VITAMIN A SUPPLEMENTATION

Transcription

1 VITAMIN A SUPPLEMENTATION RESULTS FROM THE 2010 SUSTAINABILITY STUDY Assessing the Sustainability of the Jharkhand District Vitamin A Supplementation Program Prakash Kotecha Iqbal Syed Chandranath Mishra

2 This report is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of Cooperative Agreement No. GHS- A The contents are the responsibility of the Academy for Educational Development and do not necessarily reflect the view of USAID or the United States Government. Recommended Citation: Kotecha, P.; Syed, I. and Chandranath, M.. Assessing the Sustainability of the Jharkhand District Vitamin A Supplementation Program. A2Z: The USAID Micronutrient and Child Blindness Project, AED, Washington D.C., Copies of the report can be obtained from: A2Z: The USAID Micronutrient and Child Blindness Project AED 1825 Connecticut Ave., NW Washington D.C., Tel: Fax: a2z_info@aed.org Website: Acknowledgements: A2Z: The USAID Micronutrient and Child Blindness Project wishes to acknowledge the important contributions, technical assistance, and active participation of the Government of Jharkhand (GoJ) Department of Health and Family Welfare and the following GoJ officials: Mrs. Aradhana Patnaik, Mission Director, NRHM; Dr. Anjali Das, Director in Chief, Health Services; Dr. Praveen Kumar, State RCH Officer; Dr. Satish Kumar Sinha, Director Health Services; Dr. Ajit Kumar Prasad, State Immunization Officer; Dr. S. K. Shukla, Director Health Services; and all Senior District Officials for their support in the collection of data, and active interest and follow-up support at the field level. A2Z would also like to thank Dr. Prakash Gurnani, UNICEF; Dr. Nileema Tirkey, Micronutrient Initiative; Mr. Subhendra Jha, MN Cell; Linda Tawfik, A2Z/AED; Zo Rambeloson, A2Z/AED; and development partners A2Z, UNICEF, MI, CINI, VISTAR, MCHIP, and WHO for their technical support and assistance. Special thanks to Vishwajeet Pankaj for assisting in data analysis and formatting as necessary. Vitamin A Sustainability Report: Six Districts of Jharkhand Page 2

3 Contents 1. Introduction The National Prophylaxis Program for Prevention of Blindness due to Vitamin A Deficiency Status of Vitamin A Supplementation Programs in Jharkhand Objectives Delivery Strategies Schedule/Calendar Vitamin A, Nutritional Counseling, and De-worming Services Available during the JMSSPM Vitamin A Nutritional Counseling De-worming Critical Elements for Successful JMSSPM Vitamin A Coverage as Part of JMSSPM in Jharkhand Process of Developing and Implementing the VAS Sustainability Assessment Tool Selection of Six Districts Vitamin A Sustainability Assessment Tool Development Process in Jharkhand Results and Discussion Funding Policy Human Resources Planning Supply and Logistics Monitoring Social Mobilization District Specific Scores Ramgarh District Garwah District Dumka District Ranchi District Pakur District E. Singhbhum District Concluding Remarks Sustainability vs. Vulnerability Tables Table 1. Vitamin A rich food, supplements and de-worming received by children in India... 6 Table 2. Contribution to the sustainability tool by level of respondent for seven components Table 3. Maximum possible score for each component by respondent Table 4. Total scores and percentage for funding pooled from all the six districts Table 5. Total scores and percentage for policy pooled from all the six districts Table 6. Total scores and percentage for human resource pooled from all the six districts Table 7. Total scores and percentage for planning pooled from all the six districts Table 8. Total scores and percentage for supply pooled from all six districts Table 9. Monitoring scores in percentages for the six districts Table 10. Social mobilization scores in percentages for the six districts Table 11. Scores of all components for Ramgarh district Table 12. Scores of all components for Garwah district Table 13. Scores of all components for Dumka district Table 14. Scores of all components for Ranchi district Vitamin A Sustainability Report: Six Districts of Jharkhand Page 3

4 Table 15. Scores of all components for Pakur district Table 16. Scores of all components for E. Singhbhumr district Table 17. District specific dustainability using 80% score as sustainable Table 18. Area specific sustainability using 80% score as sustainable Figures Figure 1. Vitamin A coverage rates (children who received dose in the biannual round or during RI) Figure 2. Funding scores in percentages for the six districts Figure 3. Policy scores in percentages for the six districts Figure 4. Human resource scores in percentages for the six districts Figure 5. Planning scores in percentages for the six districts Figure 6. Supply scores in percentages for the six districts Figure 7. Monitoring scores in percentages for the six districts Figure 8. Social mobilization scores in percentages for the six districts Figure 9. Total scores for Ramgarh for all components and pooled score Figure 10. Total scores for Garwah for all components and pooled score Figure 11. Total scores for Dumka for all components and pooled score Figure 12. Total scores for Ranchi for all components and pooled score Figure 13. Total scores for Pakur for all components and pooled score Figure 14. Total scores for E. Singhbhum for all components and pooled score Vitamin A Sustainability Report: Six Districts of Jharkhand Page 4

