How To Improve Health Care In India

Transcription

1 EDITORIAL TOWARDS UNIVERSALIZATION OF INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS) The ICDS Programme has covered many milestones since its inception in Today, ICDS is globally acknowledged and recognized as one of the world s largest and most unique community based outreach system for Women and Child Development. Universalization of ICDS was originally contemplated to be achieved by the end of , through expansion of the services all over the country. Out of 5614 sanctioned projects till 1996, only 4200 could become operational by the end of eighth Plan and the same position continued even during the fist two years of Ninth Plan. The process of universalization was expected to be completed by the end of Ninth Plan by covering all the 5652 blocks/wards spread all over the country, however only 4608 blocks could be operationalized by the end of Ninth Plan period due to paucity of funds, and by Sept total numbers of 5068 projects become operational 2-3. Tenth five year Plan envisages to universalize ICDS in the country and expects to cover 54.3 million children and 10.9 million mothers. Ever since the inception of ICDS in 1975 several changes have occurred over the past three decades, significant changes in policies and programmes have been embodied in the National Education Policy 1986, revised in 1992, National Nutrition Policy of 1993, National Agriculture policy of 2000, National Population Policy 2000, National Policy for Empowerment of women in India 2001, & National Health Policy ; Several World Bank supported ICDS Projects have been established in various states with additional spectrum of services and inputs. In the light of experience gained over the last 28 years the ICDS Programme in the near future would be enriched through enlarging the spectrum of services and interventions related to empowerment of women and communities and convergence of services. As a matter of fact at village level, the anganwadi centre has become a pivot of basic health care activities, Contraceptive Counseling and supply, nutrition education and supplementation, as well as pre-school activities. Anganwadi centre also functions as depots for ORS, basic medicines and contraceptives and integrated management of childhood diseases 3,6. Thrust areas: So far the order of Priority under ICDS has been first on backward rural areas and followed by urban slums and tribal areas. During the Tenth Plan, first priority will go to slums in urban/semi-urban areas, followed by tribal areas and backward 147 rural areas. This step is essential as it would facilitate to cover under-served population and groups of urban slums, as nearly 100 millions people live in urban slums, with little or no access to basic amenities, leading to high morbidity and mortality in young children and women. Convergence of ICDS with RCH urban projects can serve as viable model for urban health and development services with focus on women and children. The constituency of ICDS can focus on urban slums to promote universal immunization, women empowerment child protection, child survival and development 3. The Government continues to accord high priority to supplementary nutrition programmes in ICDS to fight macro and micro-nutrient deficiencies across the life cycle, specifically targeting at the young children of below 24 months, adolescent girls, expectant and nursing mothers. The focus of shifting the priority group below 3 years is welcome approach which is much more realistic as malnutrition morbidity and mortality effects are more severe during the period of vulnerability. Young children below three years of age are to be reached in homes and family, & parents are to be communicated on the development, nutrition and health needs of young children, therefore the focus has to be on mothers. Action Plans and work schedules of Anganwadi of ICDS system has to be parents (family) friendly. Of necessity the contacts with family and parents have to be more frequent and long lasting, for, tracking adolescent girls, pregnant women for adequate nutrition, safe-pregnancy, safe delivery, safeabortions, neonatal care, Postnatal care breast feeding, early childhood care, immunization and integrated management of childhood illness for child protection survival and development. Proportionately more energies and time AWW s (Anganwadi workers) has to be devoted to families and organized women groups to establish healthy practices. This also necessitates to enhance communication skills of AWW s and ANM s for effective communication on Health, nutrition and development needs of young children. These issues have been partially addressed to, through UDISHA- a new dawn in basic training, the national training component of ICDS for building Human resources for meeting women and child development goals Quality of communication and package of services will largely depend upon the initial training, continued education and on the job training of ICDS functionaries Improving access and quality of services has been chosen as new thrust area under ICDS : Reaching under three children (precisely parents,

