Health Development in Gram Panchayats
Active Panchayat Series Book VII
West Bengal ABOUT THIS BOOK
ost public health services are delivered by the Health Department of the State Government that is not directly accountable to the Gram Panchayats. Nevertheless, Gram Panchayats are expected to monitor the access and quality of delivery of those services. Elected Representatives Mmust have the knowledge and skills to monitor the quality of services being delivered so as to ensure that no one is left unreached, and must have the competence and confidence to hold officials, service providers and frontline functionaries of the Department accountable.Every State provides for capacity building of Gram Panchayats to enhance their knowledge and skills about the various services being delivered so that they can mobilize the people to access the services, take part in awareness generation drives, effectively supervise the existing health initiatives and ensure that the ongoing activities are properly implemented. The book Health Development in Gram Panchayats will enable Elected Representatives and functionaries of the Gram Panchayat to be informed about their responsibilities and to take action at the community level to improve health status of people in the GP area. In this book we will focus specifically on building the understanding of the Elected Representatives on health, the health system and the role of the Gram Panchayat in health and its related social and environmental determinants. The structure of the book is as follows: Chapter 1provides a broad overview of health, its determinants and a discussion of the role of the Gram Panchayat. In second Chapter, the health system and the key national health programmes have been discussed. Chapter 3, contains a brief overview of the various institutions within the Panchayati Raj System, their roles and responsibilities and the interface with community and facility level structures within the health system. Chapter 4 discusses specific actions to be taken by the Gram Panchayat to improve health in the GP area, with special focus on the health needs of women, children, elderly, persons with disability etc. In Chapter 5, response of the Gram Panchayat to health needs during emergency has been given. Chapter 6details out the role of the Gram Panchayat in Planning for Health by Gram Panchayat and in the last Chapter i.e. Chapter 7 Governance and Accountability including monitoring role of Gram Panchayat has been discussed. The book will be helpful in rolling out Sustainable Development Goals related to health, most specifically SDG-3 at Gram Panchayat level.
CONTENTS
Chapter-1 07 Understanding Health Chapter-2 15 Health Systems and National Health Programmes Chapter-3 30 Institutions of Gram Panchayat and their Collaboration with the Health System Chapter-4 37 Primary Health Care and the Role of Gram Panchayat Chapter-5 54 Health During Emergency and the Role of Gram Panchayat Chapter-6 58 Health Planning by the Gram Panchayat Chapter-7 65 Role of Gram Panchayat in Coordination and Monitoring for Health Annexure 1 71 List of indicators – Swasth Panchayat Yojna, Chhattisgarh Annexure 2 72 Key components of the National Health Mission Annexure 3 77 National Immunization Schedule Annexure 4 78 Public Services Monitoring Tool Annexure 5 80 Checklist for Village Health Nutrition Day Annexure 6 82 Checklist for Assessing Quality of Services at Health Facilities Abbreviations 84
It is the health that is real wealth and not pieces of gold and silver. – Mahatma Gandhi Health Development in Gram PanchayatsCHAPTER Active Panchayat Series Book VII1
Understanding Health Health is a state of complete physical, mental and social wellbeing and not merely the absence of diseases or infirmity that enables one to lead a socially and economically productive life. -World Health Organisation (WHO)
ealth is a condition of being well enough to function well physically, mentally and socially. Good health is something that we all want, and we are unhappy when we do not have it. Without good health, we cannot do all the things that we wish to Hdo in life. When we are healthy, we can walk a lot, run, climb stairs or hills and do our day to day work easily. When we are not healthy, doing these things becomes difficult or even impossible. Good health not only makes us happy and cheerful, it also increases our efficiency for doing good work. For a person to be called a healthy person, it is important that s/he is both physically as well as mentally healthy. In this introductory chapter of the book, we will learn about the pre- requisites for good health as well as the factors that cause ill health; communicable and non-communicable diseases and socialand environmental determinants of health. We will also build our
7 Health Development in Gram Panchayats Active Panchayat Series Book VII understanding about the critical aspects that you as Elective Representatives need to know like the idea of public health, out of pocket expenditure on health care and right to health as means of social justice. Towards the end of the Chapter, we will learn the broad roles of Gram Panchayats in ensuring good health of people in the Gram Panchayat (GP) area and also in addressing the social and environmental determinants. Specific roles of Panchayats in different areas of health will be detailed in the following chapters.
1.1 Pre requisites for good health and factors for ill health Pre requisites for attaining good health Key Factors that contribute to ill health – Healthy food for good nutrition – Malnutrition – Safe drinking water, sanitation, and – Unsafe water and lack of sanitation housing – Unhealthy living conditions – Clean environment, healthy living – Open defecation conditions and health lifestyle – Hard labour and unsafe work environment – Access to better health services – Mental stress – Education and awareness – Patriarchy where women’s health is not – Social security measures and proper given priority and equal wages – Lack of access to health services – Freedom from exploitation and – Lack of health education discrimination – Drug addiction – Protected work environment – Poverty and ignorance – Relaxation, recreation and healthy relationships – Poor or no family or social support
1.2 Communicable and non-communicable Diseases: An illness due to a specific infection directly or indirectly transmitted from man to man, animal to man or from the environment to man through direct contact, air, dust, soil, water, food, etc. is called a communicable disease. The common communicable diseases are – Malaria, Typhoid, Hepatitis, Diarrhoea, Amoebiasis, Influenza and Tuberculosis (TB) etc. Non-Communicable diseases (NCDs), also known as chronic diseases, are not passed on from person to the other but they are generally of long duration- like heart attacks and strokes, cancer, asthma, obesity and diabetes etc. Unhealthy life style like use of tobacco, lack of physical activities, unhealthy diet and the excessive use of alcohol increase the risk of NCDs. Both communicable and non-communicable diseases can be threats to human health and human development. We will learn more about various components of communicable and Non-Communicable diseases and their management in the following chapters.
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In this context, it is important to know what public health is. Public health refers to the set of measures that need to be taken at the community/ Gram Panchayat level to ensure good health of all in the area like reducing exposure to diseases, control of infections, prevention of life-style diseases and promotion of good health, hygienic practices, adequate nutrition, providing safe drinking water and maintaining good physical and social environment. Thus it is not concerned with mere illness of any individual but overall health status of the people of the area and with appropriate actions for improvement of their health status. We will learn in detail about public health and public health programmes in the next Chapter.
1.3 Social Determinants of Health While the immediate factors leading to ill health would include infections through germs/ bacteria/ viruses, injuries, use of harmful/toxic substances and unhealthy living and food habits etc., number of social as well as environmental determinants play crucial role in determining the health of people in our villages and cities. Social factors can be such as lack of access to healthy living conditions and poor access to health services for vulnerable people. Let us understand these from example below. Tuberculosis is caused by the Tuberculosis bacteria, and that same bacteria can cause Tuberculosis (TB) to any person whether a rich or a poor. But the social and economic circumstances of the individual will affect her or his recovery from this disease. A rich farmer or a person with a regular salary and some savings may be able to take leave, will be able to take healthy food, regular medicines adequate rest and also necessary support from his family and community and all this will help him in timely recovery. On the other hand, a poor casual worker who does not have his own land, regular income and financial support from the family, may not be able to have good nutrition and adequate rest, collect the medicines in time and also visit the doctor/ health centre for regular medical check-ups. This will slow down his or her recovery accordingly. Prolonged illness for a poor person may also result in the family spending all their savings or even falling into a debt trap. Ignoring the treatment may lead to unnecessary suffering and death while selling property or taking debts may end a family’s hope of ever coming out of poverty. Habitations of poor, those from lower castes or minority communities are generally far away from the main populationand also from the key facilities including health facilities in the village.
A majority of women in India suffer from Anaemia i.e. deficiency of red blood cells in their body that causes fatigue, shortness of breath, lightheadness, dizziness or a fast heartbeat. Anaemia amongst pregnant women can be the reason for pre term or low birth weight babies. As per National Family Health Survey -3, it was found that 59 percent women in India suffer from Anaemia during pregnancy.
It is also a fact that a woman often suffers with the same disease more than a man would suffer. Women often find it difficult to take time off from their daily houseworkand avail the health services. Generally, their health needs are considered last priority and
9 Health Development in Gram Panchayats Active Panchayat Series Book VII they also do not have much say in using the household money on themselves without permission from the elders and male family members. As a result, their health problems get diagnosed much later, mostly when their falling health conditions become visible to others. Due to never ending household responsibilities, women also find it difficult to take adequate rest during illness. Despite the fact that women have to bear children, in most of the Indian families, they often eat after everyone in the family has eaten. In addition, many of them are subjected to violence within the family which affects their physical and mental health significantly. Thus it is clear that the same disease can have different impacts on the individuals and their families depending on their varied social circumstances. Environmental determinants also play crucial role in health status of people. These include lack of regular supply of clean drinking water, poor sanitation, air pollution, dirty surroundings etc., which promote the growth of flies and mosquitoes mainly responsible for causing diseases. Similarly due to non-use of toilets and defecating in open, disease causing worms that are excreted in the faecal matter mix in the soil and can infect others who walk along that way and / or infect vegetables grown on that soil.
There are many unhealthy occupations that cause illness and long-term health problems. For example, people working in glass and bangle factories or those in bidi rolling jobs are vulnerable to diseases like asthma and TB. Some occupations like working in factory or on big heavy machines can cause injuries and accidents. Exposure to toxic substances like pesticides used during agriculture, chemicals used in manufacturing industries, or exposure to dust during mining and in stone cutting activities can cause serious health damages and affect vital parts of our body. Similarly, those handling chemicals or working in fire crackers or match box making etc., can get skin diseases. Poor people are more vulnerable to such occupational health hazards due to limited opportunities for livelihood and lack of choice for work.
1.4 Challenges in Health Care As we learnt above, challenges in accessing heath care may include various factors like poverty, illiteracy and ignorance, poor social status of a person or a community, non-availability of health services in nearby areas and social taboos etc. In some male dominated societies, nutrition and immunisation are not considered important for girl children. Similarly, widows are not allowed to eat more than one cooked meal a day in some areas. Personal health of people also depends on efforts for cure of disease and right kind of self- care. It includes healthy personal hygiene practices to prevent infection and illness such as regular bathing and washing hands with soap, cleaning teeth, preparing, safe handling and storing of food etc. Mental health also depends on the social life of a person. If we maintain healthy social relationships, help others and keep ourselves involved in other social activities, it will help us to gain positive mental health and also lead a longer healthy life. On the other
10 Health Development in Gram Panchayats Active Panchayat Series Book VII hand, prolonged mental stress can badly affect our physical and mental health and can cause problems like depression. Due to shortage of health care and transport facilities, sometimes, sick persons have to travel many miles to reach a doctor. Due to heavy expenses involved in medical care, fear of fear of loss of wages or even running into debt etc., poor people generally do not get medical treatment until they are seriously ill. Insufficient number of medical stores/ chemists in some areas further make it difficult for the patients to avail and take prescribed medicines in time.
What is Right to Health? – It means the enjoyment of the highest attainable standards of health. – It includes the right to health for all. – It includes the underlying determinants of health, such as safe drinking water, adequate sanitation and access to health-related information.
1.5 Right to Health and Health as Social Justice Health and access to health services is a basic human right of every human being, whetherrich or poor, man or woman, young or old or of any religion or caste. Right to Health includes the Right to participate in decisions that affect one’s health.It is the duty of the government to ensure healthy food, safe drinking water, employment, leisure and basic health services to all people. For this, all concerned agencies need to work together to ensure ‘health for all’.
1.6 What are the indicators for measuring Health Status? To understand the health status of people in the GP area, we can use a set of indicators to gather specific information on several key factors based on groups that are particularly vulnerable and for which the public health system have specific programs to enhance their health. These include: • Number of new born and infant deaths • Number of malnourished children • Number of women who are pregnant and who have received antennal care • Number of pregnant women who delivered in a health facility
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• Number of girls going to school • Number of marriages among boys and girls less than the legal age • Status of open defecation /households with toilets.
1.7 What are the main responsibilities of the Gram Panchayat towards ensuring health for all in the GP area? The Gram panchayat (GP) as the local government at the village level, has a crucial role in representing the voice of the people in decisions regarding health. At the same time, it needs to work in collaboration with the health functionaries to ensure access to quality health care for people in the GP area. This is important for the Gram Panchayat to know about different challenges and needs in health care so that it can do the needful to address these challenges and needs of people. The roles and responsibilities of a Gram Panchayat in Health can be broadly categorized under three headings:
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• Making sure that the services that are necessary for the community or the community is entitled to, are available and are of good quality. This includes both health care services and other public services like drinking water and sanitation, which are essential for health. • Making sure that all groups within the Gram Panchayat area are able to avail and benefit from health services. Different groups based on caste, class, gender and religion may have different reasons for lack of access to services and the GP needs to be aware of and take action on these. Some services may be individual specific like pre-natal check-ups and some may be beneficial to whole communities like initiatives to reduce communicable diseases. • Influencing the governance of the health system – this means that the GP has a role not only in monitoring the health services but also in setting its priorities and plans for the future with participation of community members. The Panchayat thus represents the interests of its community to the health system. To perform its health related roles, Gram Panchayat should be aware of the status of health of people and critical aspects of health in the GP area like the number of deaths of infants, children and women- specifically deaths of girl children and maternal deaths, nutritional status, age at marriage & first pregnancy, and prevalence of diarrhoea, malaria, respiratory Infections, tuberculosis, leprosy, etc. To address the social determinants as discussed in this Chapter, it is important for the Gram Panchayat to maintain a map of all the marginalized communities, those with high risks in terms of malnourished children, high risk pregnancies, TB patients, areas with environmental risk of vectors that can spread malaria, dengue etc. and families with frequent incidences of domestic violence etc. The GP can discuss these issues in the Gram Sabhas and Gram Panchayat meetings to identify specific problems that such groups / families / individuals may be facing. For example, for anemia amongst women during pregnancy, information about their healthand nutrition needs can be shared in Gram Sabha. Gram Panchayat can also ensure that ASHA keeps stock of such cases and provides necessary health support. The GP can make sure that benefits of all social welfare schemes reach the needy in time. For such persons like the elderly, single women or widows without any family support or the persons with disability, GP should maintain a list and see to it that they are registered for benefits under a relevant scheme and also receiving the benefits. For the environmental determinants affecting health, the GP would need to map out drinking water sources, frequency of cleaning these and water quality testing etc. It would also need to ensure that all communities have equal access to water. Similarly in terms of sanitation, it would need to see if there are any stagnant pools of water that are potential breeding sites for vectors and that which are the communities living close to such places who need special attention. It would also need to see if there are any industrial activities in the GP area or nearby that are affecting the health and welfare of the community. It may be useful for the GP to hold meetings with all the officials of the various departments in order to get a better understanding of the various schemes and programmes as well as to explore areas of regular co-ordination and convergence.
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Gram Panchayat can also organise talks/ discussions in the GP area by expert NGOs, for community sensitisation on issues like domestic violence, gender discrimination, need for healthy work conditions, need for cleanliness, use of toilets etc. In the following chapters, we will learn in detail about specific roles that a Gram Panchayat through its Elected Representatives (ERs) and Functionaries can perform to improve health of their people.
What have we learnt in this Chapter?
• Good health is not only the absence of a disease. A healthy person in the one who is physically and mentally healthy and happy and enjoys life. • Adequate nutrition, safe drinking water, sanitation, personal hygiene, clean environment and healthy lifestyles are important for gaining good health. • Malnutrition, unsafe drinking water, lack of sanitation, stress, and unhealthy habits like alcohol/drug abuse, patriarchal norms against health are some of the reasons for poor health. • Various social and environmental determinants affect our health and thus quality of our lives. • We all have right to good health and to access health services and facilities so as to secure good health. • Gram Panchayats as bodies of governance at the lowest level in the rural areas need to play crucial roles towards ensuring health for all in the GP area.
14 Health Development in Gram PanchayatsCHAPTER Active Panchayat Series Book VII2
Health Systems and National Health Programmes
“Public health refers to all organized measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole. Its activities aim to provide conditions in which people can be healthy and focus on entire populations, not on individual patients or diseases.” – World Health Organisation
aving learnt about the basics of health in the first chapter, challenges in health care as well as the roles that the GPs needs to play, in the present chapter, we will learn about the systems, institutions, programmes and functionaries of public Hhealth in rural parts of India. The role of ICDS in promoting health of women, children and adolescents is also being discussed in detail.
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2.1 What is Public Health? The focus of public health interventions is to prevent and manage diseases, injuries and other health conditions through the following three functions: • Assessment and monitoring of the health of people, possible risks and ways to reduce these risks • Formulation of public policies to solve identified health problems • To assure that all members of the community can avail appropriate and affordable care, including health promotion and disease prevention services At the village level, interventions made by the Gram Panchayat for improving health of whole population in the GP area and promoting healthy lifestyles amongst people, comes under the umbrella of public health. A GP can ensure public health through various ways like awareness generation on crucial aspects of health, monitoring health education and disease control programmes implemented by health department, ensuring people’s participation in public health activities and surveys and also contributing fromown revenue sources, if needed. In short, a Gram Panchayat needs to assure all the conditions in which people can be healthy with special focus on ensuring services to people in difficult to reach geographic areas, and to those who are more vulnerable or needy than others. These include ensuring access to health care for the poor, pregnant women and lactating mothers, children of all ages, the aged persons and persons with disabilities.
