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Indian Journal of Community Medicine

Vol. 26, No. 3 (2001-07 - 2001-09)

Editorial

Editorial: Strategies of Incorporating RCH Strategies and Newer Develpments into Curriculum to Enrich Teaching-Training and Research Programme of Community Medicine

Prof. Sunder Lal

Reproductive and child health programme (RCH) signals a new approach to family planning and health care of mothers and children. In essence, it is a major policy reform and paradigm shift with a view to integrate family welfare programme with system of maternity care in the Primary Health Care System. This communication endeavours to highlight and focus on major strategies under RCH programme and probable mechanisms of incorporating these into the curriculum of undergraduates and postgraduates, within the ambit of new regulation of Medical Council of India. As departments of Community Medicine all over India are already persuing their teaching, training and research programmes in the community and cover substantial part of the subject, thus there would be no problem of incorporating newer strategies into the curriculum without any extra time requirement. It is envisaged that incorporating these thrust areas and strategies would rather enrich the teaching and training programmes as the students will be able to see themselves the operational aspects of these strategies in the community. Teachers of Community Medicine will derive high level of satisfaction by making use of live situation as also use of learning resource material in most effective manner.

Client and Community centred approach:

The focus of RCH programme is "client and community", Client or consumer of services occupies pivotal position. Listening to the clients and assessing their health/service needs has been recognized as a key strategy under RCH. Every contact with the clients (home visits, friendly visits, clinic contact) should be used as an opportunity to assess their needs and satisfaction as also to obtain feed-back with a view to effect further improvement in coverage and quality of user friendly RCH services.

The service providers at various levels used to be given "targets" for various services/methods of contraception on annual basis by the central and state governments. Under the new strategy, the targets have been done away with and target free approach has been adopted and further refined as Community Needs Assessment Approach (CNAA). This approach has sound scientific epidemiological basis, wherein workers are expected to greet and meet the clients on sustained basis to generate a level of confidence and ascertain needs of each client as also collectively the community needs (needs of all clients). Needs of clients conventionally are assessed through annual household surveys undertaken in the month of March every year. However, surveys update the numbers and provide an account of population, eligible couples and young children under the jurisdiction of each worker or facility, but it is no substitute to regular and continuous/sustained contacts with each client. Resident health workers achieve better contacts with their clients. The exercise of CNAA is done by Health Workers (Female and Male) every year on specific performae.

Hitherto the assessment of health needs was a domain of experts, under RCH programme it has been unfolded that CNA will be an endeavour of people and health workers in partnership. Health workers will use household and village data and community resources to map out needs of targetted groups (adolescents, women and young children) on realistic basis at local level for a defined population. Community needs assessment under RCH programme necessitates use of demographic data, socio-economic and cultural profile of people, morbidity and mortality experiences besides information available on evironmental sanitation, available facilities, services, contraceptive prevalence, utilization and coverage.

Community need assessment approach envisages preparation of action plans at several levels in consultation with community. At the village level, workers are required to conduct consultative process with anganwadi workers, members of mahila swasthya sangh, local panchayat members, teachers and development functionaries. This is the mechanism of involving community in decentralized action plans. In practice this process is seldom followed. During the consultative process the spectrum of services, material and supplies available and the work schedule of the health teams must be discussed and better to be displayed at the office of PRI or women organizations. PRI ownership and responsibilities must be discussed which is most relevant for decentralized planning, as the management/funding and implementation of health and education programmes has been decentralized to panchayats. The prescribed format for subcentre for CNA Action Plan heavily leans on demographic approach to estimate the number of beneficiaries of reproductive and child health programme and consequently the health workers struggle with formulae to work out the number of beneficiaries. National/state/district level rates are applied to population to arrive at the number of antenatals, deliveries, postnatals and number of young children. The Indian Association of Preventive and Social Medicine recommends alternative and effective measures to be adopted for effective plan of action at the level of community. The health workers should register at the earliest all marriages, pregnancies, births and deaths in their area in one or two registers made available to them. Continuous tracking of pregnancies and births and segmenting the clients for differential approach should become the action plan. Workers need to spend more time with most needy segment of population. The task of tracking births and pregnancies in non-subcentre villages should be entrusted to health workers male and TBAs and anganwadi workers or additional ANMs under RCH programme. Work schedule and plan of action should be evolved village-wise by health workers team with clear cut area responsibility. Developing functional linkages with anganwadis can help produce a better action plan at community level. Planning of RCH services at village level should rest with village committee consisting of mahila panches, anganwadi workers, TBAs, mahila mandals and health workers. These functionaries should meet every month to plan, monitor and evaluate the work plan and performance village-wise. This should be built in the health care delivery system. Many such fora like mahila swasthya sangh, mahila mandals and village panchayats already exist to spearhead these activities, provided the leadership of primary health care effectively uses these fora with a sense of pride and ownership by the community.

