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Intersectoral convergence between DWCD and DHFW - DOHFW

1. Background

1.1 India has a long history of programmatic efforts to improve the health of mothers and children and has made significant gains in the fifty years since independence. Despite these gains, maternal and child deaths constitute a significant burden of disease. According to WHO estimates, India contributes about 2.4 million of the 10.8 global child deaths and 25% of 529,000 global maternal deaths.
1.2 The slow pace of progress in infant mortality and child malnutrition is an area of serious concern. 69% of all infant deaths occur in the neonatal period. Malnutrition is an important cause of death in under fives. Fifty six percent of deaths among under-fives are due to the underlying effects of malnutrition on disease. On an average a child who is severely underweight is 8.4 times more likely to die from an infectious disease than a healthy child. Infant and child deaths are a mix of several risk factors. Proximate determinants of infant and child survival include a mix of preventive and curative interventions- maternal tetanus toxoid, safe delivery, home based care of the newborn, immediate breastfeeding and appropriate weaning and complementary feeding, access to safe water and sanitation, immunization, administration of Vitamin A, ORT and antibiotics for neonatal sepsis, respiratory and other infections. Many child survival interventions can be successfully implemented through a mix of actions at the household level/community level and a basic package of primary health care that does not rely on complex technology.
1.3 For a variety of reasons, (not the least being gender inequities and consequent disempowerment) women throughout the life cycle face numerous obstacles in recognizing, seeking, and receiving care for health problems. While well-organized outreach and facility based health care is a critical component of improving womens (and their familys) health, empowerment, leadership development, and knowledge and skills are equally important. However these latter components lie outside the realm of traditional health service delivery systems. Community level action for increasing mobilization, action and behavior change processes, supported by well organized primary and secondary health systems, are required to enable women cross a range of barriers, including gender inequity and poor access to quality health services.
1.4 The Department of Women and Children (DWCD) is the repository of national programmes for the holistic development of women and children. It includes: the Integrated Child Development Services (ICDS), to provide supplementary nutrition for pregnant and lactating mothers and children under six, and non-formal preschool education; programmes to ensure social and economic empowerment of women through collectivization, welfare and support services, training for employment and income generation, and gender sensitization. At the village level, the DWCD is represented by a village level honorary worker, the Anganwadi Worker (AWW) and her assistant, an Angnawadi helper. DWCD norms stipulate one Anganwadi Center (AWC) for a population of 1000 in plains and 700 in tribal areas. (Check) Supervision of AWW is by the Mukhiya Sevika, who is in charge of about 15-20 AWC. At the block Level, the Child Development project Officer is the functionary in charge of DWCD schemes. (Need confirmation and input)
1.5 The goal of the Department of Health and Family Welfare (DHFW) is to ensure universal access to quality health care. All programmes of the DHFW are channeled through a three-tier system. The unit closest to the community is the sub center. It is staffed by an Auxiliary Nurse Midwife, covers a population of 5000 (about 3-5 villages) and offers a mix of center based and field outreach. The sub center is expected to provide services for a range of primary health care interventions, but is substantially focused on maternal and child health.
1.6 At the community level informal collaboration exists between the ANM and the AWW, given that the target group of the AWW substantially overlaps with the ANM. Small and large-scale convergence efforts have been attempted across the country, and there are models of success in various states that have attempted convergence of nutrition, health and womens empowerment. In ten states across the country, ICDS and the State departments of Health and Family Welfare (with technical support from CARE) have integrated health and nutrition interventions at the village, block and district level through a series of operational processes. They include: capacity building of the ICDS workers, identification and training of village level community health volunteers, and joint training of health and ICDS functionaries to improve community access and strengthen service delivery. Fixed health and nutrition days, block level resource mapping (as a planning and monitoring tool), and community based monitoring systems are now functional in about 100,000 villages to a variable degree.
1.7 The MOHFW and DWCD have developed a manual for capacity building of self help groups and PRI members that focuses on key primary health care issues, rights and responsibilities of the public sector health service delivery system, and community and household action for preventive and promotive health.
1.8 In some states (Gujarat and Goa) the AWW is under the purview of the health department and performs the duties of frontline grass roots workers. The AWW is also involved in several vertical programmes- Blindness Control, Leprosy, National Maternity Benefit Schemes, Pulse Polio Immunization, and the RCH programme. However many of these efforts are disjointed and often operate under informal mechanisms, with little coordination between the departments on capacity building, planning and monitoring in place. A study on the collaboration between the ANM and the AWW in Kerala showed that this was an important aspect in the effective implementation of family planning programmes. Coordination was obvious in areas such as health services, nutrition, immunization, and referral. In addition it also took place in areas such as health education, house visits, and community meetings.
1.9 DWCD and DHFW have overlapping goals, and thus complementary programming is essential. Such programming needs to extend to other stakeholders, such as NGOs, academic, research, and training institutions, involved in health, nutrition, and womens empowerment.
1.10 Convergence at the village level appears integral to the functions of both programmes. It involves the definition of critical objectives, detailing effective operational approaches, laying out clear roles and outcomes, clear mechanisms for joint planning and monitoring, including common monitoring indicators.
1.11 Such convergence is critical to the success of the soon to be launched National Rural Health mission. The National Rural Health Mission (NHM) is seen as a vehicle to ensure that preventive and promotive interventions reach the vulnerable and marginalized through expanding outreach and linking with local governance institutions. Key to the success of the NHM are: intersectoral convergence, community ownership steered through Village Health Committees at the level of the Gram Panchayat, and a strong public sector health system with support from the private sector. Intersectoral convergence in NHM is visualized with drinking water, sanitation, hygiene and nutrition. An Accredited Social Health Activist (ASHA), is expected to work with communities for social mobilization and improve access to services. She will be located in every village/habitation. ASHAs role will be to facilitate care seeking and serve as a depot holder for a package of basic medicines. The AWW, schoolteacher, members of local community based organizations, such as SHGs, and the Village Health Committee are expected to support the ASHA in her in her work.

