Rural Internship Report

Assignments

CARE India, Patna, Bihar

SUBMITTED BY

Shreya Anjali -M2020HE034

Master of Public Health - Health Administration

School of Health Systems Studies

Tata Institute of Social Sciences

Mumbai
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 Table of Contents

1.Organisation Profile…………………………………………………………………3-10
2.Community Profile…………………………………………………………………..11-15
3.Individual Assignment A……………………………………………………………
4.Individual Assignment B……………………………………………………………

Annexure
Barriers and challenges in Routine Immunisation Tools
Weak New-born tracking form/case record
Assessment Sheet
Attendance Sheet
Weekly Reports

List of Figures and Tables

Figure 1- Themes on which CARE India works

Figure 2- Functions of CML
Figure 3- Grants & donations received (in %)
Table 1- General characteristics of households in Arap
Table 2- Age wise distribution of households in Arap
Table 3- Distribution of households by religion and caste groups in Arap (%)
Table 4- Occupation diversification in Arap (%)
Table 5- Incidence of migration in Arap

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 GROUP ASSIGNMENT I

1.ORGANISATION PROFILE

INTRODUCTION

For more than 65 years, CARE has worked in India to alleviate poverty and social isolation. They
accomplish it through implementing well-thought-out and comprehensive health, education, livelihoods, and
disaster planning and response programmes. They also concentrate on producing and sharing knowledge
with a variety of stakeholders in order to influence long-term impact at a large scale.

EVOLUTION-HISTORY

CARE (Cooperative for Assistance and Relief Everywhere, formerly Cooperative for American Remittances
to Europe) is a significant worldwide humanitarian organisation that provides emergency aid as well as long-
term international development projects. CARE is a non-profit organisation founded in 1945 that is "non-
sectarian, non-partisan, and non-governmental”. It is one of the world's largest and oldest humanitarian relief
organisations dedicated to eradicating poverty around the world. CARE worked in 94 countries in 2016,
supporting 962 poverty-fighting and humanitarian aid initiatives, and affecting over 80 million people
directly and 256 million indirectly. While CARE has been working in India since 1946, the Indo-CARE
Bilateral Agreement was signed in 1950, making it the organization's official arrival in the country. Through
different interventions, CARE India has actively contributed to the country's overall social development
over the years.

During the year 2019-20,CARE India directly reached out to 50.4 million people through 53 projects across
19 states.

PHILOSOPHY, GOALS AND APPROACH:

PHILOSOPHY: Women and girls are disproportionately affected by poverty and inequality, and they are
subjected to "abuse and violations in the realisation of their rights", entitlements, and access to and control
over resources, according to CARE.

PROGRAM GOAL: “Women and girls from the most marginalised communities are empowered, live in
dignity and their households have secure and resilient lives. CARE India aims to accomplish this goal by
working with 50 million people to help them meet their health, education, and livelihoods entitlements and
aspirations.”

VISION: “CARE India seeks a world of hope, tolerance and social injustice, where poverty has been
overcome and people lie in dignity and security.”

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MISSION: “CARE India helps alleviate poverty and social exclusion by facilitating empowerment of
women and girls from poor and marginalised communities.”

APPROACH: Over the years, CARE India's programming strategy has changed significantly. CARE India
has evolved into a "rights-based organisation" in order to address the fundamental causes of poverty, from
direct service provision to empowering poor and vulnerable populations. The well-being, standing in
society, and rights of women and girls from marginalised communities are explicitly prioritised.

Figure 1: Themes on which CARE India works

STRUCTURE OF CARE India-Bihar

In 2010, the Government of Bihar (GoB) and the Bill and Melinda Gates Foundation (BMGF) signed a
Memorandum of Cooperation (MoC) under which BMGF pledged to give technical assistance to GoB in
order to enhance "health and nutrition outcomes" across the state. A Technical Support Unit (TSU) was
established in 2013 as part of this MoC, with CARE India as the principal development partner. The Bihar
TSU intends to assist the Government of Bihar's Health and Social Welfare (ICDS) Departments in their
efforts to achieve fast and long-term improvements in health and nutrition outcomes. The TSU aims to
provide specialized technical assistance across the State for the Government of India's (GoI) "RMNCH+A
interventions, the GoB's Manav Vikas Mission goals, and the Kala-Azar eradication goals". Towards end of
2015, the GoB and BMGF have extended the MoC resolving to support the state till 2021 to achieve the

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developmental goals. This assistance is provided at all levels, from the state level to the Health Department,
the ICDS department, and the State Health Society of Bihar (SHSB), as well as at the district and block
levels across the state's 534 blocks. Bihar TSU has built a State Resource Unit (SRU) and District Resource
Units (DRUs) in 38 districts as part of the MoC agreement to effectively serve the goverment's intention for
embedded facilitation at the district level. The SRUs and DRUs are intended to provide high-quality
technical assistance to the Health and ICDS Departments in the areas of "reproductive, maternal, and child
health and nutrition, as well as visceral leishmaniasis". The DRUs provide organised assistance for
programme operations in the above technical domains to "district and block level teams of the Health and
ICDS Departments". The SRU and DRUs' programme implementation operations assist government
projects, and they virtually always involve government officials. The SRU and DRUs rely on CARE's state-
based programme support team to carry out scheduled operations and meet any pressing demands from
district and state administration. SRUs and DRUs frequently require services and goods to be available in
several places for specific technological components. The Strategic Program Management Team (SPMT) at
the state level offers overall management support to SRUs and DRUs, as well as facilitating prompt
administrative support from the programme support unit.