2 mothers and care-givers) has to be dovetailed with health sector, ANM's programme through functional linkages, joint surveys, joint home visits, team's training, sharing of reports and organizing women groups jointly and holding periodic meetings of women groups or self help groups for sustained activities. Supporting families and women groups for self help would be the key for young child development, mindset of AWW and ANM & other functionaries should change to accept this reality The status of under-nutrition and malnutrition in women and children, through ICDS, by direct intervention (Provision of supplementary nutrition) is not likely to improve unless the dietary practices improve at the household level. Selective supplementary nutrition programme for below poverty lines may be continued Since the ICDS has expanded and is heading for universalization, the training of over 600,000 AWW, Helpers, supervisors, 4600 CDPOs, 2124 ACDPO's & large numbers of community women has been a gigantic task. There has been distinct change and paradigm shift in philosophy of ICDS programme, which is geared towards accessibility, quality improvement, and team work at the community level. NIPCCD has been playing a pivotal role in training programme. Quality and contents of training of AWW has been variable and resulted into poor quality of services, lack of motivation as also lack of focus on priority issues and goals of women and child development. Training needs assessment and evaluation of training were seldom undertaken. A new push was given in 1999 to the training programmes under ICDS, which led to birth of UDISHA - the new dawn in national training component of ICDS. The process of training was decentralized under this initiative. The duration of basic training of AWW has been reduced from three months to 45 days and whole syllabus has been revised which is child centred, with priority focus on under three year children, & adolescent girls. The curriculum is restructured along the life cycle and development continuum of the child, addresses gender issues and associates parents-families (women in particular) and community as the key and cardinal partners in the process of development. Further the new training curriculum constitutes 75% national core contents and 25% state specific; providing flexibility to states to incorporate state specific situations as also innovations The whole emphasis now is on quality training. The new approach sets apart 40 days institutional training and 5 days supervised field training. It poses new challenge to respective state to implement the new curriculum. States have long inertia and training is seldom considered as priority area and it is always low on their agenda. 148 During the Ninth Plan, 2304 Child Development Project Officer/Additional child Development Project Officers, 4993 supervisors and 2.8 lacs AWW were trained under UDISHA In our experience the whole training of AWW should be learning by doing and should happen in the field situation in the families and community and in the anganwadis itself. The theory part has least relevance to job functions of AWW. Conventional trainers should be replaced by trained AWW, helpers, supervisors and CDPO s including women panches and women groups along with ANM s and traditional birth attendants. Training should be responsive to changing scenario and demands, necessitating on the job training and sector level monitoring-motivation and training of teams for women and child development. We have seldom attempted team s training, sector meeting provides a unique opportunity for team trainings, it depends on local initiatives, local enthusiasm and clarities of objectives, contents, issues, problems and priorities. Even during basic training of ANM s and AWW team's training can be attempted in districts which offer both these trainings. Some part of the basic training could be joint training. Training methodologies have to be demonstration and return demonstration and hands on training by doing things repeatedly, theory part should be minimum 16. Implementation of UDISHA through State Plans of action has been distressingly slow and whole process has been reviewed and now ICDS training has been restored to NIPCCD, recently to cover back log and improve the quality of training 2. Adolescent health : Component of adolescent health has been included in ICDS programme in over 2000 ICDS projects since all over the country after initial successful results from 507 experimental projects. Tenth five year plan envisages universalization of Kishori Shakti Yojna (KSY) - KSY a key component of ICDS scheme which aims at empowerment of adolescent girls, in all ICDS Projects with necessary linkages in other sectors and schemes. Limited numbers; 10% of anganwadis are being covered in 2000 ICDS projects each anganwadi covers 20 adolescent girls between years who belong to weaker section families (BPL) and are school drop outs or not enrolled in schools. The present model of adolescent health programme in ICDS needs explicit focus on communication needs of adolescent on vital areas of reproductive health, literacy, behavior change and adoption of healthy life styles apart from vocational skills. The efforts of Anganwadi workers when combined with efforts of ANM s and teachers can enrich the programme outcome and achieve the set goal 17.

