Gaps and Gains: Citizen s Reports on Health Programmes Implementation in India

Transcription

1 Gaps and Gains: Citizen s Reports on Health Programmes Implementation in India Organized by Centre for Health and Social Justice and School of Public Health, SRM University, Chennai With support from UNFPA 16 th September 2011, Indian Social Institute, Lodhi Road, New Delhi-17 Organized by CHSJ, SRM and UNFPA Page 1

2 Content 1. Introduction a. Background of the workshop b. Role of each research 2. Introduction to the workshop a. Welcome address b. Objectives and agenda c. Inaugural and keynote address 3. Sharing of research a. NRHM and access to health services among socially excluded communities b. Improving access and quality of health services c. Increasing communitisation d. Interface/linkages of ASHS with community and services 4. Next steps and way forward 5. Annexure 1. Agenda 2. RAHP study partners 3. Key findings of the research 4. Participants list Organized by CHSJ, SRM and UNFPA Page 2

3 Introduction Background of the workshop The Centre for Health and Social Justice (CHSJ) has been facilitating a process of annual feedback on the National Rural Health Mission (NRHM). CHSJ has prepared two citizen s reports on the NRHM (2006 and 2007) and a set of Rapid Appraisal Studies (2009) and these have been shared at National Stakeholders Consultation which have been attended by bilateral organizations, UN agencies, Civil Society Organisations from across the country as well as the Government, and very well received. It has been acknowledged by the Government that such independent feedback is important and essential for understanding the process of implementation and for mid course corrections. Continuing the process, for the year , CHSJ with support from UNFPA and in collaboration with the SRM University, Chennai conducted a Capacity Building programme aiming to build capacity in the civil society sector (NGOs) in India so that they are better equipped to conduct rapid assessment of the implementation of different components of NRHM in different parts of the country (RAHP II). A total of 15 civil society organizations (NGOs) from different states were selected on basis of their interest and some experience in public health issues and capacity to undertake the documentation. Two researchers from each organization were given training in Rapid assessment methodology in two residential Programmes organized at Chennai and New Delhi. Fifteen studies conducted in 8 states of the country through this programme were shared in this workshop Gaps and Gains: Citizen s Reports on Health Programmes Implementation in India on 16 th September 2011 (See Annexure 1 for Agenda). These studies have examined different aspects of NRHM, including health system strengthening, women s experiences of receiving reproductive health services, maternal mortality and so on. The main objective of the workshop is to bring the grassroots realities of public health programme implementation across the country. Apart from sharing the findings, the meeting also focussed on identifying implementation bottlenecks and recommending actions for streamlining desired processes. The meeting was attended by key functionaries from Ministry of Health and Family Welfare, (government of India) Civil Society Organisations and Networks, public Health experts, academicians, UN organisations involved in providing technical support to MoHFW, international organisations, donors and Foundations involved in supporting health activities and media personnel. (See annexure 4) Research Areas These studies by 15 organisations (see Annexure 3) had explored different aspects of programme implementation of Health programs in India, especially with regard to NRHM. These researches had included the issue access to health service delivery by marginalised communities to improving access and quality of health services. These studies also explored the extent of convergence at the level of VHND and ASHA functioning, reason behind maternal deaths and costs, consequences of institutional delivery among poor communities and the nature of post natal care. Theme NRHM and access to health services among socially excluded communities Study Topics NRHM: Do tribal matter? Costs and consequences of utilizing maternal health care: findings from two districts of India Caste to be Inclusive- Under NACO Mapping Perception of SC/ST PLHAs in Accessing & Utilization HIV prevention, care and support services in Andhra Pradesh Organisation Name SVYM, Maysore CHSJ, Delhi SAKSHI, Secunderabad Organized by CHSJ, SRM and UNFPA Page 3

4 Improving access and quality of health services Increasing communitisation Interface/linkages of ASHA with Community and services Awaiting Change: Determinants of utilization of Maternal Health Services among SCs and Muslims in Patna District, Bihar Status and utilization of Maternal Health Services among Migrant families in Rajasthan Exploring Utilization of Health Care Services from 24X7 PHCs in West Bengal Beyond Delivery: Assessing Post Partum Care and Complications in District Mirzapur, Uttar Pradesh Continuing Concerns: An Assessment of Quality of Care and Consequences of Sterilization in Bundi District of Rajasthan in An Assessment of the status of Public Health Facility centre of District Sheikhpura as per IPHS Maternal Death Audit for Action towards making every Pregnancy Safer in Jharkhand Assessment of level of involvement of Village Health and Sanitation Committee with focus on Utilization of Untied Fund, Baran district of Rajasthan Understanding services, convergence & community participation at (VHND)in Bankura District of West Bengal An attempt hardly begun: Communitisation of Health Services among Dalit communities Assessment of functioning of ASHA SAHYOGINI under intersectoral coordination of DWCD & DHFW in Jhunjhunu District of Rajasthan CHARM, Patna JATAN, Udaipur CINI, Pailan SAHAYOG, Lucknow MANJARI, Bundi BVHA, Patna NEEDS, Deoghar CHEERS, Kota IMAN, Kolkota PARA, Hyderabad SRKPS, Jhunjunu Working together: Convergence and coordination related to ASHA functioning in Chhindwara district, Madhya Pradesh MPVS, Bhopal There are four studies from Rajasthan, two from Bihar, one each from Uttar Pradesh and Jharkhand, Assam, Madhya Pradesh, Karnataka and Orissa, Two from West Bengal and Andhra Pradesh. Organized by CHSJ, SRM and UNFPA Page 4

