VILLAGE HEALTH AND
NUTRITION DAY IN COMPLETE
CONVERGENCE MODE
(VHND)
UNAKOTI DISTRICT, TRIPURA
DISTRICT PROFILE
 Most remote district in Tripura (now
bifurcated into two districts)
 Bordering Bangladesh, Mizoram and Assam
 Formal agriculture in plain areas, subsistence
shifting agriculture i.e. Jhum in tribal hilly
areas.
 Numerous habitations without electricity
road, drinking water, telephone connectivity.
 Hardly any private practitioner doctors, only
single doctor PHCs in tribal areas
FEATURES OF SOCIAL INFRASTRUCTURE
Physical infrastructure more or less developed
Most of PHC’s run by one medical officer in remote tribal
areas. So difficult for doctors to go into the remote
villages.
Due to low education levels, recruitment criterion diluted
Numerous Anganwadi workers illiterate,specially in
tribal areas, training is scarce and ineffective
Monitoring difficult due to duality of control in tribal
areas, of Tribal Areas Autonomous District Council and
Govt of Tripura
BACK GROUND OF THE INITIATIVE
 In April to June 2010, 24 people (19 infants), died in Kangrai, a
very remote village
 No information filtered out of the village for three months, while
the deaths were going on.
 No road, no electricity, no mobile connectivity
 NO REACTION from the families, death accepted as a way of
life.
 No complaints against Health or Social Welfare department.
 This was the pivotal force to start VHND in complete
convergence mode.
ANALYSIS FOR IMPROVEMENT IN
SERVICE DELIVERY
 There were 8 AWWs, 9 AWHs, and 7 ASHA workers in the
village.
 As per records, Anganwadi Supervisor, and MPW, had both,
done meetings in the village. A health camp had been done two
weeks ago.The Chairman of the village, the Headmaster of the
school, also were supposedly present in the village but
information did not come to the Block or Sub-Divisional level.
 The registers and charts of the MPW, AWW and AWS were all
fully maintained.
 Meeting of CDPO and MO in PHC had been held.
 Online reports were generated for state portal.
 Due to lack of public awareness, the actual service delivery is
dependent on personal integrity and ground level staff.
POSITIVE FEATURES ALREADY
AVAILABLE IN TRIPURA
• Government has provided the physical infrastructure in
each village. (Anganwadi Centre Buildings and Health Sub
Centres available in most villages)
• The staff has been deployed
• Reports are being generated, meetings are held, figures
are reported.
• A fund of approximately 1 crore was already available in
the district under NRHM, ICDS and IEC funds of other
schemes, for awareness generation.
• Yet how to monitor and coordinate the activities of 1915
Anganwadi workers, 1402 ASHA workers etc, is the main
challenge?
DIFFERENCE b/w NEED and DEMAND
FOR SERVICES
Thus there is need for health services in rural areas.
But there is no demand for the same
Shockingly, people are not even aware who are their
field level functionaries
PRI member’s focus on MGNREGA, IAY etc
Need to establish accountability of grassroot
government functionaries
Need for coordination between and within
departments like Health, Social Welfare, Drinking
Water and Sanitation, Rural Development, Panchayat
and School Education.
VHND AS EXISTING IN NRHM, BUT
PRACTICALLY NOT BEING
IMPLEMENTED DUE TO…
 No awareness of the concept of VHND among general public
and PRI’s
 Distributed amongst all AWCs, meaning 7-8 VHND’s per
month per village to be held as per paper.
 Rs 125 per AWC given, Rs 300 per AWC given to Health
 Hardly 10 to 20 women used to attend (if at all!)
 Complete lack of co-ordination between AWW and ASHA,
MPW even though 4 out of 6 ICDS services need
coordination.
 System of data recording was not there, thus no monitoring
 No PRI involvement
 No way of checking whether an AWW, MPW, ANM etc have
gone to a village or not.
BASIC IDEA OF VHND IN CONVERGENCE
MODE
Instead under new initiative, ALL the Anganwadi Centres in 3-4
habitations will come together for VHND.
•All the functionaries of various departments will come together.
Schedule of VHND will be painted on walls of Panchayat in
advance.
EVERY activity related to health, nutrition, drinking water and
sanitation, irrespective of scheme or deptt which requires
mobilisation of people or awareness generation to be merged.
Fund for IEC activities merged.
Onus on PRI bodies.
All women, children in Anganwadis, Schools attend.