5 Acronyms ACMO ANC ANM AWW BEE CINI CS DIO DHS DPM DPO DRCHO DRCHO HSC ICDS ICMR IEC IU JMSSPM LHV MCHIP MCHN MI MO MOIC NGO NFHS NRHM PHC PIP PMU RCH REACH RI UNICEF VAD VAS VIPP WCD WHO Additional Chief Medical Officer Antenatal Care Auxiliary Nurse Midwives Anganwadi Worker Block Extension Educator Child in Need Institute Civil Surgeon District Immunization Officers Demographic and Health Surveys District Program Manager District Program Officer District Reproductive Child Health Officer State Reproductive Child Health Officer Health Sub-Center Integrated Child Development Services India Council on Medical Research Information, Education, and Communication International Unit Jharkhand Matri Shishu Swasthya evam Poshan Maah Lady Health Visitor Maternal and Child Health Integrated Program Maternal and Child Health and Nutrition Micronutrient Initiative Medical Officer Ministry of Information and Communication Nongovernmental Organization National Family Health Survey National Rural Health Mission Primary Health Center Project Implementation Plan Project Management Unit Reproductive and Child Health Program Regular Events to Advance Child Health Routine Immunization United Nations Children s Fund Vitamin A Deficiency Vitamin A Supplementation Visualization in Participatory Programs Ministry of Women and Child Development World Health Organization Vitamin A Sustainability Report: Six Districts of Jharkhand Page 5

6 1. Introduction Vitamin A deficiency (VAD) is a severe yet preventable public health and nutrition problem. It inhibits immune function in children, and is therefore a major contributor to childhood mortality, blindness, and illness. Vitamin A deficient children are at increased risk of dying from diseases such as measles, diarrhea, and malaria, and recent evidence suggests that even mild VAD may increase mortality in children. In addition, an estimated five to seven percent of children in India suffer from eye problems related to VAD. Supplementation of vitamin A deficient populations reduces child mortality by as much as 20-23% The National Prophylaxis Program for Prevention of Blindness due to Vitamin A Deficiency The Tenth Five Year Plan of the Government of India stresses the need for sustained efforts to reduce micronutrient deficiencies, and aims to eliminate VAD as a public health problem. While there have been policies in place to address malnutrition in India for more than a decade, a variety of challenges have limited the coverage and impact of existing programs-especially those that address micronutrient disorders, such as VAD. 2 India s National Prophylaxis Programme for the Prevention of Blindness due to Vitamin A Deficiency works to protect children ages six months to five years from the risks associated with VAD. The Prophylaxis Programme is comprised of a short and long-term strategy. The short-term intervention uses periodic administration of mega doses of vitamin A to expand coverage, while the long-term intervention emphasizes overall dietary improvement. Table 1. Vitamin A rich food, supplements, and de-worming received by children in India Age in months % of children who consumed vitamin A rich food in last 24 hours ( % of children who were de-wormed in last six months % o f children given vitamin A supplement in last six months Data not collected in the survey Total Male Female *Source: NFHS Black, RE; Morris, SS; Bryce, J. Where and why are 10 million children dying every year? Lancet 2003; 361: Government of India. No. Z 28020/06/2005-CH. Department of Health and Family Welfare; Child Health Division, Government of India. 2 November, Government of India. Tenth Five Year Plan ( ). Planning Commission, Government of India, New Delhi Vitamin A Sustainability Report: Six Districts of Jharkhand Page 6

7 The vitamin A supplementation (VAS) program in India has entered a new phase in which many states are administering vitamin A doses during month-long integrated bi-annual health sessions, usually held in April/May and October/November. The decision to use this intervention was made after the Indian Council of Medical Research s National Workshop on Micronutrients in 2003 recommended Biannual Child Health and Nutrition Promotion Months as a platform for delivering packages of child health and nutrition interventions (including vitamin A supplementation) to target populations. It was recommended that children ages nine months to three years receive two doses of vitamin A at six month intervals. The Government of India (GoI) policy document on vitamin A reiterates this protocol, supporting the administration of vitamin A to children ages 1-5 years through bi-annual health sessions. 4 The document specifies that the initial dose of vitamin A should be administered during a child s routine measles immunization, with the following eight doses administered six months apart during bi-annual health sessions. This recommendation is in line with the global REACH strategy (Regular Events to Advanced Child Health), which focuses on providing contact points for the delivery of child friendly health services to pre-school children. The National Prophylaxis Programme for the Prevention of Blindness due to Vitamin A Deficiency is implemented through India s primary health centers (PHC) and health sub-centers (HSC). Auxiliary Nurse Midwives (ANM) and other paramedicals working in PHCs administer vitamin A to children under five, and provide education and counseling to families. The Integrated Child Development Services Program (ICDS) of the Department of Women and Child Development of the Ministry of Welfare distributes vitamin A to children in the ICDS blocks, and educates mothers on the importance of preventing VAD. 3. Status of Vitamin A Supplementation Programs in Jharkhand The national policies of India serve as a model for states to adopt and implement vitamin A programs throughout the health care system. The National Family Health Survey (NFHS) III for Jharkhand revealed that only 23.3 percent of children (age months) reportedly received a dose of vitamin A during that time period. 5 The National Family Health Survey III revealed that 77.7 percent of children (ages 6-35 months) in Jharkhand are anemic, and that 59.2 percent of children (under three years of age) are underweight. The survey also reveals that 41 percent of children (under three years of age) are stunted from chronic undernutrition. Addressing VAD through the administration of mega doses of vitamin A to target populations Periodic administration of mega doses of vitamin A ensures adequate nutrition as vitamin A is stored in the body for prolonged periods of time. It is the most simple, effective and direct short-term strategy to reach pre-school children. Every infant (age 6-11 months), and child (age 1-5 years) must be administered vitamin A every six months. Children ages six months to three years must be given priority, as this age group exhibits the highest prevalence of clinical signs of VAD. A child must receive a total of nine oral doses of vitamin A by age five. 4 Government of India. No. Z 28020/06/2005-CH. Department of Health and Family Welfare; Child Health Division, Government of India. 2 November, International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-3), : India: Volume I. Mumbai: IIPS Vitamin A Sustainability Report: Six Districts of Jharkhand Page 7