2.2 Major Health Programmes and Schemes in India National Health Mission (NHM): In 2005 the Government of India launched the National Rural Health Mission (NRHM) in order to provide accessible, affordable and quality health care to people living in rural areas of our country. The mission aimed to reduce maternal and child mortality and provide better access to health services especially for vulnerable sections. In 2013, the NRHM was subsumed under the National Health Mission, which has now two major components- NRHM and National Urban Health mission (NUHM). NRHM and NUHM address the health needs of people living in rural and urban areas respectively. The vision of the NHM is “Attainment of Universal Access to Equitable, Affordable and Quality health care services, accountable and responsive to people’s needs, with effective inter-sectoral convergent action to address the wider social determinants of health”. Several National Health Programme such as the National Vector Borne Diseases Control, Leprosy Eradication, TB Control, Blindness Control and Iodine Deficiency Disorder Control Programmes, have come under the umbrella of National Health Mission. (Details of the key components of NHM are in Annexure 2 of the Book)
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Major National Health Programmes and Key intervention areas as detailed inthe Framework for implementation under NHM are as below: Major National Health Key intervention areas Programmes 1. Reproductive, Maternal health Maternal, New-born, Access to safe abortion services Child Health and Prevention and Management of Reproductive Tract Adolescent (RMNCH + Infections (RTI) and sexually Transmitted Infections A) Services (STI) Gender based Violence New-born and Child health Universal Immunization Child health screening and early Intervention services Adolescent health Family Planning Addressing the declining sex ratio 2. Control of The National Vector Borne Diseases Control Communicable Diseases Programme (NVBDCP) Revised National Tuberculosis Control Programme (RNTCP) National Leprosy Control Programme (NLCP) Integrated Disease Surveillance Programme (IDSP) 3. Control of Non- National Programme for Prevention and Control Communicable Diseases of Cancer, Diabetes, Cardio-vascular Diseases and (NCD) Stroke (NPCDCS) National Programme for the Control of Blindness (NPCB) National Mental Health Programme (NMHP) National Programme for the Health Care of the Elderly (NPHCE) National Programme for the Prevention and Control of Deafness (NPPCD) National Tobacco Control Programme (NTCP) National Programme for Palliative Care (NPPC) National Programme for the Prevention and Management of Burn Injuries (NPPMBI) National Programme for Prevention and Control of Fluorosis (NPPCF) Promotion of AYUSH (Ayurveda system of medicines) for increased health care services in the Country in preventive, promotive health care for NCDs
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Mobile Medical Unit (MMU): MMU is a mechanism to provide outreach services in rural and remote areas. This is not meant to transfer patients. MMUs comprise of one/ two or three vehicles for transport of medical and Para-medical personnel, equipment/ accessories and basic laboratory facilities and for carrying diagnostic equipments such as X-Ray, ultrasound, ECG machine and generator. Each MMU unit has- one doctor, one nurse, one radiologist, one lab attendant, one pharmacist and a helper and driver. There is also provision of medicines in the unit.
We are briefly discussing some of key schemes related to health in this chapter. Janani Suraksha Yojana (JSY): JSY aims to reduce maternal mortality among pregnant women by encouraging them to deliver in government health facilities. Under the scheme, cash assistance is provided to eligible pregnant women for giving birth in a government health facility. Janani Shishu Suraksha Karyakarm: JSSK entitles all pregnant women delivering in public health institutions absolutely free and no-expense delivery, including caesarean section. Benefits under the scheme include free medicines, diagnostics, and diet during stay in the health institutions, provision of free blood, free transport from home to health institution and back, and no user charges. Similar benefits are provided for treatment of infants (up to 1 year of age). Mission Indradhanush: Mission Indradhanush, immunisation programme aims to ensure that all children under the age of two years as well as pregnant women are fully immunized with seven vaccine preventable diseases namely Diphtheria, Pertussis (Whooping Cough), Tetanus, Tuberculosis (TB), Polio, Hepatitis B and Measles. In addition, vaccines for Japanese Encephalitis (JE) and Haemophilus influenza type B (HIB) are also provided in selected states where these diseases are more prevalent. Rashtriya Bal Swasthya Karyakram (RBSK): RBSK provides for Child health screening and early intervention services through early detection and management of 4 Ds i.e. Defects at birth, Diseases, Deficiencies, Development delays including disability. School Health Programme: School Health programme under National Health Mission is specifically meant for school going children to address physical and mental health needs of children. In addition, it provides for nutrition interventions, yoga facilities and counselling. National Vector Borne Disease Control Programme (NVBDCP): NVBDCP is meant for the prevention and control of vector borne diseases i.e. Malaria, Dengue, Lymphatic Filariasis, Kala-azar, Japanese Encephalitis and Chikungunya in India. Rasthriya Swasthya Bima Yojana (RSBY): RSBY has been launched by Ministry of Labour
18 Health Development in Gram Panchayats Active Panchayat Series Book VII and Employment, Government of India to provide health insurance coverage for the poor families to meet medical treatment and hospital expenses up to Rs.30,000/- for most of the diseases that require hospitalization. Beneficiaries would include the poor and the needy i.e. BPL as listed in District BPL list, Street vendors, MNREGS workers (minimum 15 days of work in preceding year), beedi workers, domestic workers, sanitation workers, mine workers, rickshaw pullers/Taxi/auto drivers, licensed rail porters and construction workers registered with welfare boards. Benefits can be provided to five members of the family including the head of household, spouse and upto three dependents. Beneficiaries need to pay only Rs.30/- as registration fee while central and state Government pays the premium to the insurer. A beneficiary of RSBY gets cashless benefit in any of the empanelled hospitals. He/she only needs to carry his/her smart card and provide verification through his/ her finger print. Swachh Bharat Mission: SBM- the programme of Ministry of Drinking Water and Sanitation (MoDWS), Government of India (GoI), focuses on the elimination ofopen defecation by providing access to toilets for each household and in public places and promoting use of these toilets. It also requires generating awareness about sanitation and its linkages with public health and ensuring an enabling environment for everyone to participate. The important features of Swachh Bharat Mission are as following: • Safe disposal of human excreta • Safe disposal of used and waste water • Safe disposal of garbage and other waste • Storage of drinking water and proper use • Personal Hygiene as per Health Standard • Environmental Sanitation • To convert all service latrine to hygienic toilets
2.3 Health facilities and health institutions Three levels of Health Care services - primary, secondary and tertiary health care. Primary Health Care: It is first level of contact between individuals and families and the health system. it includes care for mother and child, family planning, immunization, treatment of common diseases or injuries, provision of essential facilities, health education, provision of food and nutrition and adequate supply of safe drinking water. Primary Healthcare is provided through a network of Health Sub-Centres and Primary Health Centres in rural areas. At the village level, the ASHA, Anganwadi Worker and ANM provide awareness generation, facilitation of access to the basic curative health facilities and community level services. Secondary Health Care: In secondary Healthcare, patients from primary health care are referred to specialists in higher hospitals for treatment. Health centres for secondary health care include District hospitals and Community Health Centre at block level.
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Tertiary Health Care: In this, specialized consultative care is provided usually on referral from primary and secondary medical care. Facilities of specialized intensive care units for serious illness, advanced diagnostic support services and specialized medical personnel are provided. Tertiary care service is provided by medical colleges and advanced medical research institutes. For the implementation of all health programmes and schemes at all levels ranging from the state to the village level, there are a number of health institutions like hospitals, health centres, various committees, and functionaries etc. Health facilities available at various levels are mentioned below: • At village level: At the village level, basic health & nutrition services are provided by health functionaries, like - Accredited Social Health Activist (ASHA), Auxiliary Nurse Midwife (ANM) and Anganwadi Worker (AWW). There is one ICDS Centre for every 400-800 population and one Health Sub-Centre for every 5000 population atthe village level. • At the sub-centre there are two ANMs. Above the sub-centre there is one Primary Health Centre for every 30000 population. In Primary Health Centre, there are Medical Officer (MO), health workers like nurse, compounder or pharmacist and attendants. All these health services are generally available at the village and GP level or below block. • At the block level: there is Block Primary Health Centre (BPHC) or community health centre (CHC) with medical officers, specialist doctors, nurses, and attendants. These centres also have diagnostic facilities and medical technologists. There are generally 30 beds in BPHC/CHC. • At the sub-divisional level: There is Sub-Divisional Hospital with approximately 150 beds and common specialist services are provided in such hospitals. • Between block and sub division, there are two more types of hospitals - Rural Hospital (RH) and State General Hospitals (SGH). A Rural Hospital has facilities similar to BPHC but has more beds and State General Hospitals have facilities similar to those of a sub-divisional Hospital. • At the District and State level: there is a District Hospital having generally 500 or more beds and with some more specialist services compared to Sub-Divisional Hospitals. • Specialised Hospital, Medical College & Hospital are generally available at State level.
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From the following table, we can learn about the service providers and services available in various health facilities in rural areas:
Health Facility Population Service Services Provided Coverage Providers Health Sub- 3000 One ANM Conducting Village Health Nutrition Centres(HSC): population Multipurpose Day (VHND) and other outreach in tribal/hilly health worker services areas and in some Family Planning services Health Sub-Centres up to 5000 places Complete package of Ante natal care, are of two types - population Post Natal care and immunization type A and type B. in plain A second ANM Growth monitoring and nutritional ( Type B Centre areas ( placed in counselling provides all Some states) Treatment of minor illnesses and recommended childhood diseases including referral services and facilities Treatment for TB, leprosy, malaria for conducting Facilitating activities for control of deliveries) diseases caused by insect bites Delivery services (if ANM trained as Skilled Birth Attendant and well equipped labour room available)
Primary health 20,000 in One or two All the services mentioned under Centres (PHC): hilly, tribal, MBBS/ MO HSC or difficult One AYUSH 24 Hours institutional delivery areas and Doctor services (if designated as 24X7 PHC) 30,000 One Staff nurse Out-patient care for all ailments population One Sanitary Essential New born care( with in plain Staff provision of New born corner in areas (Many PHCs labour room) Primary health have two Abortion services with linkage for Centres are 4-6 Medical timely referral to the facility approved bedded and acts as Officers) for 2nd trimester of MTP a referral unit for Male/ female Sterilization services 6 Health Sub- Health check- up and treatment Centres of school children and adolescent friendly clinic for 2 hours once a week on a fixed day Screening of general health, assessment of anaemia / nutritional status, visual acuity, hearing problems, dental check- up, common skin conditions, heart defects, physical disabilities, learning disorders, behaviour problems, etc.
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Community 80,000 5-6 doctors Apart from all services that a PHC is health Centres in tribal / including meant to provide as detailed above, (CHC) : hilly / desert specialists for each CHC also provides clinical care Community areas and different types services in some of the specialist health Centres are 1,20,000 of health care, areas and institutional delivery 30-bedded hospital in plain Nurses and services. Some CHCs are designated and acts as referral areas Paramedical and equipped to provide services of for 4 PHCs staff more than Caesarean Delivery. PHC District One per Specialist for All basic speciality services and also Hospitals : District different types some highly specialized services of Specialized New-born Care Unit for District Hospitals are health care sick and high risk new born, blood 75 to 500 bedded with bank, specialized labs, services for depending on the adequate caesarean sections, post- partum size, terrain and number care, safe abortion and all kinds of population of of nurses and family planning procedures the district. It is paramedic staff Operation Theatre for surgical a hospital at the services secondary referral Provisions for dealing with level accident and emergency referrals, rehabilitation, mental illnesses and other forms of communicable and non- communicable diseases Source: VHSNC Guidelines, Ministry of Health and Family Welfare (MoHFW), GoI In some states, for example in West Bengal, development and maintenance of Block Primary Health Centres, Primary Health Centres, Health Sub-Centres and Anganwadi Centres in collaboration with the Health & Family Welfare Department, the Woman & Child Development Department and the Public Health Engineering Department are important functions of Gram Panchayats. Generally, construction and maintenance of Health Sub-Centres and Anganwadis are taken care of by Gram Panchayats by allocating funds from the State Finance Commission Grants, National Finance Commission Grants and even the other sources of revenue (OSR) generated by the Gram Panchayats themselves.
2.4 Key Platforms at the Village and Community Level Key health service providers at village level are ASHA, ANM and Anganwadi Worker who regularly keep in touch with the community and act as links between the people, health system and the Gram Panchayat. We will learn about ASHA and ANM in this section and their specific roles in ensuring health care to the people in the GP area. In next section, we will learn about the ICDS Centre and role of Anganwadi Worker too.
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1. ASHA One of the key components of the National Rural Health Mission is to provide every village in the country with a trained female community health worker called the ASHA. The ASHA is a woman selected by the community, resident in the community, who is trained and deployed to function in her own village for improving the health status of the community. She works under supervision of VHSNC and the Gram Panchayat. ASHA is generally selected for a population of 1000 people, but can be provided for smaller populations in case of geographically dispersed areas or smaller hamlets. ASHA provides community level care for common illness and builds health awareness on nutrition, sanitation, prevention of diseases, immunisation and other public health programmes in coordination with ANM & AWW. She also guides the people on what are the health services available, how to access these services and what their entitlements are. Roles and responsibilities of ASHA - The roles and responsibilities of ASHA include the functions of a healthcare facilitator, a service provider and a health activist. Her functions are listed below: • ASHA can take steps to create awareness and provide information to the community on nutrition, basic sanitation and hygienic practices, healthy living and working conditions, existing health services and the need for timely use of health services. She can also promote construction and usage of household toilets under Swachh Bharat Mission. • She should provide counselling to women and families on preparing for child birth, importance of safe delivery, breastfeeding and complementary feeding, immunization, contraception and prevention of common infections including reproductive tract infection (RTI) and sexually Transmitted Diseases (STDs) and care of the young child. • ASHA mobilises people for seeking services like immunization, Ante Natal and Post Natal Check-up (ANC and PNC), health care at Anganwadis • ASHA works with the VHSNC and GP to develop a comprehensive village health plan, and mobilizes the community for standing up against gender based violence • ASHA can provide community level curative care for minor ailments such as diarrhoea, fevers, care for the normal and sick new-born, childhood illnesses and first aid. A drug Kit is also available with her. • Directly Observed Treatment Short-course (DOTS) for TB patients is also available with trained ASHAs. • The ASHA provides information about the births and deaths in her village and any unusual health problems / disease outbreaks in the community to the Health Sub- Centres / Primary Health Centre. To ensure the above role, ASHA has to perform the following tasks on regular basis: • Home Visits for up to two hours every day, at least four or five days a week with special attention to marginalized families, houses of pregnant woman and child below two years of age/ malnourished children. At least one visit a month to all
23 Health Development in Gram Panchayats Active Panchayat Series Book VII
these households and a series of six visits or more in the family where there is a new- born child are essential. • Mobilising community for availing services at Village health nutrition day (VHND), special health campaigns and the government health facilities. • Visits to the health facility, usually accompanying a pregnant woman, sick child, or some member of the community needing facility based care. • Attend the monthly review meeting held at the PHC and Village Health and Nutrition Day and provide counselling and health education to people. • Help VHSNC in convening its monthly meeting and if needed, additional habitation level meetings for providing health education to the community. • Maintaining health records in the village
2. Auxiliary Nursing Midwife (ANM) In the rural health care system, the ANM is the key field level functionary with focus on child health programmes and is involved in family welfare, maternal health and preventive services. ANM is supposed to streamline the outreach clinic for immunization. Roles and responsibilities of an ANM at the GP level: • Provide information to VHSNC regarding available services, schemes, and services for maternity and child health. • Share details on marginalized and unreached groups or those in difficult regions and seek the support of the VHSNC to reach these populations. • Inform the VHSNC on the deaths in the village, especially maternal and child deaths and their possible causes. • Facilitate or support the committee in preparing a village action plan to address the issue of reaching the marginalized and unreached groups with health services. • Compile Sub-Centre level health data and update the same to the Health Supervisor & Gram Panchayats on regular basis. At the village level, it would be difficult for ASHA and ANM to function effectively without adequate institutional support from the Gram Panchayats concerned. GP can also generate awareness about their role in the community and also monitor their activities in the GP area.
3. Rogi Kalyan Samiti Rogi Kalyan Samiti (RKS) is a registered society that acts as a group of trustees for the hospitals to manage the affairs of the hospital. It consists of members from local Panchayati Raj Institutions (PRIs), NGOs, ERs from the State and the PRIs, and officials from the government sector. Financial assistance is provided to these Committees through untied fund under NHM to undertake activities for patient welfare. Since ERs and functionaries of GPs are also members of RKS, it is important for them to know about this committee. Key objectives of the RKS mentioned in the Guidelines for Rogi Kalyan Samitis in Public
24 Health Development in Gram Panchayats Active Panchayat Series Book VII
Health Facilities (2015), MoHFW, GoI are listed below: 1. Give suggestions active citizen participation for the improvement of patient care and welfare in health facilities. 2. Ensure that essentially no user fees or charges are taken for treatment related pregnancy, delivery, family planning, postpartum period, new-born and infants care, childhood malnutrition, national disease control programmes such as TB, Malaria, HIV/AIDS, etc. 3. Decide on the user fee structure for outpatient and inpatient treatment, which should be displayed in a public place and be set at rates which are minimal and do not become financial burden for accessing healthcare. 4. Ensure that patients from BPL families, vulnerable and marginalized groups and other groups do not face financial hardship for their treatment, and to create mechanisms to cover part/full costs related to transport, diet, and stay of attendant. 5. Develop mechanisms to ensure that poor patients are not denied health services that are being provided at the government’s expense. 6. Ensure provision of all non-clinical services such as provisioning of safe drinking water, diet, litter free premises, clean toilets, clean linen, help desks, support for navigation, comfortable, patient waiting halls, security, clear signage systems, and prominent display of Citizens’ Charter 7. Ensure availability of essential drugs and diagnostics, and use of standard treatment protocols/ standard operating procedures, patient safety, effective mechanisms for maintaining patient records, periodic review of medical care/deaths 8. Ensure procurement of essential drugs/ diagnostics not available in the health facility out of the RKS funds. 9. Promote a culture of user-friendly behaviour amongst service providers and hospital staff for improved patient welfare, responsiveness and satisfaction through inter-alia organizing training/ orientation/ sensitisation workshops periodically. 10. Operationalize a Grievance Redressal Mechanism including a prominent display of the “Charter of Patient Rights in the Health facility and address complaints promptly thus building confidence of people in the public health facilities 11. Create mechanisms for feedback from patients, at least at the time of discharge and take timely and appropriate action on such feedback. 12. Undertake special measures to reach the unreached / disadvantaged groups e.g. Campaigns to increase awareness about services available in the facility. 13. Ensure overall facility maintenance to ensure that the facility conforms/aspires to conform to the Indian Public Health Standards (IPHS). 14. Supervise, maintain, and enable expansion of hospital building for efficient and rational use and management of hospital land and buildings. 15. Facilitate the operationalization of National and State Health programmes as appropriate for the level of the facility. 16. Proactively seek out participation from charitable and religious institutions,
25 Health Development in Gram Panchayats Active Panchayat Series Book VII
community organisations, corporates for cleanliness and upkeep of the facility 17. Facilitate participation and contribution from the community in cash/kind, labour including free professional services.