2. Programmatic Interventions of DWCD And DHFW

2.1 ICDS is the worlds largest community based outreach programme for women and children. At the village level, the Anganwadi Center (AWC) is the locus of action for nutrition and a primary package of health services. Currently there are. Anganwadi centers in the country. Key functions of the AWC include: supplementary nutrition to children less than six years of age, pregnant and lactating mothers and in some areas to adolescent girls, immunization, health check up, and referral services, and pre-school nonformal education. The near universal location of the AWC and AWW (mostly local women) and the functions of nutrition and health make them a natural ally for the health sector.
2.2 Key participants in the ICDS scheme are children below six years, pregnant and lactating women, specifically marginalized women. Thus the programme design of ICDS is such that it can make significant contributions to malnutrition and mortality- the success in ensuring healthy childhoods and outcomes for pregnant mothers.
2.3 Programmes for womens empowerment run by DWCD are dependent on the formation of large numbers of Self Help Groups (SHG) set up in the community. Such SHGs are organized around savings/credit, livelihoods, and leadership development. The SGSY, Swa Shakti, Swayam Siddha, (add more) are examples of such programmes. The DWCD also includes programmes to protect and safeguard the rights of women (such as the National and State Womens Commissions) and adolescent empowerment programmes.(Kishori Shakti Yojana)
2.4 The Tenth Five year plan, National Nutrition Policy, 1993, the National Plan of Action of Nutrition, 1995, National Population Policy, 2000, and the National Health Policy, 2002 include goals that require convergent action for implementing key technical strategies. Direct health outcomes of NHM also include reduction of IMR and MMR as well as universal immunization and provision of integrated health care. While the current reach of the AWW is to children and women (and adolescents in some areas), they are residents of the village and are almost equivalent in their profile to the ASHA.