5 Session 1: Introduction The introductory session was attended by Dr Abhijit Das, Director, CHSJ; Prof Satish, Dean, SPH- SRM University, Ms Frederika Meijer, Country Representative, UNFPA and Mr. P.K. Pradhan, Mission Director, NRHM who was the Chief Guest. Welcome address Dr. Abhijit Das, Director, Centre for Health and Social Justice In the welcome address, Dr. Das provided a brief overview of the purpose of the meeting and various studies conducted under the Programme of Rapid Assessment. He spoke about involving the individuals working at the grassroots as their participation towards the study involved great passion and hard work. He also mentioned that the purpose of conducting studies to find the situation of health programmes was not to find out follies but to provide recommendations for making situations better. Dr. Das emphasized about making two percent budgetary provisions for evaluations to be conducted by NGOs under the NRHM in order to give timely feedback to the Government during the course of any programme for improving the services. He also added that none of the studies were conducted by professional researchers or academicians but by practitioners and activist who are engaged in improving health and lives of the poor and marginalized people, in securing their human rights. These studies were conducted systematically and with rigour so that they can bring evidence. Many of the studies revealed gaps and it is not surprising because the issues were complex. He also asked to consider these studies done by NGOs as sources of evidence based feedback for improving health programme delivery. About the Rapid Assessment of Public Health Programme (RAHP) initiative Prof. Satish, Dean, School of Public Health, SRM University, Chennai Prof. Satish mentioned that RAHP is an initiative of partnership and collaboration of an NGO, an academic institution and UNFPA. Through this initiative eighteen NGOs were trained to conduct the research and in the end we have fifteen studies that have been completed through this process. He had explained the phase wise processes of RAHP. The first phase included partner selection to trainings and study topic selection. In second phase training, the partners were trained on data collection, data management and data analysis and in the third phase, the NGOs were given training on report writing. There were mentors assigned for each of the organisations. During the study period, mentors were also visited the organisation and helped in data collection process. For field level guidance, the mentors were continuously in touch with the organisation on phone and s. He also said that they are privileged to provide academic inputs to civil society organizations and NGOs to conduct health research and was great learning exercise for an academic institution like SRM. It was entirely a different experience for an academic institution like SRM to work with NGOs where all feedback is given in the form of activism and advocacy. He felt that there was still a long way to go on writing the study reports by the NGOs. Inaugural Address Ms. Frederika Meijer, Country Representative, UNFPA She mentioned in her inaugural address that it would be a great honour to her and UNFPA to hear the perspectives and ground realties from grassroots people. She expected that the national dissemination workshop would provide valuable inputs to successful implementation of NRHM. She said that presently meetings are being held at Planning Commission and they are looking for feedback from the field. We all know the NRHM has made good progress but more progress is needed. She emphasized that programmes like RAHP are strong pillars of assessment of NRHM and it would help to bring good amount of data and evidences. She encouraged conducting such kind of research studies for quick feedback on health programmes. Organized by CHSJ, SRM and UNFPA Page 5

6 She appreciated the initiative of CHSJ and its work and it is one of the most influential NGOs in the field of public health. She congratulated CHSJ for their initiative such as RAHP which reflects pro-poor marginalized efforts and skills. Address by Chief Guest Mr. P K Pradhan, Mission Director, National Rural Health Mission Mr. P K Padhan, in his address gave a brief background on NRHM. He also mentioned that the presentation of national dissemination will provide NRHM a very useful insight for better implementation. He said that NRHM has a special focus on issues of Maternal and Child Health (MCH) by improving infrastructure, adding human resources and greater community participation through Village Health and Sanitation Committee (VHSC) and Rogi Kalyan Samiti (RKS). He said that there had been improvements in health status of the people but this varied among the states. Also he acknowledged that in the most remote and hilly areas the progress of NRHM is still very low. In tribal belt, desert areas, hilly areas and remote areas, the progress is still limited he said. He mentioned that there is a need to develop an institutional mechanism, where the participation of communities is much stronger. He mentioned about recently published Annual Health Survey and variations in findings across nine states of India. The report shows very interesting figures and striking variations in nine states. In Uttarakhand, the Pitthoragarh district (one of the remote districts) has very low IMR compared to Haridwar, where accessibility is very good, has high IMR. There is need to identify the areas where the variations is very high in case of IMR, MMR, etc. and address it through a better micro planning. Mr Pradhan said there is a need to involve the civil society organisations in a more structured manner to find out the gaps and helpful insights of health programmes. Capacity building of NGOs is needed and this can be done through a network of NGOs, and academic institutions. Following the inaugural session, parallel sessions were conducted to present the study findings. A chair and a rapporteur provided inputs after each presentation and questions were raised from the audience. The key findings of the presentations are annexed (Annexure 3) and discussions are described below. Session 2: NRHM and access to services among socially excluded communities Chair- A R Nanda; Rapporteur- Joe Varghese Presentation 1: NRHM: Do tribal women matter? Bindu Balasubramaniam and Shanthi G, SVYM, Mysore The presentation was done by Dr Bindu. It was said that if the researchers were thinking of publishing their study report they should work more on qualitative aspects as the sample was too small for quantitative generalization. Being tribal was not the only reason for denial of entitlements but other factors could also contribute toward this which should have been explored by the researcher. If cash incentives are not given on time than what is the purpose of these incentives, has the community development officer had taken any process for this? Organized by CHSJ, SRM and UNFPA Page 6

7 Presentation 2: Costs and consequences of utilising maternal; health care: from two districts in India Moumita Ghosh, Deepti Morang, Sunita Singh, Centre for Health and Social Justice, New Delhi The presentation was done by Moumita. In the context of maternal health care what was the total cost incurred by the women who had undergone institutional delivery. What were the coping mechanisms adopted by families of pregnant women who did not have the required money for emergency. The answer provided was that the families gathered the required amount of money was mobilised from family savings and taking loan on interest Presentation 3: Mapping Perception of SC/ST PLHAs in accessing and utilization HIV prevention, care and support services in Andhra Pradesh D.Leslie Martin and Ch.Isaac, SAKSHI Human Rights Watch, Hyderabad The presentation was done by Leslie. What is the percentage of total SC/ST population and what is the percentage of HIV positive people in both the study districts? What are the causes of denial of services to HIV+ patients. Presentation 4: Awaiting Change: Determinants of utilization of maternal health services among SCs and Muslims in Patna district, Bihar Anamika Priya and Arman Suhail, CHARM Patna The presentation was done by Arman. The voices from the community have not come out well in this study so the researcher needs to capture the community s voice in a more elaborate manner. The community monitoring aspect needs to be included in the study for looking at accountability measure of government. Presentation 5: Status of utilisation of maternal health services among migrant families in Rajasthan Ranveer Singh and Vinita Paliwal, Jatan Sansthan, Rajsamand The presentation was done by Vinita. Whether the situation of accessing maternal health services differs in case of nuclear and joint families. It could have been much more interesting if the study looked at this aspect also. Organized by CHSJ, SRM and UNFPA Page 7