4. Village Health, Sanitation & Nutrition Committee (VHSNC) As per National Health Mission, a VHSNC is formed to promote community participation in health programmes, support implementation of health activities in the area and also for planning and monitoring of programmes on health, nutrition and sanitation, under direct guidance and supervision of Gram Panchayats. VHSNC is formed at revenue village. State Governments have been advised by the MoHFW and Ministry of Panchayati Raj (MoPR), GoI, to name village health and sanitation committee i.e. VHSC as VHSNC and preferably be made the health sub- committee of Gram Panchayat. It should have a minimum of 15 members. The members of VHSNC include the elected representatives (ERs) of the GP Standing Committee on Health, all village level health staff, community members/ beneficiaries and members of all community sub-groups especially the vulnerable sections and hamlets/habitations. ASHA residing in the village is the Member-Secretary and Convener of the VHSNC and the women elected representative of that ward concerned is the ex officio head of VHSNC. To undertake activities, financial assistance is provided to the VHSNC with fund under NHM. It is the responsibility of any Gram Panchayat to form a VHSNC at each Ward Sabha and/ or Gram Sabha. The key objectives of the VHSNCs are to: • Inform the community about the health programmes and government initiatives • Enable community to participate in the planning and implementation of the programmes, and take collective action for improving health status in the village • Take action on social determinants and all public services that directly or indirectly affect health of people • Facilitate the community to speak about their health needs, experiences and issues related to- access of health services • Equip Panchayats with the understanding and mechanisms required for them to play their role in governance of health and other public services and provide leadership to the community for collective action to improve health status. • Provide support and facilitate the work of community health workers like ASHA and other frontline health care providers, who form a crucial interface between the community and health institutions Source: VHSNC Guidelines, MoHFW, GoI The roles of the VHSNC include monitoring of health services and ensuring access to all, organizing collective action at local level for promotion of health, facilitating service delivery at the village level, village health planning, facilitating community monitoring of health facilities, organising monthly meetings, management and accounting of untied village health fund and maintaining records.
26 Health Development in Gram Panchayats Active Panchayat Series Book VII
(For more details on the VHSNC, please refer to Handbook for Members of Village Health Sanitation and Nutrition Committee, MoHFW, GOI.)
Let us discuss below various kind of activities and interventions that VHSNC can undertake in the Village. • Awareness generation on child marriage and early motherhood, promotion of safe motherhood through Institutional delivery or delivery through a trained birth attendant, feeding of colostrum (first thick yellow coloured breast milk after child birth) to the new-borns and exclusive breast feeding for infants upto 6 months, community sensitization on prevention of HIV/ AIDS • Take necessary steps for addressing malnutrition amongst women and children • Preparation of low cost nutritious food for pregnant and lactating women and children with the help of Self Help Groups (SHGs)and also arrange for distribution of the same • Mobilize drives for complete immunization of pregnant women and children especially those who are more vulnerable to breaking the chain or those living in hard to reach areas. • Take effective steps for behavioural change so that hygienic practices are followed by everyone • Ensure safe drinking water, sanitary toilets and proper waste disposal system • Inform health workers about the sudden outbreak of any disease • Ensure school health programmes for awareness generation and to arrange for health check-ups to prevent any infection or disease • Provide weighing machine to the SHGs and Anganwadi Workers so that they can monitor the health and nutrition status of children • Organise vehicles for transportation of the patients to the nearest health institution so that they can avail themselves of the health services • Arrange awareness camps on public health in the locality • Promote health related campaigns and mobilization through wall writing and other media • Oversee the maintenance of drainage system and garbage disposal in the locality • Undertake repair of tube wells / wells and their cemented foundation
VHSNCs under the leadership of Gram Panchayats can work along with the rest of the community to improve the health status of the village. It is necessary to remember that in order to improve people’s health, all agencies have to work on all social, economic and cultural determinants of health.
2.5 Anganwadis under ICDS for improving health of women and children Nutrition plays a major role in gaining and keeping good health. It is gained through balanced food that contains all essential nutrients like proteins, minerals and vitamins.
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Similarly, food that is not rich in nutrients, causes malnutrition. Malnutrition can be due to either too little or too much food, or diet from which one or more important nutrients are missing. Malnutrition among the women, children and adolescents is a major concern in public health. Malnourished children fall ill very often and it badly affects their physical & mental development. This, in turn, affects all phases of later life. To address this situation and to provide an environment for holistic development of children, there are Anganwadi Centres in rural and urban parts of India, set up under Integrated Child Development Scheme. An Anganwadi Centre is established for every 400-800 population. Key services provided at the Anganwadi centre are: • Supplementary nutrition for children below 6 years of age and pregnant and lactating mothers • Immunization of all children below 6 years and to the pregnant and lactating mothers • health check-ups of children below 6 years and to the pregnant and lactating mothers • Non-formal pre-school education to children of 3-6 years of age • Health and nutrition education/ counselling to the women of the age group of 15-45 years • Referral of serious cases of malnutrition or illness to hospitals, Community Health Centres (CHCs) or district hospitals with the support from Health Sub-Centre, Primary Health Centre or Block Primary Health Centre.
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Anganwadi Centre should take weight of each and every child every month to monitor their growth and to take appropriate measures in cases where the growth is below normal. For reducing number of infants with low birth weight, regular health check-ups of the pregnant women (ANC), intake of nutritious food, sufficient rest and Iron-Folic Acid during pregnancy are necessary. Other three important factors are that first pregnancy should not be before 19 years; there should be gap of at least 3 years for second pregnancy and appropriate family planning measures to be adopted.
2.6 Village Health & Nutrition Day (VHND) As per NHM provisions of NHM, Village Health & Nutrition Day (VHND) is to be observed once every month (preferably on Wednesday, and for those villages that have been left out, on any other day of the same month) at the Anganwadi Centre in the village, to provide health care services to women, adolescents and children. ASHA, AWW & ANM organize VHND and mobilize the women, adolescents and children and discuss health related issues like nutrition, personal hygiene, care during pregnancy, importance of pre-natal & post-natal care, institutional deliveries, immunization, etc. Arrangements for health and nutrition services and counselling on health & nutrition issues are made at the venue on that day. Since the VHND is held at a site very close to their habitation, health services are provided at their doorstep.
What have we learnt in this Chapter?
• Public health interventions are necessary to prevent and manage diseases, injuries and other health conditions. • National Health Mission, Swachh Bharat Mission and a number of central and state sponsored schemes are available for addressing health issues in GP area. • There are health facilities at all the levels- village, block, district and state level and specialised hospitals to address health problems of people. • Village Health, Sanitation & Nutrition Committee (VHSNC) and Rogi Kalyan Samiti are the key committee at village level to support and improve health care interventions. • ASHA, Anganwadi Worker and ANM are the key health functionaries at the village level. • Anganwadis set up under ICDS play important role in health care and nutrition support to children from 0-6 years and pregnant and lactating mothers and health counselling to adolescents in the GP area.
29 CHAPTERHealth Development in Gram Panchayats 3Active Panchayat Series Book VII
Institutions of Gram Panchayat and their Collaboration with the Health System
y now, you must have understood well about the health system and facilities from District and Sub- district to the village level, key health programmes of the Government and also about the important components of National Health Mission Bincluding various committees and service providers on health in the GP area. Now we will learn about the systems of Gram Panchayat that play crucial role in improving health like health sub-committee of Gram Panchayat and also platform of Gram Sabha and their interface with the health system. We will also discuss about the role of Gram Panchayat in effective implementation of ICDS and functioning of Anganwadis.
3.1 Sub-Committee or Standing Committee of Gram Panchayat: Health and Family Welfare is one of the key roles of Gram Panchayats assigned to them under the Constitution of India i.e. 73rd Amendment. For promoting good health
30 Health Development in Gram Panchayats Active Panchayat Series Book VII practices amongst people, and for ensuring good service delivery from the health facilities and functionaries at the village level, the Standing Committees or Sub-Committees are formed in the Gram Panchayat. Provision of these Standing Committees on health has been included in almost every state Panchayati Raj Act.
As per the Rajasthan Panchayati Raj Act, a GP would constitute a Standing Committee on Social Services and Social Justice including rural water supply, health and sanitation, gramdan, communication, welfare of weaker sections. In Karnataka PR Act, there is provision for Amenities Committee to perform functions of education, public health, public works etc. These Committees are generally headed by the Pradhan orUp Pradhan of the GP and can co-opt members who are experts on health. List of responsibilities of the health related standing committees may vary in different State PR Acts, but almost in each State, Standing Committee on Health needs to play a significant role in dealing with public health delivery system in their Gram Panchayat and ensuring access of health care for all in the GP area. Generally, a Standing Committee on health would need to perform the following roles: • Hold meeting of the Sub-Committee and discuss health matters on regular basis • Collect and analyse data and information on health, nutrition & sanitation inthe Gram Panchayat area and maintain database on public health • Coordinate with the Health Sub-Centres and Anganwadi Centres in the GP area, linkage & coordination among the ASHAs, ANMs, AWWs and members of the Village Health, Sanitation & Nutrition Committee/s (VHSNC)in the GP area • Facilitating preparation of comprehensive health plans for the entire Gram Panchayat area (both the Perspective Plan for 5 years and an Annual Action Plan) and ensure implementation as well as monitoring of the planned activities • Provide support in health service delivery institutions like the Anganwadi, Sub Centre, PHC etc. and monitor the health service delivery in the GP area. This is necessary for all members of the Standing Committee to regularly participate in the meetings and actively participate in the preparation of annual plan and budget of the Sub-committee on Public Health.
In some States e.g. Assam, Chhattisgarh, Haryana, Puducherry, VHSNCs have been made sub committees of Gram Panchayats to be headed by an elected member of the GP and to function under the overall supervision of Gram Panchayat.
3.2 Gram Sabha and Ward Sabha Gram Panchayats are responsible to share periodic progress of development activities and achievements and income-expenditure statement to the people in the GP area. It is also the responsibility of the Pradhan/ Sarpanch of Gram Panchayat to organise Gram Sabha on regular basis, as per the provisions of State Panchayati Raj Act. In this Gram Sabha, various issues including yearly income, expenditure, and plan for the coming year,
31 Health Development in Gram Panchayats Active Panchayat Series Book VII and various development schemes including those on Health, Nutrition and Sanitation are discussed. Gram Sabha comprises of all the voters of the respective Gram Panchayat/village/ habitation. Since Gram Sabha is a village level institution that comprises of the village electorate itself, it is easier for the people to participate in the Gram Sabha. Besides, there is provision of Gram Sansad Sabha or Ward Sabha in many states. Any member of Gram Sabha can raise issues related to health in Gram Sabha. Some illustrative Issues that can be discussed in Gram Sabha may include: left out/dropped out of immunization and nutrition services, number of malnourished children, pregnant and lactating mothers missing ANCs and PNCs, the availability of health care services for contraception, injury, and other common illnesses. Other crucial aspects that have direct impact on physical and mental health like domestic violence, child marriage, open defecation, safe drinking water should be discussed in the Gram Sabha and actionable points identified for follow up with people’s participation.
3.3 Convergence and coordination for improvement in Health in GP area Improvement in public health status is in many ways related to some duties and responsibilities of Gram Panchayats. Gram Panchayats can coordinate activities of all the interventions/services and mobilize people to access these health services. Gram Panchayats can identify the gaps in health service delivery through the members of VHSNC, the elected members of the Gram Panchayat, SHG members and also from the monthly review meetings on health at Gram Panchayat level. If any gap is identified, Gram Panchayats can take up the issue with the Health Supervisor or the Block Medical Officer- Health (BMOH). Please see the following chart of health facilities and their parallel PRI at all levels that would be important for us to understand areas of collaboration and coordination between health system and PRIs.
32 Health Development in Gram Panchayats Active Panchayat Series Book VII
Coordination for Health- A Stakeholder Map
District Health Office of the CMOH Public Health Standing & Family Committee of ZP Welfare Samiti
Block Health BPHC / RH Public Health Standing & Family Committee of PS Welfare Samiti
PHC
Headquarter Health Sub- Public Health Sub- Centre at GP Committee of GP
VHSNC Health Sub-Centre
ANM
SBA / TBA ASHA AWW SHG
Following are important platforms where the issues of health can be discussed by the Gram Panchayat that would in turn, help in identification of key areas requiring attention and follow up action. These may also contribute to prioritisation and planning for health in the GP area. • The first one is the VHSNC that is required to act as the health sub- committee of the Gram Panchayat as per provisions of NRHM. VHSNC should be a forum for discussing issues regarding the health services in the village. Gram Panchayat or Health subcommittee of the GP can share its feedback and suggestions regarding the availability and quality of services and/or any grievances related to health services with VHSNC and take corrective action.
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• The second platform is the Gram Sabha where the VHSNC and health functionaries at GP level can share progress on health, take feedbacks from people for improving health services in the GP area or even send alerts/ generate awareness about foreseen epidemics like dengue/malaria etc. members of Gram Sabha can also express their grievances and offer suggestions for improving health services in the GP area or even compliment health functionaries for any good work done. Also, VHSNCs may share the details on annual health plan, its progress and utilisation of the untied fund. • The third one is the Rogi Kalyan Samiti (RKS)1 at the facility level. As per national guidelines on RKS, ERs of Gram Panchayat should be included in the Rogi Kalyan Samiti of the health facility at the district, Block and sector level. . The RKS is a forum for community inputs and oversight into the running of the public health institutions. It is a good forum for feedback from the GP to the health system regarding the health issues and priorities of the community. • The fourth one can be the health planning exercise. This is the process by which the Gram Panchayat identifies its needs and priorities in participatory processes and these culminate into projects and holistic annual development plan of the Gram Panchayat. • We will learn about these in detail in Chapters 5 and 6 i.e. while discussing role of Gram Panchayats in planning for health and incoordination and monitoring of health by Gram Panchayats. 3.4 Role of Gram Panchayat in health system strengthening • Gram Panchayat can also play a crucial role in strengthening of health system in its GP 1. There are RKS guidelines issued by MoHFW to be adapted by the respective states. Each Gram Panchayat must refer to the RKS guidelines of their respective state for the provisions of membership of the PRI members in its committees.
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area through supporting the functioning of the various health workers in performing their public health functions and effective delivery of services. • The GP can provide support like infrastructural facilities for VHND, room for the meetings of VHSNC etc. from its own sources of revenue. It can also provide mobilization support for VHND and other outreach services, help in both identification of high risk groups and places in the GP area as well as in ensuring health services to these difficult groups and in difficult areas through interventions like sharing of information, awareness generation and mobilisation etc.
3.5 Role of Gram Panchayat in strengthening the functioning of Anganwadis and VNHD activities in the GP area • Ensure growth monitoring of all children up to 6 years of age under the ICDS Scheme • Compile the data on status of nutrition of all children by aggregating the data from all the Anganwadi Centres within its area. This database can be an important element for the preparation of perspective plan and annual plan of Gram Panchayats • Take initiatives for awareness building in the community on nutrition, for identification of the malnourished children and ensure supplementary nutrition through existing schemes/ programmes. If required, Gram Panchayats can utilize their own fund or own source revenue in nutrition support. • Convergence with MGNREGS and Women & Child development Department for construction and maintenance of the ICDS Centres at the Gram Panchayat • Ensure timely organisation of VHND, participate in the meetings and also ensure community participation in VHND
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GP played pro-active role in smooth functioning of Anganwadi ICDS Worker (AWW) and ICDS Helper (AWH) of an Anganwadi Centre (AWC) of Abujhati-I Gram Panchayat under Jamalpur Panchayat Samiti in the district of Burdwan in West Bengal could not attend the Centre for around one month because of their illness. To meet the Gap, ICDS Worker (AWW) and ICDS Helper of another nearby Centre had been given additional responsibility by the concerned ICDS Supervisor & CDPO. Realising the challenge of managing two AWCs, the Gram Panchayat sensed their problems and played a proactive in addressing the issue. Gram Panchayat engaged a women SHG named Muktakeshi in consultation with the concerned ICDS Supervisor as stop gap arrangement. The SHG took over the responsibility and rendered its services effectively. Gram Panchayat also provided some incentive to the SHG from its Own Source Revenue (OSR).