Concurrent Measurement and Learning (CML) team: A separate vertical within the TSU, the CML
team is equipped to play three key roles:

 Generate data independently of reported numbers, on a wide range of input-process outcome

indicators periodically, to serve as a dependable mirror for TSU and government programme
leadership
 Conduct or support exploratory, formative and intervention studies and pilots
 Utilize its extensive data experience to assist other TSU teams in their efforts to improve quality of
the data and use in collaboration with government programme teams.

The available information from MIS of the two government projects, as well as the data gathered by DRUs
and SRUs, is supplemented and validated to some extent by the data created by the CML team. A month - to
- month rhythm of "internal data-based reviews", planned for a week every month as a 'home' week, has
helped guide the TSU's internal functioning as well as provide opportunities for continuous internal capacity
building in order to enforce this framework with the envisioned roles and functions for each stakeholder.

CML-FRAMEWORK-Concurrent Measurement and Learning provides actionable evidence to program

eco-system for sustainable and scalable programming through evidence-based program management. This is
aimed towards making the system more data-hungry and data-savvy so that the appetite and capacity of data
usage are built into the system to culminate into data-driven decision-making without further catalysis.

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 Figure 2: Functions of CML

PROGRAMS AND PROJECTS OF CARE INDIA IN BIHAR:

CARE India has a number of projects on the ground that focus on "improving nutrition, maternal and
newborn health, and communicable diseases" for the marginalised people who are otherwise dependent on
the government systems to access health care. The collaboration between BMGF and the Government of
Bihar to enhance health systems in the state has been strengthened to ensure that some of the poorest
communities have "access to quality health and nutrition services". CARE India's operating model is as
follows: While fighting poverty, one of the most important elements to consider is Health. Good health not
only improves one's quality of life, but it also allows women to lower their financial burden from
unanticipated expenses.

1. Strengthening health systems in Bihar: All 38 districts of Bihar are involved in efforts to increase
disadvantaged households' access to health services. The Technical Support Project of CARE India has
increased its reach in support of the Government of Bihar's health programmes to include several families
that previously did not have access to health care. Since 2012, the Bill and Melinda Gates Foundation has
been a supporter of the programme.

2. Bihar Technical Support Programme (BTSP): The Bihar Government's Health and Social Welfare
Departments benefit from the BTSP's catalytic support. The programme assists the two departments in
"improving the quality and coverage of maternal and child health, family planning, and nutrition
interventions" by transforming capabilities and behaviours, increasing ownership of health programmes, and
unlocking the potential of both public and private sector providers.

3. Improving treatment for child health: The project's primary objective was to figure out how better
"community and low-level facility management" may lead to a lower pneumonia and diarrhoea case fatality
rate at the block level in Bihar. With financing from the BMGF, CARE launched the "Integrated Family
Health Initiative (IFHI) in 2011 as part of the Ananya initiative".

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4. Strengthening health and nutrition strategies in community platforms: The Government of India has given
the National Rural Livelihoods Mission (NRLM) / Aajeevika the task of ensuring that India's economic
progress is inclusive and lead to significant reductions in rural poverty.

5. ICDS Systems Strengthening and Nutrition Improvement Project (ISSNIP): In order to improve
performance of ICDS program and to strengthen key systems in ICDS, World Bank group assists the
Ministry of Women and Child Development (MWCD), through a project named “ICDS Systems
Strengthening and Nutrition Improvement Project (ISSNIP)”.

6. Public Health Campaign: To strengthen healthcare systems and promote the health and social value,
CARE India created the very first "Public Health Campaign Brand" in India, 'Swasth Bihar, Samriddh
Bihar' (Healthy Bihar, Prosperous Bihar), which was accepted by the Bihar government as a communication
innovation.

7. Capacity Building of Health Workers: A “skill building programme AMANAT- (Apatkalin Matritva
Avum Navjaat Tatparta Karyakram)” for “doctors, nurses, and midwives in all public health facilities” was
started in Bihar.

8. Better Monitoring of Immunisation reach: The success of Bihar's routine immunisation programme,
which was previously maintained manually, is now tracked online via a web portal interface, allowing for
real-time analysis and online sharing of statistics and graphs.

9. Providing Techno- Managerial Support to government: Since June 2014, the State Resource Unit (SRU)
has been assisting the Government of Bihar in implementing the "National Urban Health Mission" in
fourteen districts.

