BY

CONTENTS
SL. NO TITLE
1. Executive Summary
1.1 Introduction
1.2 Evolution of a common tool for rapid assessment survey.
2 Background of the rapid assessment survey
2.1 About the survey programme of health status of rural pregnant and nursing mo
ther in chendipada Block.
2.2 The rapid assessment of various components under NRHM included
2.3 Preparation of village profile
2.4 Rapid appraisal of the district
3 Objective of the Study
3.1 Areas of Operation
3.2 need of study
4 Criteria for selecting the sample
4.1 Involving stakeholders for the survey at various levels
4.2 Collection & compilation of information
5. Findings
5.1 Analyzing the current status of various components of NRHM
5.2 Community perceptions on ASHA
5.3 General Finding
6. PROBLEM
6.1 problems faced by the ASHA include
6.2 Block level specific findings
6.3 Quality of services received through Maternal Health Guarantee scheme
6.3 The following are the general findings
7. GRAM KALYAN SAMITI
7.1 Regarding Role of GKS in the chhendipada Block
7.2 Funding
8. IMR/MMR
9. Recommendations
• Ensuring regular supply of drugs with ASHA
• Making the VHNDs more effective
• Enhancing the skills of ASHA
• Strengthening of referral & follow up of cases by ASHA
• Streamlining the payments of ASHA
• Providing mobility support to ASHA
• Upgrading the skills of ANMs
• Increasing awareness on JSY
• Strengthening the GKS
• Situation of GKS prior to intervention
• Actions Initiated
10. 10.1 Conclusion
1.1Introduction: The rapid assessment survey of the district health profile was
part of the on-going community health fellowship programme of Master in Social w
ork course. The purpose of this rapid assessment was to understand the gaps in d
ifferent community level processes of public health programmes in the districts
and take up selected interventions on pilot basis and on the basis of the findin
gs the district level public health authority can be approached for initiating s
imilar approach as far as communitization agenda of NRHM is concerned.
The rapid assessment survey was started in 8th August to 23rd August 2010 in chh
endipada block of Angul district to involve 34 panchayat and 100 revenue village
s with 2500 sample size including ASHA, ANM and respective official involve in h
ealth development programme of concern block.
The frame work rapid assessment survey programme focused on three major aspects.
These includes: a) Rapid assessment of the functioning of various components un
der NRHM for pregnant and nursing mother and newborn baby b) Preparation of vill
age profile and c) Rapid appraisal of the district.
1.2 Evolution of a common tool for rapid assessment survey:
The rapid assessment to be done at the district level by respective professional
student. The frame work focused on three major aspects of the survey. These inc
lude
A) Rapid assessment of the functioning of various components under NRHM for imme
diate health support to pregnant and nursing mother and as well as newborn baby
and child below one year.
B) Preparation of village profile and
C) Rapid appraisal of the district.
2. Background
2.1 About the survey programme of health status of rural pregnant and nursing mo
ther in chendipada Block.
The Lo & Mo and Strategy group of consulting has been study in the Chhendipada b
lock of Angul; Orissa from 8th of August to 23rd of August-2010 to promote actio
n research in community based health planning and management. This is a civil so
ciety initiative to support the National Rural Health Mission (NRHM) in partners
hip with National Health Systems Resource Centre, the apex technical support ins
titution for NRHM.
The National Rural Health Mission (NRHM), Government of India’s flagship programme
for health aims to improve the quality of public health services by encouraging
community participation and decentralizing public health planning and implement
ation. The community health fellowships are being to strengthen the capacities o
f field level civil society participation in the NRHM and in the process build a
team of young professionals and dedicated youth with the perspectives and skill
s to contribute to pro-poor community development work throughout the rest of th
eir careers.
2.2 Evolution of a common tool for rapid assessment survey:
The rapid assessment to be done at the district level by respective professional
student of Master in Social work. The frame work focused on three major aspects
of the survey. These include:
A) Rapid assessment of the functioning of various components under NRHM for imme
diate health support to pregnant and nursing mother and as well as newborn baby
and child below one year.