8 From the presentation it was not clear for how long the husbands or male members had been migrated from the area. The clarification given was most families migrated in cyclical manner. What is the impact on women s health when the male members had migrated for a longer duration? What is the role of in laws on the women health? How do they have collected the migration data since it is a continuous process? Do they have any mechanism to trace the migrant male members? Points from the Chair of the session The study of SVYM could have looked into maternal mortality issue. The study of CHSJ is a very complex issue and it needs more refining and further scrutiny on the subject. SAKSHI and CHARM needs to include some case studies and that they should ask UNFPA for funding to collect the case studies. The studies needs to include more dimension of health issues of marginalised section and more qualitative data and case studies could further strengthen the studies. Session 3: Improving access and quality of health services Chaired by Dr. Vandana Prasad and Rapporteur: Jashodhara Dasgupta Presentation 1: Exploring Utilization of Health Care Services FROM 24X7 PHCs of West Bengal Jaydeep Sengupta and Sudipa Das Mukherjee, CINI The presentation was done by Jaydeep. There is neglect from government side on sub centres. There is no mention about labour room and baby room in the study Issue of privatisation can be seen from the study Sub centres can be 24x7 waiting home and 24x7 PHC must have ambulance Grievance redressal mechanisms should be developed. Feedback boxes should be available at health centres Trainings and skill building should be given to the service providers, lack of trainings and skills affect the work quality. Presentation 2: Beyond Delivery: Assessing Post Partum Care and Complications in District Mirzapur, Uttar Pradesh Y K Sandhya and Saim, SAHAYOG The presentation was done by Sandhya. Is it not clear with whom the FGD was done, why and where The study did not include harmful practices of post partum care and child care practices Heavy bleeding is found in 25% women, which is very important findings of the study Organized by CHSJ, SRM and UNFPA Page 8

9 Did the CHC studied shown as FRU in the district record? Presentation 3: An Assessment of Quality of Care and Consequences of Sterilization in Bundi District of Rajasthan in Swarup Pal and Bajrang Singh, MANJARI The presentation was done by Swarup. What is the level of coordination between ASHA, ANM and AWW because there is a target of sterilisation among these three service providers. Did the ASHA, AWW and ANM provide information on other contraceptive methods? If not then obviously women will go for sterilisation. Only 13 percent women were provided information on other contraceptive methods. Was there any case where woman was pregnant still the sterilisation was done? There was failure of screening if the pregnant women were sterilised not failure of sterilisation. Presentation 4: An Assessment of the status of Public Health Facility centre as per IPHS of District Sheikhpura, Bihar Devika Biswas and Vivekanand Ojha, BVHA, Patna The presentation was done by Vivekenand. None of the facility centres are upto the IPHS standard, did the researcher tried to look at other key points on facility or service delivery? The major findings were not clear in the presentation. Presentation 5: Maternal Death Audit for Action towards making every Pregnancy Safer in Jharkhand Tanmoy Saha and Amitabh Gautam The presentation was done by Tanmoy. Are the community solutions included in the study really solutions given by community? It looks more like solutions from the researcher. Out of the total death cases occurred, three were in the private hospital. Did the study tried to look at public private partnership? Because the public sector hospitals were equally bad. Why the study only talked about institutional delivery? Then the dai should not know or trained for emergency care, the important thing is that dai should know the referral system for emergency care. What are the parameters taken for services denial in the study? Session recommendations from the chair and rapporteur Organized by CHSJ, SRM and UNFPA Page 9

10 Basic EMOC must be there in all PHCs - telephone and transport more skill building in staff grievance redressal required - also a trust deficit. Block level need some level of specialists. Post-partum care will need more facilities for 48 hour stay including electricity and water/toilets. Need APHCs to become more functional. All managers of facilities should get a manual about IPHS. VHND must go beyond an Immunization day + mass campaigns on reasons of maternal health Need to promote temporary methods instead of only sterilization. Need to strengthen reporting of sterilization failures and complications no data on whether they are getting compensation. Need better data through computerization. Not enough IEC need more information on the insurance claiming behind the discharge certificates. The frontline providers also need more skill-building and more knowledge on Sterilization and post partum complications. Community follow-up needs to be institutionalized. Need to emphasize in ASHA training for early detection of maternal complications and may need to give an incentive. Health system does not have understanding of the need for post partum care [No data on postnatal care on PHC walls] - need a policy and protocol. Informal private providers are preferred and seen as giving better care. Community practices have beneficial components need to be mainstreamed. Session 4: Increasing communitization Chaired by Prof. Satish, Rapporteur: Dr. Anant Bhan Presentation 1: Assessment of level of involvement of Village Health and Sanitation Committee with focus on Utilization of Untied Fund, Baran district of Rajasthan Vikram Raghav and Arvind Pandey, Cheers, Baran The presentation was done by Vikram. NGOs should be involved in assessment process of Village Health and Sanitation Committee works under the provision of NRHM. There is no provision of trainings and capacity building process of VHSC members for functioning their work. Ngo could also mentor the VHSC member and we could send this kind of recommendation to the concerned government. Presentation 2: Understanding services, convergence & community participation at (VHND)in Bankura District of West Bengal Rupasri Ray Barman, IMAN, Kolkata The presentation was done by Rupashri. Organized by CHSJ, SRM and UNFPA Page 10

11 There were no discussion points on this presentation. Presentation 3: An attempt hardly begun: Communitisation of Health Services among Dalit communities Penki Chittababu and Sesha, Para, Hyderabad The presentation was done by Thomas Pallithanam. In the study findings, it was mentioned that the VHSC members were not aware that they are part of VHSC so what is the procedure of selecting them. Any information on how these committees are going to share the funds. What is the quality of training if at all provided to the VHSC members? Communitisation is still not comprehensive or effective. For outreach to be truly effective, it needs to get closer to community and be sensitive to community needs. Health functionaries key to effective community mobilisation but often reduced to being the main and only actors in the process. Capacity building of VHSCs outstanding need- link to accountability mechanisms. VHSCs often seen to exclude the disadvantaged (Dalits/women etc). Need to go beyond processes to outcomes and focus on rationale of communitisation. Communitisation happening but the devil lies in the details. Need for strong mentoring structures. Local NGO and CBO based research can help in unraveling the field realities and making midcourse corrections. Session 5: Interface/linkages of ASHA with community and services Chaired by Dr. Kabir Seikh, Rapporteur: Dr. Leila Celeb Varkey Presentation 1: Assessment of functioning of ASHA SAHYOGINI under intersectoral coordination of DWCD & DHFW in Jhunjhunu District of Rajasthan Sishir Kumar, SRKPS, Jhunjhunu The presentation was done by Shishir. Is there any change in behaviour or working style of ASHA after incentive based target oriented work was given to them. Organized by CHSJ, SRM and UNFPA Page 11