10. Strengthening Blood Banks

11. Providing Logistical and Technical Support for family planning: CARE India assisted 39 providers from
nine medical institutes with logistical and technical support.

12. Scale-up of Village Health, Sanitation and Nutrition Day (VHSND) programme: VHSND is a village-
level platform that provides community members with immunisation, family planning, as well as other basic
health services.

13. Scale-up of VL Activities: CARE India ramped up the effort to fight Kala Azar, or Visceral
Leishmaniasis, in collaboration with the state Vector Borne Diseases Control Program in Bihar and
Jharkhand .

FUNDING/ FINANCIAL MANAGEMENT-Institutional funding is typically given to organisations in the

form of significant grants and financial support for large-scale actions that require a great deal of money.
Stability is ensured by institutional donors' ongoing funding, which enables for more systemic and long-term
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transformation through policy reforms, campaigning, research, and novel intervention approaches. As a
result, such support is critical in broadening the scope of outreach to "national and international levels",
ensuring that all people have equal chances to reach their full potential.

The following figure* represent grants and donations received by CARE India in the financial year 2020-21-

Institutional Grant 1,819

Corporate Grant 110

Individual Donation 1,819

Other Income 41

Total 2,022

*Rs in mn

Figure 3:Grants & donations received (in %)

CARE India’s Financial Statements

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ACHIEVEMENTS, RECENT AWARDS AND RECOGNITIONS, RECENT AWARDS AND
RECOGNITIONS

Year 2021

 At Gap Inc. P.A.C.E. Awards 2021, CARE India’s Women + Water Alliance received two awards:
“Leaving your Mark” and “Our Voice Our Power” for their work in making a difference in the lives
of marginalised women.

Year 2020
 The ‘National Awards for Exceptional Achievements’ by the Ministry for Women & Child
Development to Aanganwadi workers associated with the ‘Khushi project’

Year 2019

 The Ministry for Women and Child Development chose two Anganwadi workers for the "National
Awards for Exceptional Achievements" in January. Hindustan Zinc Limited, which sponsors the
Khushi Project, received the "CSR Health Impact Award 2019" in June for its support of the project,
which has been dubbed a "Game Changer".

Year 2018

 CRISIL awarded CARE India a “VO 1A” rating, which indicates “Very Strong Delivery Capability
and High Financial Proficiency”

Year 2017

 The Digital Trailblazers Award Today Group in Patna, Bihar.

Year 2016

 The State Government has given a special award for outstanding support and commitment to the
Kala Azar Elimination Programme in Bihar. The Where (WfRF) Community Based Adaptation
Project was named India's most trustworthy "NGO in the AXA Global Corporate Responsibility
Week Award".
 The "Horlicks Ahaar Abhiyan" won the "Best Ooster Award at the Global Symposium on Health
Systems Research Support" for the Briddhi project, which works to improve and provide nutrition
support to children in West Bengal.

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 GROUP ASSIGNMENT II

2.COMMUNITY PROFILE

Patna

The district has a total area of 3,202 sq km., 270 sq km is urban and 2932 sq km is rural. Out of total
population of Patna, 6,480,697 in the district, 2,514,590 are in urban area and 3,323,875 are in rural area.
429,424 households are in urban, 546,154 are in rural area. 1,769,307 literate people are in urban, 1,690,372
are in rural area.

Block-Bikram

According to the Census of 2011, Bikram Block in Patna district has an overall population of 169,510
people. Males account for 88,463, while females account for 81,047. In 2011, Bikram Block had a resident
area of 27,760 households. Bikram Block's average sex ratio is 916. In addition, the Urban Sex Ratio in the
block is 929, while the Rural Sex Ratio is 914.

According to the 2011 Census, 13.3 percent of the population reside in urban areas, while 86.7 percent
reside in rural regions. The literacy rate in urban region is 76.5 percent, while it is 70.5 percent in rural
areas. Block has a male literacy rate of 68.61 percent and a female literacy rate of 50.25 percent.

In the block, there are 27253 children aged 0 to 6, accounting for 16% of the total population. Between the
ages of 0 and 6, there are 14237 male children and 13016 female children.

Villages in Bikram block-

“Akhtiarpur, Amwa, Anharipur, Arap, Baghakol, Baigawan, Baliari,Barah,Barda,Bauwan,Beni, Bigha,

Berar Beri,Bhadsara,Birdhaur,Chandni,Chandri,Chauthia,Chichourha,Chihunta,Danara,Datiana,Donrapur,
Gona Dullahpur, Faridpur,Girwari Tola, , Gopalpur,Gorakhri,Gulami Chak,Habaspur, Harpur, Hathsar,
Jamalpur, Janpara, Kanpa, Katari ,Lahladpur,Mahajpura,Mahammadpur,Majhanpura,Majhauli,Math Baliari,
Milki, Moriawan, Nagahra, Nasirpur, Painapur,Pakrandha,Patut, Raghunathpur,Rahi,Saidabad,
Sangrampur,Sarwan,Shahjahanpur,Shahpur, Shivgarh,Sikaria,Sundarpur,Tari,Wazirpur”

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 Community profile of village Arap in Bikram block in Patna

Location of Arap

The village Arap, in Bikram block of Patna district, is situated at about 40 km away towards south from the
district headquarters of Patna, the capital of Bihar. The distance of the village from the block headquarters of
Bikram is about 7 km. Two small towns namely, Bihta and Naubatpur are also situated in the close
proximity of Arap and cater to day to day needs and requirements of the villagers. Bihta is about 12 km
away from the village in north-west direction and Naubatpur is in the north at a distance of 8 km.