3. Opportunities and Areas for Convergence

3.1 Opportunities for convergence between the Departments of WCD and HFW are numerous. Between the two departments the following can be achieved:
  • Improved nutritional status of women and children, particularly the marginalized, and in so doing, intervening in an area critical to health improvement
  • Womens empowerment through programmes for credit, leadership and livelihood training and engaging them to discuss and take action to improve health parameters at the household level and advocate for gender equity and improved service access and quality, through a rights perspective.
3.2 Success of convergence in health, nutrition, and empowerment requires convergence of approaches in DWCD and DHFW in: behaviour change communication strategies, planning modalities, monitoring and information systems, capacity building and training inputs. Additionally the DHFW must ensure that convergence efforts are backed by a strong service delivery system, responsive to community needs.
3.3 The following areas of convergence between DHFW and DWCD could be considered:
  • Women and Childrens Health: Mobilization of women, adolescents, and children and provision of a package of quality health education and services at the village level[1].
  • Womens empowerment, gender and equity: Involvement of community based womens groups to ensure that social and related determinants of health including gender and equity are addressed. These include prevention of early child marriages, implementation of the PNDT Act, including awareness and action against girl child elimination, leading to distorted sex ratios, domestic violence, and mobilization of resources through collective action for health and other emergencies.
  • Convergence between the following functions of both departments for nutrition, health and womens empowerment is also necessary. They include:
    • Joint formulation of BCC strategies, materials, and messages,
    • Operational strategies for joint planning at village, block and district levels,
    • Development of joint MIS including common indicators,
    • Identification of functional areas for training of staff including joint training
3.4 This paper provides a broad framework for action to address the major convergence areas. The effectiveness of convergence of key interventions is dependent on several factors, but critical is the operationalization of convergence within well functioning health systems and programme management structures at all levels. It is opportune that the DWCD and DHFW jointly look for ways to improve reach, empower women, engage communities, enhance access and coverage, provide quality services, It must be emphasized that this framework is proposed at the National level and state level consultations with key stakeholders are necessary to operationalize the plan in the context of state realities.
3.5 Section 4 highlights current interventions of DWCD and DHFW in the area of health, nutrition, and womens empowerment and suggests recommendations and specific action for convergence in each area. Section 5 includes operationalization of convergence and details institutional mechanisms to facilitate convergence.

4. Key Convergence Areas and Operational Strategies

4.1 Women and Childrens Health, more specifically, maternal and child Health are the focus of the both the DWCD and DHFW. DWCD interventions at the village level are primarily focused at the community through the ICDS. The AWC at the village level is the hub of interventions. The DHFW provides services for child health through outreach at the village level and at all three tiers of the system. The ANM is expected to visit each village and provide immunization and services for pregnant, lactating mothers and children, women in need of family planning, and other illnesses or refer as appropriate. The AWW reaches pregnant and lactating women (upto six months) and children aged 0-6 years.
  4.1.1 As part of the RCH II programme, the child health strategy concentrates on the following: essential newborn care, breastfeeding, immunization, and care of the sick newborn and child through outpatient/home based care and inpatient care. This approach is called the Integrated Management of the Neonatal and Child hood Illness (IMNCI). Table 1 provides details on the maternal and child health services provided at the village level.
   
DWCD InterventionsDHFW Interventions
Child Health Child Health
  • Monthly Weighing of children under six
  • Maintaining Growth chart
  • Child cards for children below six (for medical history)
  • Nutrition supplementation
  • Referral of children with 2SD and 3SD malnutrition to the PHC
  • Non-formal pre school education
  • Health and nutrition education
  • Elicit community support and participation in running the programme
  • Assist PHC staff in immunization of children- (means motivating mothers to bring children, and mobilizing all 0-6 year olds)
  • House visits to ensure appropriate feeding practices and attendance at AWC.
  • Identify malnutrition among children (0-5) and manage or refer to PHC
  • Provide ORS to children with diarhoea
  • IFA to infants and young children
  • Vitamin A solution
  • Immunization
  • Weigh and examine newborn as son as possible after birth.
  • Health Education
Maternal health Maternal health
  • Nutrition supplement to a sub-sect of all pregnant and lactating women (BPL)
  • Enables all pregnant and lactating mothers to collect at the AWC for ANM visit
  • Register and provide care to all pregnant women throughout pregnancy
  • Urine and Hb test, BP and three abdominal examinations
  • Refer complications and facilitate referral
  • Conduct three postnatal visits
  • Health education
Other womens health issues: Other womens health issues:
 