12 If there is a situation occurred where ASHA/Sahyogini brought one pregnant case to a hospital and there is no facility available for C-section operation then what they do. Presentation 2: Working together: Convergence and coordination related to ASHA functioning in Chhindwara district, Madhya Pradesh Prathyush and Kavita Jham, MPVS, Chhindwara The presentation was done by Prathyush. The study did not mention the VHSC s role in the study. What was their role and how do they help ASHA to provide the health services? There was no information on influence of ANMs on ASHA. Session recommendations from the chair In qualitative research the quality should be improved in looking at deviant case analysis. We usually look at majority then we also should look at minority trend. In this kind of research the reflectivity of organisation that has done the research should also include or present within the context of research. Session 6. Next Step and Way Forward Panelist: Dr. Syeda Hameed, Member, Planning Commission; Ms. Frederika Meijer, Country Representative, UNFPA; Dr. Abhijit Das, CHSJ; Prof Satish, Dean SRM; and all rapporteurs At the end of the presentations, plenary was held where all the rapporteurs presented the key findings of the studies and the suggestions that came up during discussions. This gave Dr Hameed, Member of Planning Commission an idea about the studies and gaps in health program interventions that needs to be addressed through future planning. Once the presentations by rapporteurs were over, Dr. Das expressed his gratitude to SRM University and UNFPA for their support and cooperation for successfully conducting the research studies. He said that their support had helped strengthening the capacities of the grassroots level organistaions and able to provide the decentralising feedback from all parts of the country. Frederika Meijer, Country Representative, UNFPA, expressed her thanks for being part of National Dissemination workshop. She said that it was great to hear evidences based research from different parts of the country. She said that the community voices are clearly put forward by these studies and added that the NGOs capacities needs to be strengthened further to take these research to the next level. She emphasized that there is a need to put forward the recommendations of the study findings for better implementation of health programmes in the country. The day ended with vote of thanks from Shelley, Program Manager, CHSJ, to all those who made this meeting successful. Organized by CHSJ, SRM and UNFPA Page 12

13 Annexure 1: Gaps and Gains: Citizen's Reports on Health Programmes Implementation in India th September 2011 Venue: Indian Social Institute,10, Institutional Area, Behind Sai Baba Mandir, Lodhi Road,New Delhi- 17 Registration : 9.30 am onwards Inaugural Session 1. Introductory Session (Plenary) Welcome Address and Introductory remarks: Dr. Abhijit Das 2. About the RAHP initiative: Prof Satish SRM University 3. Inaugural address by UNFPA 4. Chief Guest Address TEA Chair: Ms. Frederika Meijer, Country Representative, UNFPA Chief Guest: Mr. P.K. Pradhan, M.D. NRHM Session Name Time Session Details Presentation by Chair Rappor teur 2. NRHM and Access to services among Socially excluded communities (Parallel session 1a) (5 presentation * 15 min) (45 min discussion) 1. NRHM: Do tribal women matter? 2. Costs and consequences of utilising maternal health care: from two districts in India 3. Caste to be Inclusive- Under NACO Mapping Perception of SC/ST PLHAs in Accessing & Utilization HIV prevention, care and support services in Andhra Pradesh 4. Awaiting Change: Determinants of utilization of Maternal Health Services among SCs and Muslims in Patna District, Bihar 5. Status and utilization of Maternal Health Services among Migrant families in Rajasthan SVYM, Mysore CHSJ, Delhi SAKSHI, Secunderabad CHARM, Patna JATAN, Udaipur Mr A. R. Nanda Dr Joe Varghes e Organized by CHSJ, SRM and UNFPA Page 13

14 3.Improving access and quality of health services (Parallel session 1b) (5 presentation * 15 min) (45 min discussion) 1. Exploring Utilization of Health Care Services from 24X7 PHCs in West Bengal 2. Beyond Delivery: Assessing Post Partum Care and Complications in District Mirzapur, Uttar Pradesh 3. Continuing Concerns: An Assessment of Quality of Care and Consequences of Sterilization in Bundi District of Rajasthan in An Assessment of the status of Public Health Facility centre of District Sheikhpura as per IPHS 5. Maternal Death Audit for Action towards making every Pregnancy Safer in Jharkhand CINI, Pailan SAHAYOG, Lucknow MANJARI, Bundi BVHA, Patna NEEDS, Deogha Dr Vandana Prasad Ms Jashodh ara Dasgupt a Lunch 4. Increasing Communitisat ion (Parallel session 2a) (3presentation * 10 min) (15 mins for discussion) 1. Assessment of level of involvement of Village Health and Sanitation Committee with focus on Utilization of Untied Fund, Baran district of Rajasthan 2. Understanding services, convergence & community participation at (VHND)in Bankura District of West Bengal 3. An attempt hardly begun: Communitisation of Health Services among Dalit communities CHEERS, Kota IMAN, Kolkota PARA, Hyderabad Dr. Satish Dr. Anant Bhan 5. Interface/lin kages of ASHA with Community and services (Parallel session 2b) (2 presentation * 15 min) (15mins for discussion 1. Assessment of functioning of ASHA SAHYOGINI under intersectoral coordination of DWCD & DHFW in Jhunjhunu District of Rajasthan 2. Working together: Convergence and coordination related to ASHA functioning in Chhindwara district, Madhya Pradesh SRKPS, Jhunjunu MPVS, Bhopal Dr. Kabir Seikh Dr Leila Celeb Varkey 6. Next step and closing of the conference Presentation by Rapporteurs and way forward for inclusion in 12 th Planning Process By Rapporteurs Syeda Hameed, Member, Planning Commission (Plenary) VOTE OF THANKS Tea Organized by CHSJ, SRM and UNFPA Page 14

15 Annexure 2. RAHP Study partners Name of study Continuing Concerns: An Assessment of Quality of Care and Consequences of Sterilization in Bundi District of Rajasthan in Beyond Delivery: Assessing Post Partum Care and Complications in District Mirzapur, Uttar Pradesh Maternal Death Audit for Action towards making every Pregnancy Safer in Jharkhand Exploring Utilization of Health Care Services from 24X7 PHCs in West Bengal An Assessment of the status of Public Health Facility centre as per IPHS of District Sheikhpura, Bihar Do Tribal Women Matter: A Study of Forest Based Tribal Women of Heggadadevanakote Taluk in Mysore District Status and utilization of Maternal Health Services among Migrant families in Rajasthan Awaiting Change: Determinants of Utilization of Maternal Health Services among SCs and Muslims in Patna District, Bihar Costs and consequences of utilizing maternal health care: from two districts in India Caste to be Inclusive- Under NACO Mapping Perception of SC/ST PLHAs in Accessing & Utilization HIV prevention, care and support services in Andhra Pradesh Assessment of level of involvement of Village Health and Sanitation Committee with focus on Utilization of Untied Fund, Baran district of Rajasthan Understanding services, convergence & community participation at (VHND)in Bankura District of West Bengal An attempt hardly begun: Communitisation of Health Services among Dalit communities Assessment of functioning of ASHA SAHYOGINI under intersectoral coordination of DWCD & DHFW in Jhunjhunu District of Rajasthan Working together: Convergence and coordination related to ASHA functioning in Chhindwara district, Madhya Pradesh Study partner Manjari, Rajasthan SAHAYOG, Uttar Pradesh NEEDS, Jharkhand CINI-RRC, West Bengal BVHA, Bihar SVYM, Karnataka Jatan Sansthan, Rajasthan CHARM, Bihar CHSJ, New Delhi SAKSHI, Andhra Pradesh CHEERS, Rajasthan IMAN, West Bengal PARA, Andhra Pradesh SRKPS, Rajasthan MPVS Madhya Pradesh Organized by CHSJ, SRM and UNFPA Page 15