B) Preparation of village profile and
C) Rapid appraisal of the district.
A) The rapid assessment of various components under NRHM included
a) Community perceptions on ASHA
b) Assessment of functioning of ASHA
c) Quality of services received through Maternal Health Guarantee schemes-
d) Quality of service delivery of Janani Suraksha Yojana
e) Awareness on Janani Suraksha Yojana
f) Assessment of the functioning of Rogi Kalyan Samiti
g) Assessment of the functioning of GKS
B) Preparation of village profile- The village profile was to be compiled for th
e sample villages using specific of Social mapping, seasonality mapping, and mat
rix ranking, and time analysis, formal and informal interview with health servic
e providers (ANM/AWW / Doctor/Traditional healers) and focused group discussions
(FGD).
C) Rapid appraisal of the district- The relevant information on various aspects
was to be collected from various sources. The focus was on collection of distric
t specific a) Health Infrastructure and Human resource. 2) civil society group w
orking in public health sector.3) Identifying potential resource person and indi
vidual interested in public health etc.
2.3 Objective of the Study:
The objective of the study was to focus on situation of health status of pregnan
t and nurshing mother in rural community after 5 years intervention of National
Rural Health Mission (NRHM)
The following study was imparts multidisciplinary knowledge to the young soci
al work back ground professionals that process that has action and reflection in
built into it. The focus is on creating community health professionals with high
motivation and technical competencies to work with people, civil societies and
the state to further the ideals of “Health for All”.
2.4 Areas of Operation:
Survey programme has been initiated in 34 panchayat including 100 revenue villag
e of chhendipada block, under Angul district, Orissa.
2.5 need of study:
The need of having a study of the district health profile was a part of the Nati
onal Programme design for the improvement of health condition of rural as well a
s tribal and urban people. In this context there was a need to bring about healt
h awareness among the rural and tribal people under chhendipada block of Angul d
istrict and easily access the availability of health facility after intervention
of NRHM programme. Further it was also envisaged that a common framework shall
help to collate the findings of state by collecting information of respective di
stricts against the stated parameters while also comparisons can be made basing
on the findings of various block of district. This resulted in the initiation of
a national level induction cum orientation programme for the professional socia
l work student of Orissa.
The planning of study on health status of pregnant and nursing mother in chhendi
pada was entirely participatory and a lot of inputs of collective information th
rough primary and secondary information, which is bring a basic and common under
standing about the district public health system in the mind of the professional
social work student.
To bring clarity in the understanding regarding their interventions, equ
ip them with tools and skills for rapid assessment, and get them exposed to vari
ous replicable public health models, programmes and facilities.
To have a firsthand understanding on the levels of community participati
on in various ongoing health initiatives under NRHM and the current district hea
lth situation
To understand the gaps in different community level processes in due cou
rse of their research during the two years and help take appropriate community l
evel actions to bridge up the gap
To share the findings with key stake holders at the district and communi
ty level for sensitizing them on various emerging health issues while also initi
ating collaborative actions including training, action research, monitoring, dev
eloping replicable models, ensuring better coordination and documenting case stu
dies leading to the strengthening of various communitization initiatives of NRHM
To get accepted by the public health system run by the district health a
dministration and influence them for supporting their initiatives at the distric
t and community level.
The rapid assessment survey was an initiative by the professional social work st
udent in respective districts of Orissa.

3. Criteria for selecting the sample:

The sample size selected was on the basis of convenient sampling. Looking into t
he very short time line of the completion of the report one blocks were chosen f
rom angul district for the survey, Which was close to the district head quarter
around 20-30km distance from the head quarter. Further 2 villages were selected
from each panchayat. One village was chosen close to the facility level at the b
lock (PHC/CHC) and the other around 20km from the block. It can be noted that co
nsideration was given in selecting villages where we had key stakeholders who vo
lunteered to support our initiatives instantly and there were existing MSW stude
nt/course participants.