  • Family planning motivation
  • Distribution of contraceptives
  • Referral for IUD or terminal methods
Follow up of users for side effects:
  • RTI/STI education, recognition, and referral
  • Minor ailments treatment/referral
  4.1.2 Proposed Convergence Recommendations for Women and Childrens Health
    Currently the AWC functions as a center where children (0-6years) do collect and where nutrition and health services are being provided. In order to formalize this arrangement, the following are proposed:
  • The AWC to serve as the focal point for all health and nutrition services.
  • As part of the NHM -A fixed health day is proposed to be held every month at the AWC to provide antenatal, postnatal, family planning and child health services. An ANM and a Medical officer from the PHC will be in attendance.
    AWW and ASHA (and other community volunteers) be responsible for ensuring that all children 0-6 and children for immunization and other health services be brought to the AWC on a fixed day, when ANM and MO visit to provide immunization, and other health care services. Services to be provided on the Health Day (by the ANM or PHC MO) include: ANC, Newborn check up, Postnatal care, Immunization of mothers and children, IFA and Vitamin A administration, growth monitoring, treatment for minor ailments, and health education. (Should growth monitoring also be conducted on that day to enable the doctor to be able to provide some treatment/feeding advice and examination of malnourished children?)
  • AWW and ASHA to mobilize women and children, with support from SHG and other community group, to access services through a fixed Health Day held every month at the AWC.
  • AWW and ASHA to counsel women for institutional deliveries and facilitate referral (mapping of facilities, help in accessing transport through community SHGs, referral slips). .
  • AWW and/or ASHA to be present at all home deliveries (as second attendant) to provide care and advice for the newborn. This includes: Weighing the newborn at birth, (or within 48 hours) Safe newborn care and practices, warmth, early breastfeeding, identification of sickness.
  • AWW and ASHA could motivate newly married women and recently delivered women to use family planning. The AWC would serve as the depot for pills and condoms (social marketing could be considered) and the AWW and ASHA would also facilitate referral for other methods.
  • The AWW and ASHA would participate in routine immunization and special campaigns like pulse polio through social mobilization.
  • Vitamin A: the first two doses are given in conjunction with measles and the first DPT booster and can be administered by the AWW under the direct supervision of the ANM on the Monthly Health Day. Thereafter the remaining three doses could be given by the AWW herself.
  • AWW and ASHA to work with communities and Village Health Committee to promote cultivation of leafy green vegetables, herbs, and ensure that these are supplied to the AWC on a regular basis to improve micronutrient content of food supplements.
  • Facilitate referral to appropriate health facilities, particularly for institutional deliveries, RTI/STI, violence, abortion, and gynaecological and other morbidity.
  4.1.3 Next Steps
   
