Baseline Report-Evidence Based RI, VHND and IMNCI Service delivery through Health system strengthening in Odisha

EVIDENCE-BASED IMNCI, VHND AND RI SERVICE
DELIVERY THROUGH HEALTH SYSTEM STRENGTHENING
IN ODISHA – AN EXTERNAL MONITORING
DEMONSTRATION PROJECT
Base-line Report
October 2013
Conducted by
Public Health Foundation of India
Indian Institute of Public Health – Bhubaneswar
In collaboration with
Government of Odisha and UNICEF – Odisha
Key Words: Base-line, Routine Immunization, VHND, IMNCI, External Monitoring, Odisha

Evidence-based IMNCI, VHND and RI Service Delivery
through Health System Strengthening in Odisha – An External
Monitoring Demonstration Project
Base-line Report
October 2013
Conducted by
Indian Institute of Public Health – Bhubaneswar
In collaboration with
Government of Odisha and UNICEF – Odisha
Key Words: Routine Immunization, VHND, IMNCI, External Monitoring, Odisha

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A research study conducted by:
Indian Institute of Public Health, Bhubaneswar
2nd and 3rd floor, JSS Software Technology Park
E1/1, Infocity Road, Patia, Bhubaneswar - 24
Contact no: 0674 6655601
ISID Campus, 4 Institutional Area
Basant Kunj, New Delhi – 70
www.phfi.org
Corresponding Author:
bhuputra.panda@iiphb.org
This work was supported by UNICEF

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Principal Investigator
Dr. Bhuputra Panda (PHFI-IIPHB)
Co-Investigators
Dr. Shridhar Kadam (PHFI-IIPHB)
Dr. Meena Som (UNICEF)
Dr. A K Sen (UNICEF)
Research Advisory Team
Director of Family Welfare, Govt of Odisha
Dr. Subhash Salunke, Sr Advisor PHFI and Director, IIPHB
Dr. Lipika Nanda, Deputy Director, IIPHB
Additional Director, Child Health, Govt of Odisha
Research Support Team
Ms. Anindita Pattnaik (PHFI-IIPHB)
Dr. Gyanaranjan Pradhan PT (PHFI-IIPHB)
Dr. Nishitha Ranjan Dash (PHFI-IIPHB)
Dr. Sandeep Kumar Panigrahi (UNICEF)
Dr. Sovesh Das (PHFI-IIPHB)
Mr. Sudeep Kesh (PHFI-IIPHB)

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ACKNOWLEDGEMENT
This study report was a result of three months of incessant hard work on conceptualization, finalization
of study design, development of data collection tools, and then collecting data from the remotest sites of
five far-off districts of Odisha, followed by meticulous data analysis.
The Study was conducted by Indian Institute of Public Health – Bhubaneswar with funding support of
UNICEF between July 2013 and September 2013. We are thankful to the UNICEF team for
commissioning this study to IIPH-Bhubaneswar and for providing timely support throughout the course
of data collection, data analysis and report writing.
The department of health and family welfare (DoH& FW), government of Odisha provided all necessary
support and cooperation during data collection phase, for we are thankful to the state, district and sub-
district level officials. Specific mentions may be made of the chief district medical officers, additional
district medical officers and block programme managers of all the five intervention districts.
The crisp support provided by Dr Ajit Basanta Ray and Ms Padmavathi Yedla was useful for finalization
of the tools and writing the report. We thank them all for their contribution.
Last, but not the least, the efforts and enthusiasm of field investigators, all staff associated with this
work in data collection from the field was instrumental in completion of this study on time.
Dr Shridhar Kadam Dr Bhuputra Panda
Co-Investigator Principal Investigator

