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Indian Journal of Community Medicine

Vol. 25, No. 2 (2000-04 - 2000-06)

Editorial

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

Research Priorities in Reproductive and Child Health

The National Health Policy envisages that ultimate test of utility of Medical Research lies in the translation of existing knowhow into simple, low cost, easily applicable appropriate technologies, devices and intervention, within the reach of people. Therefore, high priority should be accorded to applied, operational research including action research. Priorities would have to be identified and laid down clearly. Further, the research issues have to be area specific and socially relevant. The experience of determining research priorities in Reproductive and Child Health in the State of Haryana is being documented for wider dissemination to stimulate the colleagues and faculty of community medicine to undertake relevant operational/action research endeavours in the community and exploit rapid assessment techniques and use the information locally to improve the service delivery, enhance its utilization and improving the quality of reproductive and child health services. The local research data/information can also be used, for enhancing the training programmes as also developing scientific temper.

The state of Haryana was carved out of erstwhile state of Punjab way back in the year 1966. There are four administrative divisions at Ambala, Rohtak, Gurgaon and Hisar respectively, with nineteen districts having estimated population of 19.5 millions of which 19.4% is urban and the rest 80.6% being rural. Haryana shares the economic prosperity of Punjab with per capita state domestic product of Rs. 16199 as compared to Rs. 18213 in Punjab. There are regional variations within the state, the Mewat area in district Faridabad and Gurgaon is least developed as compared to the rest of the state. Haryana was the first state in the country to achieve 100% rural electrification way back in 1970. Roads communication is optimal and size of each district very small, much easier to administer and manage. Over 73% of the population has access to safe drinking water, 22.2% of people have sanitary latrines and nearly 46% of the villages are subcentre villages. The state spends 13.3% of its total budget on education and 3.6% on health and family welfare. The life expectation at birth in the state is around 63.4 years with Human Development Index of 50, the Gender Index is low at 54 and Reproductive Health Index is also low at 46. Overall social indicators are very poor in the state. The adverse sex ratio of 865 in the state is lowest in the country. Similarly, adult female literacy levels were low at 36.1%. The health infrastructure in the state is well organized with 2299 Subcentres, 400 Primary Health Centres, 64 Community Health Centres, 44 Sub-divisional and District hospitals. Private nursing homes and private practitioners of various systems are in place to serve population of over 19 millions in rural and urban areas.

The current situation and problems of reproductive and child health were assessed in the state of Haryana by utilising the date of NFHS, RCH rapid district survey, population based studies/surveys undertaken in the state of Haryana by the deptt. of community medicine, ICDS annual surveys as also census and SRS data.

The specific problems identified through interpretation and analysis of data from above mentioned sources indicated, high fertility, early age of marriage, short birth interval, high infant and maternal mortality, unsafe deliveries, inadequate post natal and early childhood care, low birth weights, diarrhoeal diseases and acute respiratory infections, besides low status of women. Low output of health care delivery and quality is obvious from the evidence of ORS use rate, vitamin-A prophylaxis, inadequate home visits and lower level of contact with eligible couples. There is lack of data in respect of maternal morbidity, adolescent health, reproductive tract and sexually transmitted infections and unsafe abortions. Insanitary conditions are wide spread. Urban health services have not been organized well, inspite of impressive infrastructure available in urban settings.

Operational research on contraception as to how to promote spacing methods in men and women and how to enhance men participation in the contraception programme is a real challenge, in view of high birth rate of 28.3 (SRS 1997) with overemphasis on female sterilization of low quality without much demographic impact and distressingly low level of condom and IUD acceptance. It is paradoxical that the state has achieved high couple protection rate of 56.6% which is near to the level of 60%, yet the birth rate is very high. It indicates that workers often inflate their performance level in respect of IUDs, condoms and pills and women undergo sterilization after having 2-3 children. There is need to document the contribution of private sectors and voluntary organizations in spacing and terminal methods as also how to promote such contribution. Rapid methods of client surveys to generate data on contraceptive prevalence and unmet needs for local use could be most valuable along with case studies.

Research on policy issues on contraceptives and population needs to be undertaken by well organized institutions. Training needs assessment of all categories of workers including skills in communication and technical skills like pelvic examination, IUD insertion and recognition of reproductive tract infection should become a priority area of assessment and research. Mix of methods should be broadened to have informed choices and counselling skills of workers must be improved. Formation of men groups and orientation camps for informal and formal leaders as also of potential men in reproductive age group should be restarted and their impact should be measured. Responsibilities taken by PRI for promotion of contraception as an integral part of RCH programme and its outcome needs to be carefully documented.

