|Year : 2020 | Volume
| Issue : 4 | Page : 345-350
Revamping village health sanitation and nutrition days for improved delivery of maternal and child health services at village level – Experiences from a pilot phase study
Nisha Sharma1, Malvika Sharma2, Dinesh Jagtap3, Ashwin Deshmukh4, Shailendra Hegde5, Alok Kumar6
1 Research Analyst, Aspirational Districts Transformation Programme, Piramal Foundation, New Delhi, India
2 Senior Manager-Epidemiology, Aspirational Districts Transformation Programme, Piramal Foundation, New Delhi, India
3 National Transformation Manager, Aspirational Districts Transformation Programme, Piramal Foundation, New Delhi, India
4 Vice President and Head, Aspirational Districts Transformation Programme, Piramal Swasthya Management and Research Institute, Hyderabad, Telangana, India
5 Senior Vice President and Head, Public Health Innovations, Piramal Swasthya Management and Research Institute, Hyderabad, Telangana, India
6 Advisor, Health and Nutrition, National Institution for Transforming India (NITI Aayog), New Delhi, India
|Date of Submission||26-Sep-2019|
|Date of Decision||12-Oct-2019|
|Date of Acceptance||08-Dec-2020|
|Date of Web Publication||11-Dec-2020|
Flat No. 201/6, First Floor, Kaushalya Park, Hauz Khas, New Delhi - 110 016
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Village health sanitation and nutrition day (VHSND) was conceived under the National Rural Health Mission to deliver maternal and child health and nutrition services at the village level in the anganwadi center. Multiple challenges, including a lack of convergence of frontline workers, were affecting service delivery at VHSND. As a public–private partnership Piramal Foundation proposed to revive the concept of VHSND. Objectives: The present study was aimed to demonstrate a model of VHSND to provide primary care related to maternal and child health and nutrition at the village level in 25 aspirational districts across seven states of India. Methods: The descriptive study was undertaken as a pilot phase. Of the purposively identified 506 VHSND sites, monitoring data on delivery of six basic primary care services at VHSND, collected as part of routine operations were compared for 229 sites for the month of September 2018 (baseline) and January 2019 (endline). Results: In model sites, there was the increased availability of drinking water and functional toilets; a significant improvement of availability of equipment for providing antenatal care services, immunization, and growth monitoring. However, the supply of drugs at these sites did not show a statistically significant change. There was also a significant improvement in the engagement of the Village Health Sanitation and Nutrition Committee (VHSNC) in the villages of the model VHSND sites. Conclusion: The model demonstrated the significant changes with effective supervision and participation of VHSNC members, demand generation activities complemented with improved supplies and widening range of services at the VHSND are required to be undertaken.
Keywords: Antenatal care, aspirational district, immunization, model, village health sanitation and nutrition day
|How to cite this article:|
Sharma N, Sharma M, Jagtap D, Deshmukh A, Hegde S, Kumar A. Revamping village health sanitation and nutrition days for improved delivery of maternal and child health services at village level – Experiences from a pilot phase study. Indian J Public Health 2020;64:345-50
|How to cite this URL:|
Sharma N, Sharma M, Jagtap D, Deshmukh A, Hegde S, Kumar A. Revamping village health sanitation and nutrition days for improved delivery of maternal and child health services at village level – Experiences from a pilot phase study. Indian J Public Health [serial online] 2020 [cited 2022 Jul 2];64:345-50. Available from: https://www.ijph.in/text.asp?2020/64/4/345/303100
| Introduction|| |
Village health sanitation and nutrition day (VHSND) was conceived under National Rural Health Mission (NRHM) to improve access to maternal health, child health, and nutrition services at the village level as a monthly activity. An Anganwadi Centre established for every 1000 population, under the Integrated Child Development Services Scheme was envisaged to be the hub of service delivery to conduct VHSND at the village level, where the frontline health workers would interface with the community on a designated day. The guidelines for VHSND (earlier called Village Health and Nutrition Day) were published in 2007. However, recently, there has been a renewed focus on VHSND with the launch of the Prime Minister's Overarching Scheme for Holistic Nourishment (POSHAN) Abhiyaan in 2018, which aims to improve the nutritional status of children, adolescent girls, pregnant, and lactating mothers. POSHAN Abhiyaan has highlighted VHSND as a platform to provide key services related to nutrition at the village level.