8 Jharkhand Matri Shishu Swasthya evam Poshan Maah (JMSSPM) In accordance with the Government of India Policy Document on vitamin A, the Government of Jharkhand conducts bi-annual health sessions called Jharkhand Matru Shishu Swasthya evam Poshan Maah in the months of August/September and February. The JMSSPM is not a stand alone program, but is integrated into an optimum package of services and interventions that are necessary to promote child survival in the local context. National government programs in India (such as Integrated Child Development Services (ICDS), Reproductive and Child Health (RCH), and National Rural Health Mission (NRHM)) are built on a basic administrative structure. At most of these levels, both ICDS and the RCH have key individuals responsible for different aspects of the vitamin A program. Each has headquarters at the national and state levels, offering overall policy guidance, planning, and administrative support. Managerial responsibilities are handled at the district level, while service delivery responsibilities are handled at the block level. 3.1 Objectives Goals of the 10 th Five Year Plan of the Government of India include: Achieve universal coverage of five doses of vitamin A for children up to three years of age. Reduce the prevalence of night blindness to less than 1%, and bitots spots to below 0.5% in children sixth months to five years of age. Eliminate VAD as a public health problem. Recommended goals for the 11 th Five Year Plan of the Government of India include: Reduce the percentage of underweight children under five to 20%. Eradicate the prevalence of severe under-nutrition in children under five. Eliminate VAD in children under five, and reduce sub-clinical deficiency of vitamin A in children by 50%. Services needed to reach these goals include: Administration of vitamin A to all eligible children aged nine months to five years who have not received vitamin A in the last six months. Administration of vaccines to eligible children, with priority given to children who have never been vaccinated, or those who have been partially vaccinated. De-worming of children (ages1-5 years) through the administration of albendazole tablets. 3.2 Delivery Strategies Vitamin A is available at the HSC, AWC, and other places as per HSC micro-plan on all Thursdays and Saturdays of February and August of each year. House-to-house social mobilization is conducted by Anganwadi Workers (AWW), Sahiya, etc. ANM activities: Prepare and share routine immunization (RI) micro-plans in consultation with the AWWs and Sahiyas of the HSC area. Vitamin A administration De-worming Compilation of coverage reports (by session site and by AWC) and timely submission of the same to PHC in the given formats. AWW activities: In preparation for JMSSPM vitamin A distribution: Up-date AWC s survey register and support the ANM in the preparation of microplans. Vitamin A Sustainability Report: Six Districts of Jharkhand Page 8

9 Motivate and inform communities, households, and families about the date and location of health session sites, and publicize services that will be available. Ensure the participation of traditional panchayats heads and opinion leaders of the village in the activities of round. Prepare AWC for providing services. Prepare beneficiary lists for VAS and de-worming in each AWC jurisdiction. Activities on JMSSPM days: Nutritional counseling of pregnant women and nursing mothers, especially on infant and young child feeding practices. Compile, format, and submit AWCs coverage reports. Sahiya activities: Motivate and inform communities, households, and families about the date and location of health session sites, and publicize services that are available. Escort target beneficiaries to the session site. Support the ANM and AWW in conducting their activities. Urban strategies: Urban areas have low coverage rates as compared to rural areas due to a lack of a public health service delivery infrastructure. Immunization services are delivered through multiple providers, with a predominant role played by private practitioners, hospitals, and government and private preparatory schools. Careful planning and coordination among all players including hospitals, health clinics, AWCs, and preparatory schools is critical for sustained improvements in the immunization program and other child survival interventions in urban areas. A Nodal Officer is identified and coordinates activities in the urban areas. The catchment areas under each health facility are clearly defined, and sessions are continued at the same sites during subsequent immunization days. Micro plans are prepared for urban areas, which are divided into sectors. All urban ICDS centers and primary schools are identified and used as session sites. A special urban area intervention strategy is used to implement the package of services of the JMSSPM. The Pulse polio micro-plans are often used to plan the activities of the round. 3.3 Schedule/Calendar Activities take place on all Thursdays and Saturdays of February and August of each year. Each ANM revises the RI micro-plan every six months in consultation with the AWW and Sahiyas of the HSC area in such a way that all the habitations (areas where there are a number of houses that exist together) are covered during the month (preferably on the Thursdays and Saturdays). The updated microplan is then used for future service delivery of immunization and other services every month. If any HSC area has more than eight AWCs, the ANM plans her roster in such a way that she covers the remaining AWCs on other days of the month or may extend to the next week of the coming month. If there are more habitations and eight sessions are not enough to cover all households, then additional sessions are planned. Vitamin A Sustainability Report: Six Districts of Jharkhand Page 9