CONVERGENCE OF FUND
Existing funds PUT TO USE in a planned manner
From health dept. Rs.300 per VHND per month x 5 =
Rs.1,500.
From ICDS Rs.125 per AWC per VHND per month i.e.
X 5 = Rs.625.
Total fund available Rs.2125 per VHND per month x 2
X 182 villages X 12 months = Rs 1.32 crores
Additional fund for IEC activities from
District Blindness Control Program, AIDS society,
Tuberculosis Program, Malaria Control Board,
Drinking Water Scheme, Total Sanitation Campaign,etc.
SCHEDULE OF VHND
• The CDPO, MOIC, Deputy Inspector of Schools and
Sub ZDO meet quarterly and make draft schedule.
• Location, Date, Names and Mobile numbers of village
level functionaries of 5 key deptts given village wise.
• The village programs where health camps of PHC,
Disability Rehab, TB, AIDS, Malaria, Blindness Control,
Mobile Medical Unit etc are to be merged are shown
• Schedule approved, sometimes with amendments, by
Block level PRI body, known as BAC/Panchayat Samity.
• Painted on walls of Panchayat/Schools
CONVERGENCE OF STAFF
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AWW
AW Supervisor
MPW / MPS
ASHA
Pump operator of Drinking Water Department
GRS under MGNREGA and RPS
Gram Pradhan
Field facilitator
Livelihood facilitator
Youth volunteers
Dalabandhu
Headmaster of School
Teacher of Mid Day Meal
Mid day meal cook and helper
Disaster Management
District Disability Rehabilitation Centre
Awareness volunteers of District Administration etc,
COMPULSORY ACTIVITIES CARRIED OUT
IN VHND DAY
 Awareness discussion on 14 issues of preventive health care for
the community , using the VHND FLIP CHART by Headmaster
of School
 Small quiz for mothers and children on health issues
 Immunization of children
 Ante Natal Check up and health monitoring of pregnant
mothers.
 Weighment of children and plotting of WHO chart
 School Health Program
 Chlorination/ Cleaning of water sources and discussion
regarding their maintenance and repair.
 Filling up of forms for fresh issuance and renewal of RSBY
smart card.
 Supplementary nutrition, Mid Day Meal
OPTIONAL ACTIVITIES CARRIED OUT IN
VHND DAY
Blindness Control Board
Malaria Eradication Program
Revised National Tuberculosis Control Program
AIDS prevention
All health camps
School health camp by doctors
District Disability Rehabilitation Centre activities
First Aid Training under Disaster Management
INVOLVEMENT OF SCHOOL EDUCATION
DEPTT
All HeadMasters given 1 day training on modalities of VHND
The school health program is also merged in the VHND.
The students up to 10th class attend the VHND with Headmaster
and teacher in-charge of mid day meal.
The headmaster has been given the responsibility of giving an
awareness talk using the 14 flip charts under the project.
The mid day meal is merged with community meal cooked during
VHND and supplementary nutrition program of ICDS
BENEFIT OF CONVERGENCE OF MID
DAY MEAL INTO VHND
• Thus parents and villagers partake of the food distributed in
MDM/SNP of AWC, on day of VHND and if there is divergence in
quality of food distributed normally in school/AWC vis-à-vis that,
on day of VHND, the students report the same, as happened in a few
villages, thus leading to overall improvement in quality of Mid Day
Meal.
CULTURAL ACTIVITIES DONE TO ENSURE LARGER
PARTICIPATION
• Local Dance
• Group song.
• Quiz on health issues.
• Fully immunized baby show.
• Sports activities for children and mothers.
• Street drama.
(All done using the Rs.10,000 per village given to Village
Health and Sanitation Committee from 13th Finance
Commission fund.)
FOCUS ON MALNOURISHED CHILDREN
 Training of AWWs on plotting of WHO chart for identification of
malnourished children.
 As per SW & SE dept, GR-III and GR-IV malnourished children
will be given double ration.
 During the few hours of duration of VHND, to create awareness
amongst the parents and villagers regarding malnourishment a
yellow ribbon is tied on the wrist of malnourished children.
IEC MATERIAL DEVELOPED
• 14 Sheets of large size plastic printed material
• To be used as a flip chart by the headmaster to talk about
health issues so that vital points are not missed out
• In Local language
• 42 sheets given per village
• Also put up as posters for mass dissemination
MOVIE FOR AWARENESS GENERATION
• A national award winning director, Father P. Joseph has made a
movie in Kaubru, Kokborok language, English subtitles, of 28
minutes duration – Better Tomorrows
• The setting is the Primitive Tribal village of Kangrai
• Issues
like
drinking
water,
sanitation,
malaria,
avoiding
witchdoctors etc dealt with.