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ABBREVIATIONS
ANM: Auxiliary Nursing and Midwifery
MPHW (F): Multi Purpose Health Worker (Female)
AWW: Anganwadi Workers
BPO: Block Program Organizer
CHC: Community Health Centre
ICDS: Integrated Child Development Scheme
ILR: Ice Line Refrigerator
IMR: Infant Mortality Rate
LHV: Lady Health Visitor
MCH: Maternal & Child Health
MMR: Maternal Mortality Ratio
MO: Medical Officers
NRHM: National Rural Health Mission
PHC: Primary Health Centre
SC: Sub Centre
RI: Routine Immunization
VHND: Village Health & Nutrition Day
IMNCI: Integrated Management of Neonatal & Childhood Illness
AVD: Alternate Vaccine Delivery
PRI: Panchayati Raj Institutions
GKS: Gaon Kalyan Samiti

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CONTENTS
EXECUTIVE SUMMARY........................................................................................................................................1
BACKGROUND........................................................................................................................................................5
REVIEW OF LITERATURE.....................................................................................................................................7
AIMS & OBJECTIVES OF THE STUDY ................................................................................................................9
MATERIALS AND METHODS .............................................................................................................................10
RESULTS - BOLANGIR.........................................................................................................................................14
RESULTS - NUAPADA..........................................................................................................................................37
RESULTS - KORAPUT...........................................................................................................................................58
RESULTS - NABRANGPUR..................................................................................................................................79
RESULTS - MALKANGIRI..................................................................................................................................101
DISCUSSION ........................................................................................................................................................123
CONCLUSION & RECOMMENDATIONS.........................................................................................................126
ETHICAL ISSUES AND QUALITY ASSURANCE............................................................................................128
STUDY LIMITATIONS........................................................................................................................................128
BIBLIOGRAPHY ..................................................................................................................................................129
ANNEXURES........................................................................................................................................................130

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TABLES
Tables
Page No(s).
Bolan
gir
Nuapa
da
Kora
put
Nabar
angpur
Malka
ngiri
Table-1: Availability of vaccines at routine
immunization session sites
15 38 59 80 102
Table-2: Availability of logistics at routine immunization
session sites
15 38 59 80 102
Table-3: Quality indicators-I at RI session sites 16 39 60 81 103
Table-4: Quality indicators-II at RI session sites 17 40 61 82 104
Table-5: Health supervisors visited in last three months
v/s 4 key messages delivered to caregivers
18 40 62 83 105
Table-6: Availability of logistics at VHND sites 19 42 63 84 106
Table-7: Session site of VHND 20 43 64 85 107
Table-8: Availability of health workers at VHND sites 21 44 64 86 108
Table-9: Maternal health service delivery at VHND sites 21 44 65 86 108
Table-10: Child health & family planning service
delivery at VHND session sites
22 45 66 87 109
Table-11: Quality attributes of VHND services 23 46 67 88 110
Table-12: Review of IMNCI records 24 47 68 89 111
Table-13: Assessment of skills of IMNCI trained
workers
24 47 68 89 111
Table-14: Availability of logistics at AWC 25 48 69 90 112
Table-15: Skill assessment of IMNCI trained workers on
assessment, classification & management of sick
neonates
26 49 70 91 113
Table-16: Skill assessment of IMNCI trained workers on
assessment, classification & management of sick children
of 2 months to 5 years
27 50 71 92 114
Table-17: Profile of supervisors 30 52 73 94 116
Table-18: Supervisory visits made by internal
supervisors in last one month
30 52 73 94 116
Table-19: Frequency, method and place of feedback
received on IMNCI from higher officials
31 53 74 95 117
Table-20: Programme management of IMNCI by the
supervisors
31 53 74 96 118
received on RI from higher officials
32 54 75 97 119
Table-22: Programme management of RI by the
supervisors
33 55 76 97 119
received on VHND from higher officials
34 56 77 99 121
Table-24: Programme management of VHND by the
supervisors
35 57 78 99 122

