Models of Supportive Supervision for IMNCI Implementation in Selected Districts of Bihar, Orissa and Rajasthan in India

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1 224 Indian Journal of Public Health Research & Development. January-March 2013, Vol. 4, No. 1 Models of Supportive Supervision for IMNCI Implementation in Selected Districts of Bihar, Orissa and Rajasthan in India Madhu Gupta 1, Venkatachalam J 2, Nidhi Goyal 3, Ravinder Kaur 4, Sonu Goel 5, Manmeet Kaur 6, Arun Kumar Aggarwal 7, Pavitra Mohan 8 1,5,6 Assistant Professor, 3 Project Manager, 4 MPH Scholar, 7 2 Professor, School of Public Health, PGIMER, Chandigarh Assistant professor in PIMS, Pondicherry, 8 Health Specialist, UNICEF, New Delhi ABSTRACT Human resource insufficiency in the resource constraint countries like India insists that the existing human resources are optimally utilized. Supportive supervision is one such strategy to ensure retention of knowledge and skills of existing service providers for optimal implementation of any national health programme. The present study ascertained and documented various models of supportive supervision for implementation of Integrated Management of Neonatal and Childhood Illnesses (IMNCI) strategy, to reduce under 5 mortality, in terms of its feasibility, sustainability, effectiveness, success and limitation in selected districts of Rajasthan, Orissa and Bihar states in India. The comparison of IMNCI indicators one year after the initiation of supportive supervision had shown that three post natal visits by health workers within 10 days of birth increased by 11.3 %, 20.2% and 37.6% in the districts - Tonk in Rajasthan, Mayurbhanj in Orissa and Vaishali in Bihar, respectively. There was a marked increase in the referral rates for both young infants and sick children in these states. More focused and regular supervisory visits kept health workers motivated and led to better IMNCI indicators in Bihar as compared to Rajasthan and Orissa. Model of supportive supervision involving both internal and external agency was found to be more feasible, sustainable and successful. INTRODUCTION India aims to reduce the under five mortality rate by two thirds between 1990 and 2015 under the Millennium Development Goals (MDG-4). Hence one of the very important goals of family welfare programmes is to bring down the infant and child mortality rates for improving child health in India. Although India witnessed a decline in Infant Mortality 1 Rate (IMR) of 50 per 1000 live births in 2008 from 68 per 1000 live births in 1990 still there are certain programmatic issues which need attention. 2,3 Improved child health is tried to be achieved through building knowledge and skills of health service providers as well as grass root level workers including anganwadi workers, auxillary nurse midwives (ANMs), medical officers (MOs) and nurses by imparting training under Integrated Management of Neonatal and Childhood Illnesses (IMNCI) in India. 4 However, these skills would be lost with time if not practiced and reiterated by Corresponding author: Venkatachalam (Assistant Professor, Dept of Community Medicine, PIMS, Pondicherry) - drvenkatpgi@gmail.com supportive supervision 5. The aim of the present study was to document various models of supportive supervision for IMNCI and ascertain the feasibility, sustainability, effectiveness, success and limitations in India METHOD Models of supportive supervision were reviewed in district of Vaishali, Jaipur, Mayurbhanj.Three research teams (one for each state), including a faculty member and two post graduates from School of Public Health, Post graduate Institute of Medical Education and Research, Chandigarh, India visited Rajasthan in March 2009, Bihar in April 2009 and Orissa in November 2009 for five days. The districts visited by the team were Jaipur in Rajasthan, Vaishali in Bihar, and Mayurbhanj in Orissa. The state officials of Unicef and Directorate of Family Health and Welfare from government sector also accompanied the team during the visit. Prior to the visits necessary permissions were obtained from the state level officials of government sector and the state UNCIEF office. To ensure uniform collection of data research teams were sensitized for