• SHG of Reang boys is showing the movie on incentive based
payment pattern in remote tribal villages using DG set and
projector etc.
TEAM OF AWARENESS VOLUNTEERS
A team of boys age group 18 to 22 mostly 12th passed or in college
from Reang community have been trained regarding various health
related activities organized in four groups of 5 each.
They are formed into an SHG and paid as per performance and in
their free time they also attend the VHNDs in the remote areas.
They are called in the district and sub-divisional level workshops
and meetings held quarterly.
INTEGRATION OF DISASTER
MANAGEMENT AND JICA
After recent earthquake at Sikkim, Disaster
Management team is also being participated in
VHND to show the various first aid measure.
In some VHND specially in the hilly area the
JICA facilitator is also encourage to participate
and create awareness activity regarding their
various scheme to the public.
TRAINING IMPARTED
 Preparatory meeting with health, ICDS and other related dept.
 Sensitization of top level PRI leaders.
 Standardized training module with CDPO / MO I/C as resource
person, BDO as organizer for 100% Gram Pradhans, and
AWWs, Health & Panchayat staff, at PHC level, with training
material and checklists.
 Training of Headmasters of all Schools
 Preparation of pamphlet in Bengali and quarterly calendar of
VHND
 Sub-Divisional level training for officers..
 TRAINING MOVIE of 8 minutes in Bengali for showing an
ideal, converged VHND to grassroot workers.(recently
developed)
 Intensive trainings for 2 months.
CHECKLIST USED DURING TRAINING OF
FIELD STAFF
• To ensure coordination between various functionaries, necessary to fix specific
responsibility on each functionary
• For Example, Anganwadi Worker should know her specific role
• Checklist given in Bengali language.
• Detailed Checklist for every functionary in the chain, including CMO down to
ASHA worker and including Headmasters, CDPO, AW Supervisors, Gram
Pradhans, NYK volunteers, dalabandhus under SGSY etc.
ADMINISTRATIVE ORDERS FROM STATE
LEVEL TO ALL PARTICIPATING
DEPARTMENTS
• The project was started after approval in District Level Health
Society co-chaired by DM & Sabhadipati.
• However, resistance was encountered due to additional work
and responsibility.
• Thus, Chief Secretary, Principal Secretary, School Education,
ICDS, Health, Drinking Water etc all issued written instruction
to their departments for participation, on written request of DM
for the same.
MONITORING PROCEDURES
• Any project which involves convergence of schedules, funds and
manpower of multiple departments needs robust monitoring procedures
for sustainability.
• Thus village level VHND Register provided which is to be maintained
in the village Panchayat by Rural Panchayat Secretary.
• Reporting Register with duplicate perforated sheets for sending
upwards upto CDPO level where they are entered into online website
• Validation of data entered by health department
• Register to be counter signed by gram pradhan and various deptts to
avoid figure fudging
• Discrepancy in figures reported by various deptts analysed
systematically, thus cooking of figures not possible and quality of
health data is much more reliable and robust.
• Block level and Sub Divisional committees active headed by BDO and
SDM with compulsory attendance of commensurate PRI leaders for
monitoring the VHND reports.
• Online website put on public portal for 100% transparency in
reporting.
VILLAGE LEVEL REGISTER CONTAINS..
• Resolution by village committee to hold
VHND
• Attendance Chart
• Visitor Sheet
• Awareness Generation
• Immunization, Ante Natal Check Up and
other health activities
• Accounts of expenditure
DISTRICT WEBSITE SNAP SHOT
OUTCOMES OF PROJECT
Parameter
Before Start of the
Project
(Figures for 200910)
Regularity of Was
very
holding VHND dispersed, and due
to
difficulty
of
monitoring no data
was
available
regarding frequency
or
regularity
of
holding such camps
Effect of Project Implementation
(Figures of 2010-11 and 2011-12)
4648 VH & N Days held till March,
2012. i.e. around 26 VH&N Days per
village over past 18 months,
meaning that in some months either
some scheduled VHND’s have not
been held or not been reported or
data not uploaded. Some gaps due
to local festivals/elections etc have
been recorded
Parameter
Before Start of
the Project
(Figures for
2009-10)
Effect of Project Implementation
(Figures of 2010-11 and 2011-12)
Public
mobilisato
n
Very
Sparse, 1020 women
at the most.