10 3.4 Vitamin A, Nutritional Counseling, and De-worming Services Available during the JMSSPM Vitamin A WHO guidelines state that the optimal interval between vitamin A doses in children is four to six months, with a minimum recommended interval of one month between doses. Therefore, children are dosed during health sessions if they have not received a dose within the last month. As a part of RI, the JMSSPM program provides prophylactic doses of vitamin A solution to all children between nine and twelve months of age. The recommended dosage schedule is: 9-12 months: one dose of 100,000 IU, in conjunction with measles vaccine. 1-5 yrs: 200,000 IU every six months (twice-yearly) during bi-annual health sessions Nutritional Counseling All children ages one month to five years of age who attend health sessions are weighed by AWW, and their weight is plotted against age on a growth chart. ANM report this information during JMSSPM months. Counseling on exclusive breastfeeding is given to pregnant and lactating women with children up to six months of age, and infant and young child feeding counseling is given to all mothers. Malnourished children (grades III and IV) who exhibit medical complications such as bi-pedal pitting oedema, refusal to feed, and lethargy are referred to the nearest PHC/hospital for appropriate evaluation and treatment De-worming Worm infections contribute to VAD, and de-worming reduces anemia in children (which is associated with VAD). Research has shown that bi-annual de-worming increases weight gain by 10% in children. 6 Albendazole syrup for de-worming is safe, requires a single dose, and is simple to administer. During JMSSPM, albendazole is administered to children who are between one and five years of age. The doses for albendazole syrup are as follows: months: 5 ml (200 mg) months: 10 ml (400 mg) The mother/care-giver of the child receives the dose, and is instructed to dose the child after dinner when the child has a full stomach. 3.5 Critical Elements for Successful JMSSPM The following are some elements considered to be essential to the success of JMSSPM: Strong leadership and commitment at all levels. Administrative commitment and leadership at state and district levels is critical to the success of the initiative. Continuous involvement of the state and district officials (particularly Deputy Commissioners, Civil Surgeons (CS), Additional Chief Medical Officers (ACMO), District Immunization Officers (DIO), and District Programme Officers (DPO) etc.) is vital. 6 Harold Alderman, Joseph Konde-Lule, Isaac Sebuliba, Donald Bundy, Andrew Hall. Effect on weight gain of routinely giving albendazole to preschool children during child health days in Uganda: cluster randomized controlled trial. BMJ; 2005, Vol Vitamin A Sustainability Report: Six Districts of Jharkhand Page 10

11 Inter-sectoral coordination and convergence. Support from other government departments is crucial for generating demand and effective monitoring and supervision. These departments include ICDS, education, rural development, urban local bodies, development partners, local NGOs, and private and public sector institutions (such as railways, industries, mines, etc.). This crosssectoral coordination yields high dividends in terms of improved visibility and coverage. Micro-plans. Micro-plans are reviewed, revised, and refined to include all villages and hamlets within a sub-center area during the JMSSPM month. The primary unit for developing and revising micro-plans is the sub-center. PHC Medical Officers provide the overall leadership for developing the sub-center micro-plan. The ANM, computer clerks, and medical officers compile the sub-center micro-plans in consultation with the AWWs of the area and send them to the Medical Officer in Charge of the PHC. The Medical Officer in Charge compiles the micro-plans for all sub-centers in the block and sends them to the district level. The prepared RI micro-plan is then used for planning the activities during JMSSPM to strengthen routine RI services. Before each bi-annual round of activities, these micro-plans are reviewed according to the local needs to optimize the outreach of services to all. The micro planning exercise for JMSSPM has three formats. These include: The existing RI micro plans for each HSC Special micro-plans for the hard to reach areas for each PHC Special micro-plans for urban centers using the pulse-polio micro plans and applying a sectoral approach in the urban areas with the involvement of all stakeholders. Sub-Center Level Micro-Planning At the sub-center level, micro-plans are developed during joint meetings of AWWs, ANMs, and Sahiyas. These meetings are ideal opportunities to categorize and prioritize villages, and to plan for identification and mobilization efforts to reach hard-to-reach children. The services of the supervisory level of ICDS (i.e. lady supervisors), are also used to develop sub-center micro-plans. Village level functionaries and volunteers (Sahiyas, change agents, local resource people, and other volunteers) are also involved in this process. Once the micro-plans are finalized, they are shared with the AWWs, Sahiya, and community leaders. Components of an effective micro-plan include: Listing of all villages/hamlets/urban units in the hard-to-reach areas in the vicinity. This exercise is completed with the help of ICDS, general administration, revenue departments, etc. Detailed maps including area boundaries. Identification of vaccinators. All ANMs and other trained vaccinators, such as male multipurpose workers, are involved. Hired vaccinators or lady health visitors are also often included as temporary ANMs in case an ANM position is vacant during the rounds. Route chart for alternate vaccine delivery. Supervision plan. IEC and social mobilization plan with roster of vaccinators, AWWs and mobilizers by session site and date. Vaccine and supply requirements. PHC Level Micro-Planning At the PHC level, micro-plans are developed through a joint effort between health (LHV, male supervisor) and ICDS functionaries (CDPOs and lady supervisors). All relevant partners, including NGOs, industries, and private providers, are included. At this level, micro-plans are compiled and then sent to the district level. MOIC is responsible for the preparation of micro-plans of hard to reach areas, Vitamin A Sustainability Report: Six Districts of Jharkhand Page 11

12 which is done by mobilizing the available resources (both human and physical) of the block. All micro and supervision plans are then sent to the district. District Level Micro-Planning At the district level, civil surgeons compile all the PHC area micro-plans and send them to the state level. Civil surgeons also share the micro and supervision plans with DPO/DWO (ICDS). Reporting and Recording System The following materials are used for recording and reporting of JMSSPM activities: AWW reporting and recording material: VAS and de-worming register for the AWC. AWC based routine recording registers immunization register, growth monitoring register, survey register, etc. AWC to HSC reporting format. Session site to HSC reporting format on VAS & de-worming. AWC through lady supervisors to ICDS Project office reporting format on weighing & salt testing. ANM reporting and recording material: Mother and child health card (immunization card). Mother and child health register (immunization register). VAS and de-worming register for reporting for sites such as HSC, schools, etc. Session site tally sheet or compilation form. Session site to HSC reporting format. Sub-center to PHC reporting format. PHC Reporting and Recording: PHC to district reporting formats. District reporting and recording: District to state reporting formats. Format for reporting on proceedings of district task force meetings. Format for feedback and recommendations for better implementation of round. Supervision and Monitoring Good quality supervision and monitoring are critical elements that contribute to the success of the program. Supervision focuses not only on the quality of the sessions, but also on the process of planning, preparations for the JMSSPM, and quality of reporting. There are a range of possible supervisors at each health system level. State level supervisors: Directors Joint directors State immunization officers Ministry of Women and Child Development (WCD) officials Development partners State PMU team Vitamin A Sustainability Report: Six Districts of Jharkhand Page 12

