| 4. In which ways is the initiative creative and innovative?
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The programme was rolled out in a phased manner with complete roll-out taking around 2 years starting from 2001. It involved a wide variety of civil society actors and government functionaries.
The first step in the implementation was selection of a CHW called ‘Mitanin’ for each of the 60,000 rural habitations in the state. Each Mitanin was to represent and serve one rural habitation. The habitation based design was useful in allowing the communities to select the most suited person as ‘Mitanin’. It also helped in getting proportional representation of vulnerable sections – Scheduled tribes and Scheduled castes in selection as CHWs. Only women could be selected as Mitanins. The actual selection process was accompanied by a large social mobilisation campaign which informed the communities on social basis of health and created an enthusiastic environment about the need to select a CHW. Each Mitanin was selected through 2-3 community meetings facilitated by a trained facilitator. Women formed the majority and principal decision makers in selection of Mitanin.
The Training Curriculum of Mitanins was designed based on needs of women. It defined health in comprehensive terms and included overall well-being and empowerment as good health. The first training module in 2002 taught Mitanins the social basis of health with exercises to understand gender as a key determinant. The third training module of Mitanins in 2004 focused on gender and health in further detail. It looked at women’s needs beyond ‘maternal’ and emphasized the need to collectively work to reduce gender based discrimination across age-groups including violence against women (VAW). Mitanins received a revised training on gender in 2011. By 2013, Mitanins have received training on 18 modules. The programme was able to maintain rigour in its large scale capacity building efforts, involving nearly 4 million person days of residential training for Mitanins. In addition, Mitanins have received around 20 million person days of training effort.
The third key aspect was system of support and supervision. Mitanins were supported by community-led village level health committees as well as larger networks of Mitanins. The structure created to provide training and continuous supportive supervision also had an overwhelming majority of women in its total strength of around 3500 Trainers and Coordinators. The programme encouraged men to participate in village committees but the leadership was always in hands of women.
Mitanins started organizing women as habitation level women’s health committees. In 2008, the committee was formalized as Village Health Sanitation and Nutrition Committee. Mitanin acts as convener of this committee which is headed by a woman elected representative of the village. Women formed more than two-third of the committee membership. One of the key activities that Village Health Committee took up was of monitoring delivery of public services to rural communities. The communities started recording monthly performance of key public services. It led to greater awareness on entitlements and allowed the women to demand greater accountability from various service providers covering areas of healthcare, nutrition, education, drinking water and rural development. The gaps identified were also used by committees to plan collective action to address them.
Another important aspect that Village Health Committees monitor is gender discrimination through indicators of Violence against women and education of girls. This monitoring helps the women to discuss these issues in presence of men and thus pushes the community to find a collective solution to protect the rights of women and girls. This process was piloted in 2006 to 2008 and then expanded to cover the entire state by 2011.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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Dr Alok Shukla, Secretary of Health and Family Welfare, Government of Chhattisgarh along with Mr Harsh Mander a civil society leader representing ActionAid, an international NGO, together brought the idea of CHW programme to fore and built the necessary consensus around it. Government of Chhattisgarh and its civil society partners agreed to create a new institution to implement the programme. The dedicated institution called State Health Resource Centre was set up in 2002 with facilitation support from ActionAid, an international NGO. Around 10 local NGOs partnered with the Department of Health and Family Welfare for piloting the programme.
Dr T Sundararaman with experience of health systems as well as community health worker interventions in other states of India, designed the main aspects of the programme and led the programme implementation as the first Director of State Health Resource Centre. Dr Premanjali Dipti Singh and Ms Nisha Gautam contributed to the technical and the social components of the detailed strategy respectively.
The Department of Health provided funds for training, medicines, and linkages to public healthcare services. State Health Resource Centre’s role was focused on arranging training, capacity building and supportive supervision along with managing the interface between communities and Department of Health. Apart from the above two bodies, rural women and local elected bodies (Panchayats) were the key stakeholders in the implementation of the programme. They played the key role in selection of CHWs, providing them motivation through social recognition and acting as a supportive network in CHW’s work as a change agent. Rural women had the overall ownership of the programme at local level. It gets illustrated by the fact that replacement of CHW could be done only through a collective resolution of rural women while no Government official is authorized to remove or replace a Mitanin.
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| 6. How was the strategy implemented and what resources were mobilized?
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Since Chhattisgarh at the time of conceptualization of Mitanin programme was a new state with limited financial resources, it needed external grants to start-up the programme. European Commission provided most of the initial funding between year 2001 to 2005. The total cost in the 4 year period was around Rs. 110 million (around $ 3 million). State Government introduced its contribution from state budget, starting with Rs. 12 million for Mitanin Programme and then adding another Rs.30 million annually to provide essential drugs to CHWs as a part of National Rural Health Mission. Mitanins were recognized by the central government as CHWs under National Rural Health Mission and started receiving financial and support from it.
The annual cost of the programme in 2013 was around Rs.600 million ($ 10 million) for 66,179 Mitanins. The central Government funds now around 60% of this cost and rest is funded by the State government. The cost per Mitanin is around Rs.8500 ($150) per annum. The per capita cost in terms of population covered is around half a dollar per annum, making it one of the most cost efficient programmes of its nature.
The 66,179 Mitanins are supported by 3150 facilitators and trainers. Around 450 Block Coordinators provide leadership at block level in the 146 administrative blocks of the state. They are supported by 35 District Coordinators. Around 90% of these human resources have been drawn from the local rural women.