Climate and Rainfall

The climate of Arap village is characterized by quite hot summers to moderately cold winters. The day
temperature ranges from 21°C in January to 43°C in June/ July and night temperature ranges from 7°C in
December to 28°C in June. The summer season begins from April and peaks in May-June. The rainy season
starts from late June and continues sometimes up to early October.

Demography

Particulars Labour Small Medium Large ALL

Size of land ≤0.50 0.51 to 1.32 to 3.00 ≥3.01
1.31
Area 145.34 99.11 151.81 251.89 658.15
Population(no.) 479 (66.34) 96 (13.30) 87 (12.05) 60 (8.31) 722 (100)
Average age (in years) 24.99 28.29 28.71 30.89 26.54
Education (years in average) 3.40 6.38 7.26 8.37 4.83
Family size (no. in avg.) 5.86 5.96 6.67 8.10 6.16
Headed by male (%) 96.23 93.68 95.40 96.67 95.83
Female to male ratio (per 875 784 911 755 853
1000)
Literacy Rate (%)
All 60.52 82.90 83.34 91.22 70.73
Male 71.91 92.91 95.02 97.98 80.97
Female 47.59 70.14 80.58 82.74 58.76
Table 1: General characteristics of households in Arap

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 Age group Labour Small Medium Large All
Below 5 years 407 66 57 42 572
6 to 16 years 750 117 111 89 1067
17 to 30 years 751 177 154 149 1231
31 to 60 years 798 173 195 154 1320
Above 60 years 95 66 41 52 224
Table 2: Age wise distribution of households in Arap

Population detail Labour Small Medium Large All

Muslim 7.1 0.0 0.0 1.7 4.9
Hindu 92.9 100 100 98.3 95.2
SC 33.3 5.2 0.0 1.7 22.4
ST 0.0 0.0 0.0 0.0 0.0
General 2.5 35.4 67.8 86.4 22.6
OBC 64.3 59.4 32.2 11.9 55
Table 3: Distribution of households by religion and caste groups in Arap (%)

Social Groups

Arap has a mosaic of population of different castes and creeds. It has Hindus and Muslims in the proportion
of about 95 per cent and 5 per cent, respectively (Table 3). Among Hindus, the OBC population out numbers
that of all other caste groups. “Bhumihar Brahmin, Kankubj Brahmin, Koiriee, Chamar, Dusadh, Pasi, Nutt,
Kanu, Teli, Nayee, Kumhar, Badhai (Carpenter), Dom” etc. are among the different caste groups in the
village.

Occupation

The majority of households are engaged in diversified livelihood activities in Arap village. About 30 per
cent population of different categories of households are found to be working and pursuing a variety of
occupations. Non-farm employment emerges as main employment generating activity in the village.

Particulars Labour Small Medium Large All

Working population (%) 30.1 32.1 32.3 28.6 30.5
Share in working population (%)
Cultivators 18.4 43.2 51.3 47.8 29.3
Dairy farmers 1.7 0.6 2.1 2.2 1.6
Agricultural worker/labourer 3.5 0.6 0.0 0.0 2.2
Non-farm worker 58.2 33.3 27.3 13 45.9
Government employees 2.7 9.8 13.4 26.1 7.6
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 Others 15.6 12.6 5.9 10.9 13.4
Table 4: Occupation diversification in Arap (%)

Migration

The incidence of migration from the village is common. People have been migrating to other places/states
for employment. Among the various caste groups, "migration of OBC and SCs" is common and
widespread. Ironically, the migration from the large farm households is more than any other household class
as against the common perception that members of labour and small farm households migrate more from the
villages of Bihar. It is seen from Table 8 that 10.5 per cent of the labour, 22 per cent of the small, 20.9 per
cent of medium and 28.4 per cent of large households live outside the village due to one or other reasons.