16 Annexure 3: Key Section 1: Improving access and quality of health services Continuing Concerns: An Assessment of Quality of Care and Consequences of Sterilization in Bundi District of Rajasthan in District- Study Key Bundi- Nainwa To assess the quality of care provided to women prior to sterilization To estimate the rate of post sterilization adverse consequences among women- major side effects, complications, failure To assess the quality of follow up care of sterilization services received by women Age at Sterilization : 23 to 28 yrs (36.6% ); 29 to 34 yrs (57.4%), Median Age = 29 years Literacy: 79.3% women were without any education Mean number of children at the time of sterilization was % women received no advice regarding post sterilization care 58 percent women who have undergone sterilization reporting to experience at least one type of adverse health condition after sterilization. 69% women underwent sterilization after having 2 sons Discharge after Sterilization- within 1 hr (45%), 1 to 4 hrs (46.6%), and unconscious state (7.6%) Only 20% women were checked by a doctor before being discharged from the facility after sterilization. The rate of sterilization failure found in the current study is 2.5% which is far higher than the international standard of 0.5% A relationship seems to exist between the quality of healthcare service and incidence of adverse health outcome with 72% of the women who had received Poor healthcare service reporting at least one adverse health outcome subsequently. The odds ratio test result strongly confirms that with an improvement in quality of sterilization service, the rate of incidence of adverse outcome after sterilization can be reduced by 5 times. Beyond Delivery: Assessing Post Partum Care and Complications in District Mirzapur, Uttar Pradesh Districts- Study Mirzapur- Rajgarh To document the customs and traditional practices of postpartum care at the household and institutional level. To trace the referral pathways commonly utilized, in case women suffer from postpartum complications. To compare against NRHM guidelines and to identify the role of public health system in the management of postpartum care. Organized by CHSJ, SRM and UNFPA Page 16

17 Key Community s postpartum care consists of (i) Special foods that are considered beneficial and help women to regain strength and resist infections are given (ii) Complete rest for 12 day. Women depending on their economic status returned to paid work after one to 3 months and if they could afford it, even a year (iii) Massages by Dais or relatives to relax and strengthen the woman and child s body. (iv) Irrespective of the place of delivery (home/hospital) the same traditional methods of care of child and mother in the postpartum period were observed. Community has own specific methods for routine postpartum care aimed at better health for mother and child. However there is no understanding of this care by the health system. System performance in the provisioning of Postnatal care- (i) Most of the women who delivered in institutions were only given the advice of initiating immediate breastfeeding (ii) None of the women reported having being checked up before discharge (iii) No government protocol exists for dealing with post partum complications; the CHC has devised its own protocol to deal with it (iv) In case of normal deliveries CHC staff do not advice the women to return for a postpartum checkup. As stated by the MO, In cases of normal delivery we do not ask the women to return as the OPD load is already so great, that is it difficult for us to tackle. The community is seeking care for postpartum complications but the public health system does not have services for providing it in place. Both in home and institutional deliveries, postpartum care by public system is either absent or rudimentary Post Partum Complications- (i) Of the 40 women, 32 reported complications (some reported multiple complications) (ii) Families prepared for possible delivery and postpartum complications by keeping aside money; however very poor families found it difficult to do so System s Performance- (i) Other than a labour room, Rajgarh has no blood storage facility or a gynecologist; this even though it is a CHC that is supposed to be providing referral EmOC services (ii) Average post delivery stay in facility as reported by women was two calendar days, but it is not clear if this was 48 hours. (iii) In the area with difficult access to the CHC, the ASHA did not visit 9 out of 10 women who had home deliveries, although guidelines recommend a visit within 7 days of delivery. (iv) Ambulance services were not free and worked out to be more expensive than private vehicles. (v) Although there is a generator, 8 women reported using dibris while spending the night in the facility. Maternal Death Audit for Action towards making every Pregnancy Safer in Jharkhand Districts- Study Key Deoghar- Devipur block To identify adverse maternal outcomes and the reasons behind these as they relate to Devipur block To understand institutional mechanisms and practices which lead to adverse maternal outcomes To understand the community level practices which lead to adverse maternal outcomes To develop solutions for improving maternal health outcomes in Jharkhand Of the 40 women who died in the reproductive age in the 1 year prior to survey in the block, 11 deaths (27% of total death) were classified as maternal deaths. Lack of 24/7 service in Block PHC; Doctors were unavailable after 3pm, because of which people had to travel as far as 20kms (traveling for 2 hrs) in case of emergencies which led to maternal deaths of 3 women. Denial by the System- Among 10 cases, 3 women were denied admission to the hospital reasons being unavailability of blood, lack of facility for operation or inability to pay bribe. Organized by CHSJ, SRM and UNFPA Page 17

18 Deaths have also occurred because of untimely treatment and negligence by health professionals 8 out of these 10 women who decided to have home deliveries did not get complete ANC, nor were they made aware about the benefits of ANC, delivery by skilled personnel and symptoms of complications during pregnancy. Out of these 8 cases, 2 women died at home without any sort of medical treatment. Community suggested that ANM and ASHA should play their role as per the laid guidelines. Exploring Utilization of Health Care Services from 24X7 PHCs in West Bengal Districts- Study Key Birbhum- Khoirasole, Muraroi II; Bankura Saltora, Onda, Borjora; Paschim Midnapur- Binpur II, Lalgarh To assess the infrastructure, staffing and services provided through 24 by 7 PHCs (8 PHCs were undertaken for study) To understand the quality of care of services provided through these PHCs To assess the extent to which these services are utilized by the users particularly women and children To provide suggestions for improvement of PHC services by drawing insights from users and service providers. All the PHCs covered have basic amenities like a permanent building, drinking water and electricity. The condition of building ranges widely from PHCs, from good buildings in Rudranager to Ramsagar PHCs where water leaks during rains. Although all PHCs had toilets, separate provision for men and women were found only in Lalgarh, Jajigram and Beliatore. None of the PHCs had grievance boxes None of the PHCs have telephonic connection during the time of study. Doctors could only be reached over mobile with uncertainty. There is no computers and Internet connection either across all the covered PHCs. Only 1 PHC (Lalgarh) had patient waiting area. On an average PHCs had 10 beds as per norms but Gogra and Jajigram had only 2, Odolchua had none, whereas Lalgarh had 24. Many beds were not in a usable condition, they were either put away for repairing or else they were not procured. Although OPD services are functional, IPD services are lacking. PHCs rarely provide diagnostic services. Basic MCH services are provided through SCs. Despite up gradation PHCs conduct normal delivery only. Slightest complications are referred No provision to retain mothers after delivery. Transportation and road facilities are not developed in many points. Emergency services are met with difficulty Medical Officers were not available around the clock in 6 PHCs. Doctors were found doing private practice from their residences during clinic hours. Across all the PHCs service providers have admitted to shortage of doctors in delivering services. They are heavily overloaded with administrative duty that affect health service delivery Paucity of equipments, diagnostic facilities and medicines affect health outcomes and in some cases leading to fatal outcomes. Organized by CHSJ, SRM and UNFPA Page 18

