months ? † None † Health Supervisor † MO † Others……………..

29 How many sessions have you planned and conducted in last 3 months ? Planned……………, Conducted……………..

30

If, any Vaccine or logistic is not available or ANM is absent, please visit the PHC to ascertain the reason of non‐availability:

…………………………………………………………………………………………………………………………………………………………………………………………………………..

1. Response keys for “ Reason for monitoring ”

HR= Hard to reach, MG= Migrant, SL= Slum, XR= Refusing community, VS= Vacant Sub

Centre,

MOB= Measles Outbreak in last 1 year

VDPV= Vaccine derived Polio Virus detected ever in the area, WPV= Wild Polio Virus in last 3 yrs, OTH=Others

2. Response keys for “ Q1b”

A2= Neither ANM/ Vaccinator nor vaccines/logistics is

available, B2= ANM/vaccinator present but vaccine/logistics not

available,

C2 = Vaccine / logistics available but ANM / vaccinator absent, D2= Others

(specify);

3. Response keys for “ Q 19”

A3= Hub‐cutter not available, B3= Hub‐cutter not functioning, C3=Untrained

ANM, D3= Others,

4. Response keys for “ Q

25” 1= ASHA, 2= ICDS worker, 3= ANM, 4= SHG, 5= PRI personnel,

6= NGO, 7= Relative/Neighbor, 8= CMC, 9 = others, 10= None

5. Response keys for “ Q

27” A5= Dumped near session site, B5= Carried to

PHC, C5= Open burning, D5= Others

157

VHND Session Monitoring Format (Modified for Odisha in 2012-13)

Monitor’s Name: ……………………..

Dept. / Organization:

Govt. UNICEF Others

Designation: ………………………….

Date of visit: …….. / …… /……….. Time of visit: ………………………… Day: Tue Fri Other …………

State

District

Block/Planning Unit

Sub Center/ Urban Post

Area/village

Settings: Rural Tribal Urban Urban Slum Session Site: Sub Centre AWC Others ……

Numbers by category of target group

Plan: Pregnant women _____Lactating women_____ Children 0-6mon._____Children 6mon-3 yrs. ____Children 3-6yrs_____

Actual: Pregnant women _____Lactating women_____ Children 0-6mon._____ Children 6mon-3 yrs. ____Children 3-6yrs_____

Tick whichever is applicable

1. Whether Session is held Yes No

If ‘No’, Reason for not holding the session

(See bottom of the page)

A B C D

If ‘Yes’, whether the session being held as per Micro

plan

Yes No

2. Who all are present at the VHND site? MPHW(F) MPHW(M)

AWW ASHA

AWH

Member of GKS/PRI

Health Supervisor

ICDS Supervisor

Any other (specify) ……….

3. Are beneficiaries being mobilized to session site by

(See bottom of the page) £

ICDS worker ASHA Others None

4. Which of the

mentioned

logistics are

available at

session site*

Examination table

Screen for Privacy

BP Instrument

Stethoscope

Foetoscope

Inch tape

MUAC tape

Weighing scale (adult)

Weighing scale (baby)

Haemoglobin testing

Kit / Talquist paper

Needle/Lancet

Nischay kit

ORS Sachets

Zinc tablets

Albendazole tablets / Syrup

Anti-malarial tablets/ Syrup

Cotrimoxazole tablets

Paediatric Paracetamol

IFA Tablets (large)

IFA Tablets (small)

IFA syrup

Urine testing kit / Uristix

RDK kit

Condoms

Oral Contraceptives

Emergency contraceptive

Pills

Gentian violet lotion

Test tubes

Hand gloves

Toilet

Water Supply

Soap

Red bag for disposal

Cotton bandage

Absorbent cotton

IMNCI chart booklet

Blank MCP Cards

Referral cards

Monthly topic calendar

Due list of beneficiaries

Reporting format

5. Are Reproductive & Child Health related IEC

materials displayed at site?

Banner Wall writing Tinplate Poster

Flip chart Pamphlets Other None


A =Both ANM as well as logistics are not available B= ANM present but logistics not available C= Logistics available but ANM absent, D=

others (specify) £ Multiple responses may be applicable AVD= Alternate vaccine delivery

158

6. Is relevant history (obstetric/past/family/menstrual) elicited especially for women coming

for the first antenatal check- up?

