Health Branch,District Panchayat, Sabarkantha, Himatnagar

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
In Gujarat, District Sabarkantha with its both tribal and non-tribal population is considered as High Priority Districts by Government of India(GOI). The District has very much intra district variation in terms of geography and health indicators. District has 46 Primary Health Centers (PHCs) where 33 AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy) doctors under National Health Mission (NHM), 48 Rashtriya Bal Swasthya Karyakram (RBSK) AYUSH are available. OPD of these doctors was not sufficient as they were restricted to the facility level. These OPD cases comprised of people who dwelt in a neighborhood of 10-12kms around the facility. So the rural population living in villages beyond the reach of Primary Health Centers (PHCs) was unable to get proper medical attention and facilities. To control the spread of diseases and to further reduce the morbidity and mortality due to lack of accessibility to adequate health facilities, special attention needed to be given to the vulnerable and socially disadvantaged people.Despite the supposed proximity of the poor to the health facilities their access to them was restricted. This was on account of their being “crowded out” because of the inadequacy of the public health delivery system. So basically two main problems came out after discussion, one is poor accessibility and other is inadequate utilization of available manpower as AYUSH doctors.

B. Strategic Approach

 2. What was the solution?
In FY 2013-14, it was seen by looking at the OPD data of AYUSH that it is only 4639 per month i.e 4-5 patients per day per Ayush. So it was decided to increase their AYUSH service delivery in Maternal & Child Health(MCH) and other National Health Programs with a new approach which was later on named as ‘’AYUSH Mamta Clinic’’. The idea was developed from the comprehensive care the State is providing through Village Health and Nutrition Day(VHND), focusing clearly on alleviating the distress of the underserved in seeking quality health services.The concept of AMC revolves around the optimal use of all available human resources for health care provision in the district. ‘’AYUSH Mamta Clinic’’(AMC) has essentially following aspects –  Accessibility to quality public health care at doorstep level  Rapport building of government health care system in the community.  Strengthening of existing public health system.  Expanding faith in the current health care service delivery system

 3. How did the initiative solve the problem and improve people’s lives?
When accessibility was increased to the parts of community bereft of health care services, slowly and gradually trust on Government health system increased in the community and as a side product, total OPD and delivery at the Public health facility showed an increasing trend in the current financial year. Engagement of opinion leaders as allies helped with shifting their own practices and inspiring others in the community for increased utilization of health services. Accessibility to quality public health care at doorstep level prevents them from shifting to local private health sector as their first choice of care, which besides being unreliable for the illiterate, is also unaffordable by low income rural folks.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The Ayush Mamta Clinic concept is seen as a vehicle to ensure that preventive and promotive interventions reach the vulnerable and marginalized sections of community through expanding outreach and linking with local influencers. Below given are the key aspects which make this initiative one of its kind.  Maximum utilization of available health resources  No cost or minimal cost involved  By bringing in the AMCs and local leaders, tribal people connected to what they said and hence people started to avail the benefits of the services provided by the government health sector.  Outreach services provided empowers community through awareness generation, whereby they are able to demand services from the Health System.  Addresses health needs of under- served areas  Based on community level action for increasing preliminary treatment, mobilization and behavior change process required to enable women from poor access to quality health services.  Referral to higher health facility for chronic diseases and follow up of the same has been increased.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
Health and Family Welfare Department of Sabarkantha District under Chief District Health Officer guidance implemented the initiative. The size of the population affected is 13.88 lacs as per the census of year 2011.
 6. How was the strategy implemented and what resources were mobilized?
After “Call to Action”, district agreed to accelerate RMNCH+A strategy with all available interventions. The main objectives were to increase service coverage especially in Maternal, Child, Adolescent and Geriatric Health. All interventions are directed to achieve highest level of service delivery and so the service utilization.So in this approach, district utilized available AYUSH MOs for conducting health clinic at community level. Three days in a week were identified i.e. Tuesday, Thursday and Friday of every week for NHM AYUSH and Tuesday and Thursday two days in a week for RBSK AYUSH. In the start of the financial year all PHC AYUSH MO had prepared a micro plan of fixed day clinic in their respective catchment areas, where main focus was given to farther most villages or difficult to reach areas. Time to Care approach was also used to identify the villages to conduct AMC. The plan was then shared with the FHWs (Female Health Worker) and ASHAs (Accredited Social Health Activist) in order to make the community aware about the day, time and venue of the clinic as well as to mobilize the beneficiaries. Mainly pregnant women and infants are mobilized at the site with the help of ASHAs. Available facilities like Anganwadis and sub-centers are being used for the clinic. So it also serves as an example of convergence between ICDS (Integrated Child Development Services) and Health department. Other services provided on this day are screening of people more than 30 years of age for the diabetes, hypertension, arthritis, asthma, TB, skin diseases, RTI/STI etc. among community, registration of disabilities for the Ability Gujarat program and referral of the high risk ANC’s to higher health care center. AYUSH arrange a meeting with the local influencer’s atleast once in a month in a given village to make them aware about all the Government health schemes, available services at public health facilities and to solve their issues related to common ailments.Patients are screened for high blood pressure, hemoglobin levels and diabetes, Tb and asthma. All suspected cases are sent to the PHC for confirmation of diagnosis. The data about all the clinics held during the month, suspected cases for various NCD’s, cases referred etcetera is uploaded at the end of month on the google based online reporting form, which is further analyzed and monitored on monthly basis.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The Program advocacy, strategy planning, technical inputs, guideline development and implementation of the program was carried out by Department of Health and Family Welfare, Sabarkantha District. ASHA, FHW, AWW, (Multi Purpose Health Worker) MPHW, MPHS (Multi Purpose Health Supervisor),Laboratory Technician are others from the Health department. Key Stakeholders from village functionaries are – Village Sarpanch, Panchayati Raj Institution (PRI) members, Local leader/ influential person of the village Stakeholders at beneficiary level - Pregnant women and lactating mothers, children(0-5 years), Adolescents, Geriatric people, RTI/STI symptoms.