  • Review job descriptions of the AWW, ANM, and ASHA and ensure that roles and responsibilities for convergence are clearly defined.
  • Examine training curriculum of AWW and ASHA and ensure that newer areas such as Newborn Care, Vitamin A administration, IMNCI, and their role in IMR and NMR reduction is highlighted
  • Examine contents of drug kit of AWW And ASHA and ensure that a drug kit for minor aliments, in keeping with rational drug use, is available at the village level.
  • Joint training of ANM, AWW, and ASHA on key technical areas as well as on roles and responsibilities with reference to convergence.
  • Short in service course for AWW/ASHA on newborn care and sick child referral.
  4.1.4 Nodal Officers and time line :
4.2 Womens Empowerment, Gender, and Equity
  4.2.1 Issues of empowerment, gender, and equity while not in the domain of health services are critical to ensuring good health. The DWCD includes several programmes for womens empowerment and mobilization as well as provision and skills for leadership and economic empowerment. The DHFW is not significantly engaged in forming groups, except perhaps the Mahila Swasthya Samitis (MSS) (whose functioning is variable and beset by several issues including the lack of a significant focus for discussion and action).
  4.2.2 Engagement of community groups of women for diffusion of knowledge and support for changed behaviors has been shown to increase mobilization of women needing services thus facilitating the ANMs task, increase accountability of local health staff, and improve utilization of sub center and primary health care. Self Help Groups (SHGs) can be engaged to improve demand for high quality Primary Health Care services, promote community awareness and action on issues that contribute to gender inequity and social exclusion, they can be mobilized to ensure access of the most vulnerable and needy to health and other social development programmes, and as community monitoring bodies.
  4.2.3 While SHGs are the key institutions at village level to promote convergence in this area, it is necessary to involve and build capacity of resource agencies and line functionaries to ensure a common understanding of health, gender and equity issues.
  4.2.3. Proposed Convergence Recommendations to promote womens empowerment, gender and equity
    4.2.3.1 Convergence between DWCD and DHFW through self-help groups can be achieved by the following:
  • Discussion of health issues in SH G meetings, facilitated by ANM/AWW and ASHA.
  • Building skills among SHG women to disseminate into general community key messages on family planning, RTI/STI/HIV/AIDS, safe abortion, and other health issues of women and children.
  • Enable SHG women to communicate information to AWW and ASHA on marriage, pregnancy, birth, and death to help registration process.
  • Provision of knowledge and skills to SHG members to understand and take action as a collective on issues of social importance such as: Prevention of early child marriages, female foeticide and the Pre-Natal Diagnostics (PNDT) Act, domestic violence, dowry, and womens empowerment, beyond economic self-sufficiency.
  • Promote community ownership through SHGs to maintain key facilities like water and sanitation at health centers, schools, and other common properties and monitor their use/misuse.
  • Serve as forum for discussion of sectoral issues such as nutrition, sanitation, education, and drinking water.
  • Support attendance of women and children at immunization, and antenatal check up sessions and other events, such as camps.
  • Serve as forum to disseminate information about key government schemes, like Janani Suraksha Yojana and other such entitlements, particularly for the poor and marginalized.
  • Enable support to the female extension workers- ANM, ASHA, AWW and others to carry out their responsibilities in an atmosphere of security and safety.
  • SHG members after appropriate training could engage in production of health related products such as sanitary towels, Disposable Delivery kits, nutritional supplements, and bed nets.
    4.2.3.2 Convergence between line functionaries and other agencies- National and State womens Commissions, NGOs, academic and research institutions on areas of womens empowerment and health. It is necessary that such agencies be jointly involved in planning and building capacity of SHG.
  4.2.4 Next Steps :
  • Review of SHG training material by DWCD and DHFW to ensure that key issues (as above) are incorporated
  • Identify resource institutions to enable training of SHG members (with AWW and ASHA) in above issues
  • Skill building of SHG members to take action against various forms of community discrimination and build linkages with appropriate agencies such a s the legal system and state womens commission
  4.2.5 Nodal officers and Time line :
4.3 Joint Planning for convergence related interventions
  4.3.1 In areas where convergence between DWCD ad DHFW is well established, joint planning is an efficacious strategy to promote coordination.
  4.3.2 In order to ensure effective functioning of the two areas of convergence discussed above, joint planning of between DWCD and DHFW at various levels is necessary.
   