3 National Nutrition Mission (NNM) which has been set up in 2002 with an overall responsibility of educing/eliminating both macro and micro nutritional leficiencies in the country. As part of the efforts of NNM, a lew programme to combat under-nutrition among adolescent girls and expectant and nursing mothers is being launched by he Department of Women and Child Development on pilot basis during ; covering two most backward districts in each of the major states and most populous districts in rest of the smaller states and UT s. Under this pilot programme, food grains are supplied free of cost through targeted Public Distribution system directly to identified families with under/malnourished persons 3. Tenth plan identified a strong need for conversion of Anganwadi centers into Anganwadi cum creches. The day care services under ICDS are available only for a limited period i.e. up to 12 noon. Because of this the working and ailing mothers have not been able to make full use of the day care facilities at AWC's. Therefore there is strong need as well as justification for having extended day care facilities at AWC's, especially in areas where the women work force is in large numbers. Similarly setting up of temporary AWC's even at the construction/work site at the cost of contractor is imperative. Inspite of 27 beneficiary oriented schemes for women and multitudes of programmes; the situation of women is unacceptable because of unfavourable sex ratio, high mortality, high morbidity, discrimination, lower level of literacy, poverty, heavy work load and non recognition of their contribution. Declining sex ratio of women and children below six years is a grim reminder through census National policy for the empowerment of women (2001) is yet another attempt to focus on issues related to women. States have evolved respective plans of action for women and many are in the process of formulating their action plans to achieve time bound targets as set in the policy frame work. ICDS holds promise to empower women to achieve the targets at faster rates as set under National Policy on Nutrition, & National Health Policy and National Population Policy, National Education Policy as also Sarva Shiksha Abhiyan (Education for all) by 2007,. Rightfully the component of women empowerment has been incorporated into the curriculum of AWW and hopefully it is done for ANM & MBBS training courses as well. Anganwadi workers should strive to organize women groups, adolescent girls and communicate with them on various issues through sustained contacts programme. Ultimately child development is family based and more so mother based, who holds key position to make decisions and provide stimuli for all round development of child in the family and community Ultimately it is envisaged that community and women will take over to run the functions of Anganwadi themselves through self help group and with the help of PRI & elected members and NGO's hence advocacy by AWW for women empowerment is central to ICDS system of which the women are integral part and partner. 73rd & 74th amendment of the constitution in 1993 has provided one third of reservation for women in Municipalities and Panchayati Raj Institutions, ensuring effective participation of women in decision making a step forward for women empowerment. However under ICDS scheme families, women and community participation and empowerment has been a neglected area, only isolated instances of successful community participation and women empowerment are cited in the programme. The job responsibilities of AWW were defined way back in 1975, these have stood to test of time, however lot many changes have occurred and many new policies and programmes have come up. To keep pace with the time and newer developments the job functions of AWW and other functionaries have been redefined to enrich the job and make these more relevant to the needs and aspiration of women and children. Some of the newer job responsibilities which needs special mentions are, strengthening of advocacy, communication & social mobilization for survival-protection and development of young child especially girl child, Prevention & detection of disability among children, management of childhood illnesses, enlisting adolescent girls, Health & nutrition education to Adolescent girls, life cycle basis of interventions & improving quality o service delivery & management. On the basis of job description & job analysis new syllabus has been drawn up, to update and training of AWW in these areas. Focus has been shifted to under three year children as a vulnerable and priority group for contacts and intervention. Attitudes building & motivation components have been incorporated into the curriculum. Similarly roles and responsibilities of supervisors & CDPO's have been clearly redefined In view of these developments it is imperative that Health personnel's (Health workers, Male & female Health Supervisors & Medical Officers) job descriptions & job responsibilities which were defined way back in 1986, after National Health Policy 1983 needs to be redrafted & revised to incorporate all these components as also other components of various policies & programmes introduced subsequent to formulation of Health Policy Similarly curriculi of MBBS and Postgraduates should incorporate these changes for larger interest & needs. 149