 8. What were the most successful outputs and why was the initiative effective?
 The Ayush Mamta Clinic was able to increase institutional OPD by 25 percent.  Through Ayush Mamta Clinic, in a monthly schedule of 30 days, Ayush & RBSK doctors cover 390 villages screening about 16000 people every month which in FY 2013-14, can be seen by looking at the OPD data of AYUSH that it was only 4639 per month.  With 780 clinics being held every month, a total 9360 AYUSH Mamta clinics are held in a year in Sabarkantha district.  So far since the initiation of this programme, Out of 112266 Total OPD  2220 suspected cases – for diabetes,  3721 suspected cases – for hypertension  710suspected cases - TB,  4412 suspected cases – asthma,  12457suspected cases - arthritis,  3592 suspected cases - RTI/STI,  Blood smear collection for 6243 suspected cases of malaria.  A total of 2860 suspected cases were referred to further higher health facilities.  5181 people were screened for Anaemia of which 791 had Hb levels less than 7gm and were referred for Iron Sucrose Therapy at PHCs.  Out of 9460 ANC’s screened, 1927 ANC’s were referred to higher facilities. As can be seen in the above specified data, District’s new healthcare concept has performed remarkably well in specific areas that it has chosen to focus upon, principally in rise in the OPD of government health centers along with increased trust of communities on government health care system and ensuring that an overwhelming proportion of births are from institutional deliveries thereby contributing in bringing down maternal and infant mortality. Identification of cases of disability, malnutrition, anaemia, high risk pregnancy, TB, Malaria treatment of minor ailments of children using IMNCI protocols and high impact essential NCD interventions are delivered through a primary health-care approach by strengthening of early detection and timely treatment.