Although the VHSNDs are being organized on a monthly basis, there are multiple challenges affecting service delivery. Experience in the field has indicated that the scope of VHSND has been diluted, and most sites now provide only routine immunization in the name of VHSND., Further, there is an absence of expected convergence between the three key frontline workers, namely the Anganwadi Worker (AWW), the Auxiliary Nurse Midwife (ANM), and the Accredited Social Health Activist (ASHA), which leads to ineffective service provision and beneficiary coverage.
There is a need to re-energize the platform of VHSND and broaden the focus from just providing routine immunization to delivering a complete package of quality maternal and child health and nutrition services, thereby ensuring that services such as antenatal care (ANC), supplementary nutrition, counseling and referral are provided at the grassroots level.
National Institution for Transforming India (NITI Aayog), is a policy think tank of the Government of India, established in the year 2015, with an aim to achieve Sustainable Development Goals and to enhance cooperative federalism by fostering the involvement of state and union territories of India using a “Top-down and bottom-up design.” One of the key initiatives undertaken in the transformation journey is the Aspirational Districts Transformation Program, which aims to expeditiously improve the socioeconomic status of 112 districts from across 28 states. The program has identified 81 key performance indicators across various themes, including health and nutrition, education, agriculture, and water resources, skill development, financial inclusion, and basic infrastructure. Performance in the health and nutrition sector is measured through a set of 31 indicators and accounts for 30% of the total weightage in the Aspirational Districts Transformation Program.
The NITI Aayog partnered with Piramal Foundation through a public-philanthropic partnership model to transform the health and nutrition landscape of 25 aspirational districts across seven states, for 4 years. These aspirational districts are: 5 in Assam (Baksa, Barpeta, Darrang, Dhubri, and Goalpara); 5 in Bihar (Araria, Begusarai, Katihar, Sheikhpura, and Sitamarhi); 2 in Jharkhand (Pakur and Sahibganj); 5 in Madhya Pradesh (Barwani, Damoh, Khandwa, Singrauli, and Vidisha); 1 in Maharashtra (Nandurbar); 2 in Rajasthan (Baran and Jaisalmer) and 5 in Uttar Pradesh (Bahraich, Balrampur, Chitrakoot, Shrawasti, and Sonbhadra).
While the senior leadership at NITI Aayog provides strategic and technical counsel and administrative support, Piramal Foundation facilitates the implementation of the program.
As an implementing partner, Piramal Foundation has appointed a District Transformation Manager (DTM) for each of the 25 districts to engage with and assist the district administration for the implementation of health and nutrition programs. The DTM has a team of Block Transformation Officers (BTO) who look after each block in the district. To lend support to these field-level staff, the Foundation has also appointed a team of 31 people at the State level (6–7 people in each state) and a team of 22 people at the National level.
Piramal Foundation proposed to revive the concept of VHSND and demonstrate it as a model to provide six core services related to maternal and child health and nutrition at the village level. These core services include ante-natal check-ups, immunization, growth monitoring of children, supplementary nutrition, health and nutrition counseling, and referrals. The platform of VHSND not only has the potential to improve 20 out of 31 health and nutrition indicators of the Aspirational District Program but also provides a unique opportunity to stimulate demand generation for health-care services at the grassroots level.
The objective of this paper is to describe the conduct of a model VHSND and to study the effectiveness of carrying out this intervention in the context of maternal and child health issues in the 25 aspirational districts.
| Materials and Methods|| |
Design and framework of the study
A descriptive comparative study was undertaken as a pilot phase. VHSND sites were considered as primary study units. In the pilot phase, up to five model VHSND sites per block were selected in each of the 25 aspirational districts, amounting to a total of 506 sites in seven states of India. The selection was purposive, based on Piramal Foundation's state team recommendations.
Ethical approval for the study was obtained from the Institutional Ethics Committee of Piramal Swasthya Management and Research Institute, Hyderabad.
Establishing a model village health, sanitation, and nutrition day
The focus of the model VHSND was to provide six basic primary care services through a convergent action between the three front line workers, i.e., ANM, ASHA and AWW. These services include quality ANC, growth monitoring, immunization, supplementary nutrition, counseling, and referral. Operational guidelines were prepared and disseminated for the conduct of model VHSND, which elaborated a step-wise action plan for the block and district teams of the Piramal Foundation. The plan highlighted the organization of Model VHSND session in three phases [Figure 1].
|Figure 1: Phases of conducting a model village health sanitation and nutrition day.|
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The pilot phase was envisaged to last 5 months, i.e., from September 2018 to January 2019. After this phase, based on the outcomes, the plan was to scale up to all the 25 districts in seven states of the country.