For detailed role of Gram Panchayat with regard to Anganwadis, please see the Elementary Book published by the Ministry of Panchayati Raj- Child Development in Gram Panchayats published by MoPR in 2015. Another publication of MoPR- Governance in Gram Panchayats may be referred to for understanding procedural aspects of governance by the Gram Panchayat. It has been seen that in last few years, public health system and services have improved in our country. It has helped in not only reducing number of deaths of infants and children but also duration of life of people, in general, has increased. With the interventions and support of ERs and functionaries, every Gram Panchayat can be a health conscious as well as a healthy Gram Panchayat
What have we learnt in this Chapter? • A Gram Panchayat needs to ensure those minimal necessary conditions in which people can be healthy, with special focus on services to people in difficult to reach geographic areas, and all other vulnerable groups. • Health Sub Committee of Gram Panchayat plays crucial role in ensuring access to quality health services for people in the GP area, in collaboration with the health functionaries. • VHSNC and health functionaries of Gram Panchayat need to actively participate in Gram Sabha and share status of health activities and initiatives in the GP area and also take stock of people’s grievances with regard to health facilities so as to resolve these grievances. • The GP can provide support for identification of high risk groups and hard to reach places and delivery of necessary health services to these groups and pockets in the GP area. • GPs can also ensure smooth effective functioning of Anganwadis through monitoring and quality of services and effectively organising VHNDs.
36 Health Development in Gram PanchayatsCHAPTER Active Panchayat Series Book VII4
Primary Health Care and the Role of Gram Panchayat
t is the responsibility of all ERs and functionaries of each Gram Panchayat to ensure that their Gram Panchayat becomes a healthy as well as a health conscious Gram Panchayat. And for that, they themselves need to be aware of the key health issues in Itheir GP area, and also vulnerable groups whose health needs should be given special attention. In this chapter, we will learn about the primary health care, frequent health issues in a village about which Gram Panchayats need to know, specifically about the health issues of the vulnerable categories and groups and the role and responsibilities that a GP has to perform in ensuring people access to primary health care.
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4.1 Understanding Primary Health Care As we learnt in the first chapter, healthcare is the right of every individual and it should be within the reach of every citizen. Health care covers not only medical care but also all aspects of preventive care. There is a need to ensure that good health care i.e. quality and timely healthcare reaches everyone including the difficult corners of theIndian villages. Primary health care includes: • Knowledge and awareness about the prevailing health issues/problems and the methods of preventing and controlling them • Promotion of proper nutrition • Adequate supply of safe drinking water and basic sanitation • Maternal and child health care, including family planning • Immunization • Prevention and control of local communicable diseases • Appropriate treatment of common diseases • Provision of essential medicines, first aid and referral of cases to higher health facilities As it is known to all of us, Departments of Health & Family Welfare Department, the Social Welfare and Woman & Child Development are responsible for providing health care services to the rural population. So it is important to what is the role of Gram Panchayat in ensuring primary health in the GP area. There are four kinds of interventions in the health sector – prevention, promotion, cure and rehabilitation. We all need to know that primary responsibility of Gram Panchayats is for preventive, promotive and rehabilitative health care. GPs can generate awareness about importance of good health, healthy ways of living, and prevention from contacting communicable or non-communicable diseases. It can also facilitate information dissemination about the health care and curative services amongst people and how they can avail services. Gram Panchayats can also strengthen the delivery of health care services by support to and coordination with the health institutions and functionaries at the village level. We will learn about the specific roles of Gram Panchayats in the following chapters while learning about primary health needs and services for specific categories of people in the GP area. Addressing health needs of all and the needy and vulnerable categories: Health services at the village level can be understood by following the life cycle of an individual and understanding what are the key services to protect and promote health at each stage. Broadly we can divide this into: • New born • Infants • Children • Adolescents
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• Adults – general • Adults – women • Elderly persons Amongst all these age groups, women, poor, destitute, persons with disabilities would be more in need of health care and support. In the following pages of the chapter, we will learn about the various frequent primary health care issues and role of the Gram Panchayat and also various aspects of public health for the specific groups/ categories that need special attention along with role of GPs for each of these.
4.2 Communicable and non-communicable Diseases Communicable diseases: As we learnt in Chapter 1, an illness that is directly or indirectlypassed on from one human being to the other, from animal to humans or from the environment to humans is called a communicable disease that can be transmitted through direct contact like breathing, touching, kissing or a sexual activity. It can also be passed on through water,food,dust and soil, etc. At times, a communicable disease can be life threatening also. Most common communicable diseases in India are –Typhoid, Hepatitis, Diarrhoea, Amoebiasis, Influenza, Tuberculosis and vector borne diseases like Malaria, Dengue etc.
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• Typhoid: Typhoid is caused by eating food or drinking water contaminated by the faeces or urine of infected people. It occurs in places, where sanitation standards are poor. It causes fever, headache, constipation or diarrhoea etc. In severe cases, it can be life threatening also. • Hepatitis: Hepatitis is a virus that attacks the liver. There are different forms of Hepatitis termed A, B, C, D and E caused by five different viruses. Main causes of spread of Hepatitis viruses are as below: • Hepatitis A and E- contaminated food or water • Hepatitis B – through unsafe sex • Hepatitis C- through direct contact with the blood of an infected person • Hepatitis D – through Hepatitis D Virus (HDV). It affects only those already infected with Hepatitis B. • Diarrhoea is frequent passage of loose, liquid or watery stools that spreads through contaminated food or drinking contaminated water. It is a significant cause of deaths of children due to poor hygiene and sanitation conditions in rural areas. • Amoebiasisis a common infection caused through contaminated food or water or through direct contact with fecal matter. The symptoms of Amoebiasis include loose stool, abdominal cramping, and stomach pain. • Influenza spreads from one person to other through coughing and sneezing. It can cause mild to severe illness and at times can even lead to death, if not treated well and in time. Fever, headache, muscle aches, sore throat, runny nose may be the symptoms of influenza. • Tuberculosis: Tuberculosis (TB) is a highly communicable disease caused by bacteria that attack the lungs or other parts of the body such as the kidney, spine or brain and can even cause death, if not treated well and in time. • Vector borne diseases like Malaria, Filaria, Japanese Encephalitis, Kala-azar, Dengue and Chikungunya are transmitted by insects carrying bacteria and viruses from one person or living being to the other. Source: www.nvbdcp.gov.in. (Ministry of Health and Family Welfare, Government of India) Early detection and treatment for malaria and other vector borne diseases at the Health Centre is essential and at the same time complete treatment is required for early recovery. For prevention and control of water borne diseases the following issues need to be taken care of – • Usage of safe drinking water • Regular cleaning/maintenance of all the water bodies • No open defecation • No washing in the ponds • No drainage of liquid chemicals or waste in the water bodies
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Open defecation is the single most dangerous factor of infections and deaths amongst children. When people defecate in open, bacteria and viruses from human excreta enter our food through hands, insects, files, soil or water etc. and then contaminate our food items. This causes a number of deadly diseases. Construction and use of sanitary toilets in each household and in community is necessary. It will not only help in controlling water and sanitation related diseases or but also environmental pollution. Above all, it protects the dignity of women by providing them safe and private place for defecation.
Role of the Gram Panchayat in management of Communicable diseases • Sensitize the communities towards control of flies & mosquitoes and secure community participation in vector control measures like preventing breeding of mosquitoes, promoting use of mosquito nets etc. • Ensuring proper drainage system, proper sanitation arrangements across the Gram Panchayat area • Take suitable measures for installation and use of household sanitary latrines, proper sewerage, management of solid waste and environmental sanitation • Build awareness among community regarding the consequences of open defecation and for making itself an open defecation free (ODF) Gram Panchayat • Timely sharing of information with the related departments in incidences of epidemics • Sensitization of street/ fast food sellers in the GP area about selling hygienic food items and can regulate this through issuance and renewal of trade licences (More information can be availed from the two publications of the Ministry of Panchayati Raj- Sanitation in Gram Panchayats and Drinking Water in Gram Panchayats.)
Non-Communicable diseases and role of Gram Panchayats Non-Communicable Diseases (NCDs), are not passed from one person to the other but can cause serious threats to health and life of a person. NCDs include diseases like cancers, arthritis, asthma, heart attacks & stroke, obesity and diabetes etc. Alcoholism and drug addiction Use of tobacco, alcohol or other intoxicating drugs, lack of physical work/ exercise, unhealthy food, use of alcohol and other intoxicants etc. cause and/ or increase the risk of NCDs. A Gram Panchayat can • Make people aware about the causes and effects of these diseases and motivating them to lead healthy life styles • Ensure Construction and use of sufficient number of playgrounds, volleyball courts and parks etc., celebrate sports days, organise sports competitions to promote habit of sports and health talks in the GP area • Ensure that health facilities at GP level are well equipped for early detection and immediate referral to appropriate hospitals in case of an emergency
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4.3 Primary Health care for infants and Children Children are most vulnerable to health problems like low birth weight, malnutrition and communicable diseases which quite often end in deaths of infants and children below 5-6 years of age. Due to discrimination against girl children and poor nutrition and health care, they often suffer even more. Some key health care services for children and role of Gram Panchayats are as below: i. Immunization: It helps in building immunity of the child against infections and diseases. Primary immunization means completion of all vaccinations which are supposed to be given to an infant during the first nine months after birth. These include vaccines like BCG for childhood TB, protection against as below:
Name of the Vaccine Disease for which it is given BCG (Injection) Tuberculosis Oral Polio Vaccine (Oral) Polio Pentavalent [Diphtheria, Diphtheria, Pertussis, Tetanus, Hepatitis B, Pertussis, Tetanus(DPT), Hepatitis Haemophilus influenza type B associated B and Haemophilus influenza b Pneumonia and Meningitis (Hib)] Hepatitis – B (injection) Hepatitis-B. It is popularly known as jaundice which is a contagious liver disease that may last lifelong and may result in death Measles Vaccine (Injection) Measles Vitamin “A” oil (Oral) Night Blindness or Blindness (Current Immunisation Schedule of Ministry of Health and Family Welfare, Government of India, is annexed as Annexure 3 in this book.) ii. Periodic deworming of children together with improved water, sanitation and health education can help in reducing bad effects of worms on child health. iii. Nutrition and regular health and growth monitoring of the children at the Anganwadi is necessary. A Gram Panchayats should: • Provide necessary support to the functionaries of Health in organizing regular village level immunization camps specifically in poor and difficult to reach areas/ habitations so as to ensure immunisation of all children • Ensure regular supply of good quality nutrition and other services at the Anganwadis through necessary support, monitoring and also by contributing from own sources of revenue, if needed. • Ensure special health care for children from poor and marginalised families, those restored from trafficking, child labourers etc. due to their special health and nutrition needs
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4.4 Primary Health Care for Women Special attention needs to be given to women’s health due to their special health needs. Due to their reproductive roles, women’s nutritional needs are different from those of men. For example, Women need more iron than men since they lose around 1 mg of iron each day in in their menstrual period. Their nutritional needs change during menstruation, pregnancy, breastfeeding and even during menopause. Iron deficiency can lead to anaemia that will cause weakness, fatigue and breathlessness.
In our society, health of women is generally neglected by them and by others due to their lower status and gender discrimination in various forms like eating in last after everyone in the family has eaten and the least, lack of decision making in their own health matters, poor access to health care, poverty, lack of awareness about health needs and services, social taboos about discussing about their own bodies, violence, abuse and harassment etc.
Some specific areas that need to be taken care of to ensure primary health care for women are: 1. Primary health care for girl children: Health and nutrition interventions for adolescent girls are very important so that their next generations are healthy. In the absence of right nutrition and primary health care in the early growth years, at a later stage when they get married and have their own children, their children- whether boys or girls, may also be born with multiple physical and mental problems. Early marriage of girls and early pregnancies are also harmful for their well-being and their future generations’ health. 2. Prevention of Female Feticide: Female foeticide is the act of aborting a foetus because it is female. This has led to continuous fall in the number of girls in our country. As per the 2011 Census, there are 918 girls per every 1000 boys in 0-5 year’s age group. Women are often forced to undergo multiple pregnancies in desire of sonand the repeated abortions after knowing the sex of foetus in womb through ultrasound scan. This causes them severe health problems, at times also death. Pre-Conception and Pre-Natal Diagnostic Beti Bachao Beti Padhao scheme started Techniques (PCPNDT) Act, 1994 was in January 2015 by GOI focuses on enacted to stop female foeticides and prevention of sex selection of babies and control declining sex ratio in India. The Act abortion of girls before birth; ensuring has banned sex determination of a child survival & protection of the girl child and before birth and doing this is a punishable ensuring education and participation of offence under the law. the girl child. 3. Prevention of Child Marriage - Minimum legal age for marriage of a girl in India is 18 years since she her body and mind are not mature enough to bear the burden of pregnancy and child care till that age. Child marriage and early pregnancy increases the chances of serious health complications for the mother and the child. Child may also be born with low birth weight or mental retardation too. 4. Maternal Healthcare and safe motherhood: Status of health and nutrition of a
43 Health Development in Gram Panchayats Active Panchayat Series Book VII woman during her pregnancy and after child birth is considered maternal health. Death of a woman during pregnancy or within 42 days after delivery due to any reason related to the pregnancy or her motherhood is considered as maternal death. Majority of maternal deaths that take place in India can be prevented with adequate and timely maternal health care. Regular health check-ups and care for pregnant and lactating women is essential for ensuring safe motherhood. At least four Ante Natal Check-ups (ANC) during pregnancy and four post- natal check-ups (PNCs) after delivery are necessity for every pregnant woman at the Health Sub-Centre / Health Centre as per the schedule below:
Ante Natal Check-ups (ANC) Post- Natal Check-ups (PNCs) First check-up within 12 weeks of within 24 hours of delivery pregnancy Second check-up during 14 to 26 weeks of within 48 hours of delivery pregnancy Third check-up during 28 to 34 weeks of within 1 week of delivery pregnancy Fourth check-up after 36 weeks of pregnancy within 6 weeks of delivery
Special care needs to be taken for women with at-risk pregnancies like pregnant women who are less than 19 or more than 40 years old; women suffering from anaemia or high blood pressure; those who have become pregnant for more than 5th time or have had three or more miscarriages; incidence(s) of still birth; who have given birth to low birth weight babies earlier and women who had one or more caesarean deliveries i.e. deliveries through surgery in the past.
5. Safe medical termination of pregnancies i.e. safe abortions; physical and mental health care and support for women victims of violence including domestic violence, sexual abuse or trafficking should be the key priority areas in primary health care. Women from vulnerable categories like poor women, women working in unorganised sectors, destitute, widows or those belonging to SC/ST sections may be more in need of health support due to their difficult situations.
Role of Gram Panchayats • Ensure that health care services reach out to all pregnant and lactating women in the Gram Panchayat area • Generate awareness and take initiatives to ensure 100% registration within 12 weeks of pregnancy, with support from ANMs, AWWs and ASHAs. • Awareness building and promoting institutional delivery through support in necessary arrangements for institutional delivery. If required GP Head-Quarter Sub-Centre at the Gram Panchayat premises may be upgraded to that extent.
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• Support health functionaries in maternal and child death audit i.e. review of incidences of maternal death & child death at the Gram Panchayat area and take up adequate measures in alarming situations • Based on finding of the Health Supervisor’s report, take necessary action at the Gram Panchayat level for possible prevention of such incidences in future and If needed, take up matter with the concerned Panchayat Samiti or the Health & Family Welfare Department for necessary interventions. • Promote family planning and population stabilization through awareness building at the community level and ensure availability of the family planning services at the community level through ASHAs • Community sensitisation for health needs of women and girl children and against social ill practices like low status of women, female feticide and about Beti Bachao Beti Padhao Scheme, with the help of Self Help Groups, youth groups or any other village level organisations.
To substantially improve the health and nutrition status of women and children it is necessary to involve the men in the community. Initiatives need to be taken by the Gram Panchayats to increase the awareness among men on issues like sharing of workload, importance of nutrition for women and their due care during pregnancy, significance of small family, time spacing between two children and better education of girls.
4.5 Adolescents and Reproductive Sexual Health Adolescence is the period after childhood and before adulthood- generally from 10 years to 18/19 years of age. During adolescence, there is rapid physical growth, and many social and psychological changes including sexual maturity take place. Adolescents are neither considered children not adults. They attain puberty in this period and their bodies undergo many changes from that of a child to an adult. Because of these changes which are emotional too, adolescents often find it difficult to understand and adjust to the changes and thus they need support and guidance. Social taboos about discussing the crucial needs of adolescence prevent children from accessing right information and guidance about crucial aspects related to their growth and age specific needs, more specifically about sexual and reproductive aspects. Girls can be especially vulnerable during adolescence due to lack of information. For example, menstruation is still considered a dirty and unclean event and improper menstrual hygiene results in many health problems for girls. Common challenges faced by the adolescents include dropping out of school, child marriages, unwanted pregnancies, malnutrition, poverty, family pressure, drug addiction, crimes against adolescents like trafficking, exposure to substance abuse, problem of unprotected sex etc. Adolescents are vulnerable to developing unhealthy food habits as well as bad habits like smoking and chewing tobacco or drinking alcohol. There is need to ensure that our adolescents eat nutritious and well balanced diet, lead
45 Health Development in Gram Panchayats Active Panchayat Series Book VII appropriate lifestyles and are actively engaged in physical activities such as sports and cultural activities. The Ministry of Health & Family Welfare, has launched a health programme for adolescents, in the age group of 10-19 years named Rashtriya Kishor Swasthya Karyakram (RKSK) to improve their nutrition, sexual and reproductive health, mental health, and to prevent Injuries and violence and substance abuse i.e. use of drugs. It aims to ensure that all adolescents in our Country are able to realise their full potential by making informed and responsible decisions related to their health and well-being. Key components of the programme include community based interventions like peer educators, outreach by counsellors, involvement of parents and the community through a dedicated adolescent health day; communication for information and behaviour change i.e. Social and Behaviour Change Communication; and Adolescent Friendly Health Clinics across levels of care. Adolescent Friendly Health Clinics (AFHCs) are run at the primary, community and district level under RKSK. At the PHC level, an AFHC offers counselling services by ANMs, and management of common health problems and referrals by Medical Officers. These clinics meet the specific needs of adolescents. The Gram Panchayat can play its role for improving adolescents’ health in many ways: • Ensure that appropriate services are provided for adolescents in Anganwadis in the GP area. • Take lead for the establishment of an AFHC in the GP area and with the help of Rogi Kalyan Samiti (RKS), ensure that the AFHC opens at stipulated time as well as provides quality services to the adolescents. • Encourage the PHC to organise training programmes for all the ERs and staff of the Anganwadi, school, members of VHSNC, SMC and SHG on Adolescents’ Reproductive and Sexual health i.e. ARSH and related issues • Generate awareness about the issues of adolescence and services available for them, with support from NGOs working with children/ adolescents in the GP area • Ensure availability and use of play grounds, children parks, resource centres for the adolescents and children. If need be, GP can contribute from own sources too for such facilities or to improve quality of existing ones.