 9. What were the main obstacles encountered and how were they overcome?
a) Improving Community participation During the earlier weeks of the initiation of this programme, there was some resistance in the community about how to get patients to use PHCs and other primary treatment options optimally. In order to cover that it was decided by the Health and family welfare department of Sabarkantha District that ASHA being the focal point at community level would organize sensitization meetings of AYUSH/ RBSK MO with local authorities, community & religious leaders at Ayush Mamta Clinic. These meetings organized by ASHA helped Ayush to interact with the influential persons of community, unshackling them from age old mentalities, gradually shifting their own practices and inspiring others in the community. b) Transportation issues for the Ayush & RBSK doctors – The problem was resolved by provision of PHC Vehicle for the AMC sessions and also same vehicle was used for the referral of High Risk ANC’s with low Hb levels for Iron Sucrose Therapy. c) Lack of availability of Traditional Ayurveda medicines – The issue was put up at State level by the District Officer, and was later resolved by the state officials and Ayurveda and Homeopathy medicines were provided to the AYUSH doctors.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Increased accessibility to the part of community bereft of health care services and increased faith in the government health care system among the rural and tribal population in the villages of Sabarkantha district and as a side product, total OPD and delivery at the Public health facility is showing an increasing trend in the current financial year. The effort brought a change in the health seeking behavior of the community where they got into the habit of accessing the government health facilities for preliminary treatment. At these service points screening and drug dispensing services are made available for the following 1. Pregnant women, mothers (PNC), neonates, infants and children. 2. Communicable diseases (Malaria and Tuberculosis). 3. Non-communicable diseases (Hypertension, Diabetes, Asthma, Epilepsy). 4. Adolescent and 5. Geriatric people with chronic debilitating diseases, musculoskeletal and joint disorders. 6. Childhood illnesses 7. RTI/STI symptomatic. One of the key benefits being - constant follow up of beneficiaries for Non-Communicable Diseases.  These outreach sessions also present as opportunities to provide women, children, and their families with other vital interventions such as vitamin A supplementation, deworming tablets, and insecticide-treated nets.  Reaching populations living in remote areas with limited access to fixed services i.e. underserved or hard-to-reach groups at their doorsteps led to reduction in their out of pocket expenditure on health and building their confidence in public health systems.  The sensitization meetings organized by ASHA helped Ayush to interact with the influential persons of community, unshackle them from age old mentalities & conventions of social taboos. Engaging opinion leaders as allies not only helped with shifting their own practices and inspiring others in the community but also for increased utilization and accountability of existing health services.  Serves as an institutional mechanism for the community for information on various National Health Programmes and government, leading to better outcomes.  Platform for convergent action on social determinants and all public services directly or indirectly related to health.  Serves as focal point for the community to voice health needs, experiences and issues with access to health services, such that the institutions of local government and public health service providers can take note and respond appropriately.  Provides support and facilitation to the community health workers – ASHA and other frontline health care providers who have to interface with the community and provide services thereby playing a critical & effective role in bridging the gap between them and the communities.  Accessibility to quality public health care at door step level prevents them from shifting to local private health sector as their first choice of care, which besides being unreliable for the illiterate, is also unaffordable by low income folks.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
More and more people got aware and benefited with schemes such as Janani Suraksha Yojna, Janani Shishu Suraksha Karyakaram (JSSK), Chiranjeevi Yojna for promoting the Institutional Deliveries for the BPL population which improved faith of the community in the public health care delivery system. Ayush Mamta Clinic being serving as an institutional mechanism for information on various National Health programmes, empowerment of community. Stories from the field suggest that there is definitely an increase in knowledge about maternal health related schemes as well as interaction between the men’s groups and the formal village level structures associated with health e.g. ASHA, VHSC, Panchayat, Anganwadi workers, etc which was not the situation earlier.

 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)
For a variety of reasons, women and the underserved sections of the community throughout their life cycle face numerous obstacles in recognizing, seeking, and receiving care for health problems, hence well-organized outreach sessions for the purpose of improving adolescents, women and children’saccess to quality health services was made a critical component of this initiative. With the help of ASHA, patients especially women with complaints and symptoms of possible RTI / STI are counselled and mobilized to the session site where AYUSH/RBSK MO diagnose and treat at the first contact and thereby reduce infectiousness further in the community. Each patient is examined separately maintaining confidentiality. Individuals with suspected RTI / STI are provided with Colour coded syndromic drug kits centrally procured and supplied so as to ensure uniformity of service delivery across all facilities. Both adolescent girls and Women in reproductive age are provided and counselled for the importance, benefits and regime of Iron Folic Acid (IFA) and Calcium tablets. • All the pregnant and lactating mothers along with their partners and/or families are taken care of, counselled and provided with key information on postnatal care and danger signs in the new mother and baby, importance of seeking help quickly,ORS preparation and its usage, personal hygiene and Hand washing practice in context of local practices and environment, infant feeding and breast care, need for warmth, good ventilation and hygiene for both mother and baby.the importance of mother and baby sleeping under an insecticide-treated bed net in an area with malaria.

Contact Information

Institution Name:   Health Branch,District Panchayat, Sabarkantha, Himatnagar
Institution Type:   Government Department  
Contact Person:   Dr Manishkumar Fancy
Telephone/ Fax:   02772242350
Institution's / Project's Website:  
E-mail:   cdho.health.sabarkantha@gmail.com  
Address:   2nd Floor, Health Branch,District Panchayat, Sabarkantha
Postal Code:   383001
City:   Himatnagar
State/Province:   Gujarat

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