Data collection and assessment
Piramal Foundation prepared standard operating guidelines for conducting model VHSNDs in the 25 aspirational districts. A reporting format was also developed to capture data for monitoring of the activities. The format was filled by the BTO visiting the model VHSND site. Data points captured included availability of basic amenities such as drinking water, toilets and electricity, availability of equipment, and drugs for various services and beneficiary attendance at the site. An analysis of the routinely collected monitoring data was performed comparing the data 4th month of September 2018 (taken as baseline) and January 2019 (endline). Of the 506 identified sites, only those sites for which complete data for both the months were available were included in the analysis.
For the purpose of this paper, the captured data points were grouped into five categories. Scoring was done for each category based on the availability of the included line items. If the line item was available, it was given a score of 1, and if it was unavailable, it was scored as 0. The total sum of the line item scores was the score achieved by each category. The categories and the line items monitored in each category are as follows:
- Growth monitoring equipment included stadiometer, infantometer, mid-upper arm circumference tape, infant weighing scale, and weighing scale for mother and child. The maximum score for this category was five
- Equipment for ANC included stethoscope, sphygmomanometer, examination table, curtain for privacy, measuring tape, hemoglobinometer, pregnancy testing kit, glucometer, glucometer strip, lancets, urine dipstick for sugar and protein and HIV testing kits. The maximum score for this category was twelve
- Equipment for vaccine delivery included thermometer, vaccine carrier with vaccines as per due-list, hub cutter, disposable gloves and colour coded bags for biomedical waste management. The maximum score for this category was five
- Drugs required during ANC and postnatal care included tablets of iron and folic acid (IFA), calcium, and albendazole. The maximum score for this category was three
- Pediatric drugs included syrup IFA, paracetamol and amoxicillin, Vitamin A, Oral Rehydration Solution (ORS) and Zinc. The maximum score for this category was six.
Apart from the above categories, the availability of basic amenities such as drinking water, toilets and electricity as well as community engagement through Village Health Sanitation and Nutrition Committee (VHSNC) were also compared at baseline and endline.
The data were entered and cleaned in Microsoft Excel 2016, following which it was exported to IBM SPSS Statistics, Version 25.0 (International Business Machines Corporation, New York, United States of America) for statistical analysis. For continuous variables distributed normally, paired t-test was performed. For comparison of categorical variables at baseline and endline, McNemar's Chi-square test was performed. Value of P = 0.05 was considered to be statistically significant.
| Results|| |
Five hundred and six VHSND sites were identified for the demonstration as a model. However, due to administrative issues (n = 190), gaps in planning the VHSND sessions including cancellation due to measles-rubella campaign (n = 43), no beneficiary participation (n = 27) and on strike or on leave frontline worker or BTO (n = 17), 277 sites were dropped. Sites for which complete data for both baseline and endline months were available (n = 229) were included in the analysis. These 229 sites were analyzed for their performance in September 2018 (baseline) and January 2019 (endline).
Basic amenities such as electricity, toilets, and drinking water are essential to ensure comfortable and quality service delivery. At the end of the pilot phase, the proportion of model sites with drinking water increased significantly from 76% to 86% (P < 0.001) and proportion of model sites with the availability of toilets increased significantly from 48% to 66% (P < 0.001) [Table 1].
|Table 1: Comparison of availability of amenities and services at baseline and endline at Village Health Sanitation and Nutrition Day sites (n=229)|
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There was a significant improvement in the availability of all three categories of equipment, i.e., equipment for providing ANC services, equipment for immunization and growth monitoring. However, the supply of drugs at these sites did not show a statistically significant change [Table 1].
There was a significant improvement in the engagement of VHSNC in the villages of the model VHSND sites. The VHSNC meetings before VHSND session happened at 36% of the villages (n = 82) at baseline and increased to 76% of the villages (n = 174) by endline (P < 0.001).