Particulars Labour Small Medium Large All

% People living outside the village 10.5 22.1 20.9 28.4 15.3
Purpose of living outside the village
Education 2.1 9.8 10.7 24.8 9.8
Salaried job 72.8 54.9 49.6 33.3 57.1
Daily wage employment 1.7 0.8 0.0 0.0 0.9
Own business 2.4 1.6 3.3 5 3
Searching for jobs 0.0 0.8 0.0 0.0 0.2
Other 21.0 32 36.4 36.9 29.1
Table 5: Incidence of migration in Arap

Health

There is a Primary Health Centre (PHC) in Arap village which is functioning since 1952. During early days,
the PHC had all necessary infrastructure of primary health services and first aid facilities. A doctor with a
number of other supporting staff was posted at the PHC.But during last 20-25 years, the situation has
substantially deteriorated due to lack of desirable support from the government, and negligence on the part
of doctors and other supporting staff. Patients are, therefore, hesitant to go to PHC and for their treatment
,prefer to consult private doctors/clinics in stood for the medical assistance.

Market

There is a small market in the village that facilitates transaction of basic goods and services of day to day
importance. Most of the primary items like fertilizers, seeds, food grains, animal feed and fodders,

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vegetables, etc. are made available in the village market to meet local demands. For non-routine items,
people depend on other markets like Bihta market (about 10 km away), and markets at Bikram and
Naubatpur. The distance of these two markets is about 8 km from Arap. However, villagers prefer to access
Bihta market because varieties of commodities are available in this market.

Language

The main language of the village is Hindi in Magahi dialect. Bhojpuri, Angika and Maithili are also spoken.

Biodiversity

Among the trees found presently in this village are: sheesham, palmyra (Tar), khajur, mango, jack fruit,
peepal and tamarind. Among the wild animals commonly seen are jackals. Conversion of culturable waste
land and area under trees and groves into cultivable land has adverse effect on biodiversity of the village.

Transportation

Almost every family in Arap owns a bi-cycle and/ or motor-bike for personal movement. There are frequent
auto-rickshaw services on the main roads of the village. Tractors, three-wheelers and other four-wheeler
vehicles are used for carrying the goods and farm-produces.

3.INDIVIDUAL ASSIGNMENT A

Programme Specific

Barriers & Challenges in Routine Immunisation: Understanding the Provider perspective & the
Beneficiary perspective

Introduction

The importance of immunisation in the survival of children cannot be underscored. Routine Immunization
(RI) insufficiency can put an infant's life at risk. Immunization is one of the most efficient and cost-effective
approaches to save the lives and future of children. Every year, about nine million immunisation sessions are
held in India to achieve full immunisation coverage. In India, only 65% of children obtain comprehensive
immunisation within their first year of life. Large states like Bihar, Uttar Pradesh, Madhya Pradesh and
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Rajasthan have the greatest numbers of partially immunised and non-immunized children. India's dedication
towards enhancing vaccination access has been a particularly crucial intervention in lowering "child
mortality and morbidity", and immunisation continues to be a key priority among government decision-
makers.

Review of Literature

Emerging concerns in reaching full vaccination coverage include workforce shortages, especially in low-
performing states and in the field, as well as deficiencies in essential sectors like demand forecasting,
logistics, & cold chain management, which lead to high wastage rates. In addition, India lacks a
comprehensive mechanism for tracking vaccine-preventable infections. Patna has the lowest immunisation
coverage in Bihar, according to NFHS-5.

Rationale

To find out the challenges and barriers which affect the providers in providing Routine Immunisation
services and the challenges faced by the beneficiaries in availing the services of Routine Immunisations and
the barriers which prevent Routine Immunisation

PROVIDER PERSPECTIVE

Objectives

A. To assess their understanding of their job roles

Research Questions

 What is your role as a service provider?

 Did you give information to the family after vaccination?
 Have you received the training for what you do?
 Do you require more training?
 What are the storage facilities?
B. To explore the barriers faced by service providers

Research Questions

 Is there adequacy of supplies?

 How are the issues related to supply chain managed?
 What do you suggest to improve the facilities?
 Has the pandemic acted as barrier to your work?
 What are the health services related challenges that are interfering with the immunization coverage?

Methodology

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Cross-sectional qualitative study

Area of the study

Khagaul in Patna,Bihar(Areas covered-Govindpur Masauhri, Sivala Par,Khagaul PHC)

Source of Data

Primary data from Healthcare professionals

Respondents

ANM (5)*

ASHA (5)*

MOIC (1)*

BHM (1)*

*number of each respondent

Methods and Tools for Data Collection

Semi-structured interviews with open-ended questions

Data analysis

Data collected was collated at one place, transcribed, translated into English and then further analyzed
thematically

CARE’s Intervention

Redesign of key elements of immunization service delivery

– session sites

– vaccine delivery kits

– RI card

Findings

All the providers were very well aware about their job roles

ANM’s faced difficulty in managing the Routine Immunization along with “Har Ghar Dastak” program of door to
door COVID vaccination

During the COVID, the ASHA’s & ANM’s were busy in surveys so could not pay sufficient attention ton Routine
Immunization

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There was no supply of vaccines for two months so there was a break in the Routine immunization programme. Apart
from this, there is adequate supply of vaccines as per the healthcare providers

Difficulty faced in traveling by ANM’s & ASHAs especially to remote areas

Delay in provision of MCP cards, loss of cards by beneficiaries

BENEFICIARIES’ PERSPECTIVE

Objectives

A. To assess the knowledge and attributes with respect to Routine Immunization

Research Questions

 Do you have MCP card or immunization card?

