Issue No. 10

Learnings From Bihar-Childhood Diarrhoea Management Program In Chhattisgarh

ince 2009, MI has been working in Bihar and Chhattisgarh

through public health projects to promote Zinc and ORS for

childhood diarrhoea management. In Bihar, MI started the

program in 15 demonstration districts, and later as

evidence of impact grew, the state government scaled-up the

operations to all districts. In the 15 MI demonstration

districts, nearly 2 million

cases of childhood diarrhoea

have been reported treated

between August 2011 and

February 2015; of which

70 percent have been treated

using both Zinc and ORS.

A p a r t f r o m i m p r o v e d

coverage of Zinc and ORS,

MI's project in Bihar has

d e l i ve re d e n co u ra g i n g

results on sustained levels of

knowledge of frontl ine

health workers, improved

and detailed reporting on

childhood diarrhoea cases by

health workers, project and

HMIS (Health Management

Information System) reporting,

streamlining of Zinc and ORS supply chains, and generating

awareness among key stakeholders. As this project funded

by the Children's Investment Fund Foundation (CIFF),

culminates in Bihar and steadily become sustainable, MI

draws upon the key lessons and forges new ties with the

Chhattisgarh government with the support of CIFF. Starting

April 2015, MI in Chhattisgarh, has initiated a project to

support in strengthening the state's program on childhood

diarrhoea management, while promoting continued feeding

during and after illness. Some of the other key components

of the project are; training of frontline health workers at the

state and district levels on Childhood Diarrhoea

Management using Zinc and ORS, and improved reporting

and treatment of diarrhoea cases.

T h e U n d e r - F i v e

M o r t a l i t y R a t e o f

children in Chhattisgarh

is 55, which is higher

t h a n t h e n a t i o n a l

average of 52 (Per 1000 1live births). Of all

under-five deaths in

India, 11 percent can be

a t t r i b u t e d t o 2d i a r r h o e a . P u b l i c

sector care-seeking for 3diarrhoea is 31.7% in

Chhattisgarh among

children (0-2 years age

group), and the rate of

O RS u s a ge a m o n g

children in this age

group is fairly high at

61.5%. There is thus significant potential for larger number

of children to be treated with the recommended combined

therapy of Zinc and ORS, provided supplies are smooth and

the health system has the capacity to deliver.

MI has achieved much impact in Chhattisgarh, through

previous child health interventions supporting the

Government. High-level discussions with government

Learnings from Bihar – Childhood Diarrhoea Management Program in ChhattisgarhImproved supplies of Zinc & ORS in the Public Health System Innovative Links in the Supply Chain Pilot - Enhancing Access to Zinc & ORS Program Champions - Institutionalizing Supportive Supervision of Frontline Health Workers

1 Millennium Development Goals India Country Report 2014, Social Statistics Division, Ministry of Statistics and Programme Implementation, Government of India.2 WHO 2012 estimates.3 Coverage Evaluation Survey 2009.

Zinc with ORS in helping children recover from diarrhoea faster, resist thedisease longer, and have fewer episodes each year.

S

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7

espite efforts by the Bihar government to improve

procurement in the public health sector, stock-outs of

essential medicines like Zinc and ORS are not uncommon.

Other supply-side challenges for Zinc and ORS, are the

procurement tenders lacking detailed product specifications,

procurement of low-price but sub-optimal formulations, and

the sporadic availability of Zinc and ORS with frontline health

workers at the village-level.

To tackle this gap situation, and in response to the follow-up

efforts of MI, RMNCH+A partners and Government of India,

the Bihar state government tracked stocks of 10.3 million

Zinc tablets (deemed sufficient for at least 735,714 cases of

childhood diarrhoea), available with the Bihar Medical

Services & Infrastructure Corporation Limited (BMSICL) and

alongwith 1.47 million packets of ORS, drew up a plan in

January 2015, for a swift dispatch. In February, all districts of

Bihar had reportedly received Zinc and ORS supplies, with

stocks soon reaching all PHCs and sub-centers.

To ensure supplies in forthcoming months as well, MI has

supported the state government to issue a new tender for

the procurement of Zinc, by providing details on product

specifications to BMSICL (Health Department, Government

of Bihar) and advocating for its e-tendering.

There is a gradual but certain improvement in the availability

of Zinc and ORS in Bihar. This is reflected in the number of

childhood diarrhoea cases being reported treated in the

public health sector, using Zinc and ORS. So far, between

August 2011 and February 2015, in the 15 demonstration

districts of MI, in the public health sector 2 million cases have

been treated with both Zinc and ORS.

Ensuring access to Zinc and ORS is key for managing childhood diarrhoea.

Improved Supplies Of Zinc & ORS In The Public Health System

counterparts and representatives of the State Health

Systems Resource Centre have resulted in MI now

working to scale-up the use of Zinc and ORS in Chhattisgarh.

Some headway has already been made in this direction by

the state government, with programmatic and technical

support provided by MI. In the first quarter of 2015, the

Government of Chhattisgarh has procured 9.8 million Zinc

tablets (700,000 courses) through state funds, believed

adequate for about six months. For the year 2015-16 too,

MI has contributed its technical expertise to the state

government for making budget allocations for Zinc

and ORS procurement, which is reflected in the state's

Program Implementation Plan, under the National

Health Mission.

More than 2 million cases of childhood diarrhoea have been reported and treated at the public health sector in the 15 demonstration districts of MI, of which 70 % have been treated with both Zinc and ORS

D

Cases reported treated through project reportingCases reported treated with Both Zn & ORS (project reporting)

Innovative Links in the Supply Chain Pilot -

Enhancing Access to Zinc & ORS

he Government Of India guidelines mandate frontline

health workers like ASHAs, to manage childhood diarrhoea

cases using ORS and Zinc at community level. Yet irregular

supplies continue to impact access to this life-saving therapy.

