The health program under the Hundred Block Plan has been given the name, " Jan Swasthya Abhiyaan" or " Public Health Movement in Bihar. The first state level to workshop to kick start the program was organized by Gyan Vigyan Samiti at the Madhyamik Shikshak Sangha Bhawan, Jahanabad§ from June 20^th 2002 -June 23^rd 2002.

The workshop was attended by state level resource persons, district level resource persons and block coordinators from most of the blocks.  5 members were invited from each block for the workshop by the organizers. The organizers had insisted on 60% women's participation in the workshop.  The resource persons included Dr. T. SunderRaman, Balaji Sampath, Mr. Ghalib, Dinesh Prasad. The objectives of the workshop were:

1)      Develop a feel for various problems affecting the blocks under consideration

2)      Impart hands-on health training to the field volunteers

3)      Identify state level full timers for the program

4)      Formulate an action plan for the program

The objectives of the visit were:

1)      To understand the basics of the health program

2)       Develop an appreciation for the need of a health program in a the states of Bihar and Jharkhand

3)      Get hands on training on health

4)      Prepare a document that would help AID to coordinate its efforts in a better way towards maximizing the learning curve from the program. (an example of bad coordination: the information given to the author about the workshop dates was incorrect. Hopefully AIDers understand the implications of such misinformation).

The main resource persons were helped by Gyan Vigyan Samiti's resource persons like Ms. Usha & Ms. Pushpa (on Small Savings Groups).  Sri. Jitendra educated us on educational aspects of the program. Sri. Kashi Nath on globalization and its impact on health in India.   Members of Panchayats came forward for a panel discussion on how to integrate the program with the government. It should be noted that in the HBP proposal this integration comes as a major component for helping the program be self-sustaining. AIDers had raised questions about this idea in the past.

The program started in the evening of June 20^th, 2002 with a discussion on the problems faced by each block in form of diseases etc.  There was also a small discussion conducted on globalization and its impact on health in India. Not much information is available about these sessions because of absence of the author on 20^th from the workshop.

 
Session 1 & 2 (Self Study on Health Issues):

The first session on the second day started with songs in the local tune on social issues. In this session the volunteers were divided into 5 groups and were given two different books to read. Through this group reading exercise the volunteers were given some preliminary information about malnutrition and diarrhea. The books were then discussed within a group, questions were posed and the volunteers tried to answer the questions by their understanding. Once the discussion within the group finished and some members still had unanswered questions, they posed the unanswered questions to members of other groups, who tried to answer them. It was interesting to note how through active participation, most of the questions in the groups were answered. Some highly technical questions like " How is the polio virus born?" needed answers from experts like Dr. SunderRaman.

In this session after the discussion phase, Dinesh Prasad (coordinator of the health program) talked about the causes of malnutrition and according to him the major causes were:

1)      Poverty

2)      Illiteracy

3)      Superstitions  (jaundice if the kids are given mustard oil)  

He also talked about the information that we as health activists should get about a child's health when we visit a family. The necessary information that we require to understand the level of malnutrition and status of child's health includes:

1)      Age and weight of the child

2)      Whether the child is breast fed by the mother (this point also includes the fact that in case the milk is not in proper quantity then the mother is not having a proper diet)

3)      Whether the child suffered from any disease in the past

4)      Economic and social status of the child's family (this would include the work mother and father do, how many children in the family, etc. and thus would help us know about the capability of the family in terms of food to the children)

5)      We also should know about the family's efforts to take care of the child's health.

Only after we assess the situation based on these parameters, some advise needs to be given to the parents.  It is very important to remember that there are a few things never to be suggested to the child's mother, like:

1)      Give a nutritious diet to the child

2)      Keep the child and your surroundings clean

Giving such advice would make the advice too general and would undermine the efforts of the mother to take care of her child. This would also hurt the mother and reduce her confidence in her capability as a mother. During our conversation with the mother we should try to find out if there is something that can be possibly added to the meal of the child.  We should refrain from giving too much advice on the same visit.  While visiting the family the second time, we should find out if the advice given on the first visit has been incorporated in the meal of the child. If not we should try to find out the reasons and try finding alternatives. In case they have been incorporated then we should advice them to add something new to the meal. 

The second session on the second day saw the groups reading books on cough, cold and immunization. The groups read two books and discussed it as in the previous session.

Following this was a session in which Dr. SunderRaman gave a talk on malnutrition. He talked at length about the relation of poverty with malnutrition. He reasoned about the need of emphasizing on malnutrition. The need arising due to the capability of malnutrition to make the child's body susceptible to other diseases. He also discussed malnutrition as an indicator of child's health.