Subcentre teams have access to village-wise/ anganwadi-wise data in terms of number of houses and households, total population, infants, children 1-5 years, eligible couples as also information on source of drinking water supply, excreta disposal, human resources like village TBAs, anganwadi workers, private practitioners, health guides, organised groups of men and women, disease pattern and malnutrition in young children along with prevalent practices relevant to health, disease and contraception. Below poverty line families, landless, illiterates and other economically weaker sections need much more attention in terms of coverage and quality of services. From the past experience the workers know the major diseases and killer diseases in their areas; who dies and where the deaths occur most, which makes them wiser to assess community needs and accordingly evolve action plan for coverage of services. While assessing community needs, priority group for service coverage must be identified. Unfortunately the CNA formats and documents do not lay any stress on this vital area, it goes mechanically and more stress is laid on calculations to arrive at work load coverage norms by use of formulae to submit report to higher formation rather than to use the information in their work plan and work schedule. The key strategy of CNA and work plan at grass root level should be preparation of efficient work plan and its implementation in the community with the help and guidance of village panchayats and local community along with effective mobilisation of all resources, most vital being human resource.

The system of recording different services in different registers has been found to hinder the approach of client based services and client based records. When the workers meet their clients, full fact sheet of client should be before them. Clients must have access to vital information of their health. This has been attempted through mother based cards on immunization and maternal health, growth monitoring card and family health cards etc. RCH programme is in favour of client based records to improve the quality of services, Health Information System (HIS) under RCH has been modified to incorporate quality and coverage parameters. Accordingly the subcentre reports have been modified to reflect parameters on coverage and quality as also to assess the adequacy of material and supplies and client satisfaction. The revised monitoring system incorporates monthly activities reports, technical assessment of subcentre level services by heath assistant and rapid survey of clients and facilities by independent agencies. The HIS under RCH is worth studying to build sound concept of epidemiology - monitoring and evaluation in the system.

Community needs assessment under RCH programme appears to be a simple task than evolving effective work plan and implementation thereof to meet the assessed needs. After community needs assessment the health teams are required to evolve action plans at various levels. Transforming action plan into work schedule/work plan to achieve acceptable coverage of range of RCH specified services over a stipulated period is far more difficult exercise. How to evolve efficient work schedule and work routine is a challenging exercise. RCH approach should stress more on this component than merely assessing needs. Decentralized planning at district level and below in RCH has been a bold step in the right direction. Now the district plans are evolved and formed locally for local and area specific actions in terms of planning, monitoring and evaluation of RCH services. Differential approach adopted by RCH programme for poorly performing districts/states with enhanced infrastructure and finances is a sound beginning. Around 142 weak districts have been identified in the country for enhanced inputs. Rapid household survey data at district levels is a real regular feed back to district teams for effecting improvements in coverage and quality of RCH services. Similarly, facility survey data draws attention for mid course correction and early action to build up reasonable inputs for better outcome. The feedback from both these surveys enable appropriate remedial actions at district and sub district level. Districts have long past and inertia; it is being keenly observed as to how the district teams make use of data of their own annual plan for meaningful district plans of action and level below.

Improving the quality of services and client satisfaction is the prime concern of RCH programme. Quality of services has been a neglected area. Health workers and services must be accountable to clients and community and community should have control over services in terms of planning, monitoring and evaluation. Quality of RCH services should be defined according to specific standards or norms and making services accessible and available for effective utilisation by the clients. Quality of antenatal care, safe delivery, postnatal care, neonatal care, immunisation, management of diarrhoea and acute respiratory infections have been defined in the system and the workers have been imparted integrated skill training. Management, information, education and communication training, on the job training, supportive supervision, improved logistics of RCH and attempts to strengthen referral system are some other thrust areas to improve the quality of services. Data on assessment of quality and coverage of services as also client satisfaction is available through rapid household surveys. Beginning of adolescent health services through RCH programme is yet another paradigm shift to enhance their quality of life. Meaningful programmes for adolescent health are being evolved.

