ASSESSMENT OF SCHOOL HEALTH PROGRAMME IN UTTARAKHAND

ASSESSMENT OF SCHOOL HEALTH PROGRAMME IN UTTARAKHAND Principal Investigator : Prof M Bhattacharya, HOD, CHA Deptt. Co-Investigators : Dr. Nanthini Subbiah, Mrs. Vandana Bhattacharya Field Team Members : Mr. Mesh Ram Dr. Kiran Rangari Mr. Subhash Chand Dr. UB Das Dr. Joy Chakma Date of Approval : March, 2013 Date for completion : December, 2013 as approved by PAC Background School Health Programme (SHP) is being implemented in the State from the financial year 2010-11. This programme is being run in the state in convergence with education department. Each Primary and Upper Primary Govt. school is targeted for health examination activity. This programme is being implemented in the state through a dedicated School Health Team (SHT) which includes two MO s (01 male & 01 female), one pharmacist, and one Community Mobilizer at district level. Besides this there are 2 Regional Coordinator (Garhwal and Kumoun) in position for monitoring and monthly report compilation about the programme.the school health team undergoes 4 days orientation training in the State HQ, on the services to be provided under the programme. At present SHTs are examining the school children of class 1 st to 8 th. Health examination card at primary school level is distributed by the Education department since the start of the program. For upper primary classes (class 6th to 8th) health examination cards are being distributed by district health department. The Health Card is designed for 5 time use, so that one health card can be utilized 5 times. Each district SHT submits the monthly work done to the concerned district CMO and DEO for necessary action and feedback. One copy is given to regional coordinator who compiles and verifies 5% of work done at the school level and sends a compiled report 1

along with his verification report to the state. State nodal officer reviews the report in the state level meeting and gives feedback to the districts for further improvement. Any school child found to be suffering from any ailment which requires specialized treatment/ hospitalization is referred to the nearest CHC and treated by the concerned specialist. In case, the relevant specialist is not available at the CHC level, the child is referred to the nearest District hospital or Speciality hospital at Haldwani or Dehradun as per level of medical care needed. Referral to higher centers of treatment (RSBY empanelled Hospitals, and as per the RSBY rates).is being done in cases that require specialized treatment and hospitalization. Write about what you found, how many referral monetary support is given in case of treatment for major ailments (heart surgery, other major medical procedures) by the district health office Specialized medical services provided at any of these health facilities are free including nutritious diet to the child.the community mobilizer prepares the list of students for the treatment and reexamination by the specialist at referral center. General Objective To assess the status of implementation of the School Health Programme in Uttarakhand Specific Objectives o To assess the status and type of services provided by School Health Team. o To identify the gaps if any in the School Health Programme as per guidelines. o To assess the qualitative outcome of the Health Examination. o To assess the perception of programme managers and community (Teachers and Parents) on School Health Programme. Methodology Study Area and Sampling After preparing the list of districts in hilly and plain regions, 4 districts (two from plain (Udham Singh Nagar, Dehradun) and the other two from hilly region (Rudraprayag, Pithoragarh) were selected for conducting the study. Out of these selected four districts the data has been collected from two districts (Udham Singh Nagar, and Rudraprayag). From these two districts, functioning of all School Health Team was observed. Then from the list of schools visited by each School Health Team in the last year, 2 schools were randomly selected to observe the implementation of health services provided by the school health team. In addition interaction with the nodal teacher and checking of the records was also done in both the schools. 2

Number of SHT functioning in Udham Singh Nagar and Rudraprayag are 4 and 1 respectively. The total number of schools visited in U.S Nagar and Rudraprayag were as follows. The number of children examined in each school were 10-15 Schools in U.S. Nagar 1. Rajkiya Ucch Prathmik Vidyalaya, Pattharchatta,U.SNagar 2. Rajkiya Prathmik Vidyalaya, Gumsani, Bazpur, U.SNagar 3. Rajkiya KanyaUcch Prathmik Vidyalaya, Kutri, Khatima, U.SNagar 4. Rajkiya Purv Madhyamik Vidyalaya, Nadanna, Khatima, U.SNagar 5. Govt.Primary School, Pattharchatta, Kicha, U.SNagar 6. Govt. Upper Primary School, Barorai, Gadarpur, U.SNagar 7. Govt. Upper Primary School Pachouria, Khatima, U.SNagar 8. Govt. Upper Primary School Karghata,Sitarganj, U.SNagar 9. Govt. Upper Primary School Turka Tirour, Sitarganj, U.SNagar Schools in Rudraprayag 1. Govt. Upper Primary School, Bhundka, Augustmooni, Rudraprayag. 2. Govt. Primary School, Bhundka, Augustmooni, Rudraprayag.. 3. Govt. Upper Primary School, Bhatwari Sain, Augustmooni Rudraprayag. 4. Govt. Upper Primary School, Kala Pahar, Jakoli, Rudraprayag 5. Govt. Upper Primary School,Palifafanj Ukimoth, Rudraprayag. Study Design The research design adopted for the study was Descriptive design. Inclusion Criteria School children who have already been examined by School health team and belonging to primary and upper primary schools of Uttarakhand, were included in the study. Study Population As the school health programme involves different stakeholders in the process of implementation, the following stakeholders were covered in the study. Programme managers at the state/divisional and district level. Service providers (i.e. School Health Team) consisting of 2 Medical officers, 1 Pharmacist and 1 Community mobilizer in each team. School children studying in primary and upper primary schools School nodal teacher and principal of the schools. Parents of school children who were referred for diagnosis and treatment. Community, whose children are studying in the schools. 3