4.6 Health for Elderly persons
Do you know? Of aged population of India, around 2/3rd live in rural areas and half of Indian elderly are dependent on others, may be their children, relatives or social care support systems like old age homes for their care and support. Due to various superstitions and social stigmas in our Country, women, especially those who are widows or have no financial security, are much more vulnerable to destitution and absence of health care.
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Due to weaker bodies and poorer immunity as compared to the adults, often old and aged persons face much more health problems like illness, injury and more frequent infections. With growing age, we are also more at risk of developing chronic diseases such as hypertension and diabetes etc. All persons above 60 are treated as elderly. There is National Programme for Health Care of the Elderly (NPHCE) under NHM. Health problems and needs of different age groups and categories of the aged persons can be different. For example, Trachoma, an infectious blinding disease particularly affects aged women. Leprosy is another disease that badly affects old persons.
Role of Gram Panchayats There is a need for creating elderly persons friendly environment in the villages and we all should be sensitive to their physical and mental health needs. There is a serious need for all of us to be sensitive and ensure due care and support to elderly persons. • Ensure availability of minimal health care and support for the aged persons and regular screening of their health at the GP level • Awareness generation and sensitization about the old age problems • Providing for library/ reading rooms for aged persons • Facilitation to seek their voluntary involvement in teaching poor children and/ or in annual Gram Panchayat Development planning activities. This will keep the aged persons meaningfully engaged and also give them sense of satisfaction for contributing to a cause. • Identification of elderly persons who are more vulnerable like those poor, deserted or destitute, who have no one to take care of them in the family and linking them with care services run by the government or voluntary organisations
4.7 Health of Persons with Disabilities A disability is any constant condition that restricts a person’s everyday activities. Majority of persons with disabilities find their situation very critical in going to school, working for a living, enjoying family life and participating as equals in social life. This, in turn, leads to increased economic and social vulnerability and social exclusion affecting not only the person, but his/her family as well. In our country, persons with disabilities have all the rights to access all entitlements to ensure them a safe, healthy and respectful life. Many laws and schemes focus on their protection and empowerment through health care, education, livelihoods and participation in decision making processes.
What can a Gram Panchayat do? The GP can take initiatives for empowering the Persons with Disability (PWDs) so that they can enjoy all the rights provided to them through the Law i.e. Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995 and take active part in the overall development process of the community.
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During planning process Gram Panchayats must identify children / persons with disability in the Gram Panchayat area and link them with the existing development / social security programmes being implemented by the Gram Panchayat itself or upper tiers of Panchayats or other line Departments Ensure disabled persons friendly facilities in public places like Panchayat Ghar, schools, health facilities at GP level, parks etc. Ensure inclusion of their health issues in public discussion forums and processes of governance like meetings of Gram Panchayat, Gram Sabha, ward sabha etc.; in need identification for the annual GP planning processes; and in identification of beneficiaries for health care, as per the need There may be some more vulnerable persons or groups specific to a State or a local area with specific health issues and needs. Gram Panchayat would need to pay them special attention, identify their health issues and do the needful for linking them with health support system accordingly. Some more crucial areas of health in which gram panchayat have role to play are mental health, alcoholism & drug addiction and prevention of HIV/ AIDs.
4.8 Mental Health As we learnt in the first chapter only, mental health is highly significant for success of overall health of people. Due to various reasons, people suffer from different mental health problems like depression, sleeplessness, feeling of hopelessness, loss of memory, suicidal tendency etc., in mild or severe forms. Sometimes, medical intervention by a mental health professional is required for addressing the problem. It has been often seen in village that people suffering from a mental illness or disability are laughed at and teased by passers-by or deserted by their families. Good mental health is the state in which a person can balance his/her feelings, desires, ambitions and ideas to face and accept the realities of life. A mentally healthy person can learn, feel, express and manage all positive and negative emotions to form and maintain good relationships with others and to cope with the uncertainties in life. Role of Gram Panchayat: While mental health treatment is an expert medical job, Gram Panchayat can play supportive role in ensuring conducive environment for a mental health patient through the following ways: • Ensuring counselling to the patients and families by linking them with appropriate health services and sensitizing community about the condition of the patient, appealing to them for a compassionate and caring attitude and behaviour towards those suffering from mental health problems. • Must have information about the availability of mental health care facilities near the GP, and if someone is found to be abnormally depressed or traumatized in the Gram
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Panchayat area, the most important thing the Gram Panchayat can do is to help the person get a diagnosis and treatment. • Encourage the person and his/her family members to start and to continue treatment. • Organize mental health awareness cum mental illness diagnosis camps from time to time.
4.9 Prevention of Drug Abuse & Alcoholism:
Drug abuse and alcoholism can have lasting effects on the family causing substantial mental health problems like anxiety, fear and depression for other family members especially women and children. It causes financial burden on the family through costs of drugs/ alcohol/ tobacco etc., costs of medical treatment, loss of wages in case of health problems caused by alcoholism and drug addiction, leaving other family members helpless. Addiction includes regular consumption of unhealthy substances like alcohol, tobacco chewing, smoking or taking drugs like smack, opium, heroine etc. Use of all these substances over long period of time affects the vital parts of our body like liver, lungs, kidneys and digestive system and our ability to think and act right. Slowly, the addict person starts losing mental balance, gets violent and at times, suicidal too. Smoking is the single largest preventable cause of diseases and premature death caused by cancer, asthma, heart or lung diseases. De-addiction is a treatment of drug habituation and craving for the abused drug. So, promoting a smoke-free, tobacco-free and alcohol-free environment is an important component of promoting healthy communities, for Gram panchayats through: • Undertaking promotional campaigns and awareness generation activities • Implementing prohibition in the GP area • Linking the affected persons with de-addiction programmes
4.10 Prevention of HIV / AIDS: The human immunodeficiency virus (HIV) is a communicable disease that affects immunity of a person to fight against any infections or diseases AIDs i.e. Acquired Immuno-Deficiency Syndrome is the most advanced stage of HIV infection. AIDS weaken the immune system of the infected person. As a result various diseases [like TB)] attack the person leading to death. There is no cure for HIV infection. However, effective treatment with antiretroviral (ARV) drugs can control the virus so that people with HIV can enjoy healthy and productive lives.
HIV passes from one person to the other HIV does not pass from one person to the through other through
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unprotected sex with an infected person touching, handshaking, hugging, living in the same house, using common bath room or sitting next to someone in a crowded bus or train
transfusion of infected blood from an breathing, sneeze or cough infected person to another use of unsterilized needles and syringes Mosquitoes bites, or other insects bites used by an infected person without proper sterilization From an infected mother to her baby during Sharing of food, drinks, plates, glasses, pregnancy, childbirth and breastfeeding equipments like telephone, mobile, computer, books, pen etc. It is often seen that families and communities is often not very sensitive and supportive to the issues and needs of HIV positive persons. They are often avoided and at times, they are thrown out of their houses or even locality. There are many such examples, especially of women from various parts of the country. Gram Panchayat can play the following roles and responsibilities in this regard: • Ensure social assistance to the HIV infected persons and ensure social security to them and their families • Raising awareness among people about prevention of HIV • Build awareness on safe sex, voluntary counseling, reducing HIV/AIDs related social stigma and discrimination against people living with HIV
Community Based Rehabilitation (CBR) is necessary through special assistance and support for some specific vulnerable sections of the community who may suffer from stigma or ostracisation i.e. social or community boycotting due to their difficult situations. These may include orphans, child labours, children in conflict with law, the children and adult people with disability, destitute, deserted women and persons with mental illness, leprosy cured people, people with HIV, commercial sex works & their children, women and children rescued from trafficking or any other affected person or group. Identification of such persons with special needs, community sensitisation about their situations and health needs, home based support like supportive care and counselling for those who cannot walk or move, formation of caregivers’ groups/ associations to support the community based rehabilitation and empowering them to advocate for their rights are some areas for Gram Panchayats to act upon.
Gram Panchayats can facilitate community sensitisation and mobilisation against such superstitions through continuous awareness generation activities and encouraging people to seek medical treatment at the hospitals or health centres. Wall paintings, organising street plays can be an effective to disseminate such messages.
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Eradication of superstitions regarding health is a very important role of Gram Panchayat - In many communities, there is a superstition that the colostrum i.e. first breast milk just after birth is not good for the health of the baby. So, the dais / birth attendants /family members remove the breast milk immediately after the delivery, which is actually crucial for the child’s immune system. - When suffering from diseases like jaundice, children are taken to witch doctors for treatment. Immunization of children is not initiated or not completed dueto misconceptions. - Sexual activity with children is considered a cure for a sexual transmitted disease and leads to sexual violence against children. - In some places, there is practice of using / wearing amulets for curing diseases instead of consulting a doctor or visiting a health centre for treatment. It is believed that amulets or trinkets have supernatural power for cure from illness.
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Having learnt about the specific roles a GP needs to play with each of the aspects mentioned in this Chapter, we can sum up the broad roles of Gram Panchayat towards primary health at the GP level as follows: • Awareness generation about the need for good health and healthy habits and lifestyles amongst people in GP area, warning them against consequences of unhealthy life styles. Such awareness should cover all aspects of public health like malnutrition, unhygienic living conditions and open defecation, improper waste disposal, breeding of mosquitoes, personal hygiene, unsafe drinking water, poor drainage, inadequate preventive services in cases of pregnancy (ante-natal and post-natal) and child care, under-age marriage of girls, early motherhood and repeated pregnancies, alcoholism and/or drug addiction and also HIV/ AIDs and also foreseen health emergencies in the GP area. • Sharing information with all the community members about the various systems and services available at the GP and also about health facilities above • Organising community level activities like health talks, health camps etc. to promote good health in the GP area • Ensure adequate health facilities in the GP area and if need be, contribute from own sources of GP or mobilise voluntary support from the community or any other stakeholders • Ensure 100% registration of births and deaths in the GP area, with the helpof ANMs, AWWs & ASHAs and in close coordination with local delivery institutions. This database will help Gram Panchayats to look into the various health indicators at the Gram Panchayat area. We will learn more about this in the chapter on health planning by Gram Panchayat.
In West Bengal, Pradhans of the Gram Panchayats have been appointed Sub-Registrar for birth and death incidences within the respective Gram Panchayat area. Information on birth and death is collected at the Gram Panchayat office where necessary registers are maintained and information is shared with all concerned from the registers. Reports of birth and death are also sent to the Registrar as per stipulated timeframe.
• Focus on the health issues of the specific categories as we mentioned the above, especially the poor, landless, those belonging to lower castes, hard to reach habitation or communities with cultural or religious taboos about health issues. For example, in the state of Chhattisgarh the government has sanctioned regular food supplies for patients with tuberculosis. The implementation of this can be designed by the Gram Panchayat and the GP can make ensure that these benefits reach to the real needy poor patients and thus the disease does not further push the patient and her / his family into extreme poverty. • Gram Panchayats can, in general, promote the culture of sports, physical activities and yoga amongst the people through awareness generation, organising sports competitions and yoga camps etc. in the GP area. It can collaborate with the civil society organisations for organising such events.
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To effectively perform all the roles mentioned above, GP has to prepare a GP level health plan and implement the same with participation from all key stakeholders. In the following chapters, we will first learn about the role of GP in the emergency health care and about planning related activities by Gram Panchayat.
What have we learnt in this Chapter?
• There are four kinds of interventions in the health sector – prevention, promotion, cure and rehabilitation. Except curative role i.e. providing treatment, Gram Panchayats have primary responsibility in all three remaining other aspects - preventive, promotive and rehabilitative health care. • Communicable diseases are diseases spread from one person to the other through, air, water or insects etc. These are Typhoid, Hepatitis, Diarrhoea, Amoebiasis, Influenza, Tuberculosis and vector borne diseases like Malaria, Dengue etc. These diseases can be life threatening if not treated well and in time. • Non communicable diseases (NCDs) like heart attack, high blood pressure, blood sugar, thyroid, arthritis etc. occur due to unhealthy life styles like unscientific eating, lack of exercise, smoking and tobacco chewing, intake of drugs and alcohol. • HIV spreads through unprotected sex with an infected person, transfusion of infected blood, use of unsterilized needles and syringes used by an infected person and from an infected mother to her baby during pregnancy, childbirth and breastfeeding. • Children, adolescents, women, aged persons, persons with disabilities, poor people and those living in hard to reach areas are some of the categories needing special attention by Gram Panchayats in accessing health care facilities. • Superstitions like not feeding first breast milk to new born or not giving proper nutrition and health care to the girls, can child use serious health hazards for whole family and future generations and Gram Panchayats need to generate awareness and sensitisation on such aspects and also work towards community based rehabilitation of victims of trauma and stigma.
53 CHAPTERHealth Development in Gram Panchayats 5Active Panchayat Series Book VII
Health During Emergency and the Role of Gram Panchayat
he chapter Health in Emergency includes emergency response measures, first aid including psychological first aid and also issues of Health during disasters and Tepidemics. 5.1 Emergency response measures As per the National Disaster Management Act, 2005, disaster means a catastrophe, mishap, calamity etc. happened due to nature. Some examples are floods in Uttarakhand and Tamil Nadu or a human negligence like Bhopal Gas tragedy which causes human suffering, loss of life and property. Disasters like floods, cyclones, droughts and earthquakes are increasing in India due to environmental problems, cutting down of forests, air pollution, soil erosion and also nuclear explosions etc.
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Often natural disasters like floods lead to outbreaks of infectious & communicable diseases, due to contamination of water and food. If not addressed properly and in time, there is also fear of spreading of these diseases to larger number of people. A disaster also affects water and food supplies, sanitation services such as water supply and sewage and also public health programs in the immediately after the disaster. Later vector-borne diseases can occur in some areas because of failure of vector control efforts, particularly after heavy rains and floods. The GP can play the following roles: • Emergency services: In collaboration with line Departments, Gram Panchayats can play a dynamic role to ensure safe drinking water, oral rehydration solution (ORS), medicines and other essential services including food and shelter during critical situations. • Village level medicine corner in remote areas: Depending on the nature of illness /ailments medicines are available at the Health Sub-Centres, PHCs, BPHCs, RHs, CHCs or other Government Hospitals and at registered medicine shops. But there are also some areas where there is no medicines shop near the PHC / BPHC. Gram Panchayats can explore the possibilities of arranging medicine shop within the reach of the community.
There was no medicine shop near Chandipur PHC in the district of Howrah in West Bengal. The PHC is located adjacent to the Chandipur Gram Panchayat. The nearest medicine shops were located at a distance of around 30 – 35 km from the Gram Panchayat area. Chandipur Gram Panchayat constructed a four-room marketing complex near the PHC for lending to local vendors as part of OSR enhancement initiatives. The Gram Panchayat lent one room out of four only for the purpose of medicine shop. This initiative of the Gram Panchayat has ensured availability of medicines at the locality.
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Gram Panchayats can also build awareness on procurement of medicines from a What can be there in medicine shop based on prescriptions by a the first aid box? doctor and at the same time collection of • Gloves for the helper’s hands cash memo from the medicine shop against • Dressings of cloth, gauze pads or the procured medicines. sanitary napkins • Arrangement for referral transport • Bandages of gauze or cloth to hold at the Gram Panchayat level: Gram dressings tightly over wounds Panchayats should have an arrangement • Rolls of tape to hold on dressings for referral transport for institutional and bandages deliveries and serious cases requiring • Scissors hospitalization. There must be a system through which the service provider • Face masks can be called by the families directly • Blanket made of cloth or Mylar or through the members of Gram (“space blanket”) Panchayats. There are some habitats / • Adhesive strips paras which are connected with narrow • Tweezers to remove stingers, path, where motor vehicles cannot splinters and thorn reach, Gram Panchayats will have to • A small first aid handbook showing make alternative arrangements for how to give first aid referral transport. • Provision of First Aid: First aid is immediate health support to a person till s/he reaches the health centre or doctor like in an accident or sudden illness like a heart attack. Gram Panchayat can ensure that a first aid kit is there in every ward and it is kept at such a place or with such person that it is easily available to anyone whenever there is a need. Gram Panchayat can also seek volunteers in the GP area who are willing to be trained in providing first aid and ensure their training in first aid. It can also acknowledge in Gram Sabha and reward people for giving first aid in emergency and saving lives so that others also feel encourage to do so.
5.2 How do Crisis Events Affect People’s Health? Bedsides natural disasters, various kinds of distressing events happen such as war, accidents, fire outbreak, communal violence and sexual violence etc. At times, people may lose their homes or loved ones, get separated from family and community, or may face violence, destruction or even death. There is no doubt that everyone gets affected in some way or the other way from such difficult situations and this may cause them pain, hurt, depression and also sense of helplessness. Some people may have mild whereas others may have severe reactions. However, some people are more vulnerable than others in a crisis situation and may need extra help. For example, children, the aged persons, persons with disabilities, women, the poor and the marginalized people or those targets of violence, atrocities or attacks etc. Thus they may be more in need of health and mental health care and support.