19 An Assessment of the status of Public Health Facility centre as per IPHS of District Sheikhpura, Bihar Districts- Study Sheikhpura Six To assess the present standard of all facility centers of the district of Sheikhpura as per the checklist provided in the IPHS guidelines for different facility Centers and To assess the improvement / gaps in those centres after DLHS 3 Key None of the Facility Centers studied of this district are up to the IPHS standards. No Time line followed as per Frame work for Implementation NRHM to upgrade any center. PHCs do run 24 7 but profusely lack in supporting human resource & other support services, Infrastructure, equipment, drug, furniture, quality control as per IPHS. All Additional PHCs are only partially run for OPD services by AYUSH doctors to prescribe only Allopathic Medicine. All beds of Additional PHCs (17 6= 102) are not in use which is gross neglect of public health services due to lack of adequate quality. Though Sub Centres are mostly equipped with two ANMs but are not open 7 days to provide services. Most of the service providers interviewed (CHC, PHC, APHC, SC) had limited knowledge about IPHS, C.S.G & about the goal set in National Population Policy for health sector to be delivered. Section 2: NRHM and access to services among socially excluded communities Do Tribal Women Matter: A Study on Access and Utilization of Cash Incentive Programs Under NRHM for the Forest Based Tribal Women of Heggadadevanakote Taluk in Mysore District in Karnataka Districts- Mysore Heggadadevanakote Study Key To understand the awareness about cash incentive programs under NRHM among Forest Based Tribal Women (FBTW) To identify the gaps if any, in accessibility and availability of the cash incentives for the FBTW and the reasons for these gaps To document the purposes for which the cash incentives were utilized by these women The mean age at marriage of the women was 17.5 years. Almost 60% of the women said that they were married when they were less than 18 years of age Almost 70% of the women belonged to families living on less than Rs.1,500 per month Almost none of the respondents recognized the nomenclature NRHM, while 46% of the study respondents had heard about cash incentive (CI) programs. Though only 43% could name JSY. 29 (47%) women lived in Haadis without ASHA, 15 (25%) women lived in Haadis without both ASHA and ANM More than 90% of the women living in difficult to access haadis (hamlets), not having a fulltime ANM had not heard about CIs. An absence of AHSA/ ANM makes it difficult for the women to procure documentary Organized by CHSJ, SRM and UNFPA Page 19

20 evidences and this adds to more money spending on travel for visiting the health centres. The mean time after delivery for receipt for money was 3.8 months for JSY and 9.8 months for Prasuti Aarike (PA) scheme by the Karnataka government. Reasons given for not getting cash incentives- The community women said no money in PHC, delivered at home or lack of documents; ASHA, ANM and MOs said there was delay in fund release, lack of funds, lack of awareness among women; After reviewing fund related documents- it was found that there was mismatch between when funds were needed and when actually received & amount of fund required and amount received. Majority who got the CI did not use the money for which it was meant; probably because of delay in getting CIs Status and utilization of Maternal Health Services among Migrant families in Rajasthan Districts- Study Rajsamand- Rajsamand and Railmagra To assess the status and pattern of male migration in Rajsamand To assess utilization of maternal health services in male migrant families Key Over 42% of the respondents of the survey were women in the age group of 23-27, followed by women in the age group of (29%), with women of years being 22% of the respondents. 35% of the respondents did not have any formal education, 32% had some formal education and were considered literate, 23 % had primary education, and almost 10% of them had more than secondary education. Over 65% of the respondents had their spouses in other states, while 35% reported inter district migration Over 73% of the men had been away for over 3 years and 12% reported having their husbands away for over 2 years Over 64% had knowledge of some type of public health centers 48% of women know ANM as the health care provider in the village Only 40% of respondents got 100 IFA Tablets Though majority received some form of ANC, however only 17% had complete ANC Child immunization was found to be 41% 60% of the mothers gave birth to their children at home. Use of safety kit is as high as 93.9%, and it is interesting to note that even untrained dais, relatives and friends were using safety kits during delivery Absence of husband or male migration affects the physical health of women in various aspects. Especially during the pregnancy period they are left to heavy physical labour in and around the house. On the other hand, when women become the decision maker, they are able to take better decisions related to her and child s health care. Awaiting Change: Determinants of Utilization of Maternal Health Services among SCs and Muslims in Patna District, Bihar Districts- Patna - Phulwarishareef block Organized by CHSJ, SRM and UNFPA Page 20

21 Study To understand the awareness about maternal health services To find out the major determinants effecting utilisation of services Key Out of 16 women, only one was aware of JSY by its name but all were aware that there is a scheme in which a woman gets Rs. 1,400 if she delivers at government health facility. All Knew about Zacha-bacha card, but 12 out of 16 didn t know about the importance of the card. All the 16 women interviewed were unaware that ambulance services for visiting the health facilities can be availed free of cost ANM had not visited any homes for either ANC or PNC Use of JSY money - Rs 300 to 400 on transport, Rs 300 on medicines including gloves and blades, cost for cutting umbilical cord, Rs tips to service providers and ASHA. Even in case of still born one has to pay providers at the centre for cutting the umbilical cord. It is being told that the money is of the government which has to come back to the employee. People are being charged for immunisation. Even during labour for good behaviour you have to depend on call of ASHA. For urine and blood test they have paid at PHC (outsource). No discrimination on basis of caste and religion was notices, but discrimination was done on the basis of economic status and willingness to pay. Poor hygiene and sanitation at PHC. Scanty supply of drugs. Non-functioning and or poor functioning of health facilities is a major factor responsible for low utilization of services SCs and Muslim communities were not made aware of many services being provided by the government health facilities. Costs and consequences of utilizing maternal health care: from two districts in India Districts- Study Key Balangir in Orissa and Chirang in Assam To assess expenditures around pregnancy, delivery and post partum period in public and private sector. To assess the different financial/economic practices at the household level to manage health care related expenditure. To assess the receipt of JSY payment and the process associated with it. In Balangir women mentioned pregnancy and childbirth related issues fall under the household domain and any decisions pertaining to their healthcare rests on family members especially the male member and often their treatment is delayed. In Chirang women specifically mentioned of problems like fever, abdominal pain, nausea for which they did not seek care because they did not want to add on to their expenditure. For outpatient services, private providers were the leading source of care in Balangir whereas in Chirang public facilities were mostly preferred. Women from Balangir mentioned, the bad behaviour of providers in public facilities and the distance of PHC/CHC force them to access private services. This study shows that the household costs of obtaining maternal health care are substantial and the situation in Balangir is alarming in this regard. Women have spent around Rs for ANC, 3003 for delivery and 3240 for PNC amounting to a total of Rs Organized by CHSJ, SRM and UNFPA Page 21