On an average, around
149 women and children
actively attended each
VHND. A total of 690465
people attended in 4648
VHND’s
(total
district
population is 693281) out
of which 268730 were
children.
Parameter
Before Start of the
Project
(Figures for 200910)
Effect of Project Implementation
(Figures of 2010-11 and 2011-12)
Public
Awareness on
health issues
hygiene and
sanitation
Lack of basic
awareness and
good
health
practices
especially in the
remote
tribal
villages
It is very difficult to gauge difference in
level of public awareness, and even
more difficult to change cultural
stereotypes.
However,
regular
discussions on health issues, especially
to the school going children, has yielded
some change in levels of consciousness
on these issues. Holding of health quiz,
cultural program, street drama, healthy
baby show etc has helped increase
attendance and emphasized public
focus on health issues..
Parameter
Before Start of the
Project
(Figures for 2009-10)
Effect of Project Implementation
(Figures of 2010-11 and 2011-12)
Institutionalisa
tion of the
concept of
VHND in the
village
There was hardly
any
recognition
amongst
the
general public or
PRIs regarding this
facet of NRHM.
Even though fund
was
available,
none was aware
that a program like
VHND is present.
Today, in North Tripura district, ANY
and EVERY gram pradhan, even the
inactive and illiterate ones, and most
panchayat members, will recognize
the english acronym of ‘VHND’. As
the same has been replicated within
next 10 months in other districts of the
state, in partial forms, most of the
Ministers are aware of the initiative,
and it was one of the listed agenda
points in the district level review
meeting of Hon’ble Chief Minister,
held at six monthly intervals.
Parameter
Before Start of the
Project
(Figures for 2009-10)
Effect of Project Implementation
(Figures of 2010-11 and 2011-12)
Conversion of
the NEED for
health care into
a DEMAND for
the same
The general
public,especially in the
remote tribal areas,
were not aware of
their rights under
various schemes like
ICDS and NRHM,
there was no
expectation from the
village level
functionaries to stay in
the village or attend in
any monthly program
and there was no
accountability in the
system.
Recently, a team of 40 district level officers
visited, possibly, the remotest village in the
state which required a walk of 3 hours,
(Simluang in Jampui ) but the public
reported the first item of complaint that
VHND is not being regularly held and that
the CDPO (block level officer) has
attended VHND only once. This is a sea
change from the earlier scenario. As
Health, and ICDS programs are implemented
by dispersed functionaries, who are
uneducated, ill-trained and monitoring and
accountability procedures remain on paper,
the only way to ensure performance is to
generate public demand and awareness of
the same, leading to pressure from PRI
bodies and public in general.
FEVER DETECTION AND DEATHS
Year
Fever Detection
Fever Death
2009-10
54229
47
2010-11
76169
24 * (This includes mass
outbreak in Kangrai
which triggered the
project)
2011-12
66988
4
Parameter
Before Start of the
Project
(Figures for 2009-10)
Detection of In 2008-09, 56,771
diseases like cases of fever
fever
were
detected,
while in 2009-10, a
similar number of
54229 cases were
detected.
Thus,
when
averaged, 55,500
cases of fever
were detected.
Effect of Project Implementation
(Figures of 2010-11 and 2011-12)
In 2010-11, a 37% increase in
detection of fever cases was
reported, with the number rising to
76,196. Again, in 2011-12, the
number of cases detected was
66988. It would be irrational to
allege a cause-effect relationship to
these statistics, and there may be
only a correlation tendency. It may
be speculated that due to more
public interface of the village level
health functionaries, more such
cases,
which
earlier
went
undetected, have been reported.
DIARRHOEA DETECTION AND DEATHS
Year
Diarrhoea
Detection
Diarrhoea Death
2009-10
25252
4
2010-11
83665
8
2011-12
52598
4
Parameter
Before Start of the
Project
(Figures for 2009-10)
Effect of Project Implementation
(Figures of 2010-11 and 2011-12)
Detection
of
Diarrohea
In
2008-09,
44,281
cases
were reported,
in 2090-10, the
number
was
25,252.
This
averages
to
34,766 cases of
diarrohea.
In 2010-11, there has been a
quantum jump, and 240%
cases were detected ie 83,665
cases. Again, the explanation
may be that greater interface
of health deptt functionaries
with the villagers may have led
to
greater
detection
of
diarrhoea cases which earlier
went undetected.