56 Health Development in Gram Panchayats Active Panchayat Series Book VII
5.3 Special health needs during disasters and epidemics People suffering from long term diseases, those with physical or mental challenges, children, pregnant women or elderly may need special help like a safer place, to connect with basic support and health care, or to take care for themselves. The experience of a crisis event can make different types of health conditions worse, such as high blood pressure, heart conditions, asthma, anxiety and other health and mental disorders. Pregnant and nursing women may experience severe stress from the crisis that can affect their pregnancy or their own and their infant’s health. People who cannot move on their own or who are blind and deaf & dumb, may have difficulty in finding loved ones or accessing the services available. Here are some things that a Gram Panchayat can do to help people with health conditions or disabilities: • Help them get to a safer place • Help them to meet their basic needs, such as being able to eat, drink, get clean water, care for themselves, or to build shelter. • Ask people if they have any health conditions, or if they regularly take medication for a health problem. Try to help people to get medication or access medical services, when available. • Stay with the person or try to make sure they have someone to help them if you need to leave. Consider linking the person with a protection agency or other relevant support, to help them in the longer term. • Give them information on how to access any services available.
What have we learnt in this Chapter?
• A disaster affects water and food supplies, sanitation services and also affects the delivery of public health services. • There is danger of outbreak of communicable diseases after the disaster. • Bedsides natural disasters, various kinds of distressing events happen such as war, accidents, fire outbreak, communal violence and sexual violence etc. in which people may need help. • People suffering from long term diseases, those with physical or mental challenges, children, pregnant women or elderly persons may need special help for addressing their nutrition and health needs during emergency. • Gram Panchayats needs to send alerts before outbreak of an emergency and make necessary arrangements to meet health needs of the people, especially those in vulnerable situations.
57 CHAPTERHealth Development in Gram Panchayats 6Active Panchayat Series Book VII
Health Planning by the Gram Panchayat
s we learnt in the previous chapters, improvement of the health status of a community would be achieved if all are well nourished, there is no incidence of infant death, child death or maternal death in the Gram Panchayat area; there is Ano incidence of child marriage; every household is using sanitary toilets i.e. there is no open defecation and every child in the area is covered under immunization programme. In this context what are the doables in the coming year; how the available resources, various government schemes & programmes can be best utilized and how effectively the services can be delivered to people, especially to the poorest of the poor and most marginalized and how the community can be involved in the development process are integral parts of the health planning process at Gram Panchayat level. Involving all sections and categories of people in the planning exercise especially those marginalised ones, women, economically and socially backward communities in development initiative to enhance their participation and ownership would make
58 Health Development in Gram Panchayats Active Panchayat Series Book VII the planning even more meaningful. In the present chapter, we will discuss about the planning processes by the Gram Panchayat in the area of heath and activities it needs to perform in the pre implementation phase.
6.1 Goals of Gram Panchayat level planning in Health • To ensure timely and effective delivery of health services the people • To mobilise the village people, particularly the poorest of the poor families, about their health rights and existing health services • To achieve the status of ODF (open defecation free Gram Panchayat) and to work for sustaining/retaining the status • To ensure safe drinking water for all households in the Gram Panchayat area • To make the community aware about health, nutrition and sanitation • To ensure 100% coverage of infants/children and pregnant women under immunization programme • To upgrade existing health infrastructure to meet the health needs of the community GP also needs to set targets along with specific indicators to track progress towards achievement of the goals. Systematic planning is essential for sustainable development of health. For effective planning Gram Panchayats must collect, update, consolidate and analyse data on health, nutrition, drinking water, sanitation etc. Gram Panchayats must then understand the current present health status of the community, based on data and facts in the context of health parameters.
6.2 The planning process As we all know that all the Gram Panchayats across the country are undertaking Gram Panchayat Development Plan (GPDP) annually. In GPDP planning is done holistically and includes planning for funds from various sources such as MGNREGA, Fourteenth Finance Commission, Swatchh Bharat Mission and state funds etc. The same planning exercise should be utilised to plan for interventions related to health. Environment generation, need assessment, identification and prioritisation of needs, appraisal and approval of plans are some broad processes of planning. Though the process of planning may vary from state to state, depending on state provisions and guidelines for preparing Gram Panchayat Development Plan, we are discussing the key components of planning in this chapter that may be modified by the State, as per the needs and provisions of planning.
Building environment The planning process can begin with the building environment for participatory planning at the GP level and mobilising all stakeholders to participate in the planning activities through initial Gram Sabha or distribution of pamphlets, public announcement, putting
59 Health Development in Gram Panchayats Active Panchayat Series Book VII up notices at prominent public places or through any other ways that GP wouldbe required to adopt.
Community health needs assessment Community health needs assessment is a process that describes the state of health of local people, enables the identification of the major risk factors and causes ofill health and enables identification of the actions needed to address these. It is a process of systematically collecting information to enable Gram Panchayats and the Health Department to identify, analyse, prioritize and meet the health needs of individuals, households and the community as a whole. The Gram Panchayats needs to identify the problems through various means like discussions in gram sabha, ward sabha and mahila sabha, door to door survey, transect walk, FGDs with the community and thus take preventive measures based on observations and careful analysis of facts and data. Suggested steps of community health needs assessment by a Gram Panchayat are as follows: • Collection of relevant information that will inform the Gram Panchayat about the state of health and health needs of the community • Analysis of this information to identify the major health issues • Deciding on priorities for action • Preparation of health plan to address the priority issues • Implementing the planned activities • Monitoring & evaluation of health outcomes ANM, AWW, ASHA, members of VHSNC and the local community should actively participate in the health needs assessment process. Elected representatives should actively facilitate the needs assessment activities at the ward level. Some GPs also conduct Gram Sabha for this purpose. The major indicators / issues that need to be taken into consideration for assessing or analyzing the present health status can be as following: • Incidences of infant deaths • Incidences of maternal deaths • Number of births per year • Number of deaths per year • Nutritional status of children of 3 and up to 5 years • Average age at marriage • Average age at first pregnancy • Status of family planning methods in use • Prevalence of Diarrhoea, Malaria, TB, Leprosy, etc.
60 Health Development in Gram Panchayats Active Panchayat Series Book VII
Collection of health related data: Data on health issues can be collected from Health Centres, Health Sub-Centres, and Anganwadis etc. that would be treated as secondary data. Apart from this, Gram Panchayats or Health Sub-committees of Gram Panchayats or a task force at GP level must collect data from the community through participatory methods like one to one discussions, group discussions, and surveys, transect walk, ward sabha, mahila sabha, gram sahba etc. These data will be treated as primary data for Gram Panchayat, without which appropriate health plans are not possible. Gram Panchayats or the Health Sub-Committee of Gram Panchayats need to collect data on health, nutrition & sanitation from the community through participatory processes. For this purpose Gram Panchayats need to take initiatives for health mapping in every Ward Sabha and collect data with active participation of the community. If needed, a Gram Panchayat may initiate health mapping at neighbourhood level first and then those maps can be consolidated for each Gram Sansad (Ward) and then finally for the entire Gram Panchayat. An indicative list is given below that may be reflected in the health map and data can be collected on these aspects of health. One may add other health issues based on their local situations. • Families with incidence(s) of infant / child death during last one year • Families with incidence(s) maternal death during last one year • Families with severely malnourished children • Families not having facility for safe drinking water • Families without having sanitary toilet facility • Families with any leprosy affected household member • Families with TB affected household member • Families without having safe drinking water facility In order to have fact-based health scenario of the Gram Panchayat area, data collection on issues related to health, nutrition, drinking water and sanitation is essential. In the process of data collection involvement of Self Help Groups, Village Health, Sanitation & Nutrition Committees and local clubs are essential.
Data compilation & analysis From the health maps of each Ward, a database can be prepared about the present health status of the community, existing health infrastructure and human resources / health service providers in the community. Based on compiled and consolidated data, problems, resources & potentials in health sector need to be analysed thoroughly i.e. what the obstacles or limitations or problems are that hinder health development process at the village level and what can be done to address those issues. Along with these what resources can be utilized for health improvement need to be thoroughly analysed. For example, it is found from data analysis that there are 5 severely malnourished children in a Gram Sansad (Ward) area, it would be necessary for the Gram Panchayat to enquire into the cases and identify the causes behind the problem and then take appropriate
61 Health Development in Gram Panchayats Active Panchayat Series Book VII actions for addressing the problem through planned interventions. To have a fact-based health status of the area, the following issues among others need to be taken into consideration by the Gram Panchayat:
Mother and child related data: • Number of pregnant women and children, not covered under full immunization programme • Number of pregnant women and children, suffering from severe malnutrition • Whether there is provision for safe delivery in the Gram Panchayat area or close to the Gram Panchayat where it is easy to travel • Number of women that availed themselves of the facility of institutional delivery • Number of cases of infant death during last one year • Number of cases of maternal death during the last one year • Whether there is any incidence of under-age marriage in the Gram Panchayat area • Whether all eligible couples are adopting family planning methods
Water and Sanitation related data • Whether every household has access to safe drinking water in the Gram Panchayat area • What are the sources of drinking water and number of sources? • How many wells and tube wells are without concrete base? • Families without having sanitary toilet facility • In how many households toilet facility is available and in spite of having toilet facility how many households do not use that facility • Whether there are toilet facility and drinking water facility in schools, Anganwadi Centres and public places • Whether there are effective mechanism for waste disposal and environmental cleanliness • Whether there is proper sewerage in the Gram Panchayat area or not
Common ailments / diseases related data • What are the major disease prevalence in the locality, who are the susceptible ones and in which seasons prevalence of such diseases occur? • Number of persons suffering from TB in the Gram Panchayat area • Number of persons suffering from leprosy in the Gram Panchayat area • Whether there is any AIDS patient in the Gram Panchayat area • Whether there is any person with disability in the Gram Panchayat area
62 Health Development in Gram Panchayats Active Panchayat Series Book VII
Health infrastructure related data • Whether all the Health Sub-Centres and Anganwadi Centres of the Gram Panchayat area are well equipped and are in good condition • Whether services on health and nutrition are reaching to the needy people • Whether health services from the Government health centres / hospitals are reaching the needy people • Whether any ambulance/ transportation facility is available in the Gram Panchayat area
Prioritisation of needs and preparation of health plan for the Gram Panchayat After collection and analysis of health related data, the report can be presented in the Gram Sabha for prioritising the needs and activities. As per the decisions made in the Gram Sabha based on the extent and urgency of an issue and the resources available, Health Sub-Committee of the Gram Panchayat or GP itself can conduct a participatory workshop for preparation of (a) a Perspective Health Plan of the Gram Panchayat for its five-year term; and (b) an Annual Action Plan for Health every year based on the goals set in the Perspective Plan. In preparation of the Health Plan, the Gram Panchayat would need to identify and quantify the resources available for implementation of the Health Plan. The following resources may be taken into consideration: • Own Source Revenue of the Gram Panchayat • Untied grants available with the Gram Panchayat (SFC Grant, FFC Grant etc.) • Resources likely to be available from the Health & Family Welfare Department on account of devolved funds under various schemes • Resources likely to be available from the Women & Child Welfare Department on account of devolved funds under various schemes • Resources likely to be available from any other Departments on account of devolved funds under health related schemes, if any. • People’s contribution in cash or kind or voluntary labour The Health Plan of the Gram Panchayat must be realistic, based on needs and priorities and resources available/ likely to be available and it must set targets to be achieved in a reasonable time frame. The health Plan must focus more on synergy and convergence than on implementation of schemes, because the plan schemes of the line Departments having technical implications will obviously be implemented by the respective line Departments themselves. But the plan should feature not only activities of the Gram Panchayat but also activities of the line Departments concerned with a note against each and every activity as to which agency would implement which activity. Finally, the Health Plan of the Gram Panchayat will have to be integrated into the overall Gram Panchayat Plan with clear indications about all necessary details.
63 Health Development in Gram Panchayats Active Panchayat Series Book VII
6.3 Role of the Gram Panchayats in pre-implementation phase: The health plan needs to be shared with the community prior to the implementation, for their participation and ownership in implementation. Quite often, it is seenthat participation of the village people is encouraged in the planning process but during implementation, monitoring and evaluation phases participation of the community is not given due importance. Gram Panchayats must take initiatives for sharing status of implementation and related expenditure with the electorate at the Ward Sabha and the Gram Sabha. The Health Sub-Committee of a Gram Panchayat and Village Health, Sanitation & Nutrition Committee at the Ward level will have to play a crucial role in implementation of the Health plan of the Gram Panchayat. So hands-on training and capacity building of the members of both these committees is to be ensured by the Gram Panchayat. Detailed discussion must be held at the Gram Panchayat level with the members of Health Sub-Committee of Gram Panchayat, Village Health Sanitation & Nutrition Committee and other departmental officials working in the health sector at Gram Panchayat level, on planned activities and their respective roles. Along with the members of the Health Sub-Committee and Village Health Sanitation & Nutrition Committees, Health Workers, ICDS Workers, ASHA, Health Supervisor and ICDS Supervisor need to be involved in the discussion and the strategy for plan implementation needs to be developed together on a partnership mode. If this is not done, it might be difficult to seek active participation of the functionaries in the health sector.
What have we learnt in this Chapter?
• Systematic planning by Gram Panchayat is essential for sustainable development of health in the GP area. • The planning process by Gram Panchayat may vary from state to state depending on the state guidelines/ manual for planning etc. but broad steps may include building environment for planning, need assessment, prioritisation of activities as per the necessity and resources available and approval of final plan. • All the stakeholders and all sections of community should participate in the planning activities and make sure that issues of all vulnerable groups are included in planning. • For effective health plan, it would be good for Gram Sabha to organise discussions in Gram Sabha, ward sabhas and other public forums, at various stages of planning, most specifically for setting the priorities and finalisation of the plan.
64 Health Development in Gram PanchayatsCHAPTER Active Panchayat Series Book VII7
Role of Gram Panchayat in Coordination and Monitoring for Health n the last chapter, we will learn about the role of Gram Panchayat in various post planning activities like coordination and linkages with departmental functionaries and other stakeholders on health, monitoring of health activities, grievance redressal etc. Ithat would be necessary for the effective implementation of the health plan in the GP area.
7.1 Coordination for enabling environment to access health entitlements GP in coordination with the VHSNC are expected to provide support to frontline workers- Anganwadi Workers, ASHAs and ANMs in organizing the Village Health Nutrition and
65 Health Development in Gram Panchayats Active Panchayat Series Book VII
Sanitation Days (VHSNDs). ERs should facilitate mobilization of the pregnant women and children, particularly from marginalized household to participate and avail services in the health outreach sessions. Panchayats could provide support in door to door contacts, mobilise people through activities like wall writings, inviting social activists and public health officials to speak on the issues to increase people’s access to the services.
7.2 Organizing local collective action This may include undertaking activities such as organizing Solan, Himachal Pradesh events where community volunteers gather and clean Women have organized the village- decaying solid waste, pools of stagnant water, special Mahila Gram source reduction activities- identify areas of mosquito Sabhas across many larva breeding and taking appropriate anti-larval measures Gram Panchayats in Solan like pouring oil on stagnant pools, ensuring overhead district to discuss issues tanks are well closed, insecticide sprays etc. Panchayats around adverse sex ratio, could also support special drives/campaigns by the health gaps in female education department such as polio, de-worming, iodine, vitamin A and early marriage. These etc. Also the Gram Panchayats can undertake community issues were subsequently mobilization on locally relevant health related issues discussed and endorsed such as malnutrition, early marriage, girls’ education etc. at the larger Gram Sabha The village level untied funds could be used to support meetings. these activities.
7.3 Community monitoring of health services Monitoring is the continuous assessment of project / scheme implementation in relation to approved plan and timeline and on the use of inputs, infrastructure and services and regular tracking of the development schemes including health, nutrition and sanitation is the key aspect of the monitoring health mechanism. So monitoring would mean – • Regular follow up on the implementation mechanism • Regular tracking of progress • Regular tracking on utilization of resources • Regular review of outputs • Regular review of expected outcomes For need based modifications/changes in implementation strategy and also for timely interventions, Gram Panchayat members should undertake monitoring of health services at the village and facility level using simple checklists with the support from the Health Sub-Committee of Gram Panchayats, elected representatives of Gram Panchayat and Village Health Sanitation and Nutrition Committee. (A public health monitoring tool has been annexed as Annexure 4 in this Book). Issues such as maternal and infant deaths, nutritional status of children etc. could especially be monitored and discussed at the monthly VHSNC meetings. The agenda of the monthly meetings of the VHSNCs and Gram Panchayat and the Health Sub-
66 Health Development in Gram Panchayats Active Panchayat Series Book VII
Committee should be prepared based on the locally identified gap area/ issues. In addition, Gram Panchayats should also review and address issues like problems of service providers e.g. proper accommodation and safety of health providers such ANMs, AWW, ASHAs and in reaching out as well as mobilizing unreached groups/ hard to reach pockets or habitations to access health services. For a monitoring meeting to be effective, the following needs to be ensured by the Gram Panchayat: • A fixed date for monitoring meeting every month at the Gram Panchayat level. For example, in West Bengal, 4th Saturday of every month is fixed for such health meeting at Gram Panchayat office. • Prior to meeting all the relevant reports, information, data etc. must be kept ready. • Finalization of agenda and sharing of the same with all concerned are to be done well in advance. At the beginning of the meeting, action taken report based on decision taken in the last meeting must be shared and discussed.
In West Bengal, Gram Panchayats are mandated to convene a health related meeting on the 4th Saturday of every month. Representatives of the Health & Family Welfare Department and the Women & Child Development Department take part in the meeting along with the elected representatives & employees of Gram Panchayats to discuss the overall health scenario of the locality.
• Regular field visits can also be made to get real understanding on progress of programmes and effectiveness of health services at the community level.