2 one day on the objective of visit. Standard terms of references for visit were prepared and given to the teams. Research teams gathered information on the number of district/blocks covered under IMNCI, type of supervision (external or internal agency), IMNCI training schedule (number of days of IMNCI training) of the workers, training for supervisors (two days follow up training), number of supervisors being provided with supervisory training, number of health workers being supervised. Work plan of the supervisors (number of visits planned for their respective villages in a month), records of the supervisors (work plan, supervisory report, supervisory form), records of health workers (record registers) and other reports for assessing the number and quality of the supervisory visits were also reviewed by the teams. Effectiveness of the supportive supervision was assessed by comparing the IMNCI indicators base line level with one year after the implementation of supportive supervision. RESULTS The health personnel s who were involved in supportive supervision in district Vaishali in Bihar, Mayurbhanj in Orissa and Jaipur in Rajasthan. Brief details of supportive supervision as follows, BIHAR IMNCI was implemented in 25 out of 38 districts of Bihar. It was in early implementation phase in most of the districts of Bihar, except Vaishali which was in consolidation phase (more than 90% training load completed). IMNCI programme was being supported technically and financially by UNICEF. Out of 25 districts, mechanism of supportive supervision had been initiated in 19 districts after the pilot study in the district Vaishali. Supportive supervision is by both internal (government) as well as external (UNICEF) agency. At state level, a state monitoring cell had been established at State Institute of Health and Family Welfare (SIHFW) to strengthen IMNCI. State programme officer from Bihar State Health Society and members of State Quality Assurance Cell supervised the activities of IMNCI from the government side. State IMNCI consultant and Health officer of child survival were involved in supervising IMNCI from Unicef s Office. Similarly at district level, there was District Quality Assurance Cell (QAC) for monitoring all National Rural Health Mission activities including IMNCI. Officials for supervision included members of the Quality Assurance Committee (government), Child Survival Coordinators and District Extenders (UNICEF) at district level. Indian Journal of Public Health Research & Development. January-March 2013, Vol. 4, No District Vaishali, Bihar There were 16 blocks in the district Vaishali. Supportive supervision was initiated in July 2006 and became functional from October UNICEF staff included an IMNCI supervisor at block level who was responsible for ensuring the completeness and quality of data and reporting to district IMNCI coordinator. These supervisors were of graduate level and had undergone training for IMNCI for 11 days (8 days basic and 3 days follow up training). Basic training had been given to 45 supervisors and follow up to 50 supervisors at the time of this study. Government staff included block extenders/ health educators/ IMNCI medical officers/ CDPOs as block level supervisors. Supervisors from government or UNICEF supervised health system supervisors i.e., MOs and LHVs at the PHC level, who further supervised grass root level workers like ANMs/ AWWs/ASHAs. Joint monthly review meetings of Unicef and government staff including health specialist (Unicef), IMNCI consultants, IMNCI medical officers, IMNCI supervisors were being conducted to strengthen the mechanism of supervision and data flow. Supervisors supervised 10 Anganwadi Centers (AWC) and a fixed number of health workers (approximately 20) per month for which they were paid a fixed amount (Rs. 50) per worker supervised. Supervisors checked two forms i.e. Form 2A (for infant up to 2 months) and 2B (For children from 2 months to 5 years) during their supervisory visit. Supervisory visit was usually not planned and no micro planning for the visit was done in advance. It was of informed type i.e., prior information about the visit was being conveyed to health workers. Supervisor usually observed the interaction of mother with AWW and reported the feedback to higher authorities. State level supervisors also visited AWCs in a month. The Anganwadi worker at Anganwadi center prepares the monthly report in the prescribed format and submits to Auxiliary Nurse Midwife (ANM) at Sub center on last Wednesday of every month. ANM then compile and submit the report to the Medical Officer in Charge (MO I/C) of the Primary Health Center by first Tuesday of the coming month. Then Medical officer collects and compiles the reports of all Sub centers at PHC and a consolidated report was then shared with the district officials (Civil surgeon and District Programme Manager) at district health society. Similarly district level official shares the compiled report of all PHCs with the state officials (Consultant of maternal and child health of state health society) and finally with the Assistant commissioner of child health at MOHFW, Government of India.

