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workshop of providers _anms_ at shahdra north on 30 may 05


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									                   Workshop of Providers (ANM’s) on 30 May 05

Issues affecting services

Safe delivery/ANC
    Awareness
    Infrastructure
    Referral issues/linkages
    Community preference for home delivery
    Labour class – not available during day time
    Staff shortages
    Migration
    Distance from centre
    Awareness
    Staff behavior
    Community resistance/gap
    Fear of side effects
    Large queues/ rush of patients
    Vaccine shortage, cold chain issues, syringes (minor issues)
Community linkages
    Minority community
    Illiteracy
    Staff behavior
    Timings of services
    Local leaders are not supportive
    Poverty
    Worker load due to very high density of population
    Staff shortage
    No link workers
    Address is not proper so follow up is difficult
Family planning
    Awareness
    Illiteracy
    Limited choice available
    Problems with case selection and follow up in Cu T cases
    Location of facilities
    Minority community
    High rate of Cu t failure
    Family pressure/ male dominance
    Staff shortage
    Referral linkages with hospitals are poor
      Privacy concerns
      Cultural differences between providers and community

Possible solutions

Family planning
   More staff
   Refresher training of staff
   More awareness
   Availability of full basket including emergency contraceptives
   Behavior modification / Stress reliving methods (mainly due to overwork)
   Good follow up/ availability of LMO
   Patient selection should be proper
   Better working protocols
   Quality of services should be ensured
   Side effects related to procedures should be explained in advance
   Better logistics/supply management
   More workers from minority community
   Include cultural issues of minority community in Training

ANC/Safe delivery
   More infrastructure/staff
   More centers providing services
   Ultrasound/diagnostic tests should be available in the centre itself
   Better referral linkages are required
   Cultural issues/privacy should be respected

   People do not come if we talk of family planning all the time. Sometimes they
     feel threatened.
   We should also treat other ailments also at the same time
   Centre should be nearby
   Better supply chain

Community linkages
   Workers including link workers should belong to the community
   Local leaders should be co-opted for program purposes
   Free health services to the most poor strata (they have to spend on transport,
    syringes etc)
   Side effects should be explained properly
   Cultural training for workers
Other comments

      ANM,s want link worker payment to be based on outputs ( incentive based
       payment) but not for themselves.
      Many medical officers feel that 8- 2 PM timing is not useful as staff only comes at
       9.30 10AM and goes back by 1 PM If they have to go to field then only 1 hour is
       available which is not sufficient. So 9 to 4 PM is better suited for clusters and
      For institutional deliveries privacy is a big issue.
      Regular staff meetings are important. Medical officers never explain the purpose
       – just give orders. There is no discussion on issues.

Other issues (operational) –

       Work load-Population based, client load based, distance etc.
      Types of services at outreach level – Immunisation,? Growth monitoring, FP,?
      Mode of delivery of services – By ANM at fixed location/HTH, Frequency etc.
      Record maintenance – No. of registers, data validation issues/ process, linkage of
      Reporting process – formats, supervision (outreach), feedback etc.
      Cross cutting issues – Transport of workers, timings, remuneration issues,
       working environment at field level, type of employment, transfer policy, appraisal

      Follow up of cases is very poor especially of family planning. Behavior of staff is
       bad. Even in maternity homes cases referred from health center are sent back e.g.
       IUD cases with bleeding are sent back without discussion. ANC cases sent for
       delivery are not taken up for e.g. in -------- MH and --------- hospital.
      There is practically no meeting of community workers with Medical officers
       except in few centers. They always discuss strategy of pulse polio before every
       round but not other service activities, on a routine basis.
      For outreach activities biggest hindrance is lack of space for examination of
       patients in clusters/slums. Most ANC cases complain that they are never
       examined by ANM’s whereas ANM’s complains that there is no place where
       examination can be conducted. So all patients are advised to go to health centre
       but they do no do so due to long distance involved (For ANC cases). So
       compliance is poor.
      For immunisation the problem is significant side effects like injection abscess.
       More education of patients and skill training of ANMs will help.
      The community workers want that they should be trained to treat minor ailments
       in their locality especially at odd hours. This could be fever, diarrhoea, small
    injuries, pains and aches etc. This will increase their credibility and effectiveness
    as health workers.
   Regarding confusion in Addresses and names of ANC cases the community
    workers are of the opinion that the confusion arises in some cases due to change
    in name or use of maiden name. In some cases the clients shift residence in the
    area from one place to another. However the percentage of these cases in not
    more than 10% and bulk of these are traceable. In any case if a worker is in place
    for several years as most of these are, than there is no confusion in names or
   At times community workers have to accompany the patient to hospitals and
    clinics at odd hours. When they go to govt. hospitals no one recognizes them, as
    they are not given any identity papers. They do not have any official recognition
    in the area also. They face similar credibility problems during immunisation
    campaigns and pulse polio activities.
   During training on 13/6/05 some other points came out such as –
        o Mahila mandals are held very infrequently. Sometimes no advance info is
            available to community workers for organizing these meeting and at the
            last moment whosoever is available is called for the meeting.
        o There is no thought given to composition of group for e.g. no effort is
            made to induct women with leadership qualities into the group.
        o Sometimes the messages are not directed at the proper audience for e.g. on
            World tobacco day ANC group was collected randomly and they were
            advised against smoking and also told about advantages of breast feeding.
        o All community workers agreed that Medical officers were never available
            for these group meetings. They were also of the opinion that if M.O.’s
            were to attend these meetings once in 2 – 3 months it will have a big
        o Regarding immunisation they were of the opinion that a large no. of
            people were afraid of immunizing their children due to side effects like
            fever and abscess formation which were significant. Also mothers were
            not informed about the possible side effects in advance. After
            complications mothers were not aware as to what action to be taken and
            where to go so that after abscess many times they had to go to private
            clinics and pay heavily.
        o Whenever they had to advise patients regarding delivery or accompany
            them for delivery there were no specific directions available as to where
            they should go. For e.g. in -------- area community workers were advising
            people to go either to medical college, or ------- MH, or to main hospital or
            ---------- MH. Also no hospital was taking cases directly for delivery and
            they had to face difficulties even when community worker accompanied
        o They again informed that in -------MH most cases coming for delivery
            were turned away or referred verbally by staff to other places. These cases
            invariably went back to Jhuggies and got deliveries done by local birth
           o Some people also informed that money was being charged by staff
             especially Ward Ayah in MH --------------. This also discouraged patients
             from going for institutional delivery.
           o No community worker had list of names of dropouts. The names were
             never provided by ANM. They were however always told to get more
           o There was no clarity on survey and resurvey requirements.
           o Some of the community workers were also giving oral pills to the new
             clients. They however were not aware of what precautions to take before
             starting clients on oral pills.