As implementer of the Gram Panchayat Health Plan, members of the Health Sub- Committee along with the members of the VHSNCs can oversee whether the activities are being implemented as per approved plan or not, whether timeline is maintained or not, whether health services are being delivered timely or not etc. The State Government/ the Central Government will see whether the resources are being utilized timely or not, whether any rectification or mid-term correction in implementation is required or not. The GPs will see whether community is getting quality health service in time or not.
(A checklist for activities on VHND has been annexed as Annexure 5 and another checklist for Assessing Quality of Services at Health Facilities is annexed as Annexure 6)
7.4 Feedback and dialogue with service providers: In coordination with the service providers- ANM, Anganwadi Workers, ASHAs and Medical Officers, GP can prepare short term plan steps like three monthly steps, as perthe annual health plan for improvement over the next 3-4 months. Issues such as availability of medicines and human resources may require support from block and district level officials and GP needs to seek support from them.
67 Health Development in Gram Panchayats Active Panchayat Series Book VII
7.5 Utilization of Funds and Resource Mobilization The Panchayat representatives should ensure that the funds are utilized based on the locally Dhamtari, Chhattisgarh identified priorities decided in the annual health Panchayat Fund has been utilized plan and are properly accounted for. Details for purchasing an ambulance of expenditures incurred should be shared at for the Belargaon Health Centre the Gram Panchayat and Gram Sabha meetings to provide emergency medical to ensure greater transparency. Besides this, assistance to the people living in Panchayats may contribute resources from their remote areas. In addition, kitchen own revenues or mobilize resources through has also been constructed near community contributions for health promotion the Belargaon Health Centre and delivery for any additional activities, it finds to provide food facilities to the important. patients. Panchayats may use funds available under various Taken from schemes such as the Swachh Bharat Mission, http://www.panchayat.gov.in/ documents/10198/0/RGGSP-2014_ Mahatma Gandhi- National Rural Employment success%20stories%20for%20 Guarantee Act (MGNREGA) for activities like MoPR%20portal-1.pdf construction of public toilets, approach roads downloaded on 19/3/15 for health centres, minor repairs for Anganwadi and Health Centres. For major works/ initiatives, the Panchayats could also send their requests to the district authorities or approach the Members of Parliament (MPs) and Members of Legislative Assembly (MLAs) for support.
7.6 Grievance redressal There may be some issues and complaints regarding the implementation of health programmes. Timely redressal of people’s grievances not only reduces discontent but also helps in improving the overall functioning of the health services. Many a time, grievances arise due to lack of awareness on entitlements, poor service delivery and lack of communication between the community and service providers. Some of the common grievances with regard to the health services could include the following: • Denial of health services • Inappropriate behaviour and discrimination by service providers • Demands for informal payments • Non availability of the service providers • Poor quality or unavailability of services at the health facilities • Unavailability of drugs, diagnostics etc. • Non-payment/ delayed payment of entitlements or incentives under schemes
There are various mechanisms through which Gram Panchayats can redress grievances at the village/ Panchayat level:
68 Health Development in Gram Panchayats Active Panchayat Series Book VII a) Complaint/ Feedback register: Panchayats should maintain a register at the Gram Panchayat level in which people can register their complaint/ feedback. Each complaint/ feedback registered should be entered with a registration number and date. Receipt/ acknowledgement of each complaint/ feedback should be given to the complainant. b) Review of complaints: The head of the Gram Panchayat/GP President along with Panchayat members and members of sub-committee on health, should do the following: • Review the progress on redressal of complaints registered in the Gram Panchayat and share details at the monthly VHSNCs meetings. • The Panchayat President may also investigate the issues raised by the community as well. • Hold discussions with service providers to seek details on the community complaints/ feedback. • Issues which are unresolved for a long time should be referred to the block and district level. Similar mechanisms, should also be institutionalized at health facilities- PHC, CHC and District Hospitals. The Rogi Kalyan Samities should seek client feedback on services, review and take appropriate measures to improve functioning of health facilities. c) Sharing of updates in Gram Sabha meetings: The Sarpanch/ GP President and VHSNC members should provide an update on the grievances raised by the people and corrective action taken on them periodically at the Gram Sabha meetings. d) Promoting use of Helplines: Many states have started their own helplines wherein community members can provide feedback on various development programmes. Under the NHM, some states have operationalised the 104 Helpline for receiving feedback/ complaints on health services. Panchayat members could play an important role in disseminating information and support community members in registering their complaints/ feedback. e) Organizing Public discussions/Jan Samwad: In case there are common grievances regarding delivery of health services across several Gram Panchayats, a public dialogue with the service providers can be organised. Gram Panchayats may seek support from the local civil society organisations/ NGOs to organise the event. The following steps may be taken for organizing a Jan Samwad: • Collecting feedback from the community on key concerns • Documentation of specific cases of negligence, discrimination and denial of health services- applications, individual testimonials • Categorization of the concerns- by issues and levels • Information/ Invitation to the block and district officials to participate in the event • Organizing the event- briefing of panellists, facilitating sharing of community concerns and individual testimonials and documenting the key decisions • Regular follow up action- meetings and discussions with health providers/ managers on status of action taken on the decision points.
69 Health Development in Gram Panchayats Active Panchayat Series Book VII
A Checklist on Governance and Accountability for Gram Panchayats is given below:
SN Suggestive indicators Yes To an No extent 1 Monthly VHSNCs, Gram Panchayat (Health Standing Committee) meetings organized 2 Initiation of community monitoring of health services 3 Meetings organized with service providers to discuss and resolve community concerns 4 Inclusion of health issues in the gram sabhas meetings 5 Grievance redressal mechanisms initiated at the Panchayat level 6 Resource mobilized by Gram Panchayats to support health initiatives
What have we learnt in this Chapter?
• Gram Panchayat in coordination with the VHSNC can provide support to frontline workers- Anganwadi Workers, ASHAs and ANMs in organizing the Village Health Nutrition and Sanitation Day and delivering services to community on regular basis. • Gram Panchayats can mobilise community actions on aspects of awareness generation, cleanliness drives, health camps etc. in the village through voluntary community support and participation or through use of funds from own sources of the GP. • Gram Panchayat should monitor key health issues like availability, access to and quality of health services in the GP area through active involvement with VHSNCs, meetings with health service providers, feedback from community members and also through visits to the health facilities. • Gram Panchayat also needs to set up grievance redressal mechanisms for timely redressal of people’s grievances related to health service provisions and facilities at GP level.
70 Annexure 1
List of indicators – Swasth Panchayat Yojna, Chhattisgarh
Sl. No. Aspect Indicator Denominator Denominator 1 Institutional delivery Total no. of delivery Total no. of women who had during last year institutional delivery 2 Complementary food No. of children of age No. of children in this age to children of 6-12 6-12 months in the group who were getting months hamlet regular complementary feeding 3 Use of mosquito net Total no. of pregnant No. of pregnant women by pregnant women women in the hamlet using mosquito nets 4 Cleanliness around No. of hand pumps in No. of hand pumps without hand pump the hamlet stagnant water around them 5 Use of Safe Drinking Total no. of families in No. of families using safe Water the hamlet drinking water 6 Use of Toilets Total no. of families in No. of families which are the hamlet using domestic/community toilet 7 School education Total no. of girls in No. of girls in this age attainment of girls 14-18 age group in the group who have passed 8th hamlet standard 8 Access to Rozgar No. of families in the No. of families who got more Guarantee Yojana hamlet than 20 days of work during last one year under Rozgar Guarantee 9 Malnutrition Total no. of children No. of these children in any weighed in age 0-3 grade of malnutrition years 10 Infant deaths No. of deliveries in the No. of deaths of any child last year below one year
71 Annexure 2 Key components of the National Health Mission
Reproductive, Maternal, Newborn, Child Health and Adolescent (RMNCH+A) Services: This envisages strategies for improving maternal and child health through a continuum of care and the life cycle approach. The main strategies include services for mothers, new-borns, children, adolescents and women and men in the reproductive age group. Maternal Health: Key strategies include improved access to skilled obstetric care increased coverage and quality of ante-natal and post-natal care, increased access to skilled birth attendance, institutional delivery; basic and comprehensive emergency obstetric care through strengthening of carefully prioritized health care facilities. The Janani Suraksha Yojana (JSY) which provides cash entitlements to enable institutional delivery will be modified in the NHM period to synergize with the new Food Security legislation. The Janani Shishu Suraksha Karyakram provides a package of free and cashless services currently covering all pregnant women, new-borns and sick infants up to the age of one year, in government health institutions, thereby reducing financial barriers to care and improving access to health services by eliminating Out of pocket expenditure in all government facilities. Comprehensive women’s health including pregnancy related morbidity, care for non-communicable diseases among women including screening and treatment of women for common cancers such as cervix and breast would be emphasized. Access to safe abortion services: The focus would be to improve access to comprehensive abortion care, including post abortion contraceptive counselling and services, by expanding the network of facilities providing services. Prevention and Management of Reproductive Tract Infections (RTI) and Sexually Transmitted Infections (STI): Key strategies include: prevention of RTI/STI to be included in communication interventions for community health education and as part of adolescent health education, provision of diagnosis and treatment services at health facilities, syndromic management at 24*7 PHCS and lower levels, and laboratory and diagnostic based services at higher level facilities. Special focus would be given on linking up with Integrated Counselling and Treatment Centres (ICTCs) and establishing appropriate referrals for HIV testing and RTI/STI management. Gender Based Violence: The consequences of gender based violence against women include physical injuries, reproductive health problems, and mental health. Because women are most often seen for the provision of reproductive and child health services, this is a starting point to identify women who are at risk for or who are subject to domestic violence. The steps towards enabling a system wide response to gender based violence (GBV) include: sensitize and train frontline workers and clinical service providers to identify and manage GBV, train ASHAs to identify and refer/counsel cases of GBV in the community, develop effective referral mechanisms from primary care to secondary and tertiary centres, with assured services, build functional referral linkages and create follow up mechanisms with government departments and NGOs providing legal and social welfare services and women’s support groups in the district. New-born and Child Health: This will be through a continuum of care from the community to facility level and include the provision of home based new-born and child care through ASHAs and ANMs, supplemented by AWW, and community level care for acute respiratory
72 Health Development in Gram Panchayats Active Panchayat Series Book VII infections, diarrhoea, and fevers, including home remedies, first contact curative care,or referral as appropriate. Essential new-born care and resuscitation at all delivery points through establishment of New-born Care Corners and skilled personnel will be ensured. Facility Based Care for sick new-borns will be provided through the establishment of New-born Stabilization Units and Special New-born Care Units. This includes strengthening public health facilities and accrediting private providers to manage referrals. Institutional care for sick children and provision for management of children with Severe Acute Malnourished (SAM) at Nutrition Rehabilitation Centres (NRC) will be linked to community based care for SAM. Infant and Young Child Feeding (IYCF) and nutrition counselling to support early and exclusive breastfeeding, complementary feeding, micronutrient supplementation and convergent action will be also encouraged through platforms like VHSNC, VHNDs etc. Reporting and reviewing of child deaths (under five years) is another area of attention. Universal Immunization: Sustaining Pulse polio campaigns and achieving over 80% routine immunization in all districts will be emphasized. Child Health Screening and Early Intervention Services: The purpose is to improve the overall quality of life of children 0-18 years through early detection of birth defects, diseases, deficiencies, development delays including disability and provide comprehensive careat appropriate levels of health facilities. These services will be delivered through the Rashtriya Bal Swasthya Karyakram (RBSK). RBSK will cover at least 30 identified health conditions for early detection, free treatment and management through dedicated mobile health teams placed in every block in the country. District Early Intervention Centres (DEIC) will be set up to provide further screening and management support to children detected with health conditions and make appropriate referrals. The mechanism to reach all the target groups of children for health screening will be through enabling facility based new-born screening at public health facilities, by existing health manpower, and community based new-born screening at home through ASHAs during home visits. Children six weeks to six years would be screened periodically by dedicated Mobile Health Teams at the Anganwadi Centre. Further, in Government and Government aided schools children six years to 18 years will be screened. This intervention will not only halt deterioration of the condition but also reduce the OOP expenditure among the poor and the marginalized. Additionally, the Child Health Screening and Early Intervention Services will also provide country-wide epidemiological data on the 4 Ds (i.e., Defects at birth, Diseases, Deficiencies, Developmental Delays and Disabilities). This is important to inform planning in the future, for area specific services. Public health institutions, private sector partnerships and partnerships with NGOs will be encouraged to provide specialized diagnostics/tests and services and to fill gaps in services. Such institutions would be reimbursed for services as per agreed costs of tests or treatment. In addition to the direct provision of such services, the state will enable convergence with ongoing schemes of other relevant ministries. Patient transport network supported under NHM will be used to transport sick children to higher facilities. Adolescent Health: Adolescent Health programmes include the following priority interventions: Iron and Folic Acid (IFA) supplementation, facility-based adolescent health services, community based health promotion activities, information and counselling on sexual and reproductive health (including menstrual hygiene), substance abuse, mental health, non- communicable diseases, injuries and violence including domestic violence. These interventions will be operationalized through various platforms including Adolescent Friendly Health Clinics (AFHC), VHNDs, Schools, Anganwadi Centres and Nehru Yuva Kendra Sangathan (NYKS), Teen Clubs and a dedicated Adolescent Health Day. Outreach activities aimed at information
73 Health Development in Gram Panchayats Active Panchayat Series Book VII provision and health promotion will be through Peer educators and mentors. Provision of nutrition counselling, treatment for RTIs/STIs, appropriate referrals and commodities such as IFA tablets, condoms, Oral Contraceptive Pills (OCPs) and pregnancy kits for all adolescent girls and boys at the AFHCs. Information and counselling will be provided by dedicated and trained counsellors. There will be enhanced focus on vulnerable and marginalized sub-groups. Menstrual hygiene practices will be promoted in rural areas through use of sanitary napkins. This is to be combined with building adequate knowledge and information about the product through ASHAs. Provision of Weekly Iron and Folic acid Supplementation (WIFS) for addressing nutritional anaemia among adolescent boys and girls in rural and urban areas would be part of the National Iron Plus Initiative. The scheme also includes nutrition and health education sessions, screening of target groups for moderate/severe anaemia and referring these cases to an appropriate health facility. There would be provision for biannual de-worming (Albendazole 400mg), six months apart, for control of helminth infestation, information and counselling for improving dietary intake and preventing intestinal worm infestation. Family Planning: Meeting unmet needs for contraception through provisioning of a range of family planning methods will be prioritized. Post-partum and post abortion contraception would be a priority. All states would be encouraged to focus on promotion of spacing methods, especially Intra-Uterine Contraceptive Devices (IUCDs). Post-partum IUCD will be emphasized as a key spacing method to leverage the increase in institutional deliveries while ensuring appropriate counselling and quality of services. In addition to existing providers, AYUSH doctors will also be trained for IUCD services. Male involvement including male sterilization would be promoted. Distribution of contraceptives at the doorstep through ASHAs and other channels will be actively promoted. Addressing the Declining Sex Ratio : Improving the adverse child sex ratio will be crucial and strategies that lie within the domain of health include: Stricter enforcement of the PCPNDT Act, improved monitoring and sensitization of the medical community, and a greater role for civil society action in addressing son preference, addressing neglect of the girl child in illness care, observing sex ratios in hospital admissions for illness in children, and providing proactive support for girl children through the ASHA and Anganwadi system.
Control of Communicable Diseases: The NHM will continue to focus on communicable disease control programmes and disease surveillance. The National Vector Borne Diseases Control Programme (NVBDCP) is an umbrella programme for prevention and control of vector borne diseases viz. Malaria, Japanese Encephalitis (JE), Dengue, Chikungunya, Kalaazar and Lymphatic Filariasis. Of these, Kala-azar and Lymphatic Filariasis have been targeted for elimination by 2015. The States are responsible for programme implementation and the Directorate of NVBDCP provides policy guidance and technical assistance, and support to the states in the form of funds and commodities. The Government of India provides technical assistance and logistics support including anti-malaria drugs, DDT, larvicides, etc. under the Programme. State Governments have to meet other requirements of the programme and to ensure effective programme implementation. Strategies employed would include early case detection and prompt treatment, strengthening of referral services, integrated vector management, use of Long Lasting Insecticidal Nets (LLIN) and larvivorous fishes. Other interventions including behaviour change communication will also be undertaken. Revised National Tuberculosis Control Programme (RNTCP). The goal is to decrease mortality
74 Health Development in Gram Panchayats Active Panchayat Series Book VII and morbidity due to TB and reduce transmission of infection until TB ceases to be a major public health problem in India. Objectives of the programme are to achieve and maintain cure rate of at least 85% among New Sputum Positive (NSP) patients and achieve and maintain case detection of at least 70% of the estimated NSP cases in the community. The current focus of the programme is on ensuring universal access to quality TB diagnosis and treatment services to TB patients in the community and now aims to widen the scope for providing standardized, good quality treatment and diagnostic services to all TB patients in a patient-friendly environment, in which ever health care facility they seek treatment from. The programme has made special provisions to reach marginalized sections including creating demand for services through specific advocacy, communication and social mobilization activities.
National Leprosy Control Programme (NLEP) Key activities include diagnosis and treatment of leprosy. Services for diagnosis and treatment (Multi Drug Therapy, MDT) are provided by all primary health centres and govt. dispensaries throughout the country free of cost. ASHAs are involved in bringing leprosy cases from villages for diagnosis at PHC, following up cases for treatment completion, and are paid an incentive for this. To address the problem in urban areas, Urban Leprosy control activities are being implemented in 422 urban areas with a population of over 100,000. These activities include MDT delivery services and follow up of patient for treatment completion, providing supportive medicines, dressing material and monitoring & supervision.