Training:

Training of late in service training of medical officers and paramedicals have been augmented and district training teams have been organized to enhance the capacity of personnels in terms of technical skills and communication skills. How much and to what extent the training is done, how the training needs are assessed and what is the impact of such training on enhancement of coverage and quality of RCH Services ? Studies on such like areas are wanting and it is imperative to have an evaluation mechanism to generate feed back and to further improve the training component. Assessment of quality of services delivered by health teams at subcentre level is a critical issue which has been neglected so far. Development of methodologies and indicators for quality of RCH services are essential requirements.

Another area which needs to be tackled is abilities of workers in microplanning and community needs assessment after training and retraining as also planning of work-schedule and its implementation at the subcentre and village level as also how to make work schedule more efficient. The schools of training for Multipurpose Health Workers, their training faculties and curriculum for initial training was designed long back, what changes have been incorporated after the introduction of RCH programme and how this is being covered is a distinct area to be worked out. Similarly, RCH content of curriculum of undergraduates for initial training as also orientation of faculties on RCH and Population policy is not only essential but an urgency. Indian Association of Preventive and Social Medicine to make assessment on wider scale for improved teaching and training programmes and coverage of vital issues relevant to RCH. In the curriculum feasibility of involving district programme officers in teaching and training programme of RCH and Population Policy should be explored and experiences be documented in the form of case studies. On the job training methodologies adopted for teams training is yet another area to be researched on. One should strive to improve it further for improving the quality of services. Integrated child development services has implemented integrated teams training at sector level on continuous basis, how this can be further enriched and enhanced the successes and failures need to be documented through process evaluation studies.

Community involvement:

The RCH programme places the clients at the pivotal position and emphatically stresses that the service should be client centred, demand driven with participatory planning. What are the essential skills being used by health teams to enhance community participation and involving people and various organizations in micorplanning activities? To what extent the Panchayati Raj Institutions (PRI) and women organizations have been involved. This is an area which baffles many of us. The ground situation varies from place to place and hence the experience needs to be pooled for adaption and adoption. What responsibilities under RCH programme have been taken by village Panchayats voluntarily and what areas of RCH have been placed under PRI's and what has been the experience of such devolution of powers and involving local communities?

How for existing women and other community groups have been involved in for identification of problems, monitoring progress, generating resources, identifying clients and spreading health information? Are we using effectively the Mahila Swasthya Sanghs and Mahila Mandals for this purpose, the answers are awaited. What are the capacities of health workers in formation of women groups and providing necessary support to such groups and how the proceedings of the group are recorded for follow-up action is another important area for exploration.

IEC activities: Information, education and communication (IEC) evolution and revolution in India is a matter of proud indeed. How well the target clients have been informed on the components of RCH programme, how often they are contacted, are thee any different strategies for priority target audience? How information, education and communication needs have been redesigned for RCH component, stated policy of IEC and different strategies, who plans the IEC activities, what are the initiatives and capacity of district managers to develop plan for implementing IEC strategies in their specific areas? Are these really area specific and meet the needs of clients? What is the available material on IEC and how is it being produced and what messages does it deliver and ultimately what is the impact of this material. Research in the area of IEC in RCH is scanty and inadequate and evaluation and feed back is seldom available, hence a priority area. A research mechanism is needed for tracking changes in knowledge, attitudes and practices as a result of IEC activities to provide feed back to implementors. Evaluation of whole lot of IEC material on RCH is urgently required in terms of its specificity, social relevance and impact. Mass media in support of RCH, its contents, target audience and audience research is an important issue. Communication needs of clients are seldom assessed and all along the line the programme of IEC is pushed and thrust upon.

How the group discussions are organized by the workers and are these effective, this is a total virgin area and needs to be evaluated scientifically.

Management in RCH coverage and quality aspects:

Health system based on the model of three tier system of sub-centres, primary health centres and community health centres performs much below its installed capacity. Most community health centres are non functional and referral system support is inadequate. A large trained staff of workers with tasks appropriately defined is in position, there remains the question of lack of team spirit and motivated leadership of health teams. Health system research is called for to fill the gap. Operational and action research models need to be evolved with innovative approaches to enhance the coverage and quality of services for mothers and children. Quality of outreach RCH services needs to be enhanced. How to improve and enhance quality of RCH services at all the levels to increase the demand and felt needs of community for increased utilization as also client satisfaction? What are the important conditions and requirements for quality of services is an important research question. How supervisors monitor and report the skills and quality of service on their routine supportive supervision function and can we generate suitable indicators of quality of service from such report ? The answers have to come through critical analysis of routine reports.