He also talked about the steps to be taken to control diarrhea. Dr. SunderRaman emphasized on the need to cautious and encouraging talk with the mothers of the children to help them solve the problem of their child's health. He explained to the volunteers the various signs of pneumonia such as fast breathing, inability to drink water properly, stomach going in on breathing, etc.

Session 4 (Field Training & Self Study):

In this session the volunteers were divided into two groups one of the groups as taken to a nearby colony of backward class, poorvi Uta , this is the same place where Priya Ranjan and Karunesh had a meeting with the women in their last visit. Dr. SunderRaman talked to a few mothers about their children's health and demonstrated to the volunteers, the way they need to converse with the mothers. Next, he asked the volunteers to go and talk to the mothers and after the talk come to him and explain the problem and the volunteer's suggestion to the mother. It was noticed that the volunteers tend to forget the need for cautious and encouraging talk. They tend to come in the advisory mode very fast without developing a full understanding of the problem.   Dr. SunderRaman reemphasized the need to total understanding of the problem before any advise. The volunteers were trained on weighing of the children and finding out the level of malnutrition. I felt at this stage that the training was a bit difficult to understand as the volunteers having not seen a malnutrition chart had no clue as to what grade a child would fall in depending on his age and weight¨. 

While there was training going on in the colony, the other group at the workshop was studying about the causes of low age marriage and the subsequent health effects in women because of it.

Session 5 (Guidelines for the Action Plan):

In the last session of the day, the core group comprising of Dr. SunderRaman, Balaji, Dinesh Prasad, Ghalib, Sarita Kumari, Pushpa sat together to setup the guidelines for the plan of action. The expenditure was approximated to be Rs. 10,000 per block per month (this expense however does not include state support + publications + travel allowances, etc.). It was proposed that after the return from the workshop the, the block level coordinators would organize meetings of people from 50 villages of their block. These meetings are meant to mobilize the villages.  In this session a tentative list of state full timers for the program was also identified. The state full timers identified included, Dinesh Prasad, Sarita Kumari, Pushpa, Usha and Kundan. The state full timers would impart training to the block personnel. It would be mandatory to have atleast one state level full timer at the training. This implies that with 5 full timers there could be 5 training camps running simultaneously.  It was also decided to publish 7 books on health issues. The sequence of publication of the books is in adherence with the requirements of the development of the program. The first and the most important being the "guide Book" or the "Margdarshika". Margdarshika is to be followed up with publication of  "Bacchon ke Liye Swasthya", " Mahilaaon ke Liye Swasthya", " Hamari Swasthya Sewayein aur Hamara Adhikaar", "Village Mdeical Kit" and "Bimaariyan".  This book would serve as a guide to the village health activists and would help them collect data about village midwives, employees of Aanganwadi (Integrated Child Development Program) programs, etc. The guide would also have information about the diseases and their symptoms. Training camps would be held at regular intervals to maintain the competency of the volunteers and make up for any volunteer attrition. Mr. Ghalib of BGVS suggested to keep the period from July and August as preparatory period in which a set of targets have to be achieved by each block. 

The objective of the program, which the AIDers consider extremely crucial, "sustainability" was also discussed. Dr. SunderRaman made it clear to the BGVS that there exists a condition for the funding to continue and the condition is that the program had to sustain itself on its own for a period of 3 years after the funding is withdrawn. All the blocks have to concentrate their efforts towards this goal and there is no looking back once the program starts.

The day started with a lecture by Dr. SunderRaman on the aims of the health program. The various aims of ther program outlines by Dr. SunderRaman were:

1)      Increase in awareness of the people and providing information to the people

2)      Make the government health facilities available to the people and the people start using them

3)      People take their health issues in their own hands

4)      The women get more organized

5)      Panchayats get involved with the health program

To achieve these goals meetings need to be organized, publicity programs need to be carried out, public awareness campaigns need to be initiated, poster campaigns to be started and radio programs need to be started if possible. However the most important means to reach this goal is to reach to each and every village and try to provide the people with information about the health facilities (their rights also). If helping the people does not help in availing the health facilities to the people steps must be taken to apply administrative pressure. The women can be organized in a better way by making them partners in financial decisions; this is achieved by starting small savings groups. Women health committees are to be formed in each village where 1 woman is chosen from 10 households. Panchayats can be integrated with the program by educating its members about their rights and using their influence to fix up a schedule for the village nurses in the village health sub center.