Selection of Sample Programme Managers State Nodal Officer (1) at state and DCMO, DEO at 4 selected districts. Service Providers - School Health Teams (SHT) who are providing services in the 4 selected districts. Each team comprising 2 MOs, 1 Pharmacist and 1 Community mobilizer. Information was obtained about services provided by them, availability of logistics from the government, constraints in providing services if any and suggestion for improvement. Nodal School Teacher Nodal Teacher/ Principal at each School responsible for school health programme (ie mobilizing the children, informing the parents if referral is needed, maintaining the health records of the children etc) were contacted and the information about the details of school children, number of school children examined, morbidity observed, number of children referred etc. were collected. School children: Out of selected 2 schools under each School Health team, 10-12 school Children from Upper Primary classes, who had been examined by SHT, were selected randomly for focus group discussion. While selecting these children randomly, it was kept in mind that the male and female students are selected proportionately. Community (Parents): One focus group discussion per school health team was conducted with the parents of primary school children. One school was randomly selected from the two schools. Parents of referred children: 10% of Parents from the total children referred in one school were randomly selected and interviewed to get their view on School Health services. Progress In brief about the work done after the last PAC meeting and No. of objectives achieved etc. Half to one pages in 1 ½ space, Type Arial, Font size 12 & Margin 1 Summary of Results so far: Observation Organization of School Health Team In Each SHT 2 MOs (1 male and 1 female) and 1 Pharmacist were available. In addition, one Community mobilizer is looking after two SHTs 4

Each School Health Team tours at least 24 primary schools in a month and conduct check up of the students. The average number of children examined by each school health team varied from 45-60/ day in hill districts and 100-120/ day in plain districts. Advance tour calendar is jointly prepared by district SHT and block education office and approved by the concern Block Education Officer. Advance intimation of health check up date is given by SHT to nodal school authorities and to the regional coordinator The school management committee is informed by the health team about the date of health examination Vehicle for each SHT is organized by health department. In every school, the education department has identified the nodal teacher for mobilizing the children and orientation training is given to the teacher regarding health examination activities. The health examination card at primary school level had been given by the education department and for upper primary (6-8 classes) by district health authorities for 5 times use. Services given by School Health Team a. Health Check up The teams were carrying out general checkup of all students. Examinations done under general checkup were weight, height, eye sight (for myopia/ hypermetropia and colour vision), Dental and ear checkup, skin condition, any physical abnormalities/ deformities, pulse, blood pressure and any injury. Clinical examination is done by the male and female medical officers separately for boys and girls. Minor illnesses are treated symptomatically. b. Health Education Health education regarding hygiene, nutritious food intake, healthy habits and menstrual hygiene are given to pre pubertal school girls (by the lady doctor) as part of school health services. Health cards prepared by the State Government has included all the above mentioned points including the schedule of immunization, presumed to have been received by the child earlier. c. Mid Day Meal Mid day meal services were found to be properly provided. The mid day meal menu was found prepared and displayed on the school wall but not always properly followed due various reasons like non availability of vegetables and 5

supplies. There was no separate designated place/hall for serving mid day meal to the school children. No soap was available for hand washing before and after the mid day meal. School children clean their utensil before and after the mid day meal. The source of drinking water is the water supplied by government. d. Monitoring & Evaluation Monthly reports of activities done under School Health Programme by School Health Team are being submitted to the CMO Office. Community Mobilizer does not always accompany the School Health Team. No designated Officer pays any surprise visit to oversee the activities of School Health activities at field level. No feedback is being given to the School Health Team on the monthly report submitted to the CMO s Office. Health Examination Anthropometric measurements were not found to be done in 4 schools out of 9 schools. In other schools it was incomplete. Anthropometric measurements (Ht, Wt etc) is done by the teachers once in 6 months and recorded in the health card. No systematic procedure was being followed during health check up of all students. The health cards were found incomplete in some schools. All the examinations enlisted in the school health card, were not being performed completely. Reason given by the MO of the SHT was that the target given for daily, monthly and yearly coverage, was very high. Tab. Albendazole (400 mg), Tab. Cetrizine (10 mg), Scaboma ointment were available with the SHTs. Distribution of medicine was found to be done in arbitrary way and in many cases without proper explanation to the student. School teachers or parents of students are not informed about details of medicine given to the students. So follow up of such students is difficult Students with moderate pallor were given Tab.albendazole and subsequently tab. Iron and Folic acid for 2 weeks. Nodal Teacher in the school is given the Iron and Folic acid tablets for weekly supervised distribution. In 3 schools it was not available with the principal/ Nodal Teacher. Involvement of teachers was found limited in assisting the SHT due to their workload. Separate record of referred children and details of ailments for which referred, were found incomplete in some schools. Interaction of SHT members and school authorities with parents regarding health issues of children was nearly non-existent. It was expressed by the SHT that due to high target of students given to them (at least 150 per day and 30,000 students annually) there was time constraint in 6