3.2 Involving stakeholders for the survey at various levels:
The rapid assessment survey marked the involvement of multiple stakeholders at v
arious levels to ensure credibility of the findings and to get a legitimate spac
e for sharing the findings among the critical mass at the community, block and d
istrict level for necessary action. The following steps were involved to ensure
complete participation of stakeholders:
a) Issue of letter from the Mission Director to the district health administrati
on regarding the support to be extended to the CHFs of the respective districts.
b) Issue of letters from the CDMO to the respective district NRHM and MOI/C of P
HC and CHC of chhendipada.
3.3 Collection & compilation of information:
The data were collected from primary sources through FGD, and personal interview
. The secondary information was collected at the district level from the office
of CDMO, RCH Coordinator, MOI/C, ASHA, ANM And AWWs, PRIs,
The information collected from primary sources was immediately validated with t
he support of stakeholders of the respective villages who were involved in facil
itating the rapid assessment survey. The secondary data were also collected from
reliable sources. Thus the reliability and authenticity of the data collected w
ere maintained.
District specific information was collated by taking the findings of the 100 sam
ple villages including 2500 stake holder. The findings were compiled as per the
components specified in the rapid assessment formats. Basing on the findings of
the respective Block and district specific report has been compiled by assimilat
ing the information of the specific block. The sample size selected was on the b
asis of convenient sampling. Looking into the very short time line of the comple
tion of the report one blocks were chosen from each district for the survey, whi
ch was close to the district head quarter and the other was around 20-30km from
the head quarter. Further 2 villages were selected from each panchayat. One vill
age was chosen close to the facility level at the block (PHC/CHC) and the other
around 20km from the block. It can be noted that consideration was given in sele
cting villages where we had key stakeholders who volunteered to support our init
iatives instantly and there were existing professional/course participants.
4. Findings
The findings of the rapid assessment have to be understood in the context of:
a) Analyzing the current status of various components of communitization process
es of NRHM
b) The issues at the community level and the possible bottle necks in ensuring e
quitable, accessible and affordable health care services.
c) The current situation at the district level regarding the management of effec
tive health care delivery.
The findings are direct observations and do not compare with any previous findin
gs or recommendations.
4. Analyzing the current status of various components of NRHM
4.1 Community perceptions on ASHA: The flagship of the community participation i
s undoubtedly the ASHA programme. It is pertinent in this context to know the re
flections of the community on the functioning of the ASHA. The group discussions
were initiated with 10-15 women members in each sample village who represented
the community. In some cases more than one group discussion was initiated with G
KS members in the same village to capture the entire social configuration.
General Finding
The general findings of the perceptions of the community are as given below: The
only information they received was from the ANM which was completely inadequate
. The ASHA has been a solace to many of their owes as they have been able to get
an opportunity to interact frequently on care during pregnancy and newborn care
.
There has been an overwhelming response of the community in stating that the ASH
A is playing a critical role in facilitating the process of registration, admini
stration of TT, consumption of IFA, chemoprophylaxis, colostrums feeding, exclus
ive breast feeding, immunization etc besides giving routine counseling. Further
the intervention of ASHA has resulted in dispelling various blind beliefs and th
ey are able to avail of proper medical counseling and services on time regarding
care during pregnancy and new born care.
ASHAs not only accompany all the pregnant women for delivery but also remain dur
ing the delivery and till the mother reaches home. In many cases the ASHA was re
ported to have stayed for more than 3 days due to complicacy and delay in pregna
ncy. It can be further noted that barring few exceptions in almost all the cases
the ASHA has reached the household within 6 hours of delivery and have counsele
d on new born care including colostrums feeding, exclusive breast feeding, immun
ization and basic hygiene.
The ASHA also has played a major role in organizing monthly health days for immu
nization and other health services. The ASHA collected the names of beneficiarie
s for the health day and informed them in advance to ensure maximum participatio
n.
The community further responded that though ASHA plays her role in provi
ding medicines on time for simple illness like fever, diarrhea, cough etc there
is a perennial problem of shortage of medicine.
