Mitanin Community Health Worker Programme
Department of Health and Family Welfare, Chhattisgarh State, India

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Chhattisgarh state came into being in year 2000. It constituted one of the poorest regions of India with one-third of its 25 million population belonging to indigenous tribes. With 44% of its land under forests and 77% of population living in rural areas in more than 60,000 scattered habitations, creating adequate outreach of public services was a huge challenge. The government departments of the state had inherited inadequate human resource capacity to provide services in remote parts of the state. Its indicators related to Child mortality, Maternal mortality and under-nutrition amongst children and women were amongst the worst in the country. The socio-economic situation in tribal regions was worse. Women faced the most severe brunt of these gaps. Their access to essential services of health, nutrition and education was severely limited. There were very few avenues for their participation in public decision-making. It was accompanied with social discrimination against women across age groups including large prevalence of domestic and other forms of violence against them. Thus the state required an initiative to strengthen health, nutrition, education and women’s empowerment in remote areas by working across sectors and improving access to multiple kinds of services. The modest financial strength of the state at the time also needed an innovative approach which could be cost-effective and sustainable.

B. Strategic Approach

 2. What was the solution?
Chhattisgarh being a new state, provided a favourable envorinment for trying out fresh approaches. Within an year of its formation, the state government chose to initiate a Community Health Worker (CHW) programme in 2001 with specific goals of strengthening women’s agency and improving access to health and healthcare services in rural areas. This decision came out of a process in which senior functionaries from Government and Civil Society came together to conceptualise the CHW programme. The programme was named ‘Mitanin Programme’. The word ‘Mitanin’ comes from the local dialect and means a ‘friend’. The stated objectives of the Mitanin Programme were: a) To make available health education, improve awareness of communities regarding health and healthcare services and associated rights and entitlements b) Improve utilisation of public healthcare services c) To provide appropriate advice and cure for common health ailments at local level d) Organise women and the other marginalized sections, promote their participation and leadership in health action e) To promote role of local elected bodies (known as Panchayats) in health sector, sensitise them and build capabilities, facilitate inter-sectoral local planning and action for improvements in Health As reflected in the objectives, the roles expected of a Mitanin in this strategy were – of a health educator, of a link-person between communities and government services, of a health provider to an extent and also of a social activist organizing women and marginalized providing them the information to demand services. Further these roles were visualized as being mutually reinforcing functions. Mitanin was to play the role of a well-informed leader of the community and women negotiating with the formal government structures. Mitanins were not seen as isolated individuals reporting to a formal health system. Instead Mitanins were visualized as representatives of communities and accountable to communities. Additional strategies were introduced to maintain motivation of Mitanin CHWs by establishing a) comprehensive social security support for Mitanins b) career development for Mitanins c) help desks in public health facilities to facilitate rural patients in accessing healthcare services d) tollfree helpline to allow Mitanins to register complaints and seek redressal of their grievances. In order to encourage autonomy of Mitanins and to maintain their accountability towards communities, the payment of cash incentives was also handed over to local elected bodies (Panchayats) starting from 2012. The tasks carried out by Mitanin are verified by an elected woman representative of the locality before payment. The programme was started in rural areas, reaching most of the remote corners of the state and covering almost entire rural population of around 19 million.

 3. How did the initiative solve the problem and improve people’s lives?
Mitanin programme was different from other Community Health Worker (CHW) programmes because it emphasized the agency of women from rural communities, it focused on Social determinants of health in form of gender, poverty and nutrition, it explicitly stated organizing and empowering women as a programme objective, it extended the scope of CHW’s work to other associated sectors particularly in terms of improving access of women to public services beyond healthcare and in specifically involving local elected bodies in health action. Thus, it promoted broad based action aimed at overall empowerment of women and their access to multiple public services as opposed to many conventional CHW programmes that focused on a narrow range of selective medical interventions. The other key factor was its scale. The programme incorporated the lessons from successful civil society based models of CHW, but the design had conscious strategies built-in to enable scaling-up. The programme design also looked at why earlier attempts by Governments to implement large scale CHW programmes had failed. Almost all earlier Government programmes had involved only men as CHWs. The Mitanin design on the other hand was women-led in most aspects. It involved creation of new platforms of participation of women in public sphere.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
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.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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.
 6. How was the strategy implemented and what resources were mobilized?
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.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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.