Yes No N/A

7. Is privacy during examination ensured (by way of separate cabin/curtains/ sheet)? Yes No N/A

8. Is the Blood pressure of pregnant woman measured properly and recorded in MCP card? Yes No N/A

9. Is Haemoglobin examination done and recorded in MCP card? Yes No N/A

10. Is Urine examination done for estimating Albumin/Protein and recorded in MCP card? Yes No N/A

11. Is the pregnant woman weighed and the weight recorded in MCP card? Yes No N/A

12. Is abdominal palpation for determining fundal height, foetal lie etc., done and recorded? Yes No N/A

13. Is the foetal heart sound examined / auscultated and recorded in MCP card? Yes No N/A

14. Are Antenatal women provided IFA tablets and counseled? Yes No N/A

15. Is advice for next antenatal check-up provided along with dietary and relevant counseling? Yes No N/A

16. Are women communicated on danger signs and action to be taken suggested (Refer MCP

card)

Yes No N/A

17. Are women referred to F-ICTC after counseling on PPTCT for blood test? Yes No N/A

Child Health Service Delivery

18.

Is appropriate advice / counselling related to the following aspects done?

Breast feeding and complementary feeding (Refer MCP Card Page No.4 & 8)

Yes No N/A

Dietary counselling for children (Refer MCP Card Page No.4, 8 &10) Yes No N/A

Need for supplementation with IFA and Vitamin A Yes No N/A

Danger signs in newborns and older children for which care is to be sought immediately and place of referral (Refer MCP Card Page No.7)

Yes No N/A

19. Are infants / children up to three years age weighed and weight recorded in MCPC card? Yes No N/A

20. Was demonstration on preparation of ORS done? Yes No N/A

21. Was demonstration of and washing and hygiene practiced? Yes No N/A

Family Planning Service Delivery

22. Is family planning counseling provided to eligible women/couples on various spacing and

permanent methods?

Yes No N/A

23. Are contraceptives provided to the beneficiaries? Yes No N/A

Counselling

24. Did ANM/AWW/ASHA conduct group meeting with any of the target group?

Women Men

Yes No N/A

25. What was the monthly

topic for group

counselling /

discussion?

Maternal Health, Four ANC, Tetanus Immunization, IFA

supplementation, Danger signs of pregnancy, Birth

preparedness, Institutional Delivery & JSY Antenatal Care (Refer

MCP Card Page No.2 & 3)

PNC: Danger signs, bleeding, P.V, Anemia, Breast feeding etc

(Refer MCP Card Page No.5)

Care of New born, Immunization, Importance of Post natal

visit (Refer MCP Card Page No.4 & 7)

Heat wave preparedness and prevention of communicable

diseases like TB, Leprosy

Age at marriage, Prevention of STI & RTI, HIV & AIDs, Prenatal

Sex selection

Prevention and home management of Diarrhea, Hand

washing, Safe drinking water, sanitation and personal hygiene

(Refer MCP Card Page No.12)

Prevention and treatment of malaria, IRS, ITBN

Exclusive Breast Feeding,

weaning and complementary

feeding and young child feeding

(Refer MCP Card Page No.4 & 8)

Growth monitoring, Growth

faltering, referral &

treatment(Refer MCP Card Page

No.4,8,9,10 & 11)

Importance of Vitamin A, ID

Disorders and Anemia control

ARI, Danger signs and early

referral

Birth Spacing &

contraceptive devices

Others(Specify)__________

26.