The following are the general findings on the functioning of ASHA in chhendipada
:
The Village Health and Nutrition days (VHND) were observed every month w
here ASHAs participated in collaboration with the ANMs and AWWs in almost all th
e villages. In few villages the SHGs also joined the Village Health and Nutritio
n Days. The ASHA gets the information of pregnant and lactating mothers, Grade-I
II and Grade-IV children from the ANM and AWW before the day is observed to have
effective coordination. In general the following activities are done in the VHN
Ds including: a) Weight measurement of pregnant woman and Children with the age
group of 0 to 3 years. b) BP and abdominal check up of pregnant women, c) Referr
al checks up of sick children and d) medicine distribution.
No specific refresher training has been given to the ASHA by any resourc
e person or the ANMs. It was stated by the ASHAs that they sometimes try to clar
ify certain doubts during the ANMs visit. Though no refresher training programme
has been done the 4th round training is completed.
The observations revealed that ASHAs have accepted that advising pregnan
t women for institutional delivery has been one of their prime agenda and they h
ave not failed in that aspect.
It was also reported that the ASHA starts rigorous counseling after know
ing the Expected Date of Delivery (EDD) of the patient regarding the benefits of
institutional delivery.
In all the cases the ASHA accompanies the pregnant women who go for inst
itutional delivery. In most cases they had to stay with the patient in the hospi
tal for 2-3 days till they are discharged and ultimately returns with the mother
.
The ASHA have timely referred the patients to the nearest PHCs/CHCs. Mos
t of the cases included patients suffering from TB, Malaria, skin disease and le
prosy. In most cases the follow up has not been possible and there was difficult
y in knowing whether the patient received the right treatment or not.
The ASHA received the financial incentives according to the norms fixed
by NRHM. Though no substantial delay in payment was stated by the ASHA, however
they raised the concern in the delay of payments in the case of slide collection
, net impregnation and immunization.

PROBLEM
The problems faced by the ASHA include:
Non availability of drugs for the drug kits on time
Mobility within the health centers due to lack of communication facilities.
Lack of proper coordination with beneficiaries and other service providers du
e to non-availability of mobile phones.
Gradual loss of skills as no refresher training is given.
Problem in residing in hospital when they accompany the pregnant women to the ho
spital as there is no special room for use.
No sufficient uniform given to them for daily use.
Frequently moving to the respective PHCs/CHCs for collection of incentives which
becomes extremely painstaking and incurs cost as payments are not made on the s
pot. In many cases they reported of travelling many times to a particular PHC/CH
C to enquire the status of their incentives.
Block level specific findings: The above findings are a generalization of the in
formation collected from the above mentioned sample size. However there are cert
ain specific observations in particular chhendipada block. In the district of An
gul the ASHA do face the problem of receiving financial incentives for slide col
lection and net impregnation. Some Asha were reporting that, they had unable to
receive the immunization fees since last 6 month.
In most of the cases the ASHAs have identified the TB symptomatic, have accompan
ied the patient to the PHC/CHC. They have acted as DOTs providers and have succe
ssfully completed the treatment regime. The initiatives taken by the local civil
societies in improving their capacity to address the issues relating to TB, HIV
/AIDS and leprosy have made the referral of cases and follow up very effective.
The ASHAs have played a significant role in participating in the Village health
and Nutrition Days (VHNDs) in the chhendipada block. The ASHA has been very effe
ctive in mobilizing the pregnant mothers and the children and have ensured that
there is a) weight measurement of the pregnant women and children with the age g
roup of 0-3 years b)BP and abdominal check up of the pregnant mother c)distribut
ion of take home ration(THR) d)referring of sick children and e)distribution of
medicines.
4.2 Quality of services received through Maternal Health Guarantee scheme:
To assess the quality of services received by the beneficiaries of the maternal
health guarantee scheme, group discussions were initiated with women in the samp
le villages who have delivered in the last 3 months either in an institution or
at home. The beneficiaries were made aware about the various entitlements in the
context of maternal and child health.
The following are the general findings:
The beneficiaries reported that the ANMs registered the beneficiary’s name
after confirmation of pregnancy. Further the study revealed in few cases it was
found that ANMs do not significantly contribute to the recommended 4 times exam
ination of BP and abdomen prior to delivery. In most cases the beneficiaries did
their examination at the sub divisional /district head quarter hospital. In cas
es where ANM has done the examination the BP checkups have been the most neglect
ed.