What are the users perspective of good quality care and similarly providers perspective of good quality care in RCH are important areas of further studies. Operational research studies in the area of integrating health services of mothers and children with outreach immunization session appears to be feasible and appropriate. Similarly, promotion and enhancement of safe deliveries through traditional birth attendants (TBAs) giving more inputs to TBA in the form of DDK and linking TBAs with subcentre system. Setting up a delivery room in the subcentre by PRI to enhance institutional and safe deliveries to be explored. Similarly, functional linkage with anganwadi workers to enhance the intersectoral co-ordination and better coverage can be evolved as model for RCH in rural and urban slum settings.

Evolving model of effective delivery of RCH services in urban slums or testing different models or approaches for urban slum population can be a fruitful applied research contribution. Since health workers are non resident in their service areas, alternate mechanism in the system to be searched to fill this gap. The other areas of equal importance being supervisory practices and monitoring for RCH services.

Health management information system appears to be weak or suboptimal at all the levels. Routine recording and reporting of births and deaths and other elements of services/care delivery system suffers from several inadequacies like incomplete reporting, incorrect recording and quality of data very poor and unacceptable. The sample registration system (SRS) provides estimates of births and deaths at the state and national level. Similarly, causes of death statistics in rural areas generates information for rural areas and its constituent states and union territories, but it has no objective to build local capacities. Two rounds of NFHS data provided useful estimates for state and the country. Most of the districts do not have worthwhile data of their own through regular system of reporting. Therefore, it is imperative to enhance skills of data collection, its management and using the information for local planning beginning at the level, though this is stipulated under RCH programme but seldom operates. Further, the data and information collected only fulfills the requirement of the system and it is never discussed with the community whose lives it affects. Hence there is an urgent need to improve the skills of data management and its use for planning and evaluation as also for self assessment at various levels. Research studies in this area are called for. Computer capabilities be built up gradually at various levels.

Availability and functional status of equipments at various levels as also adequacy of essential drugs-through regular facility survey should be built into the system.

Adolescent health:

Community based information on problem of adolescents, their self esteems, sexuality and perception on reproductive health are inadequate. Adolescents out of school are difficult to reach by the RCH system. ICDS model of taking care of adolescent health, needs to be evaluated further for its replication. Similarly, there is hardly any worthwhile school health programme for adolescent boys and girls. Only symbolic programme of TT 10 and TT 16 operates in the schools to achieve stated targets under the system. National service scheme, school health programme and Nehru Yuvak Kendras efforts need to be evaluated critically to improve these diversified models. Model of effective school health programme and role of teachers and health system as also parents needs to be evolved carefully. The most important problem is to evolve a communication model for effective communication with the adolescents. Short listing and testing of education material is another area of study and investment. Hopefully, new population policy evolves a successful innovative information, education and communication strategy for adolescents. Model of nutritional intervention in general and anaemia in particular during adolescence is worthwhile investment for safe mother hood. ICMR experiment of Yuvati Vikas Kendras for adolescent health is yet another approach which should be put to evaluation in wider area. Information on STI/RTI in rural and urban community is too scanty and patchy and same holds true about services and management of STI/RTI. Currently the facilities for management of these infections are available at the district level or in some sub divisional hospitals. Lady-medical officers are available only in few primary health centres and referral services are quite weak. The problem is enormous and challenge is real. Would RCH model match it or Family Health Awareness week which operates in isolation under the banner of National AIDS Control Organization, would be enough to build alternative model for this problem ? These answers have to come through careful evaluation of these approaches and one such approach was evaluated by the author and published in the IJCM, some time back. These organizations should involve the faculty of community medicine all over the country for operational research activities. Management of STI/RTI by health supervisors female and paramedicals based on syndromic approach should be carefully explored and assessed for a clear strategy. Who uses STD clinics at district level and how can we involve private practitioners in RTI/STI management.

To assess the trends of HIV/AIDS and its prevalence data of Sentinel Surveillance system should be used. Periodic studies on preventive indicators for HIV/AIDS on the protocol developed by WHO should be undertaken to evaluate the National Programme on HIV/AIDS.