 What is the importance of vaccination card?
 How do you get information about immunization?
 How is immunization important for you child ?
 What was the first vaccine received and why?
B. To find the factors that affect their decision w.r.t Routine Immunization

Research Questions

 How is the child's health responsibility of the family?

 Do you have any myths regarding immunization?
 Name the closest immunization center & Is immunization of your child your primary duty?
 Who is the decision maker of the family with respect to immunization?
 How will you rate the services provided at immunization site?

C. To explore the challenges in getting their child immunized

 What is the distance of the health facilities from your residence? Have you ever paid for the
immunization service?
 Do you trust the safety and efficacy of immunization?
 Did you have any adverse incidence in the family with respect to vaccination?
 Does your child get immunized on time?
 Has the pandemic acted as barrier for getting your child immunized?

Methodology

Quantitative Study

Area of the study

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Khagaul in Patna,Bihar(Areas covered-Govindpur Masauhri, Sivala Par,Khagaul PHC)

Source of Data

Primary data collected from beneficiaries

Respondents

47 Female,4 male

Variable Frequency
Age
19-29 years 40
29-39 years 11
Education
Illiterate 8
Upto class Xth 10
Class XIIth 22
Graduate & Above 11
Table 5: Demography of respondents

Methods and Tools for Data Collection

Semi structured interviews

Data analysis

Quantitative data analysed using excel

Findings

It was observed that the children who were born in private hospitals were observed to miss the zero dose (birth dose)
of BCG & Hepatitis-B. The reasons given were that the delivery in private hospital itself costs too much so we do not
pay for the vaccination.

More than half participants had MCP Card but very few were able to define the importance of MCP card

Majority of the participants were not able to recall the first vaccine the child received

Majority of the participants said they have no myths regarding immunization

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Majority of the participants said they were counseled on how to take care of the baby if the baby falls ill or has fever
after getting the vaccination dose

Most of the participants said that they do not visit the VHSND & around 1/5th were not aware about the concept of
VHSND

Low awareness 30% of the participants were not aware of the benefits of immunization

Poverty with wage loss for immunization visits AEFI Apprehension Some of the participants do not vaccinate their
child in fear of after affects of immunization

“bache ko bukhaar hoga toh usko sambhaale ya kaam pe jaaye,isse acha na hi dilwaaye”

Seasonal migration Some of the participants said the dose is missed because they to move to another place. There is
also an issue of migration as people move from one place to another in search of jobs and if there is no MCP
card or the card is lost then the beneficiaries face difficulty in getting the child immunised and therefore
there is an issue of missing the dose of the vaccine.

“maike chale gaye the,card nahi di thi ANM didi to kaise pdta sui”

Most of the participants did not miss the dose but do not get their children immunized on time

Recommendations

Limitations

The participants might have withheld some of their thoughts due to the presence of their husband & in laws and
discomfort with interviewer. The families who did not vaccinate their children were hesitant to talk & interacted very
less

4.INDIVIDUAL ASSIGNMENT B

Organisation specific

A Study on The Effectiveness of the Weak & Sick New Born Program

Introduction

Bihar is the third most populous and most impoverished Indian state, with more than 34% living below the
poverty line. Despite major improvements in health indicators, such as an increase in institutional deliveries
from 19.9% in 2005-2006 to 63.8 percent in 2015-2016, Bihar continues to have one of the highest neonatal
and infant mortality rates in the country, with a neonatal mortality rate of 25 per 1,000 live births in 2018
and an infant mortality rate of 32 per 1,000 live births.
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In the field trials on neonatal mortality (SEARCH- India), village health workers' interventions at the home
level reduced neonatal mortality by 62% over three years. Over two-thirds of the neonatal deaths took place
among preterm or with weight <2000 grams. The same trial also detected that around two-thirds of the
deaths among preterm newborns could be prevented using simple, supportive care, e.g., providing warmth
(and avoiding loss of heat), cleanliness, and breastfeeding.

As a potential solution to the high NMR in Bihar, BTSP designed an intervention based on the learnings
from the SEARCH trial. A formative study conducted in six blocks (sub-districts) of Purnia and Samastipur
districts in 2015 revealed that about 14% of neonatal deaths could be attributed to infections (pneumonia,
sepsis etc.). This project provided the insight that, unlike Gadchiroli, where the SEARCH trial was
conducted, efforts to reduce neonatal mortality in Bihar need to focus on complications of LBW/pre-term
rather than sepsis/infections.