22 In Balangir there was negligible difference in costs of utilising care from private and public sources Costs of medicines are overwhelmingly high in both states 25% of total cost of health seeking was for transport. Transport has not only pinched pockets especially when women were utilising higher level institutions more but also had severe implications on women s health during emergencies. The disbursement of JSY looks flawed in both states with instances of corruption, non-receipt of payment for home deliveries and transportation. In both places some women said they leave hospital immediately which increased their vulnerability ; or even resumed work after a week of childbirth due to poverty. Two out of six women who faced any postpartum complications in Balangir reported to have spent an amount of Rs and Rs The maximum expenditure was on medicines (Rs ) and accompaniment (Rs ). In both districts, they have not received Rs. 250 towards transportation cost and neither were they aware of this component. Major funding for ANC and delivery and post delivery care came from family savings and in some cases families opted for loans. Caste to be Inclusive- Under NACO Mapping Perception of SC/ST PLHAs in Accessing & Utilization HIV prevention, care and support services in Andhra Pradesh Districts- Mahbubnagar and Nalgonda Study To understand the perceptions of SC/ST PLHAs on the services provided through the ART centers. To ascertain discrimination if any in providing services to SC/ST PLHAs. To look at if there are any government intervention specifically towards SC/ST PLHS about their rights and entitlements. Key Out of 30 respondents 7 were males in the age group and 23 females between the age group 25 to 28 years. They do not prefer to avail services from their own ART centres and that s the reason they are visiting the nearby district to seek ART care. Feel discriminated due to caste and HIV status. All the respondents went through all the tests and were given ART medicines but the medicines for opportunistic infections(oi) are not given which are supposed to be given free of cost. During the time of registrations the respondents at ART were asked about their caste which is actually not required as per the procedure. No group counselling was given to any of the respondents nor was any counselling given regarding Stigma and Discrimination. The staffs at the centres do not treat the respondents in a proper manner. There have been instances of not responding to queries, using abusive language, delay in conducting the tests or giving the medicines, threatening to stop them from complaining. Drinking water and use of toilets were denied to the Dalit respondents in the ART centre. Section 3: Increasing Communitisation Organized by CHSJ, SRM and UNFPA Page 22

23 Assessment of level of involvement of Village Health and Sanitation Committee with focus on Utilization of Untied Fund, Baran district of Rajasthan Districts- Baran-7 blocks Study To assess the knowledge of VHSC members about their role in functioning and utilization of untied funds. To ascertain the level of involvement of VHSC members in use of untied funds. To examine the current pattern of allocation and expenditure of untied fund Key All ASHAs were aware about the existence of the VHSC 75% PRI members were aware about the existence of the VHSC 72% of community members were aware about the existence of the VHSC 3 out of 4 of VHSC members reported learning about their membership after being recruited as a member and not during the formation of the VHSC Over 80% of them learned about their membership from the ANM. 84% members did not know their role in planning and implementation of utilization of untied fund. Though 50% members were aware about frequency of meeting, there was confusion and varied responses among all the respondents regarding place, date and interval of the meeting. The status of utilization of previous year s untied fund is not known to 94.7% respondents. Almost half of the PRI members and community members explained that the registers are sent to their homes for taking signatures 92% members never monitored expenditure Understanding services, convergence & community participation at (VHND)in Bankura District of West Bengal Districts- Study Key Bankura To understand the role of various department in organising the VHND at the village level To assess community participation in utilization of service To study the role of Village health and sanitation committee in mobilizing the community VHND provides platform for inter sectoral convergence and interfacing between the community and the health system. From the block till the tail end, involvement of the PRI is missing. A part of the community which in fact is registered as beneficiary at the AWC or with Health is accessing the services. The rest are ignorant of the event. Block level- in-spite of being physically near, ICDS CDPO not able to attend due to lack of man power. PRI was not available for comment. Sub centre level- ICDS supervisor was unavailable. VHND planning is done by ANM. AWC level- well coordinated convergence exist as planning is done by AWW & ANM. Village level- there is no convergence between PRI, AWW, SHG, GUS & Health. SHGs are ignored as an important stake holder. AWW, ASHA & ANM are not aware about the need for involving SHG members. Organized by CHSJ, SRM and UNFPA Page 23

24 An attempt hardly begun: Communitisation of Health Services among Dalit communities Districts- Study Vizianagaram and East Godavari To assess the knowledge and awareness of the members of VHSCs about VHSCs To study what the members VHSC see as the important health and sanitation issues with regard to Dalits and how they respond to them. To identify critical divergence of perception of dalit communities and VHSC members Key Community response Only 25% of the respondents (sample was 30 community people) from the survey were aware about the VHSC Among the women respondents only 2.2% were aware about VHSC Village sarpanch, ANM, AWW are the most recognized members of the VHSCs. SHG leader and School teacher are the least recognized. 21% have some idea of Village health plans (VHP) 75% of dalit community have no awareness of the existence of VHSC 58% know about the functions of ASHA. 45% say ASHA is available for delivery There is marked divergence is the understanding of VHSC between the two districts. Vizianagaram showing greater awareness. Members of VHSC like the ANM, ASHA are seen as fulfilling their designated responsibilities rather than fulfilling their roles as members of the VHSCs VHSC members response The Dalit communities do not participate in VHSC meetings 73% know their roles and responsibilities 86% reported that there are meetings but they not very regular 36% said that village health fund (VHF) are spent on dalit communities Section 4: Interface/linkages of ASHA with Community and services Assessment of functioning of ASHA SAHYOGINI under intersectoral coordination of DWCD & DHFW in Jhunjhunu District of Rajasthan Districts- Jhunjhunu- Jhunjhunu and Alsisar Study To find out the perception of community and health service providers about ASHA s functioning under intersectoral convergence. To identify the barriers if any in fulfilling the responsibilities as ASHA Key CDPO s perception ASHAs are doing incentives based work so their participation is most likely in those works where they are getting good incentives. For example ignoring MCHM day work over institutional delivery. CDPO s perception As ASHA is not an employee of any department the ASHA does not feel a sense of belongingness to either department (ICDS and Health Department). ASHA s felt that they are trapped in between two departments, where everyone forces them to perform their respective departmental activities in definite time, pattern, and in the best possible manner, but neither department comes forward to sort their grievances and demands. Organized by CHSJ, SRM and UNFPA Page 24