 8. What were the most successful outputs and why was the initiative effective?
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.

 9. What were the main obstacles encountered and how were they overcome?
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.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The programme achieved very significant impacts on ground as well as on national policy. Although there was no baseline done specifically for Mitanin programme, data is available from periodic independent surveys on the changes achieved. National Family Health Surveys Round 2 & 3 (NFHS-2 & 3) conducted by IIPS and surveys done by Registrar General of India (Census of India, Sample Registration System (SRS) and 3 rounds of Annual Health Surveys -AHS -1,2,3)) are the main sources of data providing comparisons on values of key indicators over the last decade. Two independent evaluations –by European Commission (EUTA,2011) and Vir et al, Food and Nutrition Bulletin, 2014, The United Nations University) provide detailed information and analysis on outputs and outcomes achieved by Mitanin Programme and both report effectiveness of Mitanin in achieving its objectives. There is an independent study documenting the work of Mitanins on social determinants of health like gender and nutrition (Nandi et al, 2014, Health Policy and planning, Oxford Journals). The changes brought about by Mitanins are on Community side or the Demand side as well as on the supply side (EUTA 2011). Mitanins have been bringing a large number of referrals to the public healthcare system and thus creating a pressure on the system to respond to people’s needs. It has helped in strengthening the Government health system delivery. The full immunization rate of children went up from 21% in 1998 (NFHS-2) to 74% in 2010 (AHS-1). 63% of pregnant women received the 3 mandatory ante-natal check-ups in 2011 (AHS-3) as opposed to only 26% recorded in 1998 for rural areas (NFHS-2). 66% of newborn children got breastfed within an hour of birth in 2011 (AHS-3), compared to just 13% in 1998 (NFHS-2). The maternal mortality ratio (MMR) of the state was reduced from 379 per 100,000 births to 230 over a decade (SRS 2003 and 2012). The infant mortality rate (IMR) in rural Chhattisgarh registered one of sharpest declines seen anywhere in Indian history with IMR declining from 98 per 1000 live births in year 2000 to 61 per 1000 in 2004 and 47 per 1000 by 2013 (SRS). The under-5 year Child Mortality Rate in rural Chhattisgarh has come down from 123 per 1000 in 1998 (NFHS-2) to 57 per 1000 in 2012 (SRS). The overall Crude Death Rate of the rural population of state has declined from 11.2 per 1000 in year 2000 to 8.4 per 1000 in 2013 (SRS). The evidence points out that Mitanins contributed significantly to these changes (EUTA 2011). Apart from health, Mitanin programme has helped communities and women and girls to access other services as well, especially for nutrition and food security, water and education. For example, 74% of women reported receiving help from Mitanin in accessing nutrition services (EUTA 2011). The state has shown major improvements in delivery of food security programmes and independent documentations have recognized the contribution of Mitanin programme in it (Vir 2014 and Nandi 2014)). The inter-sectoral nature of the success achieved by Mitanins gets reflected in the sharp improvements in child nutrition. The childhood stunting in rural Chhattisgarh reduced by 34% and child underweight proportion declined by 24% between 2005 and 2011, largely due to the work of Mitanins (Vir 2014). A very important part of the impact achieved by Mitanin Programme is in form of strengthening the women’s agency in the state. This has got reflected in the elections of local bodies (called Panchayats) where nearly 2,400 Mitanins have got elected (EUTA 2011). The work done by Mitanins in organizing women and opposing gender discrimination has achieved very significant impact. The rural female literacy has increased from 47% to 55.4% between 2001 and 2011 (Census of India). The number of rural girls going to secondary level schooling (beyond 10th standard) has quadrupled in the state over the last decade. 94% of rural girls in 6-17 age group were attending school in 2012 (AHS-3). There is a sharp decline in the practice of under-age of marriages of girls, from 61% in 1998 (NFHS-2) to 35% in 2011 (AHS-3). Mitanin programme has been effective in creating platforms for opposing violence against women through conscious design of processes adopted by the programme (Nandi 2014).