To assess the accuracy of LBW reporting at public hospitals and determine the feasibility of implementing
an intervention to improve birth weight measurement and identify vulnerable newborns. An exploratory
study was conducted in four state-run facilities in the Gopalganj district of Bihar in 2014. It was observed
that the proper weighing of the newborn at the time of birth was almost equally poor for home and public
facility deliveries. Further, even when properly weighed, it was common malpractice to report the newborns
weighing less than 2500 grams (even a few hundred grams lower than the cut-off) as having a normal birth
weight. This practice led to an underestimation of LBW prevalence and prevented this group of vulnerable
newborns from getting identified and being brought to care.

Thus, to address this situation, it was decided to first introduce the identification and care of weak newborn
babies in public hospitals and utilize ASHAs for supporting the continuing care of such babies at home after
discharge from the hospital. The intervention began in 552 public facilities state-wide in June 2015. Later, in
June 2016, the state government issued a guideline to include similar efforts for babies born at home or in
private hospitals. By September 2016, all 694 public health facilities in Bihar (other than teaching hospitals)
had begun implementing the strategy.

‘Weak newborn (WNB) ’tracking’Intervention

Weak newborns are defined:

 Preterm (less than 37 weeks and 8.5 months)

 Having lower birth weight (less than 2.5kg)
 Having poor suckling (unable to breastfeed)

The objectives of the program are:

 To improve the identification of the Weak Newborn (WNB)

 Essential newborn care practices improvement by repeated counselling of the mother
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  Reduce Morbidity & Mortality among the WNB

Interventions introduced by CARE:

 Identification of WNB and local coordination to reach the baby

 Care & counselling at the facility
 Telephonic tracking (Up to 5 calls)
 Follow up & Home Visit by ASHA,CARE staff-DRU,BM,CVC etc.

Interventions at the facility level include:

 Regular training for labour and delivery professionals on birth weight assessment , gestational age,
breastfeeding initiation, complications management, and documentation.
 At regular intervals, labour room staff cross-checking recorded birth weights and gestational age of
mothers.
 Regular communication with mothers and caregivers about the status of babies, breastfeeding, and
supportive care demonstration (e.g., kangaroo mother care for extra warmth)
 The introduction of a specialised documentation record to follow the details of neonates with very
low birth weight
 Establishment of a form called “Weak Newborn Passport,” consisting of three sections:
i. Information on very low birth weight babies shall be attached to the case sheet by health facilities.
ii. Information on frontline health professionals' household outreach visits and follow-up visits for
neonates with extremely low birth weight.
iii. Information for caregivers and families about very low birth weight neonates, including crucial
information and contact numbers for medical personnel.

Outreach interventions at the community level include:

 Facility-based employees call frontline health outreach professionals (ASHAs/CHCs) assigned for
home visit follow up on the 1st, 3rd, 5th, and 7th days after birth.
 These calls assure that frontline outreach professionals visit "very low birth weight new-borns" at
their homes on each of these days.
 Frontline health workers give information on "home-based essential new-born care, kangaroo mother
care, exclusive breast-feeding maintenance, sanitation, cord care, and growth monitoring" during
these home visits.
 Frontline health workers provide a follow-up card to health facility workers after completing home
visits to document follow-up.

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  On the second, fourth-, and sixth-days following birth, facility-based professionals call mothers and
caregivers of low-birth-weight new-borns to offer advice on increased breast feeding, extra warmth,
and sanitation.
 In the second week following birth, facility-based professionals make home visits for very low birth
weight neonates to provide counselling on key care practises.
 On the 28th day after birth, facility-based staff makes a final phone contact to enquire about the
health status of the very low birth weight new-born.
 Frontline health workers keep track of outreach visits and submit reports to the district and block
levels.

Frontline health professionals transfer very low birth weight neonates with any of the symptoms to the
nearest hospital with a specific new-born care unit during outreach and follow up: Increased respiration,
lethargy; fever; decreased desire in breastfeeding.

Rationale

The rationale of the study is to know about the effectiveness of the Weak and Sick Newborn Programme by
CARE India

Objectives of Study

A. To find out the services received by beneficiaries

B. To assess the knowledge of home-based care among the beneficiaries
C. To assess the level of compliance with the suggestions provided by counselling
D. To explore the challenges faced by the beneficiaries
E. To explore the challenges faced by the providers

Methodology

Semi structured interviews

Setting

Khagaul Block,Patna,Bihar

Sample

WSNB Beneficiaries of last 1 year (16)*

CARE Health Coordinator (1)*

Weak Live Savers** (4)*

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*denotes number of respondents

** Weak newborn Life Savers (WLS) are trained counsellors hired to follow-up the WNB, to collect health related
information during the telephonic call and counsel the parents & provide support in referral/linking to public health
facility for further treatment

Findings

1.Issues with New Born

Low Birth weight & vLBW are the most common finding among the WNB criteria.The common health
complication include asphyxia, jaundice, skin disorders and fever.