Any Specific Observations/facts/findings :

Verification of MCP Card Record keeping for Lactating Mothers (0-6 months) Component to be correctly maintained (Page Nos. of MCP

Card)

Mother 1 (MCP

Card)

Mother 2 (MCP Card) Mother 3 (MCP Card)

37 Important phone numbers Yes No Yes No Yes No

38 ANC and Counselling(Page-1,3) Yes No Yes No Yes No

39 PNC of Mothers(Page-5) Yes No Yes No Yes No

40 PNC of New born 0-2 months(Page-6) Yes No Yes No Yes No

41 Illness history of children 2mon-5yrs(Page-6) Yes No Yes No Yes No

42 Up to date growth monitoring of child (Page-9 or 11) Yes No Yes No Yes No

43 Is the MCTS code recorded in MCP card Yes No Yes No Yes No

159

Signature of the Monitor with date : Signature of the ANM with date : Signature of the AWWs / ASHAs with date :

Interaction with ANC Mothers Components to be Interacted in details ANC Mother 1 ANC Mother 2 ANC Mother 3

27 When did you register yourself for ANC

Within 12 weeks

After 12 weeks

Within 12 weeks

After 12 weeks

Within 12 weeks

After 12 weeks 28 Have you received MCP Card on your

registration?

Yes No Yes No Yes No

29 Have you received any kind of counselling Yes No Yes No Yes No

30 If yes, What is the importance of IFA for

health

Aware Not aware Aware Not aware Aware Not aware

31 What is the diet you should be taking


32 What are the danger signs you should be

aware about


33 Are you aware about Exclusive breast feeding

and its importance


Interaction with Lactating Mothers (0-6 months) Components to be Interacted in details Lactating Mother 1 Lactating Mother 2 Lactating Mother 3

34 Where did you deliver your child Institution Home

by SBA Non SBA

Institution Home

by SBA Non SBA

Institution Home

by SBA Non SBA 35 Are you aware about complementary feeding Aware Not aware Aware Not aware Aware Not aware

36 Are you aware about Birth spacing and family

planning


160

IMNCI supervision format

Name of the worker_______________________________ Designation: AWW HWFOther

Facility: AWCSC PHC:_________________ Block:___________ District:____________

Name of Supervisor: ______________________________ Date of visit:____________

Designation: AYUSH MO LHV ICDS Supervisor Other ___________________

Sl Component Put a tick mark ()

I. Record review

1 Number of live births in last 3 months in the AWC/SC area (verify from birth

register)

2 Number of newborns born in last 3 months who have received 3 (or 6) home

visits (verify from home visit register/ any other register maintained)

3 Home visits for all newborns born in last 3 months performed timely as per

IMNCI1

No-0 Yes-1Nap-99

4 All IMNCI case assessment sheets are completely and correctly filled2 No-0 Yes-1Nap-99

5 All sick cases needing urgent referral after assessment in IMNCI have been

referred3

No-0 Yes-1Nap-99

6 Referral slips for IMNCI are properly and completely filled up No-0 Yes-1Nap-99

7 IMNCI monthly reporting forms are properly maintained4 at the AWC No-0 Yes-1Nap-99

II. Skill of worker

A- While assessing newborn 0-2 month (Use annexure 1)

8 Correctly assessed a young infant (0-2 mon) No-0 Yes-1Nap-99

9 Correctly classified the young infant5 No-0 Yes-1Nap-99

10 Correctly identified treatment for the young infant

6 No-0 Yes-1Nap-99

11 Correct counseling skills are present

7 No-0 Yes-1Nap-99

12 Child needed referral is referred after giving pre-referral treatment

8 No-0 Yes-1Nap-99

13 Immunization status of the young infant correctly assessed9 No-0 Yes-1Nap-99

B- While assessing child 2 mon-5 years (Use annexure 1)

14 Correctly assessed a child 2mths to 5 years No-0 Yes-1Nap-99

15 Correctly classified the child6 No-0 Yes-1Nap-99

1 Home visits done as per IMNCI means the child is assessed on days 1,3,7 for a normal and 6 visits on days 1,3,7,14,21 and 28

for a LBW baby using IMNCI format 2 All IMNCI Case sheets correctly and completely filled means sheets are filled from top to bottom with at least one classification

for 0-2 mon and at least 2 classifications for 2 mon to 5 years and treatment as per classification 3 Needing referral are referred means those children in red color coded category. Verify from referral slips