13 District level supervisors: Civil surgeon District immunization officers DPM DPO/DWO representatives of development partners Other district level health and ICDS officials Block and PHC level supervisors: MOIC MO CDPOs Block Extension Educator (BEE) Health and ICDS supervisors Logistics Planning and Management Rational estimation of vitamin A and de-worming supplies are made well in advance. Supplies are in place at the district level at least two months in advance. Indenting of the following materials should be considered, as outlined in micro-plans: Vitamin A bottles ( with spoons which have 1ml/2ml measure) Hub-cutters Immunization Cards De-worming tablets/syrup Reporting registers, formats, MCHN cards, compliance cards IEC materials, etc Planning also includes route charts for alternative delivery supplies. District and block-level officials ensure timely distribution of supplies and address supply bottlenecks. Supplies received at each level are duly recorded in the stock registers. The recording of the distribution of vaccines and logistics reflect the session habitations (and not by name of person). DIO ensures that there are adequate vaccine and other supplies in all the PHCs at least one week before the round. Budgetary Allocations and Fund Transfer Necessary budgetary allocations are completed, and funds are transferred to the districts at least one month prior to the round for the following activities: Logistics and supplies District level task force meetings District level trainings of block level officials Block level trainings of frontline workers IEC & social mobilization activities (Sahiya incentives) Mobility support & POL for hard to reach & monitoring purposes Alternative vaccinators for underserved and hard to reach areas Special provisions for urban areas The district level officials are expected to distribute funds to each PHC and to ensure timely implementation of round activities. Vitamin A Sustainability Report: Six Districts of Jharkhand Page 13

14 4. Vitamin A Coverage as Part of JMSSPM in Jharkhand Coverage can be calculated in a number of ways that can yield different results, including using the following methods: From tally sheets based on targets given and calculating the number of children who were given VAS from the target during the biannual round, in order to derive a percentage coverage rate. From tally sheets based on VAS given in the biannual rounds plus those children between 9-11 months given vitamin A during routine vaccination during six months Calculated from a representative survey (DHS, NFHS and other surveys). This method is likely to give more realistic and often conservative estimate. It is also important to look to the data from these surveys since they are not influenced by errors in setting targets or incorrect estimates of the population in the state or district. Figure 1, below, shows coverage calculated using the second of the three methods, above. Using this data, the coverage of vitamin A is shown to have consistently improved over the past years in Jharkhand State, with the exception of the second round in 2007 when an isolated event prevented a round from taking place. Figure 1. Vitamin A coverage rates (children who received dose in the biannual round or during RI) However, the most common coverage figure available at the district of state level originates from the tally sheet based on the targets given against the number of children that received vitamin A during that particular round. Vitamin A Sustainability Report: Six Districts of Jharkhand Page 14

15 5. Process of Developing and Implementing the VAS Sustainability Assessment Tool The tool was developed and is owned by the participants who, with their experience, developed it and will modify it for future application in other districts.. The tool was developed to obtain high levels of detail while maintaining simplicity so that it is easily used by health workers. 5.1 Selection of Six Districts At the state level, district RCH and immunization officers were contacted, and their recommendations were to include one district from each of the five geographic regions of the state, and to include those that had good or average coverage. Based on these criteria, three districts with average coverage (including Pakur, Garwah, and Ramgarh) were included, as were districts with good coverage (including Dumka, Ranchi and E. Singhbhum). 5.2 Vitamin A Sustainability Assessment Tool Development Process in Jharkhand In April, 2010, the Jharkhand State Department of Health and Family Welfare, in cooperation with stakeholders, developed a set of vitamin A and de-worming sustainability assessment tools, and conducted an initial assessment to examine factors that contribute to improved coverage. The assessment also aimed to strengthen program components that are in need of improvement. The Department of Health and Family Welfare, along with development partners including A2Z, Micronutrient Initiative (MI), UNICEF, Child In Need Institute (CINI), World WHO, VISTAR, and the Maternal and Child health Integrated Program (MCHIP) organized a two-day interactive workshop with authorities from the above mentioned six districts in Jharkhand to develop working tools for measuring sustainability. Principles Applied in Developing Tool The following principles were employed in developing the tools: Pre-conceived ideas were not used to determine what should be included or excluded in developing the tool The entire process of developing and field testing the tool was interactive and participatory Tools developed would be translated into the regional language for ANM, AWW and communities Data collection would be conducted through the existing health system when possible Participants in the workshop were comprised of state-level senior government, including the director of family health services and state immunization officers. Identifying Broad Subject Areas (Components) of the Assessment Tool During the workshop, a brain storming session was held to generate ideas for conducting a sustainability assessment. It was agreed to focus on the vitamin A and de-worming program within JMSSPM. A total of 54 participants participated in the Vitamin A Sustainability Report: Six Districts of Jharkhand Page 15