Towards the end of this session the volunteers were asked to explain about the objectives of the program if asked by a doctor at the health center, villagers, district government officials and BGVS district office bearers.

In the next session Balaji Sampat talked about the utility of the health register©. He posed this as a question to the volunteers and various reasons that came out as a result were:

1)      Give us (the volunteers) information about the village

2)      Help in quantification of work

3)      Indicate the changes occurring during the course of the program

4)      The register could also be used as a planning tool by the panchayat

A session on Health Facilities and our Rights was next to be organized. The agenda of this session was to educate us on what are the facilities available to us and how should we avail them.

It is important for the people to know about the location of Primary Health Centre (PHC), Health sub-centre, community health centre (referral). The volunteers of the health program should collect data about the various centers from different viallges, their accessibility and time of transit. There should be a PHC for 30,000 people and per PHC there should be 6 health sub-centres. For tribal and mountainous areas there should be 1 PHC for a population of 20,000 and one sub-centre per 3500 people.

Trained mid wives are supposed to be available in every village. There exists a government program to train this midwives every 5 years. It is required of the village health activist to form a list of trained/untrained midwives in the village using a form in the "Margdarshika". The state or the block level activists can then work on this with the gram panchayats to provide adequate training to these midwives. It is to be noted that the sequencing of generating the list first and then approaching the authorities is of particular importance.

Health sub-centre should technically have two workers but at most of the places there would be just one woman (ANM) commonly known as the woman nurse (1 nurse for a population of 5000). The activists need to generate the following data regading the ANM's

1)      Prepare a list of the ANM's,

2)      Find out whether they stay at the centre or not

3)       Whether the place is safe or not

4)      Whether there is electricity or not, etc.

5)      Find out her timetable as to when she is going to be in a village

Many a times the nurse is the person who is harassed a lot because of the following reasons:

1)      She constitutes the lowest strata of employees and hence whatever goes wrong, the blame goes on her.

2)      It is extremely difficult for her to work in a male dominated society. It is extremely difficult for her to talk about contraception, etc.

3)      Family problems

The activists should also make a point to ensure safety of the village nurse. They should try to help her to the best possible extent.

The facilites available to the villagers are available from three sources:

1)      Aanganwadi

2)      School

3)      Village nurse

The activists should check if there exists an Aanganwadi or not. They should also check and ensure cleanliness at the premises. The activists need to find out the amount of food grains coming to the Aanganwadi and number of people getting the food. They should also keep a note of how are the children and pregnant women getting the food selected. It has been seen that when a child starts getting food at the Aanganwadi, his portion of food at his/her house is deliberately reduced. The activists should educate the mothers about the dangers of such a practice. Technically the helper at the Aanganwadi should take the children to the premises for food. The activists also need to find out if the Aanganwadi keeps vitamin A tablets and medicines for worms in the stomach.

Most of the schools have a school health program in which children are administered a Diphtheria and Tetanus vaccine after their age crosses 5 years. A doctor should also examine the children once a year. There should be afternoon food for the children.

The village nurse should give ORS mixture if a child suffers from diarrhea. She should also have medicines for common cold, fever, pneumonia, etc. the various vaccines and immunization doses to be given to the children are as follows:

1)      BCG (at birth)

2)      DPT (three vaccines) (1^st upto 3 months, 2^nd 3-4 months, 3^rd 4-5 months)

3)      Polio (three drops) (1^st upto 3 months, 2^nd 3-4 months, 3^rd 4-5 months)

4)      Measles (Vaccine) (upto 9 months)

5)      Vitamin A (9 months) (2ml)

6)      DPT Booster dose (18months)

7)      Vitamin A and dose for worms every 6 months

Dr. SunderRaman also discussed women health rights. In case of a danger faced by a pregnant woman, the activist should work with the nurse to find out the cause of the danger and if a caesarian birth is required, referral system should be used. There is also supposed to be a disposable delivery kit (DDK) program initiated by the government. A month prior to the scheduled date of birth, the nurse or the midwife should keep a DDK at the pregnant woman's place. The pregnant woman might require an ambulance, blood, doctor to administer anesthesia, a doctor conducting the operation, etc. Various facilities at the PHC were also discussed. Within a distance of 1 km from the village there is a provision of keeping 30 essential medicines, this place is known as a depot at villages where a nurse is not present.

This session was followed by a session on pregnant women health conducted by Sarita Kumari.  A field visit to Purvi Uta followed, with the volunteers who stayed at the workshop going to the field and have a hands on experience of the health situation. The group who stayed back did a group discussion on causes of child marriage and how could it be averted. With this ended the day.