providing all the school health services, such as health education, and counseling, to all children is not possible. Main gaps identified in the SH services. Doctors in the health team are qualified AYUSH doctors but except for orientation training on SHP for 2-4 days, no formal training in clinical work, counseling/ health education to be imparted, to the doctors. In some schools, the schools are experiencing shortage of staff due to retirements and transfers which makes the school health related work, an extra burden on the school staff. Complete set of equipments were not provided to the school health team, e.g. Snellen s & Ishihara chart, torch, B.P. measuring instrument, measuring tape, weighing machine, Otoscope and tuning fork, had been provided but training to properly use them has not been given to the MOs. Number of schools to be covered by each team in a month are many which create constraint of time devoted in clinical examination, health education and counseling of the school children. Health cards were not filled up properly, as immunisation history, history of past treatment undergone, present ailment if any and treatment being received etc were not mentioned in majority of the cards. Attrition of staff due to contractual nature of job, low remuneration and unattractive service conditions acts as demotivating factor for the doctors and health staff employed in the SHT. No First Aid kit available with the school. Gaps Identified in Referral Services Though tracking of referral cases to higher health institutions and follow up activity is the responsibility of the community mobiliser, it was informed by the education department that the parents, are asked to take the children to the referral centre. There is no fixed day or counter in the referral centre to see the referred school children. This lead to long waiting time for the parents to get their children being examined by the specialist. There are no mechanism to ensure that the child referred by the school health team goes to the higher centre referred. As majority of the school students are from lower socio economic background, their parents cannot afford to lose a day s wage and take the child to a distant place (CHC, District Hospital, Super specialist hospital at Dehradun). 7

Even if the child is taken to higher referral centre at the family s own expense, no guarantee of free treatment is ensured as the family has to pay charges for investigations and medicines in many cases. This becomes a discouragement for the poor families. Proper record of referred cases and treatment they have undergone was not found with the school health team or the school authorities. Perception of Community (Parents of School going children) on SHP The community appreciated the concept but said that the SHT should come regularly ( at least once in 3 months) Schools should get the prior information about the visit of SHT. Parents should be informed in advance about the examination of their children at school by SHT. Parents need to be called by SHT to guide them about their children's treatment in case of referrals. They also expressed that the complete, thorough physical examination need to be done for each child by the SHT. Parents said that the SHT does not spend adequate time with each child to rule out health problem. They said that at present there is no mechanism to ensure that the child referred by the school health team goes to the higher centre referred. They requested for transport facility to be provided by SHT to take the school children to the referral centers. They felt that there should be a separate counter in the referral centers to register the school children referred by the SHT. At present there is no such facility in the referral centre. They wanted some financial support or free investigation and treatment for referred children in the referral center. They said that there should be a regular supply of medicines to the SHT for treating minor ailments. They also suggested that the adequate guidelines to be given to the school children about the consumption of medicines when given to them. They insisted for regular periodical meeting of SHT, school teachers and parents. Information about sanitation and cleanliness is given to the children by SHT. However, importance of seasonal fruits, vegetables and cereals may also be explained to the children by them. Perception of Programme Managers (DCMO & DEO) on SHP School health programme is beneficial to rule out health problems in school children in the early stage. Number of School Health Teams need to be 8

increased for better implementation of the SHP. At present School Health Team is not able to cover all the schools in a year. System needs to be developed for better co-ordination of School Health Team with other health functionaries for increasing immunization coverage and other preventive and promotive health care services of school children. Proper referral mechanism and facilities needed for follow-up of referred cases to make sure that the child has taken the required medical care for which he/she was referred to. Provision of FIRST AID Kit with schools and each School Health Team and First Aid training of the school teacher is essential.. Feedback from the Nodal Officer on the monthly report submitted by SHT, can facilitate to identify gaps and suggest improvement. Any Other Comments Due to natural calamity in Uttarakhand the data collection in the remaining two districts is yet to be done. 9