16 workshop (Annex 1). After brainstorming the important priority program components using the Visualization in Participatory Programs (VIPP) technique, seven important components emerged as vital to program sustainability and its assessment. These included: 1. Funding 2. Policy 3. Human Resource 4. Planning 5. Supply Chain Management 6. Social Mobilization 7. Monitoring and Evaluation Defining Relevant Questions, Issues and Scoring Criteria for Each Component of the Tool Having identified these seven components, the participants were divided into four groups in which they volunteered to identify issues, develop questions, and determine information, data sources, and how to score the responses. This was an extensive exercise, and topics discussed included how to flag issues, frame questions, whom to interview, how many to interview, and how to select participants. Once these tools were developed, all four groups came together and presented their work in the plenary to get critical feedback from the other members. Everyone actively contributed and suggested modifications and improvements. The tool was refined further, and a final draft was created, (in which interviewees were changed). Participants in the plenary agreed that community leaders and mothers are key respondents in the assessment. Specific questions for them were subsequently added and finalized. Next, the participants identified categories of respondents to be interviewed, and determined who would interview them. It was determined that the assessment tools would involve a mix of two sets of information, including verification of data in addition to the subjective responses of the persons being interviewed. Not all respondents were to be interviewed for each component. Table 2, below, identifies the relevant components for each respondent. Funding issues were to be explored at the district and block level only and policy and human resources related questions were to be answered by district, block, and front line workers. Planning, supply and monitoring questions were to be directed to district and block level authorities, or ANMs, and social mobilization related questions to AWW, Sahiya, community leaders and caregivers. Vitamin A Sustainability Report: Six Districts of Jharkhand Page 16

17 Table 2. Contribution to the sustainability tool by level of respondent for seven components District Block ANM ANM AWW AWW Sahiya Beneficiary s mother Funding Policy HR Planning Supply Monitoring Community Social Mobilization Field Testing the Tool The next day, the tool was field tested. During the field testing, each respondent was read the following disclaimer: These questions are to assess vitamin A and de-worming in your area and whether these activities can be continued on a long term basis. Your frank and correct answers would help the Government to strengthen the program. This is not to evaluate the performance of any individual and this will not be shared by name with anyone. The field testing exercise continued for about three hours, and included various probes and simplified language. After pretesting, a debriefing session was held where changes to the questionnaire based on the field testing were included. Suggestions included making sentences more gender sensitive and using more simplified language. All suggestions were incorporated, and next steps were planned and approved by the Director of Health Services, Dr. Satish Sinha. Finalization of the Tool After active participation by the attendees, the tools were finalized and printed (see Annex). The tools will eventually be translated into Hindi and will be available in both languages. Data Collection Responsibilities For the purposes of conducting the vitamin A sustainability assessment, the DPM (NRHM) and DRCHO were made responsible for data collection in their districts. Data collection was to take place at several levels and with the corresponding number of respondents (shown in parentheses). These numbers are based on the feasibility and minimum data requirements. District: DRCHO/CS (1) Block: MOIC/MO (1) Frontline workers: ANM (2) AWW (2) Sahiya (1) o Mother of the beneficiary (1) o Village leader (1) Vitamin A Sustainability Report: Six Districts of Jharkhand Page 17

18 o Total: nine sets of data per district Establishing scoring system Scores on some issues were based on previous rounds, while most of the questions were related to the most recent round. As a result the scores differ in each component. Participants decided to give equal weight to each component. The maximum score for funding was 30, for policy 36, for HR 19, for planning 16, for supply 18, for monitoring 26, and for social mobilization 48. These were converted to percentages, so that each area would contribute to 1/7 th for total assessment (see annexed tools for more details). Table 3. Maximum possible score for each component by respondent. Scores from District Scores from Block Scores from ANM 1 Scores from ANM 2 Scores from AWW 1 Scores from AWW 2 Scores from Sahiya Scores from caregive Scores from community Maximum Score Possible Weight for each component to the sustainability tool Funding /7 Policy /7 HR /7 Planning /7 Supply /7 Monitoring /7 Social Mobilization /7 Maximum Score Possible Data Collection and Analysis As envisioned, the data was collected by health workers who attended the state level workshop, or data collection was guided by the person who attended the workshop (under the guidance of district program managers and in the presence of development partners). Data collection in the initial six districts was completed by May 10th. Data collected was received at the state level and shared with the development partners. State level data was reviewed, cleaned, analyzed, and entered into excel sheets. Tables and graphs were prepared for final reports. Dissemination A core committee for the vitamin A and de-worming sustainability assessment met after the initial data collection and scoring in May, The committee approached the National Rural Health Mission Director and decided that results should be disseminated by June 21, Based on the findings and their usefulness, planning for rolling out the assessment for the remaining districts of Jharkhand will be considered. Vitamin A Sustainability Report: Six Districts of Jharkhand Page 18