4 Reporting formats are properly maintained means month wise reports are available at the AWC and signature of the ANM

confirms receipt of the report by the ANM 5 Correctly classified refers to correct classification based on signs and symptoms assessed by the worker and using an IMNCI

chart booklet 6 Correctly identified treatment refers to treatment based on the classification of the worker and after using an IMNCI chart

booklet 7 Correct counseling skills are present only if skills are present and also uses the chart booklet for referring while giving advice

8 Only for red/pink color coded category cases of sick children

9 Immunization status correctly assessed if MCP/ Immunization card used or records referred for confirmation or mother is sure

161

16 Correctly identified treatment for the child7 No-0 Yes-1Nap-99

17 Correct counseling skills are present8 No-0 Yes-1Nap-99

18 Child needed referral is referred after giving pre-referral treatment 10

No-0 Yes-1Nap-99

19 Immunization status of the child correctly assessed No-0 Yes-1Nap-99

III. Facility support [Put a tick mark () against those available]

20 IMNCI board 24 Zinc tablets 30 IMNCI forms for 0-2 mon

21 Salter scale / child

weighing scale

25 IFA tablets 31 IMNCI forms 2 mon to 5 yrs

22 One litre jar, cup and

spoon

26 Gentian violet paint/

powder

32 Referral slips

23 Ped Cotrimoxazole

tab/syp

27 MNCI chart booklet 33 Reporting forms

24 Ped Paracetamol tab/syp 28 IMNCI Module

25 ORS 29 IMNCI Photo-booklet

Annexure 1: Assessment of IMNCI skills of the worker

IV. Mark the correct skills11

with a tick mark ()

Sl A- Skills for a Child 0-2 months in Sl B- Skills for a Child 2 mon- 5 years

1 - Assessing possible serious bacterial infection 1 - Assessed General danger signs

2 - Convulsion 2 - Not able to drink or breastfeed

3 - Fast breathing 3 - Vomit everything

4 - Chest in-drawing 4 - Convulsion

5 - Nasal Flaring 5 - Lethargic or unconscious

6 - Pustule 6 - Asked for Cough or difficult breathing

7 - Temperature 7 - Fast breathing

8 - Lethargic or unconscious 8 - Chest indrawing

9 - Decreased movement 9 - Asked for Diarrhoea

10 - Assessing Diarrhoea 10 - Restless and irritable

11 - Blood in stool 11 - Sunken eyes

12 - Lethargic or unconscious 12 - Able/ Not able to drink/ Drinking eagerly/ Thirsty

13 - Restlessness/irritability 13 - Skin pinch

14 - Sunken eyes 14 - Diarrhoea for 14 days or more

15 - Skin pinch 15 - Blood in stool

16 - Assessing Breastfeeding 16 - Assessed Fever

17 - Difficulty feeding 17 - Stiff neck

18 - Not able to feed 18 - Fever present for more than 7 day

19 - Less than 8 breastfeeds in 24 hours 19 - Assessed Malnutrition

20 - Received other foods or drinks 20 - Visible severe wasting

21 - Attachment 21 - Oedema of both feet

22 - Suckling 22 - Grade of malnutrition (red/ yellow/ green)

23 - Oral thrush 23 - Assessed Anaemia

24 - Assessing Immunization 24 - Severe palmar pallor

25 - Assessing other problems 25 - Some palmar pallor

10

Only for red/pink color coded category cases of sick children 11

If left out or incorrectly done or wrong procedure followed take it as incorrect skill and do not put a tick mark against it. If any

of the skill could not be assessed for reasons such as child not being ill in that regard etc., kindly check if the worker has the

requisite skill before saying that the worker has got correct skills.

162

26 - Classification 26 - Assessed Immunization

27 - Treatment 27 - Assessed Feeding

28 - Referral of severe cases 28 - Not Exclusive breastfeeding (for less than 6 mon

infant)

29 - Given antibiotic for local infection 29 - Using bottle to feed to child

30 - Given ORS solution in facility 30 - Child is not fed actively

31 - Advise on home care 31 - Child is fed less frequently

32 - Explained signs for when to return immediately 32 - Child is fed less quantity of food

33 - Advised follow-up care 33 - During illness child is fed less quantity of food

34 - Counseled on breastfeeding 34 - Assessed other problems

35 - Next date for immunization 35 - Classification

36 - Checking mother’s/caretaker’s understanding 36 - Treatment

37 - Referral of severe cases

38 - Given antibiotic for pneumonia

39 - Given ORS solution in facility

40 - Advise home care

41 - Explained signs for when to return immediately.