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EXECUTIVE SUMMARY
Background
Over the past decades continued efforts are being made to improve under five and maternal survival in
the country. Notwithstanding a continuous improvement in the key maternal and child health indicators
(U5MR reduced from 166 in 1980 to 55 in 2011 and MMR declined from 398 in 1998 to 212 in 2011;
SRS 2011) more focused interventions need to be undertaken. Consequently, maternal and child
survival initiatives continue to remain a priority for government of India and, in turn, the state
government of Odisha. Of the various initiatives taken up by the government, this project focuses on
assessment of implementation status of three community based child survival programmes, such as,
routine immunization (RI), village health and nutrition day (VHND) and integrated management of
neonatal and childhood illnesses (IMNCI). The project also focuses upon the need for providing regular
handholding support to the frontline functionaries for continued reinforcement of skills and knowledge.
It is estimated that early diagnosis, timely referral & management and regular supervision and
monitoring by internal monitors can ensure sustainability of community based interventions and quality
of services. Thus, Indian Institute of Public Health, Bhubaneswar with the support of UNICEF,
undertook this study, based on which further interventions could be planned in order to improve the
quality of the services. The purpose is to identify high risk mothers among population who are
accessing the health system, and to reduce under-five mortality.
Materials & Methods
We conducted the base-line in five intervention districts of Odisha to assess the existing quality of
services, and to explain the knowledge, opinions and skills of the supervisory workforce on programme
supervision. Thirty clusters were selected as sample, based on the WHO thirty cluster sampling, wherein
each cluster represented a sector. The allocation of number of clusters to each sample district was done
using the PPS technique. Primary and secondary data were collected during June to August, 2013, using
the standardized supervision checklists of Government of India, adopted by Government of Odisha, for
RI, VHND and IMNCI programmes. We administered a semi-structured questionnaire (designed and
field-tested by IIPHB) for the supervisors. The data was subsequently analyzed qualitatively and
quantitatively, the results of which are discussed in the next section of the report.
Results & Discussion
In general, availability of logistics, frequency of supervisory visits and quality assurance mechanisms
across three most sought after community based maternal and child health interventions were found to
be unsatisfactory. For RI programme, we found that vaccines were not available in all the sites,
supervision frequency was very less and kind of support provided by the supervisors to the service

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providers was inadequate. With respect to IMNCI programme, there was remarkable loss of skills
among health workers. Consequently, the workers were not confident in classification, assessment,
management and referral of infants and young children, using IMNCI protocol. Availability of IMNCI
drugs, especially Cotrimoxazole, Paracetamol and Zinc, was found to be an important barrier to
successful IMNCI implementation. With regard to VHND services, we found that quality of ANC was
very poor. For instance, abdominal palpation, urine examination, haemoglobin testing and BP
measurement was not done in all the sites. Availability of examination table and provision of privacy
during examination were grossly inadequate. Even in sites wherein examination tables were available,
abdominal palpations were not done. On child health services, weight recording of infants, ORS
demonstration and communicating danger signs of newborns to parents was found to be done in less
than 40% sites. Involvement of male members in family planning meetings was virtually non-existent.
With regard to the nature and quality of support the supervisors were getting from their supervisors (who
are mostly district level officials), most of the supervisor respondents mentioned that they got vehicles
and handholding support from their supervisors for providing services in hard to reach areas. Few of
them also mentioned about the incentives and logistics support that they received from their supervisors.
When asked to identify and name the stakeholders for RI, IMNCI and VHND programmes, most of
them mentioned about health workers and ICDS workers as the key stakeholders, while some of them
also stated that beneficiaries, PRI members and GKS members were stakeholders.
When asked about the special steps which they had taken to address the issues of high left-outs and
drop-outs in RI, about one-third of respondents agreed to answer this question and most of them gave
importance to home visits and follow-up visits as the main strategies to improve upon the situation of
high left-outs and dropouts. Some of them also mentioned about the importance of community
sensitization programmes.
Conclusion
Bolangir:
With respect to RI programme, vaccine availability was satisfactory but functional hub-cutters were
available in 81% sites, while counterfoils in 72% sites; availability of red and black bags and delivery of
four key messages on RI was found in 81% sites, each. In VHND sessions, ICDS supervisors were
available in just 3% sites; urine examination was done in 12% sites; male involvement in family
planning was almost non-existent; weight recording of infants was found in 25% sites only; logistic
items, such as, screen for privacy, availability of pregnancy testing kits, IFA tab (small), test tubes and
red bags for disposal were available in less than 50% VHND sites; with respect to services, abdominal
palpations, foetal heart sound recording and privacy during examination was ensured in less than 50%
sites. Dietary counseling, danger signs of newborns and ORS demonstration was also found in less than
50% sites. For IMNCI component, we found that home visits were conducted by 12% IMNCI trained
workers. Assessment sheets were correctly filled up in 25% instances. Skills on assessment,