19 6. Results and Discussion The primary objective of the sustainability tool is to strengthen the vitamin A and de-worming program by critically reviewing the individual components of the JMSSPM that supports VAS and de-worming programs, and to see if and where there are specific areas that need extra attention. The tool uses data from the district and also incorporates subjective opinions of the providers as well as end users. 6.1 Funding An objective of the funding component of the tool was to determine if resources are adequate and used in a timely fashion for successfully conducting the biannual rounds on a long term basis. The vitamin A supplementation program is a part of the reproductive and child health bundle of services. There are no separate funds for VAS even though all the requirements of funds are included in the JMSSPM planning. Therefore, questions related to the availability and use of funds are directed towards JMSSPM. Issues of funding allocations and transfers relate mainly to the district and block levels. The questions examined funds for all key activities like planning, training, monitoring, IEC, social mobilization and mobility. Table 4. Total scores and percentage for funding pooled from all the six districts Scores from District Scores from Block Total score Percentage score Funding Assessment score (107/180) 59.4% Maximum score possible As seen in Table 4, funding is a weak area, with the pooled score of 59.4 percent. Results vary widely between districts, with Dumka, Ranchi and E. Singhbhum doing relatively well, while Garwah and Pakur scores varied significantly (see Figure 2). These two districts did not have funds from the GJ and were not included in district PIP, so funds from other organizations like UNICEF were utilized for the rounds. Other districts had funds and utilized them. Figure 2. Funding scores in percentages for the six districts 6.2 Policy The policy component of the tool was to determine if the policy is comprehensive and clear enough to successfully conduct the biannual rounds on a long term basis. The Government of India has a clear policy and, based on that, the GoJ has a policy for biannual rounds of VAS and de-worming. The tool assesses the knowledge and content of the policy that facilitates the JMSSPM rounds at the various levels of district officers, block level officers, and frontline workers at ANM and AWW. The tool assesses Vitamin A Sustainability Report: Six Districts of Jharkhand Page 19

20 whether these authorities and workers feel the policy is providing an adequate environment to successfully conduct rounds in the long run. Table 5. Total scores and percentage for policy pooled from all six districts Policy Scores from Scores from Scores from Scores from Total Percentage score District Block 2 ANM 2 AWW score Assessme (193/216) 89.4% nt scores Maximum score possible The results suggest that all the districts and staff feel comfortable with the policy and believe that it is adequate enough to ensure program sustainability. The pooled score is 89.4% (see Table 5) with each district showing the score above 80% (except Pakur, which showed a score of 75%; see Figure 3). Figure 3. Policy scores in percentages for the six districts 6.3 Human Resources The objective of the human resources component was to determine if manpower is adequate and effective enough to successfully conduct the biannual rounds. Questions included the number of vacant posts at the district and block level, with below 20% scoring zero. Other questions assessed whether there is currently enough staff to effectively execute JMSSPM rounds. Table 6. Total scores and percentage for human resource pooled from all six districts Human Scores Scores from Scores from Scores from Total Percentage score Resources from District Block 2 ANM 2 AWW score Assessment (82/114) 71.9% scores Maximum score possible Vitamin A Sustainability Report: Six Districts of Jharkhand Page 20

21 Figure 4. Human resource scores in percentages for the six districts The overall assessment of human resources varied from district to district. Dumka and Ranchi received high ratings for human resources, while Ramgarh, E. Singhbhum and Pakur showed scores of less than 60% (with an average of 72%; see Table 6 and Figure 4). The scores from the district and block indicate that the district level experiences the highest human resource constraints, followed by the block level. AWW and ANM feel that human resources at their levels are sufficient. 6.4 Planning The objective of the planning component was to determine if timely plans are in place to successfully conduct the biannual rounds on a long term basis. District and block health authorities and ANMs contributed to the scores for this section. The tool assessed the timeliness of the preparation and sharing of micro-plans with the state and others, and the preparation of a special strategy to reach the hard to reach areas. The tool also assessed planning of ANM, block, and district levels of urban areas. Table 7. Total scores and percentage for planning pooled from all the six districts Planning Scores from Scores from Scores from District Block 2 ANM Total Score Percentage score Assessment scores (82/96) 85.4% Maximum score possible Figure 5. Planning scores in percentages for the six districts Vitamin A Sustainability Report: Six Districts of Jharkhand Page 21

22 Because this is a priority activity and includes of all other RCH services, vitamin A rounds were usually well planned. To ensure consistency of planning effectively the questions were asked for the last two rounds and not the single round. The average score from all six districts was 85.4% (see Table 7) with nearly all getting score above 80% (except Ramgarh, which received a score of 75%; (see Figure 5). 6.5 Supply and Logistics The objective of this component was to determine whether the supply for vitamin A and de-worming was adequate and timely enough for rounds to be successful. Questions related to issues of supply for last six rounds, MCH card supply, and whether or not distribution plans and IEC material were received on time. Respondents included district and block authorities and ANM. Table 8. Total scores and percentage for supply pooled from all six districts Supply Scores from District Scores from Block Scores from 2 ANM Total Score Percentage score Assessment score (65/108) 60.2% Maximum score possible Since the rounds were also assessed according to the timely receipt of supplies, the scores are relatively low although a delayed supply may still enable coverage to be achieved. The total score pooled from each district showed a 60% score for supply and logistics. This score covered not only supply of vitamin A, but supply of record keeping cards as well. E. Singhbhum was the only district with above 75% scores, while Dumka, Pakur, and Ranchi fell below 56% (see Figure 6). Figure 6. Supply scores in percentages for the six districts 6.6 Monitoring The objective for the monitoring component was to determine whether or not the coverage for the rounds was adequate, Questions were restricted to district and block level authorities and ANM. They were asked if they understand what coverage measures, and whether they had collected data for the last six rounds. Questions were also asked relating to how the denominators were derived, and whether they were supplied or computed. Vitamin A Sustainability Report: Six Districts of Jharkhand Page 22