| Discussion|| |
VHSND was conceptualized to bring the health and nutrition services at the doorstep of community with basket of services for pregnant and lactating women, children under 6 years of age and adolescent girls. Studies in different states have shown that contrary to the guidelines, only a limited range of services was being provided at the VHSND. Registration of pregnant women and immunization of children were prime tasks undertaken at VHSND., Various studies have highlighted gaps in planning, functioning, infrastructure, and service delivery of VHSND. Few authors have also demonstrated that 3 months of focussed efforts can bring remarkable changes in VHSND.,
Piramal Foundation created a model to operationalize VHSND across 506 sites in 25 Aspirational Districts. For a sustainable VHSND, it was vital to create a demand for services from the beneficiary hence bringing the community closer to the health system. Various studies report low beneficiary participation due to the lack of prior information about the date of VHSND session, lack of motivation due nonavailability of services or supply of drugs and logistics.,, Further, studies also report inadequate ANC services limited to registration of pregnancy and administration of tetanus toxoid. These studies also document that several basic instruments such as sphygmomanometer, glucometer, hemoglobinometer were missing from many VHSND sites making delivery of quality ANC check-up a critical challenge.,,, Similar scenario was recorded at our study sites during baseline. However, after 4 months of concerted effort and better planning and coordination between the three front-line workers and block supervisors, there was a significant improvement in the availability of equipment and supplies for the provision of services.
To facilitate community ownership and promote decentralized health planning, VHSNCs were set up at the village level under NRHM. These committees were envisaged as being central to “local level community action” under NRHM and take leadership in providing a platform for improving health awareness and access of community for health services, address specific local needs and serve as a mechanism for community-based planning and monitoring. The members of the committee include elected members of the panchayat, community members and health service providers. Previous studies have identified gaps in composition, formation, and functioning of VHSNC at the village level in many states.,, A study by Singh and Purohit highlighted that although VHSNC had been constituted on paper, meetings were not being held with the majority of the reported VHSNCs meeting only once a year. Piramal Foundation's model VHSND initiative identified VHSNC as a key body to bring about changes at the ground level and improve community engagement and accountability. A significant improvement was seen in the engagement of VHSNC in the model VHSND sites.
Studies have found a lack of basic amenities such as the availability of drinking water at VHSND sites. Saxena et al., in their study in Uttarakhand, found that approximately 71% of the assessed site had no provision of drinking water. In the current study, there was a significant improvement in the availability of toilets and drinking water at model sites. This was made possible by the active involvement of VHSNC members, particularly the Sarpanch (elected head) of the gram panchayat, who took up the ownership of improving the status of basic amenities at the VHSND sites.
Our paper demonstrates the importance of planning and monitoring of VHSND. It also highlights the changes brought about with effective supportive supervision and participation of VHSNC members. The availability of equipment, supplies, and coverage of services was improved by planning the VHSND in advance. Innovative methods such as public announcements and sending personalized invitation cards for VHSND in advance led to greater participation by the community. These demand generation activities were complemented with improving supplies and widening range of services at the VHSND. Convergence was the underlying driver of the intervention with the three front-line workers carrying out the activities in a coordinated manner and ensuring no beneficiaries were systematically excluded from service provision.
Our study has some limitations. There is an absence of true baseline data gathered before the roll-out of the model. Instead, we have considered the monitoring data from the 1st month of implementation as a baseline for this study. This may have led to a dilution in the comparison estimates presented in this paper. In addition, the site selection of VHSND was made purposively by the state team of the Piramal Foundation in collaboration with district administration. The lack of random selection may affect the generalizability of results. Further, nearly 40% of the initially identified sites had to be dropped due to operational challenges such as vacant posts of either of the three front-line worker. While a model site with requisite workforce in place would provide the envisioned services effectively, the lack of human resources plaguing the health system in the country would reduce the effectiveness of such interventions.
Finally, while our study showed significant improvement at the model VHSND sites over a pilot phase of 5 months, whether the effects are sustained or not, cannot be studied in this paper. Subsequent follow-up studies in the same geographies will be planned in the future to examine the sustainability of improvement.
| Conclusion|| |
There is a need to create platforms that are sustainable and impactful to provide primary care services to the large rural Indian population. Our experience shows that the VHSND platform can be effectively used to provide critical primary care services while also stimulating demand from the community. To ensure sustainability, the community must be involved in managing this platform, and hence, the regular and effective functioning of the VHSNC is critical to VHSND. As more and more health and wellness centers are established across India, VHSNDs will have an increasingly significant role to play at the grass-roots level and over a period, additional primary care services will have to be added to the basket of services at the VHSND, thereby making it more holistic and comprehensive.
We are thankful to the IT and operation teams, especially Block Transformation Officers, Data Analysts, District and State Transformation Managers of Piramal Foundation, for making the data available to us for the analysis. We acknowledge the support received from the district administrations, health, and social welfare departments for conducting the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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