MALARIA
• District was 2nd highest
in Malarial deaths in the
country in 2009-10.
• PF malaria is
widespread.
Year
2009
PF
No. of
positive deaths
cases
2331
39
2010
2065
4
2011
1006
4
Parameter
Before Start of
the Project
(Figures for
2009-10)
Effect of Project Implementation
(Figures of 2010-11 and 2011-12)
Incidence of
Malaria and
PF malaria,
and death
due to
malaria
In 2009 there
were 2320 cases
of Malaria , and
2331 cases of PF
malaria,
There
were 11 deaths in
2008
and
39
deaths in 2009
due to Malaria and
PF
Malaria
respectively.
In 2010, there were 1995 cases of malaria and 2065
cases of PF malaria. The number of deaths due to
malaria reduced from 11 deaths and 39 deaths in past
two years, to 4 deaths in 2010. In 2011, the figure of
PF positive cases reduced, though the number of
deaths remained the same at 4. Again, it would be
irrational to establish cause effect reasoning to this
data, without a full scope study into the findings, and
this may be purely correlational, but greater
awareness on necessity to prevent water from
stagnating, greater usage of mosquito net, more
effective spray of DDT etc which was a part of the
VHND agenda as well as greater awareness, MAY
have contributed to this. Alternatively, it may be purely
coincidental.
MATERNAL DEATH
Year
No. of deaths
2009-10
18
2010-11
8
2011-12
9
IMMUNIZATION STATUS
Vaccine
% of achievement
during 2009-10
% of achievement
during 2010-11
% of
achievement up
to March, 2012
BCG
DPT3
74.70
71.11
92.11
82.37
95.40
103.13
OPV3
71.11
82.29
103.32
Measles
66.37
88.29
97.70
Full
immunization
48.65
53.37
71.16
TT10
40.53
81.25
55.51
TT16
39.10
54.82
45.32
FULL IMMUNIZATION
Year
% of full Immunization (For
children up to 11 months)
2009-10
48.65
2010-11
53.37
2011-12
71.16
Parameter Before Start of the
Project
(Figures for 2009-10)
Quality of The
figures
of
health data immunization achieved/
reported
health statistics were
collected, compiled by
health deptt alone and
monitored by state level
health deptt. Only a
perfunctory discussion
was done annually in the
district level health and
family
welfare
committee.
Effect of Project
Implementation
(Figures of 2010-11 and
2011-12)
Quality of data reported,
including
instances
of
diseases found or deaths
occurred
or
vaccination
achieved is much, much
better as the data of each
village, is every month,
reported by three deptts,
simultaneously,
counter
signed by gram pradhan, and
monitored intensely at the
block and sub-divisional
level.
Weaknesses in Implementation
• The formats of reporting and online reporting
website, have further scope of improvement
• Monitoring of quality of services like Ante natal
check up, haemoglobin testing etc.
• Keeping up the enthusiasm, month after month,
requires regular workshops, trainings,
monitoring.
• Wastage of vaccine vials is a possibility,
maintenance of cold chain is to be closely
monitored.
SUSTAINABILITY
• Now a demand has been generated in the rural and tribal areas
for regular VHND every month
• The number of complaints against Govt functionaries of health
and ICDS deptt of all levels has skyrocketed, which in itself is a
positive feature, showing public is demanding service delivery
• In the PIP under NRHM for year 2010-11, GOI has given fundas
to the district as per our new pattern of implementation
• All young officers presently holding posts of BDO, SDM have
received hands on training in running this program
• There is 100% PRI support to the program, with Sabhadipati
involved in its design and implementation at every step and upto
Chief Minister level the program has been recognized and is
now reviewed.
REPLICABILITY
• As the program received stupendous public response in first
3 months itself, Chief Secretary asked all other districts in
the state to implement the same program
• A committee formed by health deptt to study the same
• Independent evaluation by NRHM Consultants from GOI
• Already being implemented in other districts of Tripura in
abridged forms
• Is encouraged by a vibrant PRI presence
TRANSPARENCY
• No large funds involved in implementation
• Funds of few hundred Rupees distributed to each Panchayat
• The same accounted for by the Panchayat Secretary in VHND
Register
• Performance of VHND put in public portal on website
• Fudging of figures becomes difficult as each health indicator is
now possible to break down to village level
THANK YOU