25 According to ASHA workload is higher in NRHM. Lady Supervisor s felt that that there should be fixed guidelines for the ASHAs so that they can come out of this dilemma as to which department they have to work under. The Community has acknowledged the connection between ASHA and the community. They have suggested that they should be given a better remuneration. Working together: Convergence and coordination related to ASHA functioning in Chhindwara district, Madhya Pradesh Districts- Study Key Chhindwara - Tamia, Junnardeo and Parasia To assess the functioning of ASHA (100 ASHAs were interviewed) to understand the barriers and the motivating factors that has direct bearing on effective functioning of ASHAs. To understand the convergence and the coordination issues of ASHAs with other village level government functionaries in the community. There was good coordination between ASHAs and ANMs with 82% of ASHAs assisting the ANM for conducting health survey in the village and 64 % ASHAa are conducting awareness program on family planning. There was good coordination between ASHAs and anganwadi workers with 93 % ASHA s working with AWW. There is poor coordination between ASHAs and PRIs; Only 61% attended panchayat meetings, 50% were associated with gram sabha, only 12% ASHAs were engaged in developing health plans. Moreover, 30% ASHAs reported facing opposition from Panchayat in conducting routine work Poor coordination with hospital; 21% complained that they were treated as a health worker, 7 % said they were treated like patients and 18 % ASHAs said that they were ignored like uninvited guests. It was also found that some ASHAs who were appointed were not necessarily resident of the same village and therefore were forced to travel distances. 19 % ASHAs reported not getting any support and cooperation from the villagers. 37 % ASHA did not get cooperation from community in furnishing village health plans. It was also found that 64 % ASHA were facing opposition from the upper class. Organized by CHSJ, SRM and UNFPA Page 25

26 Annexure 4: List of Participants Name Organization Address P. K. Pradhan NRHM, GOi 244-A Nirman Bhawan, Maulana Azad Marg, New Delhi Dr. Syeda Hameed, Planning Commission, GOI Yojana Bhawan, Sansad Marg, New Delhi Arun Srivastava NHSRC NIHFW Campus, Baba Gangnath Marg, Munirka, New Delhi Rachana Atri ISI 10, Lodhi Dr. Archana Sinha ISI Institutional Area, New Delhi-3 Dr. Kabir Sheikh PHFI ISID Campus 4 Institutional Area Vasant Kunj New Delhi India [email protected] Jashodhara Dasgupta Sahayog A-240, Indira Nagar, Lucknow Dr. Joe Varghese CMAI A-3, Local Shopping Centre, Janakpuri, New Delhi INDIA Jyotsna Sivaramayya Dr. Vandana Prasad ISST PHRN (Public Health Resource Network- National) India Habitat Centre, UG Floor, Core 6A, Lodhi Road, New Delhi A, Jungi House, Shahpur Jat, New Delhi [email protected] [email protected] [email protected] [email protected] Madhurima PHRN [email protected] Dr. Sangya Trivedi FPAI New Delhi Branch [email protected] Usha Sharma FPAI FPAI Bhawan Sector IV [email protected] Mamta Srivastava FPAI R. K. Puram NEW DELHI [email protected] Gauri Choudhury Action India 5/27A, Jangpura B, [email protected] Yogender Sharma Action India New Delhi [email protected] Shalini Singh CREA 7,Mathura road, 2 nd Floor, Jangpura B, New Delhi [email protected] Organized by CHSJ, SRM and UNFPA Page 26

27 Dr. Anjali Gupta VHAI P C Bhatnagar VHAI [email protected], [email protected] Priyanka Mukherjee MCH-STAR/ CEDPA [email protected], [email protected] John Pile MCH STAR Upper Ground 4-9, [email protected] Mohta Building 4 Bhikaiji Cama Place New Delhi India Reshmi Bhaskaran Save the Children Bal Raksha Bharat, [email protected] Shinea Vakil Save the Children 3rd Floor, Vardhaman Trade Centre, New Delhi M E Khan Population Council [email protected] Anisha Agarwal IPAS [email protected] Daniel Lak BMGF [email protected] Anjali Sen IPPF [email protected],[email protected] Arvind Betigeri PATH [email protected] Ruchi The Hunger Project [email protected] Dipa Nag Chowdhury Mac Arthur Foundation [email protected] Frederika Meijer UNFPA [email protected] Vasudha Chakravarthy Trios dev Pvt Ltd T28, Manish Global Mall, Sec22, Dwarka [email protected] Dr. Anant Bhan Dr. A.R. Nanda Independent Consultant Flat 904, Building A-3, Mirchandani Palms, Near Aakashganga Society, Rahatani, Pune [email protected] [email protected] Organized by CHSJ, SRM and UNFPA Page 27

28 Dr. Leila Caleb Varkey Independent consultant/ CMNHSA Augustine Veliath Independent Consultant Aarti Dhar The Hindu RajLakshmi Frontline Nalini Srivastava UNFPA Dr. Sanjay Kumar UNFPA Satyanarayan UNFPA Prof Satish SRM Dr. Rajan Patil SRM Dr. Geetha Veliah SRM 221(A/63),New Jaydeep Raipur. P.O-Garia. CINI kolkata Sudipa CINI Bindu SVYM Shanthi SVYM Tanmoy NEEDS Anamika CHARM Armaan Suhail CHARM Leslie SAKSHI. H R [email protected] WATCH Isaac SAKSHI. H R [email protected] WATCH Devika BVHA [email protected] Vivekanand BVHA [email protected] Fr. Thomas PARA [email protected] Chittibabu PARA [email protected] Swarup MANJARI [email protected] Bajrang MANJARI [email protected] Santosh MANJARI Ranveer JATAN [email protected] Vinita JATAN [email protected] Shishir SRKPS [email protected] Arvind CHEERs [email protected] vikram CHEERs [email protected] Rupasri IMAN [email protected] Sandhya SAHAYOG [email protected] Prathyush MPVS [email protected] Kavita MPVS [email protected] Moumita CHSJ [email protected] Nibedita CHSJ [email protected] Ruhul CHSJ [email protected] Shelley CHSJ [email protected] Shreeti CHSJ [email protected] Organized by CHSJ, SRM and UNFPA Page 28

29 Pratibha CHSJ Sunita CHSJ Abhijit CHSJ Satish CHSJ Organized by CHSJ, SRM and UNFPA Page 29