3 226 Indian Journal of Public Health Research & Development. January-March 2013, Vol. 4, No. 1 ORISSA IMNCI has been implemented in 16 districts out of total of 30 districts. Out of these 16 districts two districts viz. Mayurbhanj and Koraput were in consolidation phase. A total of 600 supervisors had been trained for basic training and 530 supervisors for follow up training till the end of December There were different models of supportive supervision at block level. Free-lancer model included retired medical practioners, AYUSH (Ayuervaeda, Unani, Sidha and Homeopathy) doctors, private practioners etc who were trained for basic training and follow up training. In the second model NGOs facilitate the supportive supervision at block level. State trains the NGO staff for IMNCI supervision. These provide about 8-10 supervisory visits per month. In the third model ICDS supervisors and health supervisors were being trained in IMNCI. The area of supervision (AWC and Blocks) was divided equally among these supervisors. District Mayurbhanj, Orissa In the district Mayurbhanj Supportive supervision was started in the year The Health and ICDS supervisors supervised around 5-6 Health workers/ AWW per month. Details of supervision were not readily available from Orissa. Challenges of supervision by middle level supervisors of Health and ICDS include long distances to travel, lack of mobility support, less motivation for work among workers and lengthy follow up supervisory formats. Table -1. Coverage, type and nature of supportive supervision in Bihar, Rajasthan and Orissa, India. IMNCI Bihar Rajasthan Orissa indicators N=38N(%) N=33N(%) N=30N(%) IMNCI 25(65.7) 33(100) 16(50.3) Implemented Districts with 19(50) 4(12.1) 1(3.3) supportive supervision Type of Both External Internal supervision (Internal/External) Number of 58-60: 22-25: NA health workers block block supervised level20-24: level per month State level Duration of supervision (hrs) Nature Informed Informed Both (Informed/ Uninformed) Duration of training for supervisors (days) Rajasthan IMNCI has been implemented in all the 33 districts in Rajasthan. In Jaipur supervision was done by the external agency. Here trained supervisors were post graduates from department of Home Science, University of Rajasthan, Jaipur. These supervisors had been trained for 3 days especially for supervision in addition to two days training. These supervisors supervised one to two health workers per day per block and around health workers in a month. Supervisors checked the records, reports and the skills of the health worker along with the logistics availability. Supervisory visits were informed prior to the visit. Districts manager made the plan of the supervisory visit. Feedback of the visit was being shared after each visit with the officials at the district level. They also organized the meetings for coordination at village, sector and district level. The block co-ordinators work under the guidance of the identified faculty of Department of Home Science, University of Rajasthan, Jaipur. However, for day to day activities and for support they liaison closely with the RCHO and the Child Health Co-ordinators. The Department of Home Science, University of Rajasthan, Jaipur submit a monthly progress on IMNCI implementation in the district to RCHO and UNICEF. Table-2. IMNCI indicators one year after the implementation of the supportive supervision. IMNCI Viashali Mayurbhanj Tonk indicators N(%) N(%) N(%) 3 PNC visits within 10 days of Births Base line (2006) N=841 N=7066 N= PNC visits 329(39.1) 3307(46.8) 598(56.3) 1 year after(2007) N=5635 N=13587 N= (76.7 ) 9213(67) 447(67.6) P value IMNCI Young Infants Referral Base line (2006) N=230 N=6610 N= (9.1) 344(5.2 ) 90(8.6) 1 year after(2007) N=8733 N=5428 N= (58.6 ) 759(14 ) 25(4.2 ) P value Number of sick child referred Base line (2006) N=2318 N=10755 N= (4.2 ) 556(5.2) 104(4.1) 1 year after(2007) N=15646 N=12509 N= (26) 1204(9.7) 51(4.0 ) P value

4 Coverage and Impact of Supportive Supervision Bihar had more (50%) IMNCI districts with supportive supervision as compared to Rajasthan (12.1%) and Orissa (3.3%) as shown in table 1. InBihar, the number and duration of visits per month were slightly higher than in Rajasthan. IMNCI indicators one year immediately after the initiation of supportive supervision in these states have shown a remarkable increase as shown in table 2. There was 11.3 %, 20% and 37% increase in three PNC visits within 10 days of births, in districts Jaipur, Mayurbhanj and Viashali respectively which was statistically significant (p<0.001). Number of referral young infants and sick child assessed and referred also increased significantly (p<0.001) in district of Vaishali and Mayurbhanj. Even though in the district of Jaipur where there was no change in sick child referral but there was significant decrease with respect to young infant referral. The reason for poor referral in child component in Rajasthan could be due to poor supportive supervision and inadequate experience of supervisors. DISCUSSION IMNCI in India was implemented in the year 2003 in three districts in pilot phase, since then different models of supportive supervision were being used in different states of India, but the impact and effectiveness of these supervisory models in implementing IMNCI was not available. This study has made an attempt to document and ascertain the role of supportive supervision in IMNCI implementation. The results of this study had shown that IMNCI indicators especially, three post natal checkups within ten days of birth of the child had improved significantly after supportive supervision of health workers. There were also