The Beneficiaries have received the right dose of IFA from the ANMs. In
many cases it was stated by the beneficiaries that the ASHA played a critical ro
le in following up the actual consumption of IFA of severely anemic cases. Apart
from IFA, chloroquine has also been given to prevent malaria during pregnancy.
All the beneficiaries have received TTs from ANMs on time. However in ca
ses of beneficiaries who have done their ANCs in hospitals they have received th
e TTs directly from the hospital.
In almost all the cases it was reported that the blood and urine of the
beneficiaries were tested by the ANMs.
Though the ANMs have referred the beneficiaries for institutional delive
ry they stated that they were more influenced by the ASHA.
Further the ANMs attended the beneficiaries at least once after delivery
.
The ASHA has attended all the home deliveries and all the beneficiaries
have received regular diet from the AWW.
ASHA are more reliable to beneficiaries rather then ANM.
Regarding Role of GKS in the chhendipada Block:
There has been no structured capacity building initiative taken to strengthen th
e GKS. However there have been sporadic attempts in building capacity on record
maintenance, preparing village health plans and maintenance of accounts. The MOs
, BPOs, BEEs and BADAs were the trainers.
Funding: The GKS is designated to receive Rs.10000/- as untied funds per year. T
hese funds are deposited in their bank accounts where the chairman and the AWW a
nd ASHA are the joint signatories. They are authorized by the committee for fina
ncial transactions. The withdrawal of the money was only after the approval of t
he members of the GKS. The AWW maintains the accounts. The MOI/C is the certifie
d authority for the funds utilization. The members lacked in awareness about fin
ancial transparency like social audit. All the GKS maintains registers which con
tains resolutions and expenditure details. But it was observed many GKS did not
have idea to maintain accounts and resolution register, however they are unable
to maintain the records as no training has been given in this regard. As maximu
m of the GKS were formed at the last quarter of the previous financial year the
spending has been limited to Rs.2, 500/- on an average. This year the transfer o
f money has not been uniform and seems erratic due to lack of timely release of
money to the DPMU by the state mission directorate. Therefore the spending has n
ot been significant. The amount spent has been mostly towards preparing the Swas
thya Kantha, conducting monthly meetings, giving honorarium to AWW & ASHA and cl
eaning of village drains and minor repair and cleaning of drinking water sources
and support to poor patient who has unable to fund for further treatment or pur
chase medicine . There has been no prior estimation of expenses done by maximum
of the GKS.
Activities: The monthly meetings of the GKS were not regular. No major activitie
s have been planned nor taken up at this stage as they do not have clarity on ho
w to plan their spending. However there have been sporadic activities on develop
ing swasthya kantha, organizing cleanliness drives, repairing and cleaning drink
ing water sources.
4.3 District- Angul-The prevalence of malaria is very high and is throughout the
season. It is more prevalent in the months of June and July. The other diseases
which are also seen are dysentery, gastritis, joint pain, anemia, leprosy and T
B. Skin diseases are highly prevalent among children due to usage of polluted wa
ter.
5. IMR/MMR
The very rare Infant mortality cases are identified through discussion with bene
ficiaries in different sample village. Also it was found deaths of the children
(under 1 yr) in the last one year in the sample villages were due to malaria and
other diseases and death within a week of delivery. In case of women the deaths
were due to complications during delivery, due to anemia, malaria, irresponsibi
lity of the family members and lack of transportation facility, lack of frequent
ly availability of janani express.
The issues identified were: a) Lack of safe drinking water sources b) High preva
lence of malaria with low awareness on prevention and control c) Poor sanitation
facilities d) Low level of awareness on the roles and responsibilities of the G
KS members e) Low level of awareness of the community on various health related
entitlements f) Accessibility to health institutions.