Community based data and information on maternal mortality in the state as also in the country is inadequate. Those institutions which have good track records should undertake studies in this area. How to reduce maternal mortality, through ensuring adequate nutrition during adolescence, safe abortion services at the level of primary health centres and safe deliveries and minimum essential post natal care. First referral units have not developed at the level of community health centres. Reforms in the areas of referral services, contracting services to private practitioners, nursing homes and enhanced incentive to Lady Medical Offers could be alternative approaches worth implementing in the state till such time the first referral units are fully developed.

Level of infant mortality in the state has become static at 68 for the past five years or so. Exising interventions for reducing infant mortality are unlikely to make further impact unless diversified and additional interventions like reduction of low birth weight babies through adolescent health, improved quality of pre-natal services, care of babies soon after birth and early neonatal period with improved referral system, made available and accessible. Various new approaches to reduce IMR should be attempted and documented. Data on pregnancy outcome, birth weights should become available through routine reports provided the weighing of new born and care becomes a habit with health worker female. Currently the TBAs render early neonatal care as health workers are non resident. Training and retraining of TBA could be another areas for enhancement of skills of TBAs till such time we have effective alternative.

In conclusion the priority research areas under RCH programme have been indicated for a specific area or territory for improvement of access, coverage and quality of RCH services to achieve the set goals. These areas are indicative only and can be further refined, diversified in the form of full-fledged projects for assistance from funding agencies like Ministry of Health and Family Welfare Govt. of India, ICMR and other agencies.

The guidance and assistance provided for preparing this write up by ICMR and UNICEF is thankfully acknowledged.

References:

  1. National Family Health Survey 1992-93, India, International Institute for Population Sciences, Bombay.
  2. National Family Health Survey-2, 1998-99. India, International Institute for Population Sciences, Bombay.
  3. SRS, 1996-97 Registrar-General India, Ministry of Home Affairs, New Delhi-16.
  4. 4. The RCH Rapid household survey 1997-98, International Institute of Population Sciences, Bombay.
  5. 5. The RCH Rapid household survey 1998-99, International Institute of Population Sciences, Bombay.
  6. Kimatkar S, Roy P: Women self reported gynaecological problems according to round of data collection Karnataka and Haryana. Council for Scientific Development. Unpublished report 1996.
  7. Lal S, Vashisht BM, Punia MS, Medical Interns: Evaluation of intensive information, education and communication campaign of HIV & AIDS in rural areas. IJCM 1999; 24: 175-80.
  8. Lal S, Satpathy S, Khanna P, Vashisht BM, Punia MS, Kumar S. - Problem of mortality in women of reproductive age in rural area of Haryana. IJMCH 1995; 6: 17-21.
  9. Kumar R. Aggarwal AK: Rapid survey for measuring the level and causes of maternal mortality. IJCM 1997; 22: 22-8.
  10. Lal S, Khanna P, Sood AK: A study of attitudes, health and social status of children (11-18 years) in block Kathura, Rohtak. IJMCH 1992; 3: 19-22.
  11. Lal S: Empowering young girls for health and development Ind. J. Paed. 1991; 58: 357-62.
  12. Lal S: Mothers perceptions and ambitions about their daughters in rural area. IJCM 1997; 27: 22-8.
  13. Lal S, Sood AK: Rural working women and child development. IJCM 1992; 17: 164-8.
  14. Lal S.: Rural women health scenario. IJCM 1996; 21: 3-6.
  15. Lal S, Malik JS, Vashisht BM, Punia MS, Jain RB: General population survey in rural area to generate prevention indicators for HIV/AIDS control. IJCM 1998; 23: 50-56.
  16. Survey of causes of death (Rural) India. Annual Report 1993 Vital statistics division office of Registrar-General of India, Ministry of Home Affairs, New Delhi.
  17. Lal S, Kumar V, Vashisht BM, Malik JS, Punia MS: Surveillance of vitall events in rural areas. IJCM 1998; 23: 156-60.
  18. Lal S, Goomer R: Incidence of low birth weight in rural ICDS Block. IJMCH 1994; 5: 76-9.
  19. Lal S: Surveillance of acute diarrheal diseases at village level for effective home management of diarrhoea. Ind. Jour. Public Health 1994; 57: 65-8.
  20. Lal S, Khanna P, Vashist BM, Punia MS, Satpathy S, Kumar S: Participation of Pregnant and lactating mothers in ICDS Programme in rural area. IJMCH 1995; 6: 76-9.
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