significantly more referrals of sick young infants and sick children to health facilities after one year of implementation of supportive supervision. Various studies had shown that the role of supportive supervision can have independent positive effects on the immunization coverage and systematic supervision using clearly defined and quantifiable indicators can improve service delivery considerably, at a modest cost 7. Another study documented that intense supervision led to high provider performance in systematic influenza and pneumococcal vaccination coverage rates 8 Model of supportive supervision had been a success as there was a collaborative action by UNICEF and Government of India. Vaishali model of supportive supervision in Bihar had been shown a greater improvement of IMNCI indicators, as IMNCI was launched very early in this and more than 90% of health Indian Journal of Public Health Research & Development. January-March 2013, Vol. 4, No staff was trained. Bihar has an additional structure like the state monitoring cell which exists at the SIHFW to strengthen IMNCI. The state and district quality assurance cell are also set up, to monitor all the activities under NRHM including IMNCI. The other initiative that had led to successful implementation was availability of IMNCI supervisors at each block. In Orissa supportive supervision was started in 2006 but still there are major challenges which hinders the rolling out of the strategy successfully. There are managerial challenges which include lack of human resources, logistics and mobility support. However this district had been performing better than Rajasthan. In Rajasthan supportive supervision by external agency had been observed that in district of Jaipur. Sustainability of the supportive supervision by model of external agency remains questionable. Some of the studies also showed that external agency not a effective Tool. That was reason this model was failure in childhood component. Supportive supervision is different from the traditional supervision. 6 The work of a good supportive supervisor was to assess certain things like whether the health workers are provided with a book chart, essential equipments and drugs, case sheets, able to identify diseases and treat them, visiting homes in an efficient manner and entering data in the case sheets correctly including the immunization status of the children. It had been shown in a case study in Andhra Pradesh, that outsourcing of supportive supervision has lead to more enthusiastic response and hence better result. 9 In Bihar contact of health workers with supervisors was more frequent, so they could able to share their problems more frequently and solve it more promptly. That was why performance of the health workers in terms of following the IMNCI guidelines in managing children was better. Motivation among health workers as well as among the caretakers was also more in Bihar than in Rajasthan. Studies done in Kenya and Guinea have shown that more frequent the contact with the supervisors; the earlier the problem is solved 10 In Bihar the number and duration of supervisory visits per month was also higher than in Rajasthan. The type of visits in both the districts was informed. The advantages of informed visits are that, all the heath workers can be met at a specific time and place by arranging for a get together on a particular day. The performance and skills of all the health workers can be assessed in a simple manner and the best performer can be awarded or specially recognized which would also motivate other health workers to perform better. The only disadvantage is that in informed visit there is possibility of submitting false manipulated records whereas in surprise visit manipulation is impossible and hence original feedback obtained. To conclude supportive supervision by Vaishali model was

5 228 Indian Journal of Public Health Research & Development. January-March 2013, Vol. 4, No. 1 successful feasible approach to improve the child health in India. REFERENCES 1. Unicef : Children_and_the_MDGs. Accessed on 2/3/2012, available at [ publications/files/children_and_the_mdgs.pdf] 2. Kumar R. Integrated Management of Childhood Illness Strategy: Opportunities and Challenges. Indian J Public Health;2003;47: Sample Registration System (SRS), SRS Bulletin Accessed on 21/1/12 Available at [ censusindia.gov.in/vital_statistics/ SRS_Bulletins/SRS%20Bulletin%20- %20January% pdf] 4. IMNCI Chart booklet. Ministry of Health and Family Welfare, Government of India, New Delhi, Venkatachalam J, Kumar D, Gupta M, Aggarwal AK. Knowledge and skills of primary health care workers trained on integrated management of neonatal and childhood illness: Follow-up assessment 3 years after the training. Indian J Public Health 2011;55: Marquez L, Kean L. Making Supervision Supportive and Sustainable: New Approaches to Old Problems, Maximizing Access and Quality Initiative. Washington DC: USAID; MAQ Paper No: 4, Available online at maqpaperonsupervision.pdf 7. Loevinsohn BP, Guerrero ET, Gregorio SP. Improving primary health care through systematic supervision: a controlled field trial. Health Policy Plan. 1995; 10(2): Slobodkin D, Kitlas J, Zielske P. Opportunities not missed - systematic influenza and pneumococcal immunization in a public inner-city emergency department. Vaccine. 1998; 16(19): Children s Vaccine Program at PATH. Guidelines for Implementing Supportive Supervision: A stepby-step guide with tools to support immunization. Seattle: PATH (2003) 10. Bradley J, Igras S, Shire A, Diallo M, Matwale E, Fofana F etal. COPE for Child Health in Kenya and Guinea: An Analysis of Service Quality. Engender Health, New York, 2002.