Additional inputs in the form of hiring consultants for FRUs, additional ANMs for subcentres and nurses for PHCs to support 24 hours deliveries and funds for minor works at subcentre, PHC and CHC are other meaningful reforms in Primary Health Care under RCH.

In addition, 142 poorly performing districts in 15 states have been covered under Dai Training Programme, 50 districts have been covered for immunization strengthening as also for strengthening of outreach services of RCH programme. Similarly, 102 districts have been covered under reproductive and child health (RCH) camps. Border district cluster strategy (BDCS) has been adopted for 50 districts to reduce infant and maternal mortality through focussed interventions. Spectrum of services under RCH has been enlarged to cover full range of services including fertility regulation, safe abortion, reproductive tract infections (RTIs) and sexually transmitted infections (STIs) including HIV and AIDS. To begin with, these services have been set up at district level and attempts are underway to make first referral units (FRU) functional for meaningful referral services through the process of essential reforms in health sector.

Information, education and communication (IEC) strategies have not focused on clients and full range of services including gender issues and counselling. Specific national strategy on IEC under RCH has been developed with emphasis on decentralized district level planning of IEC activities and material development. This is an upcoming component of RCH, which is being watched with great interest.

Gender issues and enhancing the role of men has been picked up as an area of deep concern under RCH. In recent past Family Welfare Programme has underestimated the role of men, although in our society they are the key decision makers. Under RCH and national population policy it is envisaged to focus on men on equal footing. Currently over 97% of sterilizations are tubectomies and this manifestation of gender imbalance needs to be corrected. The special needs of men include, popularisation of condom and repopularising vasectomies, in particular 'no scalpel vasectomy'. Under RCH programme strategies of IEC and services will have more focus on men to remove gender imbalance. RCH advocates concern for development of health care delivery services for urban slums, urban poor and tribal areas in the country.

To provide comprehensive, basic health and reproductive and child health services by NGO's and private sector organisations including corporate houses. RCH model and ICDS model for urban slums and tribal areas with governmental and non-governmental efforts can ensure coverage of urban slums and tribal areas in the country to meet their unmet needs.

Logistics system under RCH programme has been streamlined. Drugs and equipment kits which were being supplied under CSSM programme at various levels will continue to be supplied at the subcentre, PHC and CHC/FRU level and those FRUs and PHCs which have not been covered so far, have been covered under RCH. In addition, a drug kit for essential obstetric care will be supplied to PHCs in category C districts.

Fund flow mechanism from centre to State through State Committee for Voluntary Action (SCOVA) is yet another paradigm shift under RCH to facilitate easy utilisation of available funds locally at district level, with considerable decentralized power of spending. However, critical observation is that SCOVA is only fund flow mechanism without much role and responsibility for local level planning, monitoring and evaluation of RCH programme as such. There is an attempt to experiment unification of all district level committees through European Commission funding to stimulate them for effective planning at distt. level.

Introduction of RCH in curriculum:

Vast potential and resources of Medical Colleges have not been recognised and these have not been involved in the training process of RCH programme, which is most unfortunate. They could be trusted as independent agencies for research and evaluation as also support for quality training, under programme of RCH. Consequently, the faculty of Medical Colleges is least informed or ill-informed on all the recent strategies and newer developments under RCH programme. Since Medical Colleges have been kept outside the stream and mailing list, the essential programme documents (Manual on decentralized participatory planning in family welfare programme, Manual on community needs assessment approach in family welfare programme, Reproductive and child health programme, Schemes for implementation etc.) as learning resource materials are not easily accessible to them. In view of these problems, the faculty is unable to transmit the information to the trainee doctors. The only method available to the faculty of Community Medicine is to obtain this material from primary health centres or through district health agencies. Linkages of medical colleges with district health services are weak; more the linkages, better it is for enrichment of training programmes of UGs and PGs. Involving district programme managers in training and teaching programme of community medicine can be rewarding experience. Ministry of health and family welfare should keep the Medical Colleges and departments of Community Medicine on their mailing lists, some of the learning resource material is becoming available through internet as well but access is limited. Similarly, the recent data of District Rapid Household Survey, Facility Survey and National Family Health survey I and II has not been made accessible to medical colleges and departments of Community Medicine to make its effective use for learning and teaching programmes. The faculty could use these data to enrich their training programmes on epidemiology and biostatistics. Departments of Community Medicine should be increasingly used to collect and compile such data.