4 National Population Policy 2000(NPP) recognizes the worth of ICDS & stipulates that convergence & synergies at village level can yield maximum results. NPP advocates utilization of village self help groups to organize and provide basic services for reproductive & child health care, combined with the ongoing ICDS. Organizing neighbourhood acceptor groups & providing them with revolving fund that may be accessed for income generation activities. These groups may establish rules for eligibility, interest rates, and accountability for which capital may be advanced, usually to be repaid in installments within two years. The repayments may be used to fund another acceptor group in a nearby community, who would exert pressure to ensure timely payment. Two trained birth attendants & the anganwadi worker (AWW) should be member of this group. Implementing at village level a one stop integrated & coordinated service delivery package for basic health care, family planning & maternal & child health services by self help group acceptors who could meet once a fortnight or once a week to register marriages, pregnancies, births & deaths, to monitor growth, to counsel & advocate for contraception, & free supply of contraceptives, preventive care and supply of basic medicines for common ailments (fevers, diarrhoea, anaemia etc.), nutrition supplements & promote school enrolment of children through Anganwadi centre at village level. Meaningful decentralization will result only if the convergence of the national family welfare programme with the ICDS Programme is strengthened. The focus of the ICDS programme on nutrition improvement at village level and on pre-school activities must be widened to include maternal & child health care services. Convergence of several related activities at service delivery levels with ICDS programme is critical for extending outreach & access to services 6. Honorarium of Anganwadi workers has been increased to Rs.1000 per month and that of helper to Rs.500 per month it is quite encouraging. Similarly rent for hiring of buildings in urban areas has been increased to Rs.300 per months, and for rural areas it has been enhanced to Rs.50 per month. Construction of building for anganwadi centre in Rural & urban areas have been taken up under rural development agencies. Health posts in urban slum settings could be housed in anganwadi centres and vice versa anganwadi centres could be housed in subcentres, to have better functional linkages and coordination and in our experience it has paid rich dividends.- The world bank assisted ICDS projects numbering 1953 in the states of Madhya Pradesh, Rajasthan, Uttar Pradesh, Andhra Pradesh, Orissa, Bihar, Tamil Nadu, Kerala & Chhatisgarh, Jhharkhand & Maharashtra have additional inputs; like construction of Anganwadi buildings, Income generating activities for women/mothers, nutritional rehabilitation services, training in project management and equipment etc. The scheme of Balika Samridhi Yojna (BS Y) to promote Survival and care of girl child, commenced on 2nd October 1997 provides financial help of Rs. 500 for the mother of girl child belonging to the below poverty line families. Subsequently in 1999 the BSY was reviewed & modified instead of cash payment now the amount is deposited in the Bank/ Post Office in the name of girl child & this can be withdrawn for insurance premium & incremental graded scholarship to girl child as she graduates from different grades. Similarly maternity benefit scheme run by department of rural development has been initiated which gives a cash incentive of Rs.500 to mother who have their first child after 19 years of age; for birth of first or second child only. Disbursement of cash award is linked to compliance with antenatal check up, institutional delivery by trained birth attendant, registration of birth & BCG immunization. AWW holds the responsibility to initiate & process the case. Since ANM's are crucial for supporting ICDS AWW for increasing the outreach of Reproductive & Child health, it is important to ensure that all posts of ANM's are filled and steps taken to ensure that they are available & perform the assigned duties. Deptt, of Family Welfare funded over posts of subcentres ANM's & about were funded by the state (from Non Plan). The Ninth Plan recommended that this dichotomy be removed & all the ANM's as per norms for the 1991 Population should be funded by the department of Family Welfare. This has been done from April 2002 to improve the content, coverage & quality of maternal & child health Services. Accordingly the Department of Family Welfare has taken up the funding of 1.37 lacs subcentre ANM's. The states have taken over funding of the rural family welfare & Post Partum Centers. Functional linkages between ANM's and AWW have been established at the village level but it needs to be strengthened further 15. Upto 1999 over subcentres (1:4579), Primary Health Centers (1:27364) and 2935 Community Health Centers have been established (1:214000). Referral services at FRU leaves much to be desired, which needs to be accelerated to support the efforts of ICDS to reduce low birth weights, & maternal mortality & neonatal mortality to acceptable levels. Private Public Partnership is being forged to strengthen the referral services. 150

5 Under the National Education Policy the district Primary Education Programme has established pre-primary education wing covering children 4-6 year of age & providing mid day meal. This step relieves AWW's work load and shifting PSE programme to teachers, consequently provides more time to AWW to focus her attention to mother s & young children below three years. Early childhood development through early Childhood Care & Education (ECCE) as a significant input in life long development and successful completion of Primary education has been recognized the world over. The major provider of ECCE is the integrated Child Development Services (ICDS) scheme which covers 15.8 million children (17.8% of child population of 3-6 years) through about 520,000 anganwadis in 35 states and union territories. Early Childhood Education or Pre-School Education is among the six component of the ICDS scheme and is one of the weakest. The Sarva Shiksha Abhiyan (SSA) aims to support strengthening the Pre-school Component in ICDS by need based