6. Recommendations
The recommendations are on the basis of the findings from the rapid assessment u
ndertaken in the 100 villages of the 1 sample block of angul district. The recom
mendations are:
Ensuring regular supply of drugs with ASHA- The drug kit supplied to ASH
A should always have the essential drugs to ensure timely distribution to the co
mmunity. The MOI/Cs and ANMs should play a critical role in ensuring the timely
supply of drugs to ASHA and maintenance of stocks.
Making the VHNDs more effective-The coordination of ANMs and AWW with th
e ASHA should be made more effective for ensuring greater participation of the b
eneficiaries. The participation of SHGs can be initiated as they can be potentia
l agents to follow up the activities of the VHND, discuss issues at a more close
r circuit and with regularity and can advocate for certain causes which emerge a
t the village.
Enhancing the skills of ASHA- There should be a refresher training of th
e ASHA on all the 4 rounds of trainings given to them. This shall help in upgrad
ing their skills by bringing more clarity on their responsibilities.
Strengthening of referral & follow up of cases by ASHA-Trainings on spec
ific diseases like TB, Maleria, Leprosy and other ailments can help the ASHA in
identifying symptomatic and refer cases on time. The GKS can play a critical rol
e in recording the referral cases done by ASHA and monitor the follow up of ASHA
in ensuring that the patient gets the right treatment.
Streamlining the payments of ASHA- The payments of the ASHA with respect
to slide collection, net impregnation and immunization should be streamlined. F
urther in case of additional incentive based work if designed to be given, it sh
ould be clearly defined and budgetary provisions made clear to keep the morale o
f ASHA intact.
Providing mobility support to ASHA- The ASHA can be given minimum mobility suppo
rt to ensure timely interventions and reduce the difficulty in her operation.
Upgrading the skills of ANMs- Specific refresher trainings of the ANMs on BP mea
surements, examination of blood and urine is required to have more qualitative i
nterventions. Further they should be provided with new instruments for measuring
BP and weighing machines.
Increasing awareness on JSY- The awareness on JSY should be organized at the com
munity level involving the GKS, ASHA and ANMs so that institutional delivery is
enhanced.
Strengthening the GKS- There is a need for a structured capacity building progra
mme to sensitize the GKS on their roles and responsibilities, preparing health m
icro plans, maintenance of
Situation of GKS prior to intervention
Irregularity in meeting
Minutes of the meeting not recorded
The funds utilization was only up to Rs 500/-
The members were unaware of their roles and responsibilities.
There was no plan with estimated budget.
Actions Initiated
i)Organizing a meeting with the GKS members to share a)the village health profil
e prepared from the PRA exercise, b)the objectives behind the formation of GKS a
nd c)the Untied Fund given to the GKS and its probable use with the villagers.
ii) Sharing with the DPM and District ASHA coordinator about the status of the G
KS and the need for organizing orientation and capacity building of the GKS memb
ers for better functioning.
iii) Imparting training to the convener about the writing of minutes, maintainin
g the Cash Book and preparation.
iv) Assisting the GKS members in preparing a health plan with an estimation of R
s10, 000/-.
v) Presentation of the finding in the District Coordination meeting of MO I/Cs a
nd CDPOs as well as in the monthly meeting regarding the intervention and the fo
llow up support required.
vi) Discussion with the GKS members for taking steps for Nutritional activity li
ke promoting the kitchen garden, promotion of sanitation drive etc.
vii) Intensive discussions were initiated with the DPM regarding the preparation
of Health Plan in every GKS in the district with the help local NGOs MNGO and t
he with technical guidance from the technical health support team.
ix) It has been planned to do Village micro plan in five villages on a pilot bas
is for scaling up of the same in the entire block.
7. Conclusion: The rapid assessment survey though had inherent limitations howev
er it has brought into light various current bottle necks inhibiting the success
of the communitization initiatives of NRHM. It has tried to understand the curr
ent situation and make small pilot initiatives to activate various processes and
build a group of potential individuals interested in strengthening public healt
h initiatives. The rapid assessment shall be followed by more intensive engageme
nts with support from the district health administration, civil society, potenti
al individuals, research institutions, media and the community.

Observation Report preparation By

Utpal Ku. Dasgupta