Present day teaching and training programmes of UG's and PG's cover RCH programme strategies in a sketchy manner in most of the institutions and Community Medicine departments, since the teachers of Community Medicine departments have not been oriented in an organised manner. Training of trainers is essential to achieve any meaningful result in terms of coverage of subject and recent strategies of RCH into the curriculum. One such approach is self learning and updating oneself and persuing some research on the recent issues, but this virtue is vested with a few only. The other approach is professional association, IAPSM takes responsibility to impart orientation to its members through continuing medical education programmes at regional and national levels.

Ministry of health & family welfare, GOI initiative helped professional associations like Federation of Obstetricians and Gynaecologists in India (FOGSI), Indian Association of Paediatrics (IAP), Indian Association of Preventive and Social Medicine (IAPSM) and Indian Public Health Association (IPHA), to orient their members on the recent strategies of RCH with a view to build the package of integrated RCH services into the training programmes of UGs and PGs. This is wonderful indeed, but there is imperative need to co-ordinate the efforts of these three departments at the level of Medical colleges to have convergence of teaching programmes or develop integrated teaching and training programme for UGs and PGs on the broad strategies of RCH. The apprehensions are real as the three departments may disseminate different messages to medical students or their trainees. The efforts of these three departments and experiences must be pooled and disseminated widely in the form of feed back to Ministry of Health and Family Welfare as also at the institutional level.

Integrated training of trainers programme of these three disciplines (Obst. and Gynae, Paediatrics and Community Medicine) would have paid much more dividends. Mechanism of joint training at the level of medical college is worth persuing. The teachers of Community Medicine should never miss the opportunity of getting involved in district teams training programme, training programmes at State Institute of Health & Family Welfare or Regional Institute of Family Welfare in respective states. Similarly, having involvement in basic training programme of health workers (male and female) at district level can enrich the acumen of teachers of Community Medicine.

The departments of Community Medicine should hold the responsibility for RCH services to a defined population in urban slums or rural areas. Real learning on RCH strategies and newer approaches can come through where the programme is being implemented i.e. at the level of village, subcentre, PHC and CHC, therefore, adoption of rural filed practice area is essential to learn all operational aspects of RCH programme.

During the periodic and final evaluation of students, incorporating questions in theory and viva-voce or building practical exercises on the thrust areas of RCH programme and areas of paradigm shift can go a long way.

Proposed suggestions of RCH areas and mechanism of incorporation of these into curriculum are indicated in tabular fashion.

Strengthening the capacity of the departments of Community Medicine in terms of mobility (vehicle), audio-visual aids and other infrastructure is essential. This should be undertaken by MOHFW RCH trg. wings to support training programmes of faculties as also of other categories.