23 Table 9. Monitoring scores in percentages for the six districts Scores Scores Monitoring Scores from District from Block from 2 ANM Total Score Percentage score Assessment score (95/156) 60.9% Maximum score possible The pooled score from all six districts was 61% (see Table 9). However the inter-district variation was large, with Dumka and Pakur showing the score for monitoring above 75%, while Garwah and Ranchi fell below 50% (see Figure 7). Figure 7. Monitoring scores in percentages for the six districts 6.7 Social Mobilization The objective for the social mobilization component was to assess whether or not social mobilization contributed to the success of the rounds. This information was collected from frontline health workers, including ANM, AWW and Sahiya, and also from the beneficiary s mother and village leaders. Information about social mobilization activities, including the preparation of the due list, house visits, conducting and observing wall writing, folk program, etc was obtained. Each cadre was asked relevant and specific questions. Two ANM and two AWW contributed, while one mother of the beneficiary and one village leader were also included in the list of those who contributed to the scores. Table 10. Social mobilization scores in percentages for the six districts Scores Scores Scores Scores Scores Social from the Total Percentage from 2 from 2 from from Mobilization village Score score ANM AWW Sahiaya Mothers leader Assessment 41/ score (85.4%) Maximum score possible It is evident that social mobilization activities are being carried out in a satisfactory way, and the overall score was high (85%; see Table 10). Inter district variation continued, with Garwah and E. Singhbhum doing better than Pakur (see Figure 8). Vitamin A Sustainability Report: Six Districts of Jharkhand Page 23

24 Figure 8. Social mobilization scores in percentages for the six districts 7. District Specific Scores The above discussion highlights overall scores for each component of the sustainability assessment. Data shows that scores vary from district to district, and that it may be more useful to review district specific data, since the purpose is to strengthen the weak areas. The discussion below briefly reviews the data obtained from each district in all seven components. Scores are presented in tabular form and percentages are represented graphically. 7.1 Ramgarh District Table 11. Scores for all components for Ramgarh district Ramgarh District Assessment Scores Area rict Scores from Dist Scores from Block Score from ANM 1 Score from ANM 2 Funding Policy HR Planning Supply Monitoring Social Mobilization The data suggest that Ramgarh district is strong for policy, planning, and social mobilization, but needs improvement in the areas of human resources, supply, and monitoring (see Table 11 and Figure 9). Vitamin A Sustainability Report: Six Districts of Jharkhand Page 24 Score From AWW 1 Score From AWW 2 hiya Score From Sa Score from beneficiary mother Score From Community Leader e Total Scor Percentage Score for Each Item

25 Figure 9. Total scores for Ramgarh for all components and pooled score 7.2 Garwah District Table 12. Scores for all components for Garwah district Area rict Scores from Dist Block Scores from Score from ANM 1 Score from ANM 2 Funding Policy HR Planning Supply Monitoring Social Mobilization Garwah district scor es indicate that funding was a major constraint, and that monitoring was weak (mostly at the block level; see Table 12 and Figure 10). Policy and planning components were strong. AWW 1 Score From AWW 2 Score From ahiya Score From S Score from beneficiary mother Score From Community Leader e Total Scor Item Percentage Score for Each Vitamin A Sustainability Report: Six Districts of Jharkhand Page 25

26 Figure 10. Total scores for Garwah for all components and pooled score 7.3 Dumka District Table 13. Scores for all components for Dumka district Dumka District Assessment Scores Area rict Scores from Dist Block Scores from Score from ANM 1 Score from ANM 2 Funding Policy HR Planning Supply Monitoring Social Mobilization Scores show that supply systems in Dumka are relatively weak, but that all other components are relatively strong (including human resources, which received a perfect score; see Table 13 and Figure 11). AWW 1 Score From AWW 2 Score From ahiya Score From S Score from beneficiary mother Score From Community Leader e Total Scor Item Percentage Score for Each Vitamin A Sustainability Report: Six Districts of Jharkhand Page 26

27 Figure 11. Total scores for Dumka for all components and pooled score 7.4 Ranchi District Table 14. Scores for all components for Ranchi district Ranchi District Assessment Scores Area rict Scores from Dist Block Scores from Score from ANM 1 Score from ANM 2 Funding Policy HR Planning Supply Monitoring Social Mobilization Ranchi district scores show that supply and monitoring are the weak areas, while funding, p olicy, human resources, planning and social mobilization are strong (see Table 14 and Figure 12). AWW 1 Score From AWW 2 Score From hiya Score From Sa Score from beneficiary mother Score From Community Leader e Total Scor Item Percentage Score for Each Vitamin A Sustainability Report: Six Districts of Jharkhand Page 27

28 Figure 12. Total scores for Ranchi for all components and pooled score 7.5 Pakur District Table 15. Scores for all components for Pakur district Pakur District Assessment Scores Area rict Scores from Dist Block Scores from Score from ANM 1 Score from ANM 2 Funding Policy HR Planning Supply Monitoring Social Mobilization Assessment of Pakur d istrict shows funding as the weakest link. Human resources a nd supply management also require strengthening (see Table 15 and Figure 13). AWW 1 Score From AWW 2 Score From ahiya Score From S Score from beneficiary mother Score From Community Leader e Total Scor Item Percentage Score for Each Vitamin A Sustainability Report: Six Districts of Jharkhand Page 28

29 Figure 13. Total scores for Pakur for all components and pooled score 7.6 E. Singhbhum District Table 16. Scores for all components for E. Singhbhum district E. Singhbhum District Assessment Scores Area rict Scores from Dist Block Scores from Score from ANM 1 Score from ANM 2 Funding Policy HR Planning Supply Monitoring Social Mobilization Assessment for E. Singh bhum revealed high scores in the areas of funding, policy, and planning. T his district however needs support for human resources and monitoring (see Table 16 and Figure 14). AWW 1 Score From AWW 2 Score From hiya Score From Sa Score from beneficiary mother Score From Community Leader e Total Scor Item Percentage Score for Each Vitamin A Sustainability Report: Six Districts of Jharkhand Page 29