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The low-cost nature of the programme, the level of political commitment secured by it and the inclusion of CHW strategy in national policy ensure the sustainability of Mitanin programme. Its success has influenced important changes at national level. National Rural Health Mission of India was launched in 2005 and one of its key components has been CHWs called Accredited Social Health Activists (acronym ASHA). Mitanin has been one of the key references for bringing in ASHA CHWs across the country. Mitanin Programme being a large scale, state-run initiative that had managed to thrive across transitions of power became the inspiration for modeling of ASHA. There are now around 870,000 ASHA CHWs in the country. Mitanin Programme continues to set the standards for CHWs across the country and Common Review Mission of central government has termed it as ‘national best practice for community processes’. ASHA programme has been evaluated and found to be effective as well. The village health committees and monitoring of services by women as practiced in Mitanin programme of Chhattisgarh have been absorbed into National Guidelines on Community Processes in Health, thus paving the way for replication of this aspect across the country. Another very significant influence of the Mitanin experience on national ASHA curriculum has been the inclusion of a module on Violence against Women in it nationally. Mitanin Programme has relevance for replication of CHW programmes across the world, especially in societies with high levels of poverty and gender based discrimination. Within the state, the replicability of the programme was further established when it was expanded to cover urban slum population as well. It showed that the processes designed for the programme were replicable in urban situation as well. Now there are around 4000 Mitanin CHWs covering around 2 million slum population. Mitanin programme has influenced the state government in initiating new programmes to meet women’s needs. One such programme is to provide maternity entitlements to pregnant women. Mitanins facilitate this initiative under which all pregnant women who have worked as wage workers in Government employment programme, receive maternity benefit equivalent to 30 days of wages. Another woman-focused programme which relies on the strength of Mitanin programme is called Fulwari scheme under which daycare and spot-feeding services are arranged to help rural mothers and children. Since this programme relies on management by mothers’ groups, the community mobilisation and capacity building support provided by Mitanins holds the key to its success (IFPRI 2014). Recently Mitanins have initiated a campaign to ensure greater coverage of Persons with Disability under state-run services. Thus, Mitanin programme has helped in extending delivery of new entitlements to women.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Mitanin programme leads the way for large scale Community Health Worker interventions across the world. It has the following crucial lessons to offer: a) It is desirable and feasible to integrate work on strengthening women’s agency with work on community health in scaled-up programmes b) Community Health Workers can be suitable agents of change not just for health sector but also for promoting access of women to services from multiple sectors c) Community Health Workers can be vehicles for promoting more comprehensive empowerment of women d) Social Determinants of work need to be a focus for CHW programmes in order to achieve the best impact. Gender needs to be further recognized as a determinant of health and programmes need to consciously incorporate it in their objectives. e) Monitoring of public services by local communities is very important and can be institutionalized with help of CHWs. It is more effective when women lead such forums. f) The design of such programmes in terms of mechanisms for selection, payment, capacity building, supportive supervision, networking and above all the CHW’s curriculum needs to be tuned to consciously promote action on rights of women and girls. With such conscious inputs, comprehensive outcomes on women’s rights and participation can be achieved. Adequate facilitation structures need to be created for this purpose. g) It is important to ensure larger participation of women and their leadership at all levels in such programmes h) The various roles of CHW as service provider, health educator, link-person or as an activist are mutually supportive. Credibility earned in one role helps the CHW in being more effective in other roles. i) Promoting autonomy of CHWs and their keeping their accountability with communities is crucial to their success in achieving change. They are more effective as agents of social change if community selects and controls them instead of the government. j) Organising women continues to be an effective strategy for women’s empowerment. Governments need to provide more support for promoting such actions and processes in programmes across sectors.

Contact Information

Institution Name:   Department of Health and Family Welfare, Chhattisgarh State, India
Institution Type:   Government Department  
Contact Person:   SAMIR GARG
Title:   Community Processes, State Health Resource Centre  
Telephone/ Fax:   +91-771-4247444
Institution's / Project's Website:  
E-mail:   koriya@gmail.com  
Address:   State Health Resource Centre, Bijli Office Chowk, Kali Badi
Postal Code:   492001
City:   Raipur
State/Province:   Chhattisgarh
Country:  

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