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classification and management were found in less than 50% workers. Similarly, availability of IMNCI
board, jar, cup and spoon and zinc tablets were found in less than 50% instances; only 22% of
supervisors had received feedback on IMNCI from their supervisors; comparable figures for RI was
30%, and for VHND at 26%; transportation support was found to be an important systemic barrier; use
of supervisory checklists was just 26% for IMNCI, 56% for RI and 52% for VHND.
Nuapada:
With regard to RI, we found that though the availability of logistics was good, functional hub-cutters
and counterfoils were available in just 45% RI sites; MCP cards were available in 82% sites. In VHND,
zinc tablets, foetoscopes, test-tubes, due list of beneficiaries were available in less than 50% sites. We
didn’t find any ICDS supervisor attending any of the VHND sites; urine examination and abdominal
palpation was not done in any site, while foetal health sounds recorded and danger signs communicated
to pregnant women in 17% sites; danger signs of newborns were not communicated in any of the sites;
recording of weight of infant (17%) and demonstration of ORS (42%) were two key short-comings on
VHND services. For IMNCI, management of sick neonates, classification and management of young
infants was in less than 50% instances; Paracetamol was also found to be available in less than 50%
sites.
Koraput:
Availability of OPV, DPT and TT was found in less than 90% sites; tracking bags were available in less
than 50% RI session sites; counterfoils were available in 85% sites. For VHND services, we found
examination table, screen for privacy, foetoscope, zinc tablets, gentian violet, test tubes, hand gloves and
red bags for disposal were found in less than 50% sites; ICDS supervisors were available in 6% sites and
health supervisors were present in just 25% sites; abdominal palpation, foetal heart sound recording and
PPTCT counseling was done in less than 50% sites; danger signs of newborns recording, weight of
infant recording and ORS demonstration was done in <50% sites. On IMNCI, assessment, classification
and management was done in <50% instances; IMNCI board, jar, cup, spoon, cotrimoxazole,
paracetamol, gentian violet and zinc tablets were found to be available in <50% instances.
Nabarangpur:
In RI sessions, vaccines were available in around 90% sites; tracking bags were available in only 33%
sites; red and black bags were available in 71% sites; four key messages were delivered in 58% sites.
Under VHND programme, screens for privacy, foetoscopes, baby weighing scales, hemoglobin testing
kits, zinc tablets, cotrimoxazole, paracetamol, IFA (small) tablets, IFA syrup, test tubes, hand gloves,
gentian violet and red bags for disposal were found in less than 50% sites; we didn’t find ICDS
supervisors attending any of the VHND sites and the health supervisors were found attending only in
21% of the VHND session sites; abdominal palpation, foetal heart sound recording, PPTCT counseling
and communicating danger signs to pregnant women were found to be done in less than 30% sites; with
respect to child health service delivery, communicating danger signs of newborns to parents, weighing
of infants, ORS demonstration and advice on hand washing/hygiene was being done in less than 40%