In Bihar too, sporadic supplies in recent times, have impacted

the number of childhood diarrhoea cases being treated in

the public health facilities using Zinc and ORS.

MI's Childhood Diarrhoea Management Program

implemented with the support of Children's Investment

Fund Foundation (CIFF), is providing technical and

programmatic support to the state government. As part of its

project activities, MI is helping the government streamline

supplies of Zinc and ORS. MI is also providing technical

support through training of health workers, demand

forecasting, planning distribution, storage, monitoring and

reporting on stock status. This has brought out the crucial

role that Frontline Health Workers (FLWs) play in timely

provision of Zinc and ORS to the community.

In block Dumrikatsari of Sheohar, one of the districts lagging

behind in child health indicators, MI is currently

implementing an innovative supply chain pilot project, to

ensure timely supplies of Zinc and ORS to frontline health

workers. The innovation hinges on leveraging the existing

network of government healthcare personnel in the vaccine

delivery system. To ensure that Zinc and ORS reaches last

mile beneficiaries, MI is utilising the network of Courier +Service Men (CSM)*and Cold Chain Handlers working in the

government's Vaccine Delivery System in Bihar.

As part of the pilot, CSMs are entrusted with carrying a

'Supply Chain Replenishment Kit' alongwith vaccines, during

their visit to the sub-center on the Village Health and

Nutrition Day. This kit contains adequate quantities of Zinc

and ORS for distributing to each frontline health worker as

per need. Upon reaching the VHND site, the CSM records the

Zinc and ORS stocks available with the frontline health

worker, assesses how much is needed, and accordingly

replenishes her stock with the supplies he is carrying. At the

day's end when CSMs return to the PHC, they hand over a

report on the Zinc and ORS stock status of FLWs to the Cold

Chain Handler. The Cold Chain Handler then sends forth a

compiled report, received from all CSMs, to the Medical-

Officer-In-Charge for his attention.

The innovation lies in assessing Zinc and ORS utilization rates

* - Courier Service Men transport vaccines to the sites on a pre-decided Village Health and Nutrition Day .

+ - Cold Chain Handlers are health personnel i.e pharmacists, multi-purpose health workers etc who are tasked with proper storage and handling of vaccines, daily upkeep of refrigerators and temperature charting.

and immediate replenishment of stocks with frontline health

workers in real-time. Otherwise, in the public health system,

frontline health workers receive only one-time supplies of

Zinc and ORS in the year from their respective PHCs, and

there is no mechanism of regular replenishment or stock-

taking once their stocks finish, leading to possible gaps in

treatment of childhood diarrhoea. Going a step further now,

with MI's support, the CSMs have been trained to send a

coded SMS on the real-time stock status of Zinc and ORS with

the FLW. Data from these SMSs gets entered onto the online

data entry package. Some of the challenges this innovation

seeks to overcome, stem from the semi-literate status of

CSMs, giving rise to difficulty in data capturing, and other

challanges pertaining to mobile network availability.

Timely treatment with Zinc and ORS can save millions from childhood diarrhoea, empowering the generations to come.

T

Program Champions - Institutionalizing Supportive Supervision Of Frontline Health Workers

key component of the support provided by MI to the

Bihar government under the Childhood Diarrhoea

Management Programme, has been Supportive Supervision

of Frontline Health Workers in 10 districts. Herein Block

Community Mobilizers (BCMs) working under the State

Health Society (Govt. of Bihar) were trained by MI to provide

on-the-job training and hand-holding support to frontline

health functionaries (ANMs, ASHAs, AWWs) during their

visits on Village Health and Nutrition Days. This helped

the frontline health workers tackle field-level challenges

while dealing with childhood diarrhoea-related cases.

During the BCMs visits, an ANM, atleast one ASHA and one

AWW under the purview of a BCM were supervised. Further

the BCM visited two caregivers serviced by this ANM and one

caregiver each serviced by the ASHA and AWW. A BCM from

block Salkhua, who had earlier attended a state-level

training on Supportive Supervision facilitated by MI says,

“Now I can better empathize with ASHAs and ANMs and the

challenges they face in the field. It has helped me connect

with them more effectively”. In the three years of supportive

supervision, nearly 22,000 frontline functionaries have been

visited by BCMs, to fill capacity gaps and address service

delivery issues in childhood diarrhoea management using

Zinc and ORS. As a result, the data on supportive supervision

reflects that knowledge levels of frontline health workers on

childhood diarrhoea management, have remained

consistent.

As MI's Childhood Diarrhoea Management Program in Bihar

steadily becomes sustainable, a systematic process

evaluation of the Supportive Supervision component has

revealed that Supportive Supervision has indeed

contributed to improving frontline healthcare worker's

motivation levels, especially in context of their knowledge

on Zinc and ORS for managing childhood diarrhoea, their

counselling skills, helping them meet job expectations

and gain social recognition as skilled medical service

providers. “Our efficiency at work improves as we are

provided with a lot of information and good advice by the

BCMs. This helps us improve at our work”, says an ASHA in

district Madhepura.

Now that the project is gradually becoming sustainable, MI is

working with the Bihar government to ensure that

supportive supervision of frontline health workers continues

as a part of the BCMs routine supportive supervision and

community visit tasks.

A BCM (Right) in Sultanganj village (Bhagalpur district) observes an ASHA as she prepares the ORS solution at a caregivers' home.

A