2.Health Status

1 out of 16 of the babies was not alive. Half of the beneficiaries' agreed that their child’s status improved by
the counseling received

“counseling has helped,my baby is not weak anymore”

-mother of the baby

3.Views on counseling

11 out of 16 of the beneficiaries’ received all the 5 calls & were satisfied with the provided advice . Some of
the beneficiaries' did not follow up till the 5 th call as they were not interested in the counseling and the
reasons given were that they know how to care of the baby, no gain from received counseling, baby is sick
so he/she needs treatment in the hospitals not on call, busy in daily chores so there is no time to talk on the
phone and the cellphone is with the father who is always out for work.

“what will happen by calling when there is no food and money to eat”

-mother of the baby

4.Application of counseling

More than half of the beneficiaries’s agreed to comply to counseling and applied-

 KMC(Kangaroo Mother Care0

 frequent breastfeeding

 extra warmth

 dry cord care

 cleanliness

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  delayed bathing

5.Knowledge & Attributes

All of the beneficiaries were not aware of the home based care before counselling. Majority of them agreed
that they were informed about home based care either in the hospital, by ASHA or WLS.

6.Issues faced

i. Irritated with calls

Some of the beneficiaries felt that the calls are unnecessary as they ask the same questions and therefore
they get irritated with the calls. Also when a baby is born and falls sick then he/she is admitted and parents
are busy in taking care of the baby or moving from one health facility to another so they are not in the
position to receive calls.

“my baby was admitted, should I look after him or receive the call”

-mother of the baby

ii. Lack of treatment in govt. hospitals

Beneficiaries who do not receive proper treatment in government hospitals whether it be in case of delivery
or when the mother or child is sick do not want to talk on the phone to the WLS. They feel neglected and
there is resented from the lack of treatment or poor treatment received in the government hospitals. They are
forced to opt for treatment in private hospitals which costs too much .

“there is no treatment in government hospitals,and it private the treatment costs too much”

-father of the baby

iii. Migration

There is issue in tracking the baby if a baby is born in a particular village/block/district and then moves to
another. Often the pregnant mothers visit their maternal home or the baby id delivered there and then they
move back to their native place and vice versa.

“My wife had gone to her maternal house and the phone was with me, how could I have made her talk”

-father of the baby

7.Gender

It was observed by the WLS that the beneficiaries sometimes tend to neglect the female baby especially
when the baby is 2nd or 3rd born child.

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“There was an incidence when the mother called me up that her daughter is ill and she will not survive if not
treated immediately. She asked for help and also not to tell her husband that she approached me. Her father
was admitting her because she was the 2nd girl child and he wanted a boy. I contacted the local team and
made the ambulance available to get her baby admitted”

-WLS

8.RBSK Cases

One of the common issues reported by the WLS was that in the RBSK cases the baby is referred to PMCH
or IGIMS in Patna and the paperwork takes time and sometimes even after reaching the facilities, the
families are denied treatment.

Followings are the key impact as per vLBW study conducted(by CARE India) in April 2021--

1. There is a significant improvement in 3 or more home visits by FLWs during the 1st week of life
from 22% to 41%.

2. 70% of families received at least one visit of FLW in the first week of life. 

3. 57% of Families were visited by health workers other than an FLW.

4. 46% of families received counselling on KMC, which is more than doubled compared to the
previous round. 

5. 60% of families were informed after reaching home that their neonate is ‘weak’, 17 percentiles
increase from last year.

6. 18% more families were counselled on ‘extra’ care after reaching home (40% to 58%). 

7. Three or more home visits by FLWs during the 1st week of life increased from 22% to 41%.

Discussions of Findings

Challenges faced by providers

 Absence of correct address and/or phone numbers of family and concerned FLW
 Insufficient support from ASHA,BM
 Lack of services or treatment in public hospitals due to which even the poor families opt for delivery
in private hospitals and the intervention does not cover private hospitals.
 Due to the covid pandemic, the health system is less responsive.
 Sometimes beneficiaries demand money which cannot be fulfilled
 Difficulty in tracking in urban areas as there is no ASHA in urban areas.
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Challenges faced by beneficiaries

 The beneficiary’s face difficulty in availing treatment due to unavailability of ambulance

unavailability of beds, rude behaviour of staff, demand of bribery & non responsive staff
 Difficulty in getting treatment in RBSK cases as paperwork takes time & treatment only available in
PMCH & IGIMS in Patna
 Counseling alone do not solve the problem of nutrition & lack of resources
 Hesitant to talk as there is no incentive involved
 No solution for post partum issues
 Non availability of cell phones and recharge issues

Recommendations

 Capacity building of ASHAs on counseling skills, motivation for regular follow up

 Maternal complications can also be listed at the block level in the same way as block manger lists
weak newborns as the major chunk of the queries received by the WLS include postpartum care of
the mother & postpartum complications.
 Nutrition counseling can also be provided to the pregnant mothers & also after delivery.
 Sometimes the child is not alive to follow up till the 5 th call due to lack of treatment so there is need
for strong ground level support & strengthening of health systems
 Increase the awareness regarding the programme

ANNEXURE

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