42 - Advised follow-up care

43 - Next date for immunization

44 - Counseling on feeding

45 - Checking mother’s/caretaker’s understanding

Comments:

163

INTERVIEW SCHEDULE

(MPHS-F/MPHS-M/ICDS Supervisor/AYUSH MO/Sector MO)

Details of Interview:

I. Name of the Interviewer: IV. Sector:

II. Date of Interview: V. Block:

III. Place of Interview: VI. District:

Personal Profile of Respondent:

1. Respondent Code:----------------------------- 2. Designation:

a) MPHS-F b) MPHS-M c) ICDS Supervisor b) AYUSH MO e) Sector MO

3. Age (years):------------------------------------

4. Sex:

a) Male b) Female

5. Marital Status: a) Unmarried b) Married c) Widowed d) Divorced/separated

6. Education Level:

a) Matriculation

b) Intermediate

c) Graduation ------------------------------

d) Post Graduation------------------------

e) Others (specify)-------------------------

7. Number of years of experience as a Supervisor: ----------------

8. Number of years of service as a supervisor in the current place of posting:------------- Overall Assessment:

9 Total number of sectors assigned:

Q Attribute Sector l Sector ll 10 Catchment area (population):

11 No of Sub Centres under the Sector:

12 No of supervisory visits made last month:

Page 1 of 6

164

Q Attribute Sector l Sector ll

13 No of supervisory visits made in last one

month on IMNCI

14 No of filled-in IMNCI supervisory checklists

submitted to Block level, last month


month on RI

16 No of filled-in RI supervisory checklists



month on VHND

18 No of filled-in VHND supervisory checklists


Below are the questions (19, 20, 21) related to feedback received from your Supervisor. Please give your opinion.

19. IMNCI 20. RI 21. VHND

a. Frequency

i. Always

ii. Sometimes

iii. Never b. Method

i. Verbal ii. Written

c. Place

i. Sector meet ii. Block meet iii. OJ training

22. Do you get any support from your supervisors while providing services in hard to reach areas? a) Yes No)

23. If answer to the earlier question is ‘yes’ please mention what kind of support you are getting from your supervisors and how frequently you provide RI, VHND and IMNCI services in Hard to reach areas of your sector? _______________________________________________________________________

_______________________________________________________________________

24. In your view who all are the stakeholders in RI, IMNCI and VHND.

_______________________________________________________________________ _______________________________________________________________________

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165

Routine Immunization:

Which of the following activities are you directly involved in? (Please tick Y/N appropriately)

Sl.No Questions Yes/No

25 Preparation of RI micro-plan?

26 Provide On job training to ANM on Micro-plan Preparation?

27 Verify Sub Center level RI Micro-plan during final compilation?

28 Verify sessions planned Vs held in your sector?

29 Monitor Counterfoils in the session site?

30 Verify session Log Book of ANM at the session site?

31 Regular indenting in your sector for RI?

32 Conduct review meetings at Block level?

33 Conduct review meeting at District level?

34 Monitor the cold chain maintenance system at session site

35 Monitor the cold chain maintenance system at ILR point

36 Are you getting transportation support for RI supervision?

37 Are you getting financial incentives for RI supervision?

38. Do you have any Left out /Drop out cases of RI in your Sector?

a) Yes b) No

39. If the answer to the earlier question is ‘yes’, what steps have you taken in last three months to address this issue?