Non Communicable Diseases (NCD) National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS): Primary care includes primary prevention of hypertension and diabetes, screening and secondary prevention by routine follow up with medication to prevent strokes and ischemic heart disease. This needs to be linked through two way referral linkages with appropriate secondary and tertiary care providers. Cardiac Care Units for treatment of Ischemic heart disease, stroke and other cardiovascular emergencies, and facilities for diagnosis and treatment of chronic kidney diseases including dialysis will be made available at district hospital level. For cancer control, one dimension is care at the primary level, i.e. prevention, promotion, and early detection, assisted access to higher specialist care, guidance and support. Another dimension is to create a network of hospitals that could provide free care for cancer patients. Facilities for screening of common cancers (Cervical Cancer, Breast Cancer and Oral cancer) and Day care centres for chemotherapy prescribed by Tertiary level cancer hospitals would be provided. National Programme for the Control of Blindness (NPCB): The focus in the 12th Plan period would be to consolidate gains in controlling cataract blindness and also initiate activities to prevent and control blindness due to other causes. Key strategies are to increase public awareness about prevention and timely treatment of eye ailments; with a special focus on illiterate women in rural areas; continuing emphasis on primary healthcare (eye care) by establishing Vision Centres in all PHCs; active screening of population above 50 years through screening camps; transporting operable cases to eye care facilities; screening of school age children for identification and treatment of refractive errors (in synergy with the RBSK); with special attention in under-served areas and provision of assistance for other eye diseases. NGOs will be involved and the private sector will be contracted-in where required. National Mental Health Programme (NMHP): In addition to managing common mental
75 Health Development in Gram Panchayats Active Panchayat Series Book VII problems, severe mental diseases, and mental emergencies, new components like suicide prevention, workplace stress management, adolescent mental health and college counselling services will be included. Services for alcohol and substance use, rehabilitation of the mentally ill and community and home care for chronic and enduring mental illness will be provided and synergies will be built with RMNCH+A to identify and manage post-partum depression. Outreach services will be provided by community mental health nurses supported by the PHC. National Programme for the Healthcare of the Elderly (NPHCE): The aim of the NPHCE is to provide comprehensive health care to senior citizens through all levels of the health care delivery system including outreach services. This is being implemented in selected districts. National Programme for the Prevention and Control of Deafness (NPPCD): This is being implemented in 200 districts. Its key objectives are to prevent avoidable hearing loss, early identification, diagnosis and treatment of ear problems responsible for hearing lossand deafness, rehabilitate persons of all age groups, suffering with deafness, and strengthen the existing inter-sectoral linkages for continuity of the rehabilitation programme, and develop institutional capacity for ear care services by providing support for equipment and material and training personnel. National Tobacco Control Programme (NTCP): Interventions under the NTCP will be largely at the primordial and primary levels of prevention. Key thrust areas include training of health and social workers including ASHAs, NGOs, school teachers, enforcement officers; IEC activities; School based programmes; monitoring tobacco control laws; co-ordination with PRI/VHSNC for village level activities and strengthening/establishment of cessation facilities including provision of pharmacological treatment facilities at district level. National Oral Health Programme (NOHP): A total of 200 districts in a phased manner would be taken up to strengthen the existing healthcare delivery system at primary and secondary level in order to provide promotive and preventive oral health care. National Programme for Palliative Care (NPPC): Palliative care improves the quality of life by alleviating pain and suffering, and may influence the course of the disease in patients with cancer, AIDS, chronic disease, and the bed ridden elderly. Palliative care strategies will be synergized with programmes for the care of the elderly, cancer and chronic diseases. Strategies for palliative care in NHM will use the continuum of care approach, through IEC, outreach and coordination of referral at the level of the PHC, out-patient and home-based care at the PHC and in-patient care through allocating specific beds at the DH, Medical College and Regional Cancer Centres. National Programme for the Prevention and Management of Burn Injuries (NPPMBI): Prevention would be through school based programmes, mass media programmes for general public and appropriate advocacy. District hospitals would be provided with six beds for burn units. Rehabilitation services would be provided through facility and community based rehabilitation services, and HR would be trained appropriately. National Programme for Prevention and Control of Fluorosis (NPPCF): The programme will be expanded from the existing 100 to an additional 95 new districts. The key strategies are surveillance of fluorosis in the community, capacity building in the form of training and manpower support as required, management of fluorosis cases including surgery, rehabilitation and health education for prevention and control of fluorosis.
76 Annexure 3
National Immunization Schedule
Vaccine Protection Doses Vaccination Schedule BCG Childhood 1 At birth(up to 1 year if not given earlier) (Bacillus Chalmette Tuberculosis Guerin) Pentavalent Diphtheria, Pertussis, 3 Three doses at 6, 10 &14week [Diphtheria, Tetanus, Hepatitis Pertussis, B, Haemophilus Tetanus(DPT), influenza type Hepatitis B and B associated Haemophilus Pneumonia and influenza b (Hib)] Meningitis DPT (Diphtheria, Diphtheria, Pertussis 2 Two booster doses at 16-24 months and 5 Pertussis and Tetanus and Tetanus years of age. Three primary doses at 6, 1 0 & Toxoid) 14week are part of Pentavalent vaccine. Hepatitis B Hepatitis B 1 Birth dose for institutional deliveries with 24 hour. Three primarydosesat6, 10&14week are part of Pentavalent vaccine. OPV(Oral Polio Polio 5 Birth dose for institutional deliveries. Three Vaccine) primary doses at 6, 10 &14 week and one booster dose at 16-24 month of age. Given Orally. IPV (Inactivated Polio Polio 1 One dose at 14 weeks, along with OPV3. vaccine)$ Injectable dose given. Japanese Japanese Encephalitis 2 9-12months of age and 2nd dose at 16-24 Encephalitis# months Measles Measles 2 9-12months of age and 2nd dose at 16-24 months Vitamin A Night Blindness 9 -1st dose at 9 months -2nd dose at 18 months -3rd to 9th dose given at 6 monthly interval upto 5 years. Rotavirus* Rotavirus diarrhoea 3 Three doses at 6, 10 &14 week. Given Orally.
TT (Tetanus Toxoid) Tetanus 2 -10 years and16 years of age 2 -For pregnant woman, two doses given (one dose if previously vaccinated within 3 years) $ At present in six states-Assam, Bihar, Gujarat, M.P, Punjab and U.P, and in process of expansion. # In endemic districts * Phased introduction, at present in Andhra Pradesh, Haryana, Himachal Pradesh and Orissa from 2016. Source: nrhm.gov.in (link: http://nrhm.gov.in/images/pdf/programmes/immunization/manual-formats/Current_ UIP_Schedule.pdf) downloaded in September 2016
77 Annexure 4 Public Services Monitoring Tool
Indicators Jan. Feb. March.. ANGANWADI CENTRE 1 Did all Anganwadi centres open regularly during the month? 2 Number of children aged 3 - 6 years? 3 Number of children aged 3 - 6 years who came regularly to Anganwadi Centre? 4 No. of 0-3 year children in village 5 No. of 0-3 year children who are in malnourished or severe malnourished grade 6 Was the weight measurement of children done in all centres last month? 7 Were pulse and vegetables served all days in cooked meal last week in all the centres? 8 Was Ready to Eat food distributed in all centres on each Tuesday during the last month? COMPLEMENTARY FEEDING 9 Number of children aged 6-9 months whose complementary feeding has not started yet? HEALTH SERVICES 10 Did the ANM come last month for the Immunization/ VHND? 11 Whether all children of all hamlets are being vaccinated in appropriate age? 12 Whether the BP measurement of pregnant woman was done in the VHND? 13 Did the ANM provide medicines to the patients free of cost? 14 Did all the ASHAs have more than 10 chloroquine tablets with them? 15 Did all the ASHAs of the village had more than 10 Cotrimaxazole tablets with them?
78 Health Development in Gram Panchayats Active Panchayat Series Book VII
16 Whether the transportation facility was available to take the serious patients, delivery cases, sick new-born cases, etc to health facilities? 17 Number of families not using mosquito net? 18 Number of deliveries that took place in the home during the last month? 19 Number of diarrhoea cases during the last month? 20 Number of fever cases during the last month? FOOD SECURITY 21 Whether the ration shop provided all ration items during the last month? 22 Did the old age pensioners get pension in time? 23 Was the MNREGA payment made in time? EDUCATION 24 Number of girls under the age group of 6-16 not attending the school? 25 Did all the schools teachers come to the schools regularly during the last month? MID- DAY MEAL 26 Were pulse and vegetables served all days in cooked meal last week in all the schools (for children up to 8th calss)? HAND PUMP 27 How many hand pumps are non-functional as on today? 28 Number of hand pumps with stagnant water around -today? INDIVIDUAL HOUSEHOLD LATRINES 29 Number of households with individual household latrines constructed and used? OTHERS 30 Number of cases of violence against women during the last month? 31 Number of cases of early childhood marriages reported?
79 Annexure 5 Checklist for Village Health Nutrition Day
Name of block Name of PHC Name of Sub centre Name of village SN Parameters Assessment Remarks Yes/No/ Partial/ NA- Not applicable Presence of Health Workers during VHND 1 Was ANM present during VHND? 2 Was ASHA present during VHND? 3 Was AWW present during VHND? Services delivery during VHNDs by ANM 1 Was ANM doing ANC check- up of pregnant women? 2 What components of ANC were being provided? I Tetanus toxoid injections Ii Blood pressure measurement Iii Weighing of pregnant women Iv Blood test for anaemia using Haemoglobin meter V Examination of abdomen Vi Counselling of appropriate diet and rest Vii Inquiring about any danger signs like – selling in whole body, blurring of vision and severe headache or fever with chills etc. Viii Counselling for institutional delivery 3 Was ANM providing vaccination to children? 4 Did she also provide medicine or referral in case of any sickness of any child below 2 years of age? Services provided by AWW during VHND 1 Was AWW weighing all the children of 0-6 years of age?
80 Health Development in Gram Panchayats Active Panchayat Series Book VII
2 Was AWW weighing the children correctly? 3 Did AWW record the weight on the growth monitoring card correctly? 4 Did AWW give take home rations to children 6months – 6 years of age? 5 Did AWW give take home rations to adolescent girls? 6 Did AWW give take home rations to pregnant women? 7 Did AWW give take home rations to lactating mothers? Quality of services delivered during VHND 1 Weighing machine of ANM was in order 2 Weighing machine of AWW was in order 3 Thermometer was working accurately 4 BP apparatus was working accurately 5 Supplementary food was available 6 Quality of supplementary food was good Roles played by ASHA 1 Did ASHA make a list of potential beneficiaries who need either ANM or AWW services? 2 Was ASHA able to motivate most (>75%) of the beneficiaries to attend VHND? 3 Did she inform the beneficiaries at least a day before about the date of VHND? 4 Did she help ANM or AWW in organizing the VHND? General questions 1 What was the venue of the VHND i Anganwadi Centre ii Sub centre iii Panchayat hall iv Some other – open venue 2 Was VHND held on a fixed date every month?
81 Annexure 6 Checklist for Assessing Quality of Services at Health Facilities
Observation Checklist for Health Sub-Centre General information Name of the sub-centres village______Total population covered by the sub-centre______Distance from thePHC ______
I) Availability of staff at the sub-centre Is there an ANM available/appointed at the centre? Yes/No Is there health worker-male (MPW) available/appointed? Yes/No Is there a part-time attendant (female) available? Yes/No
II) Availability of infrastructure at the sub-centre Is there a designated government building available for the sub-centre?Yes/No Is the building in working condition? Yes/No Is there a regular water supply at this sub-centre? Yes/No Is there regular electricity supply at this sub-centre? Yes/No Is the blood pressure apparatus in working condition in this sub-centre?Yes/No Is the examination table in working condition in this sub-centre? Yes/No Is the steriliser instrument in working condition in this sub-centre? Yes/No. Is the weighing machine in working condition in this sub-centre? Yes/No Are there disposable delivery kits available in this sub-centre? Yes/No
III) Availability of services at the sub-centre Does the doctor visit the sub-centre at least once a month? Yes/No Is the day and time of this visit fixed? Yes/No Is facility for delivery available in this sub-centre during a full 24-hourPeriod? Yes/No Is treatment of diarrhoea and dehydration offered by the sub-centre? Yes/No Is treatment for minor illness like fever, cough, cold, etc. available in this sub- centre? Yes/No Is facility for taking a blood slide in the case of fever for detection of malaria available in this sub- centre? Yes/No Are contraceptive services available at this sub-centre? Yes/No Are oral contraceptive pills distributed through this sub-centre? Yes/No Are condoms distributed through the sub-centre? Yes/No
Observation Checklist for PHC Centre General information Name of the PHC village ______
Total population covered by the PHC______I) Availability of Infrastructure Is there a designated government building available for the PHC? Yes/ No Is the building in working condition? Yes/No Is water supply readily available in this PHC? Yes /No Is electricity supply readily available in this PHC? Yes/No Is there a telephone line available and in working condition?
82 Health Development in Gram Panchayats Active Panchayat Series Book VII
II) Availability of staff in the PHC Is a Medical Officer available/appointed at the centre? Yes/No Is a Staff Nurse available at the PHC? Yes/No Is a health educator available at the PHC? Yes/No Is a health worker-male (MPW) available/appointed? Yes/No Is a part time attendant (female) available? Yes/No
III) General services Availability of medicines in the PHC Is the anti-snake venom readily available in the PHC? Yes/No Is the anti-rabies vaccine readily available in the PHC? Yes/No Are drugs for malaria readily available in the PHC? Yes/No Are drugs for tuberculosis readily available in the PHC? Yes/No Availability of curative services Is cataract surgery done in this PHC? Yes/No Is primary management of wounds done at this PHC? (Stitches, dressing etc.)Yes/No Is primary management of fracture done at this PHC? Yes/No Are minor surgeries done at this PHC? Yes/No Is primary management of cases of poisoning done at the PHC? Yes/No Is primary management of burns done at the PHC? Yes/No
IV) Availability of Reproductive and maternal care and abortion services Are ante-natal clinics regularly organised by this PHC? Yes/No Is facility for normal delivery available in the PHC 24 hours a day? Yes/No Are facilities for tubectomy and vasectomy available at the PHC? Yes/No Are internal examination and treatment for gynaecological conditions and Disorders like leucorrhoea and menstrual disturbance available at the PHC? Yes/No. Is facility for abortion- Medical Termination of Pregnancy (MTP) available at this PHC? Yes/No Is treatment for anaemia given to both pregnant as well as non- pregnant women? Yes/No How many deliveries have been conducted in the last quarter (three Months)? ______
V) Child care and immunisation services Are low birth-weight babies treated at this PHC? Yes/No Are there fixed immunisation days? Yes/No/No information Are BCG and measles vaccine given at this PHC? Yes/No Is treatment for children with pneumonia available at this PHC? Yes/No Is treatment of children suffering from diarrhoea with severe dehydration done at this PHC? Yes/No
VI) Laboratory and epidemic management services Is laboratory service available at the PHC? Is blood examination for anaemia done at this PHC? Yes/No Is detection of malaria parasite by blood smear examination done at this PHC? Yes/No Is sputum examination to diagnose tuberculosis conducted at this PHC? Yes/No Is urine examination of pregnant women done at this PHC? Yes/No
83 Abbreviations
AIDS: Acquired Immuno-Deficiency Syndrome MDG: Millennium Development Goal ANC: Antenatal care MMR: Maternal Mortality Ratio ANM: Auxiliary Nurse Midwife MO: Medical Officer ARI: Acute Respiratory Infection MoHFW: Ministry of Health and Family Welfare ARSH: Adolescent Reproductive and Sexual MoPR: Ministry of Panchayati Raj Health MTP: Medical Termination of Pregnancy ASHA: Accredited Social Health Activist NHM: National Health Mission AWW: Anganwadi Worker NMR: Neo-natal Mortality Rate BCC: Behaviour Change Communication OPV: Oral Polio Vaccine BCG: Bacillus Calmette Guerin PHC: Primary Health Centre BMOH: Block Medical Officer of Health PMR: Peri-natal Mortality Rate BPHC: Block Primary Health Centre PPP: Public Private Partnership CDPO: Child Development Project Officer PRI: Panchayati Raj Institutions CHC: Community Health Centre PS: Panchayat Samiti (Block Panchayat) CMOH: Chief Medical Officer of Health PTSD: Post-Traumatic Stress Disorder DHFW: Department of Health and Family PWD: Persons with Disability Welfare RCH: Reproductive and Child Health DH: District Hospital RKS: Rogi KalyanS amiti DLHS: District Level Household Survey NVBDCP: National Vector Borne Disease DPT: Diphtheria, Pertussis & Tetanus Control Programme DWCD: Department of Women and Child NFHS: National Family Health Survey Development RSBY: Rasthriya Swasthya Bima Yojana FRU: First Referral Unit RTI: Reproductive Tract Infection GoI: Government of India SBA: Skilled Birth Attendant GP: Gram Panchayat (Village Panchayat) SBM: Swachh Bharat Mission HIV: Human Immuno-deficiency Virus SDH: Sub-Divisional Hospital HSC: Health Sub-Centre SGH: State General Hospital ICDS: Integrated Child Development Services STI: Sexually Transmitted Infection Scheme TBA: Trained Birth Attendant IEC: Information, Education, Communication TB: Tuberculosis IFA: Iron and Folic Acid VHND: Village Health & Nutrition Day IMR: Infant Mortality Rate VHSNC: Village Health, Sanitation & Nutrition IUD: Intra Uterine Device Committee JSSK: Janani Shishu Suraksha Karyakram WHO: World Health Organization JSY: Janani Suraksha Yojna ZP: Zila Parishad (District Panchayat) LBW: Low Birth Weight
84