Training of community workers on 21 July 05

          Mobility support for Tubectomy patients and institutional deliveries will help
          If related services like HB/Urine testing and ultrasound is available in one
           place then ANC cases are more willing to come for check up. NGO’s like -----
           - are providing such support.
          People have to come for repeated visits in centers; sometimes they are turned
           away after OPD slip making time is over at 11 or 12 PM depending on the
          Side effects are not explained properly and also not treated fully.
          Sometimes IFA/Calcium is not available.
          Pregnancy Test kit is not available
          Behaviour of staff is an issue
          Community workers should have some identity like badge etc.
          Mistrust in govt staff
          Limited Timings of health centers is a problem.

Training of community worker on 29 July 05

Reasons for poor response from community –
    Bad behaviour
    Improper care
Deliberate effort at de-motivating patients coming for delivery
    Superstitions and fear of side effects
    Proper targeting of decision makers is not done like mother – in –laws and
    During targeted sessions for ANC Care and Immunisation in outreach treatment
       of minor ailments should also be available.
Other factors
    No identity of community workers – she needs official recognition through I
       cards, uniform etc.
    Honorarium is too little and is paid after several months.
    Two way communication between community worker and ANM etc needs to
       improve as now the onus of completion of activity is on community worker. She
       informs the ANM of completed cases and also is supposed to find out dropouts
       (mostly) instead of ANM giving her the names of dropouts.
      The organisation of group meetings needs to improve through better targeting and
       focus on individual issues.
      Other than ANM, PHN and MO are rarely attending the Group meetings.
Training of community workers on 02 Aug 05

Views of community workers
    Behaviour of staff is a problem – like all lights are switched off in maternity ward
      even if patients want lights. This is because staff nurses want to sleep.
    Patients are asked to buy lot of stuff – even items like candles when lights are not
    If they take up large number of patients doctors ask them – are you taking money
      from patients?
    No recognition is available to them when they take patients to maternity homes.
      Doctors for e.g. Dr ------- ask them to stand them in line and do not value their
    They should be allowed to go for summer vacation for about 15 days and
      honorarium should not be deducted, as theirs is a continuous job.
    They should be given some basic minimum medicines, which they can disburse in
      emergency so that their credibility in the community increases and patients will
      not have to travel long distance for minor ailments.
    They should have some kind of I card which gives them recognition when they
      visit the area or pay home visits.
    Honorarium is too less.

   Training of community workers on 22 Sep 05

Views of community workers

      Honorarium is too less and that too is not paid on time.
      Treatment of other ailments should also be available in the health units besides
       MCH care and FP
      Drinking water is not available for patients and staff esp community workers
       during outdoor campaigns/health camps etc.
      Community workers should also be trained for treatment of minor ailments.
      They should be provided with I –Cards.
      In order to facilitate coverage of those left outs that are not available during
       normal timings the additional health activities like campaigns/health camps etc
       should be planned on holidays and in evenings.
      Senior staff like MO/PHN etc are invariably not present in outreach activities.
       Their regular presence would help.
      Behavior of staff towards cluster people should be more respectful.
Training of community workers on 17 Nov 05

Views of community workers
    One of the reasons for low immunisation is fear of side effects, which in the
      perception of people are significant.
    Some workers felt that sessions for immunisation should be more frequent
      whereas most people were of the view that these are significant.
    One of the main reasons for low no. of 3 visits is that these women go for work
    Institutional deliveries are low because there is no place which takes them up for
      e.g. ------- hospital refuses deliveries after primy. Most cases are referred on
      ground like anemia etc to other places but most of these cases end up with home
      delivery in the end.
    Women do not take IFA because of side effects.
    More IEC should be conducted using AV Media, street play, Nukkad natak etc
    I-card for community workers should be available
    Diary and calendar should be available on time. The quality of pens supplied is
      very poor.
    Lab test should be available in the Health center. This will encourage more ANC
      cases to attend.
    Facilities for old patients should be available as many patients are poor and have
      no one to look after them.
    Female condom should be made available as it has high demand.
    Training should not be a one-time affair and should be re-enforced.
    Chalk and other house writing material made available to them should be of better
    Honorarium should be increased.

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