  • At the village level, the AWW and ASHA will work closely with the Village Health Committee to formulate the Village Health Plan.
  • At the block level, the CDPO and the PHC staff will work together to review the Village Health plans in their jurisdiction, plan monthly health days, and discuss additional visits of ANM as required, based on feedback from their respective functionaries- AWW, Supervisor, ANM, and LHV.
  • At the district level, planning for convergence would be enabled through the District Health Mission
  4.3.3 Training of functionaries of both DWCD and DHFW in joint planning is necessary, and could be part of other joint training required for convergence.
  4.3.4 Nodal officers and Time line:
4.4 Common BCC strategy for convergence related interventions
  4.4.1 In the DHFW, the BCC division is responsible for development of material, identification of media, and content for BCC approaches for women and childrens health. Some work has also been done in the area of PNDT, sex ration, and early marriages. (DHFW and IEC???)
  4.4.2 In order to ensure commonality of message content and effective approaches to address womens groups, joint strategy development on BCC is necessary between DWCD and DHFW
  4.4.3 Nodal officers and Timeline:
4.5 Common Monitoring and Information Systems pertaining to key convergence areas
  4.5.1 Records and Registers maintained at the AWC and the DWCD contain information that contributed tot eh ANM register and the MIS of the DHFW. However, there are often duplications and omissions from one or both, suggesting the need for more stringent collection and review of data at the field level.
  4.5.2 Currently the Anganwadi survey register- includes data on every family living in the village- completed during the baseline survey and updated during each quarterly survey, monthly survey summary (includes children from 0-6 years, number of births, number of still births, deaths, (below one year, 1-3 years, 3-6 years,). The AWW is also expected to conduct village level surveys on an annual basis and update such records. The registers maintained at the AWC are:
  • Anganwadi Survey Registers
  • Immunization register
  • Register of services for children-Vitamin A and IFA
  • Growth monitoring cards for children
  • Health Cards of the children, including referral details.
  • Register of services for pregnant and lactating women (IFA and TT). This register also includes a section meant to be filled by the ANM on details of each pregnant and lactating mother.
  4.5.3 The ANM registers include : (Form (9)
  • Record births and deaths in the area and report to Health Worker (Male)???
  • Infant deaths and Child deaths (Day one, first week, first month, one year, one to five years)
  • Immunization records
  • Vitamin A record
  • Newborns-sick newborns-treated and referred
  • Report on Vaccine Preventable Diseases, ARI and diarrhoeal diseases
  • ANC< PNC and FP details
  • Pregnancy outcomes and maternal deaths,
  • MTP
  • RTI/STI
  • Stock of essential drugs and commodities
  4.5.4 Proposed Convergence Recommendations for Joint MIS :
    There appears to be substantial overlap between the data collected by the two departments at the field level. In large-scale state and national surveys such a s the DLHS and NFHS information on child nutrition, womens empowerment and violence data is being collected. Neither the DWCD nor the DHFW is involved in birth and death registration, although both collect information on births and deaths among selected groups. The following could be done:
   
  • Joint review of MIS of DWCD and DHFW MIS, particularly in regard to the two convergence areas and devise a more efficient data collection system at the field level that fits the needs of both without duplication of information.
  • Work with Gram Panchayat to ensure universal registration of births, marriages, and deaths.
  • Develop jointly a list of common process and output indicators at the level of the village and district to ensure that the goals of both DWCD and DHFW are being met.
  • Develop a common reporting format for maternal and child health services.
  • ASHA and AWW trained in collection and significance of gender disaggregated data for nutrition and health.
  4.5.4 Nodal Officers and Time line:
4.6 Adolescent Empowerment and health: The DWCD runs Kishori Shakti Yojana (need more input). In RCH II adolescent health is an important component. The spectrum of interventions ranges from empowering adolescents with life skills education to provision of safe spaces and health services appropriate to the special needs of adolescents. Convergence in this area could also be envisaged through appropriate planning and capacity building
  4.6.1 Nodal Officers and Time line:
4.7   Joint Training: Several of the convergence actions need substantive input in training. Both DWCD and DHFW have nodal training institutions at National and State levels.(UDISHA, NIPPCD, NIHFW,) Both also involve several reputed NGOs in training. A review of training resources and existing strategies for joint training could be conducted. Based on needs of joint training (after strategies for other convergence areas are finalized) and thereafter a plan for joint training and capacity building at the National and state level could be drawn. Beyond technical training, counseling, networking and advocacy skills should also be included.
  4.7.1 Nodal Officers and Time Line:

[1] such as immunization and micronutrient supplementation for children and pregnant women, Integrated Management of Newborn and Sick Child (IMNCI), examination of pregnant and post partum mothers, distribution of pills and condoms for birth spacing, health education, and referral.