In order to maintain quality standards in the health program, monitoring and evaluation was added to the action plan of the program. The evaluation has to be both internal and external. The internal evaluation is done for all the blocks and to validate the bigger sample a smaller sample of a few villages is taken and an external evaluator is used. The indicators for monitoring and evaluation are:

1)      Input Indicators (Training +material)

2)      Process Indicators (quality + what is to be done)

3)      Impact indicators

Number of people who came for training constitutes the process indicator. The number of people trained in a village constitutes the outcome indicator. Effect on the village in measured in terms of impact indicator. Analysis of the process and outcome that give impact helps in betterment of the program. It is not a wise move to look only at the impact indicator. The study of indicators makes the analysis less prone to subjectivity. The plan of action for the program was also finalized in which some critical parameters were decided upon which would ensure the quality of the program and only after going through these critical parameters the program would proceed on to the next stage. The first 12 months of the program are divided into 4 phases. The work to be undertaken in each one of these phases has been divided into block level and state level.   It was also decided that there would be 2 block level full timers preferably one woman and one man to look after accounts and other administrative functions along with health work. At village level a block would have 5 full timers who would be in charge of a cluster of  10-12 villages depending on the number of villages in a block.

Preparatory Phase (July - September, 2002)

The work to be undertaken in this phase incorporates opening of the bank account, printing of materials, a two day refresher course for the block trainers in which they would be trained on how to use the material that has been printed, on the state level. On the block level, the work is consists of:

1)      Formation of block committees^*

2)      Identification of full timers^*

3)      Identification of village activists^*

4)      Simultaneous formation of small savings groups

5)      Block training

The entries with stars constitute the   critical stages to be achieved in the first stage.

Phase 1 (October - December, 2002)

In this phase on the state level 1 week training in a block with state full timers and block trainers is proposed. Monthly meeting of activists at the block level and the preparation of material for the phase 2 of the program is also to be done in this phase. On the block level the following programs are to be undertaken:

1)      Zonal retraining of block activists and full timers^*

2)       Opening of health registers

3)      Reaching each and every household

4)      Compilation of data regarding "Dais (midwives)"^*

5)      Block level training^*

6)      A report is to be generated for villages, which have communication and transport problems with the PHC's and the state level activists are to initiate meeting district administration to address the problems.

The starred entries are again the critical stages to be achieved in phase 2. The compilation of data regarding midwives is to be achieved using forms that would be available in the margdarshika.

Phase 2 (January - March, 2003)

In service training visit of state full timers for 1 week and using ANM and Aanganwadi report to create pressure on the administration and publicity for the program constitute the state level activities for phase 2. The preparation of the material for phase 3 is the critical stage of this phase on the state level. On the block level following activities are to be undertaken:

1)      Complete weighing of the children ^*

2)       Compilation of list of children and health grades^*

3)      ANM  & Aanganwadi report to be used with the goal that health material reaches there

4)      Externalities to be incorporated in the evaluation by taking a external evaluation of a smaller sample and validating the bigger level.

Phase 3 (April - June, 2003)

(As of yet, the details of this stage are not known to the author. Balaji Sampath will be providing the details in a few days)

Dr. Sunder Raman emphasized that the coordinators of the program should try to sustain to program after 18 months and it is not to be declared now that the program is to be run for 24 months.

The first session of day 4 after the formulation of the action plan in the hotel room in which we were staying was regarding initiation of small saving groups by Pushapa and Usha. This session was demonstrative of the really good insight of the SSG coordinators of BGVS in the program. Following this was a presentation on world social forum on which was taken up by Mr. Kashi Nath and Dr. SunderRaman.

Towards the end of the camp a panel discussion session was organized about "Role and Cooperation of Panchayati Raj Institutions in Public Health" Various members of different panchayati raj institutions from village sarpanchs to zila parishad members were a part of this discussion. All of them extended their support for the program and gave some valuable advice too. They emphasized on the need to educate the village representatives on their rights and duties. Usha (member of Zila Parishad) rightly commented that most of the members went on to use the funds allotted by government to build community centers, roads, etc., these works though important are to be given second priority to works like developing education system for the kids.

Also there has been a change in the blocks in Supol and Saharsa districts. Kishanpur has replaced the Raghopur block of Supol and Patarghat has replaced the Navhatta block of Saharsa. The details about the contacts from these blocks as of now remain unchanged. Any information about change of the contact addresses would be supplied as soon as possible.