Specific thrust area? Situation Mechanisms
1. Client-community profile know your clients well. Community needs assessment. -Family study on longitudinal basis?
-Interview clients in clinic set up or OPDs
-House-hold survey in community?
-Case studies or live data of a facility?
-Presentation by health workers.
-Assess health, nutrition and reproductive needs of allotted families or clients in clinic set up.
-Ascertain specific needs from available records.
2. Microplanning or action plan at sub-centre or health post in urban area or an anganwadi, PHC and CHC. -Specify the assessed needs of adolescents, antenatal, postnatal and young children from the data of action plan. -Action to meet that need through outreach session clinic of subcentre, home visits or through referrals. (PHC-CHC-Distt. Hospital)
3. Work plan or work schedule -Sub centre or health post action plan. -Prepare work schedule of subcentre ANM, to ensure coverage of area. PGs, to prepare and demonstrate to UGs, as preceptors.
-Ascertain requirements of vaccines, ORS, Vit. A, Cotrimoxazole, essential drugs.
4. Quality of RCH services -Actual observations of quality of outreach session of immunisation. Selection of clients for contraception/nutrition intervention. Practices of antenatal care, postnatal care, growth monitoring session, records of services, nutrition education session or any other intervention. -Ask the UG and PG students to make observations on quality and coverage of services and make brief presentation.
5. Health information system - monitoring and evaluation -Study prescriptions on diarrhoeal diseases.
-Mother based/home based immunisation records, growth monitoring records.
-Sub centre/AWW/health post monthly/ annual report.
-Distt. rapid house-hold survey report
-Health facility survey data
-NFHS data
-Census data
-Presentation of observations by students in groups.
-Assess performance level or coverage level.
-Give epidemiological or statistical exercises.
6. Gender sensitization and increase male participation in health & family welfare -Experience in one's own family.
-Ascertain practices in the allotted families.
-Case studies.
-Data analysis of census/survey on sex-ratio, female literacy, health care utilisation
-Female foeticide, male female mortality.
-Narration by students.
-Presentation of findings, group discussion, seminar.
7. Participatory and decentralization of planning, trg., control of services and resources. -District-CHC-PHC and S/C action plans, urban areas plans, meeting with PRI and nagarpalika, meeting with functionaries of other sectors like education
- ICDS, development functionaries to learn the process of consultation and social mobilisation.
-Meeting organised women groups or active NGO's.
-Enlist the health responsibilities undertaken by PRI and Nagarpalikas.
-Interaction between providers and PRI, nagarpalikas and other sectors.
8. Issues of adolescent health -Meet male and female adolescents in school or out of school or in the allotted family -Assess their level of awareness on nutrition, health, immunization, sexually transmitted diseases and contraception.
-Assess nutrition through anthropometry. Their source of information, smoking practices and substance abuse.
9. RTI/STI -Visit to STD clinic and Obs Gynae clinic
-Integrated teaching by Obst., Skin and V.D. and Comm. Med.
-Problem based learning
-Family studies in allotted families
-Clients interview through preceptors
-Records study
-Seminars
-Group discussion simulation
10. Research priorities in RCH -Evaluation of interventions by PGs in urban and rural areas. Management and health system research studies of interest, different approaches in training and continuing education, I.E.C. process evaluation etc. -Teachers should use all available opportunities.

Suggested learning resource material on RCH:

  1. Govt. of India. Health Management Information System (version 2.0), subcentre registers and reporting formats (Model), New Delhi: Ministry of Health & Family Welfare; 1992.
  2. Govt. of India. Manual on decentralized participatory planning in Family Welfare Programme. New Delhi: Ministry of Health & Family Welfare; 1996.
  3. Govt. of India. Manual on Community Needs Assessment Approach (Formerly Target Free Approach) in Family Welfare Programme. New Delhi: Deptt. of Family Welfare; 1998.
  4. Govt. of India. Guidelines as a supplement to the CNAA Manual (Family Welfare Programme), New Delhi; Department of Family Welfare; 1999.
  5. Govt. of India. National Population Policy 2000. New Delhi: Department of Family Welfare; 2000.
  6. National Institute of Health & Family Welfare. Specialized Management Training for district level officers under RCH Programme. New Delhi: NIHFW.
  7. Govt. of India. District-wise social and economic, indicators, National Commission on Population. New Delhi: Yojna Bhawan; 2001.
  8. Vasudeva YL, Lal S. Assessment of health needs in rural areas and evaluation of working of Primary Health Centre complex. Proceedings of the 2nd National Workshop Seminar; 1973 Aug 5-7; New Delhi, India, IMA House; 1973.
  9. National Institute of Health and Family Welfare. Reproductive and Child Health, Module for Medical Officer, Primary Health Centre - Integrated skill development training. New Delhi; NIHFW: 2000.
  10. NIHFW. RCH module for ANM, LHV/Health Assistants and Distt. level managers. New Delhi; NIHFW; 2000.
  11. Govt. of India. Report of the sub-committee on Reproductive Health Research Needs Assessment (RHRNA). New Delhi: MOHFW; 1997.

Sunder Lal
Prof. & Head, Deptt. of SPM
Pt. BDS PGIMS, Rohtak

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