___________________________________________________________________________

___________________________________________________________________________

40. Was there a Vaccine or equipment stock out during last 3 months in your sector? a) Yes b) No

41. If yes, which of the following categories of items had a stock out in last three months? a) Vaccines b) Drugs c) Other logistics

42. What according to you are the factors behind this stock out? ___________________________________________________________________________

___________________________________________________________________________

43. What steps did you take to address this issue of stock out? ___________________________________________________________________________

__________________________________________________________________________

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166

44. Do you use the supervisory checklist?

a) Always b) Sometimes c) Rarely d) Never

45. How familiar are you with the RI supervision Checklist?

a) Poorly b) Somewhat c) Fairly d) Very well familiar

46. What in your perception are the factors for drop-outs / left-outs in your sector area (multiple responses possible)? a) Illiteracy b) Improper programme planning

c) Poor quality of services d) Cultural barriers e) Others (specify)-------------------

47. How do you address the Drop-out and Left-out population of your sector? ________________________________________________________________________ _____________________________________________________________________

Integrated Management of Neonatal and Childhood Illnesses: (Please tick Y/N appropriately in Questions 48-58)

Sl.No. Questions Yes/No

48. Are you familiar with IMNCI Supervision Check list?

49. Do you have any role in preparing integrated supervision plan?

50. Are you aware of the reporting system under IMNCI?

51. Do you know about referral services Under IMNCI?

52. Do you get transportation support for IMNCI Supervision?

53. Was there any IMNCI drug Stock out during last 3 months in your sector?

54. Do you ensure regular indenting in your sector for IMNCI?

55. Do you verify IMNCI centres supervised Vs planed in your sector?

56. Whether IMNCI programme is reviewed at Sector level review meetings

every week?

57. Whether IMNCI programme is reviewed at Block level review meetings every

month?

58. Have you received FUS training on IMNCI?

59. Do you use the supervisory checklist during supervision for IMNCI supervision?


60. Please specify what kind of role you play in preparing integrated supervision plan?

_________________________________________________________________________

________________________________________________________________________

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167

61. Briefly mention about the flow of IMNCI reporting?

_________________________________________________________________________

_________________________________________________________________________

62. What components of IMNCI programme do you supervise during your supervisory visits (Multiple

responses may be made)? a) Registers b) Assessment forms c) Referral slips

d) Drugs e) other logistics (Pls. Specify)--------------------------

63. After assessment of a child using IMNCI protocol, how do you refer, if required?

_________________________________________________________________________

_________________________________________________________________________

Please give answer to Questions 64-66 on number of children classified, treated and referred in last three months? (Respondent may refer to reports/records)

Age group 64. Classification 65. Treatment given 66. Referred

done

0-2 months

2 months – 5 years

67. What all are the drugs that should be made available in the IMNCI kit? ________________________________________________________________________ ________________________________________________________________________

Village Health and Nutrition Day:

Sl.No. Questions Yes/No

68. Do you have a VHND micro-plan at your sector level?

69. Do you provide training to ANM/AWW on Micro-plan Preparation for

VHND?

70. Do you Verify the Sub Center level VHND Micro-plan and Guide the

ANM/AWW as per need?

71. Do you Compile and finalize VHND Micro-plan at Sector level?

72. Do you review the VHND reports in your sector?

73. Do you verify the VHND session plan Vs held in your sector?

74. Do you receive any transportation support for session monitoring?

75. Whether VHND programme is reviewed at Sector level review meetings

every week?

76. Whether VHND programme is reviewed at Block level review meetings every

month?

Page 5 of 6

77. How familiar you are with VHND supervision checklist?

a) Not aware at all b) Somewhat familiar

b) Fairly familiar d) Very well familiar

78. Do you use the supervisory checklist for VHND supervision?


79. Briefly mention about the flow mechanism of VHND monthly reporting system ________________________________________________________________________

________________________________________________________________________

80. What all components of VHND programme do you supervise?

a) Registers / records b) Availability of drugs

c) Availability of other logistics c) Others (specify) -------------------

81. What are the equipments and drugs that need to be available at VHND session site? ________________________________________________________________________

________________________________________________________________________

82. Was there any instance of drug stock-out in VHND session in last three months?

a) Yes b) No

83. If ‘yes’, what steps did u take to address this issue? ________________________________________________________________________

84. Which key indicators do you review during the monthly VHND review meetings?

________________________________________________________________________

________________________________________________________________________

THANK AND CLOSE THE INTERVIEW

Page 6 of 6

baseline report-evidence based ri, vhnd and imnci service delivery through health system...

Healthcare