training of anganwadi workers, provision of learning materials, setting up of Balwadis as pre-school centres in uncovered areas, honoraria for pre-school teachers, building advocacy on the importance of early Childhood Care & development, organizing training programmes for community Leaders, providing for intensive planning for ECCE & promoting convergence between school system & ECCE to achieve convergence of ICDS with SSA. The issue of ECCE has also been addressed through UDISHA. Under SSA for any innovative intervention including early childhood care & development, a provision of Rs. 15 lacs per year in a district has been made. Right from its inception ICDS had unique feature of involvement of Universities and academic bodies & faculty of Medical Colleges as honorary consultants to support the component of training & continuing education monitoring & motivation as also for independent External evaluation through periodic surveys & special studies. This endeavour enriched the system of medical education apart from participation of medical colleges faculty in the national health programmes of mother & child development in a big way. Unfortunately the system of Central Technical Committee was discontinued in year & the formal linkages with medical colleges & universities were abandoned. However it is imperative to revive this system in the wake of proposed universalization of ICDS in tenth plan period; to improve the quality of output & services through continuous contact and feed back. As a matter of fact the expertise & nucleus of leadership to fill the gap of CTC exists, at Apex Institute of NIPCCD, New Delhi to involve & coordinate the medical colleges at the national level with additional support of available talented & experienced ICDS senior consultants drawn from the field 16. New directions and focus of ICDS on young children below 3 years of age, adolescent girls, girl child, women empowerment, involving families & community and care - givers as equal partners, renewed thrust on basic training & continuing education & life cycle approach & early childhood care & education is poised for better outcome in coming years provided sustained commitment at all level & crucial support to anganwadi workers is ensured with convergence of services above all. Investment in ICDS is real investment in human resource development. References: Development, Protection & Survival of young children & adolescent health is family based & mother centred Response 1. ICDS, Deptt, of Social Welfare Ministry of Education & & decisions of parents and mother in particular is vital for Social Welfare, Govt. of India, New Delhi-1976 their survival & development. All along the ICDS scheme has 2. Status report of the ICDS on 30th September 2003, primarily focused on children mostly 3-6 years at AWC s & DW&CD - Personal Communication. devoted most of the time & energies on this front. Precisely ICDS has been Child centred & Child focused, even the UDISHA - new dawn for national training component is Child Centred. The whole programme should be focused-on 'Family-the mother-the women' which form the basis of Child development. Basic training continuing education & on the job Planning Commission. Govt. of India New Delhi. Tenth Five Year Plan Vol. II - Sectoral Policies & Programmes. Govt. of India. National Policy on Education 1986 & Revised on 1992, Ministry of HRD, Govt. of India. Govt. of India. National Nutrition Policy training should focus on family parents & women ; 6. Govt. of India National Population Policy Anganwadis centre should run Anganwadi for women with Department of Family Welfare Ministry of Health & children or contact women in their homes to realize the objective of the scheme. Adolescent girls programme of ICDS is Family Welfare, Govt. of India Nirman Bhavan, New Delhi. partial answer but the coverage is too meager to make any 7. Govt. of India. National Policy for the Empowerment of significant change. women 2001 DW&CD, Ministry of HRD Govt. of India. 151

6 8. Govt. of India. National Health Policy 2002, Ministry of Health & Family Welfare, Govt. of India New Delhi. 9. Integrated Child Development services (ICDS). DW&CD Ministry of HRD, Govt. of India UDISHA - Syllabus for job training of Anganwadi workers National Institute of Public Cooperation & Child Development, 5-Siri Fort Institutional Area, Hauz Khas, New Delhi. 11. UDISHA - The National Training Component for ICDS. Building Human Resources for Meeting Women and Child Development Goals DW&CD, Ministry of HRD Govt. of India, July Guide Book for Anganwadi workers Training centres April 1985 NIPCCD, 5 Siri, Institutional Area, Hauz Khas, New Delhi. 13. Organising Job Training of Anganwadi Workers. Guidelines for Instructors. NIPCCD, Syllabus for Job Training of Anganwadi workers of ICDS Programme. Feb. 1989, NIPCCD, New Delhi. 15. Lal S: ICDS Harbinger of Safe Motherhood & Child development India J. Maternal & Child Health, 1993; 4(1): ICDS - Evaluation and Research Central Technical Committee DW&CD, Ministry of HRD, Govt. of India New Delhi. 17. Adolescent girls scheme - an Evaluation NIPCCD. Siri Fort Institutional Area Hauz Khas New Delhi Development in Practice. Improving Women's Health in India. A world Bank Publication The International Bank for Reconstruction and Development/The World Bank. 19. Directions in Development. Wasting Away. The Crisis of Malnutrition in India. Anthony R.Measham & Meera Chatterjee. The World Bank Washington, D.C the International Bank for Reconstruction and Development/The World Bank. 20. ICDS. A Compendium of Guidelines DW&CD, Ministry of HRD Govt. of India. 21. Better Health & Nutrition of Children. A Guide Book for Public Health workers by WHO UNICEF & CARE Sunder Lal, Dinesh Paul* Prof. & Head, Deptt. of SPM, Pt. BDS PGIMS, Rohtak *Joint Director (CD) NIPCCD, New Delhi 152