In terms of technical resources, State Health Resource Centre managed the knowledge resources using its linkages with government departments as well as civil society actors especially groups working on women’s rights, food and nutrition activists, public health activists and experts.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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The key outputs of Mitanin programme were:
a) Increased access to Health care Services: Annually, Mitanins directly provide a number of healthcare services to around 20 million population. E.g. they counsel each year around 340,000 families on newborn care. They provide counseling on nutrition of children and prevention of infections to around 2.1 million families annually. They provide oral rehydration to around 700,000 cases of diarrhea annually, mostly children. They annually treat around 175,000 cases of malaria or other fevers. They treat around 9 million patients of common illnesses annually by providing free drugs and advice.
Mitanins have been linking families with formal healthcare system by screening, advising and referring cases appropriately. E.g. Mitanins each year help in referring to Government health facilities around 260,000 institutional deliveries, 42,000 children with pneumonia, 26,000 patients with symptoms of Tuberculosis, 80,000 couples for sterilization operations.
b) Change in health related behaviours of community: Health education by Mitanins has brought changes in many community behaviours related to health, nutrition and sanitation e.g. feeding of mothers during pregnancy and after child-birth, timely initiation of breastfeeding, age appropriate complementary feeding for young children, hand-washing with soap before feeding.
c) Monitoring of Services by women in Village Health Sanitation and Nutrition Committees: This area of Mitanin’s work has helped women in knowing and demanding their entitlements. It has led to improved access to key services like drinking water, education, food security and nutrition programmes including Public Distribution System, Integrated Child Development Services and School meal programme. Around 15,000 of the nearly 20,000 village committees led by women were found to be active in monitoring of gaps in services with regularity and in undertaking collective action to force improvements in services (SHRC 2012).
d) Direct Action on Rights of Women: Apart from providing direct services to women and girls, Mitanins have carried out campaigns to promote schooling of girls and to oppose under-age marriages of girls. Mitanins have organised women to oppose violence against women. In last three years, 123,000 cases have been recorded in which Mitanins organised support for women victims of domestic violence and led community efforts to secure justice. There have been anti-alcohol drives by women under leadership of Mitanins. There are around 120 annual gatherings organised by Mitanins year where large numbers of rural women attend to raise their problems in front of officials and legislators and demand redressal.
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| 8. What were the most successful outputs and why was the initiative effective?
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Initially, the progress of the programme was recorded in terms of number of Mitanins selected, indicators of adherence to quality of community processes involved in selection of Mitanins. The second aspect measured regularly was of coverage and quality of training imparted to Mitanins.
The programme introduced indicators on health outputs from 2004 onwards with indicators on functionality of Mitanins in fulfilling their role in newborn care, childhood illnesses, TB etc. and also in terms of convening habitation level meetings of women.
The Management Informaton System (MIS) of Mitanin programme evolved further in 2010 when indicators of Mitanin performance included indicators of actual coverage achieved by Mitanins in key actions and services. The other significant part was to bring in indicators on Mitanins action on social determinants of health. Indicators on action on violence against women (VAW), action on food security and regularity of community monitoring of entitlements have been integral part of Mitanin MIS since 2010. This has helped in sharpening the focus on women’s rights in the programme.
MIS has been computerized since 2011. Quarterly reports from MIS are analysed and feedback is shared with field functionaries at various levels.
Apart from collecting data on outputs through MIS, an Internal Evaluation was organised in 2004 in which programme functionaries visted districts other than their own to evaluate the progress of programme. An external evaluation in the same year provided valuable feedback for improving processes in the programme which was still in its infancy at that time.
There is a system to evaluate each round of Training imparted to Mitanins. Apart from classroom based evaluations, skills of Mitanins are observed in actual field conditions.
Apart from internal mechanisms described above, the programme receives external scrutiny and feedback from the Common Review Missions organised by the central government of India.
A full-fledged External Evaluation was conducted by European Commission Technical Assistance in 2011 at the request of state government.
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| 9. What were the main obstacles encountered and how were they overcome?
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The programme initially faced the challenge of earning credibility with stakeholders especially the communities it served. The programme successfully responded to this by ensuring that Mitanins learn new skills despite their limited formal education and thus gain the confidence to approach the families with their health advice.
The Mitanins initially were honorary volunteers. Sustaining voluntary action for long periods required that the motivation levels of Mitanins be maintained. Providing training and continuous hand-holding support through facilitators and creating avenues of mutual interaction between Mitanins were the key inputs for overcoming this challenge. Providing drugs and healthcare linkage to Mitanins added to this. While social recognition received by Mitanins for their work continues to be the main source of their motivation, the programme design also evolved to address the needs of Mitanins. From 2006 onwards, cash incentives were introduced for specific tasks delivered by Mitanins and the number and amount of incentives have grown steadily. Comprehensive Social Security initiatives were introduced to cover all Mitanins from 2011 onwards with significant funding from state government.
The other set of challenges the programme faced was in terms of managing the tensions between its Government and Community ownership, creating and maintaining the space for its work on Social determinants of health vis-s-vis its role in medical aspects. These issues were resolved by ensuring that the accountability of Mitanin stays with community. Even the payments of their incentives were routed through elected community councils called Panchayats.
The state experienced changes in government. Mitanin programme was able to secure the political support irrespective of the party in power. It received high levels of commitment from senior civil servants also. The programme managed to overcome obstacles mainly through its sheer performance.
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