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sites. On IMNCI, assessment, classification and management was done in <50% instances. IMNCI
board, one litre jar, cup, spoon, cotrimoxazole tablets, paracetamol tablets, zinc tablets, IFA tablets and
gentian violet were found to be available in <50% instances.
Malkangiri:
With respect to RI, in one site vaccines were found in frozen state; vaccines without label and with
unreadable label were also found in one site; Measles, OPD and TT were available in 93% sites only;
MCP cards were found in 64% sites, while counterfoils in 79% sites; tracking bags were found in just
7% sites; only in 50% sites we found four key messages were delivered. In VHND, screens for privacy,
foetoscope, paracetamol tablets, urine testing kits, test tubes and duelist of beneficiaries were found to
be available in less than 50% sites; we didn’t find ICDS supervisors attending any of the VHND sites;
with respect to the maternal health service delivery, relevant history recording, ensuring privacy during
examination, urine examination, abdominal palpation and PPTCT counseling was found to be done in
less than 50% sites; foetal sound recording was not being done in any of the sites; ORS demonstration
and advice on hand washing/hygiene was found to be done in less than 25% sites. With regard to skills
of IMNCI trained health workers, we found that assessment, classification & management of sick
neonates and assessment & counseling of sick children were done in less than 50% instances; IMNCI
board, paracetamol tablets, IMNCI chart booklets, IMNCI modules and IMNCI photo booklets were
found to be available in less than 50% instances.
Recommendations
Improving availability of drugs and other logistics, across districts, is a major challenge which will have
direct effect on quality of services. Logistics and supply chain management practices may be improved
by piloting an indenting mechanism from sub centre level to the district store. Erratic supply of
materials and drugs could be reduced to a great extent through improvement of indenting system.
Periodic training of both front-line workers and supervisors is essential for skill upgradation and
motivation. Refresher on IMNCI would cement the gaps in knowledge and practices with regard to
implementation of IMNCI as a child survival strategy. Involvement of RKS and GKS members may be
envisaged to institutionalize community participation and local decision making for quality
improvement. Skill enhancement of supervisory cadre would help strengthen supportive supervision.
Regular review at block and district level would be critical for long-term sustainability of service
delivery. The reporting mechanism of VHND, IMNCI and RI may be made regular and authentic which
could be relied upon by the state and district officials to take strategic and operational decisions,
respectively.

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BACKGROUND
Provision of and access to essential healthcare services including immunization is one of the key public
health goals of India. Recent data indicate that complete immunization coverage is 59.5% (Coverage
evaluation survey, 2009). Moreover, malnutrition and low birth weight (LBW) contributes to about
50% of deaths among infants and children under five. Bringing down under five mortality rates and
improving child health & survival has been an important goal of the family welfare programmes in
India. The under five mortality rate (U5MR) of the country has come down significantly over the years
from 166 in 1980 to 55 in 2011 (SRS, 2011); one of the recent surveys reveals that the same for Odisha
is 78 (AHS, 2011). Of the 100 worst-performing districts, 40 are in Uttar Pradesh, 22 in Bihar, 15 in
Jharkhand, 12 in Madhya Pradesh, 10 in Rajasthan and five in Odisha (Naandi Survey).
Reports from routine health management information system (HMIS) of NRHM for 2010-11 indicate
that the eleven KBK Plus Districts report maximum number of under-five deaths in Odisha. The data of
AHS 2011 also confirms this finding (Bolangir – 115/1000 live births; Nabarangpur – 81/1000 live
births; Malkangiri – 79/1000 live births; Nuapada – 75/1000 live births; Koraput – 72/1000 live births)-
our intervention districts and Kandhamal with a highest of 145/1000 live births.
Failure to recognize warning signs owing to poor knowledge, delayed referral of sick children, lack of
supportive supervision, provision of prompt and appropriate care at the facility, etc. are identified as the
key factors behind such high mortalities. Thus, Public Health Foundation of India (PHFI) through its
constituent institution Indian Institute of Public Health Bhubaneswar (IIPHB) recognized the needs and
priorities of the state and proposed to contribute to the reduction of mortalities and morbidities amongst
under-five children by strengthening implementation & monitoring of IMNCI, VHND and RI through
hand-holding support to the internal monitors & facilitating regular visit of the system supervisors to the
field for programme monitoring.
We propose to facilitate in the capacity building efforts of district and sub-district functionaries on the
above issues. The project would comprise a baseline survey, followed by a series of interventions at
sector, block, district and state levels and culminate in an endline survey after about one year of
intervention. The results would provide a comprehensive understanding of the relative and attributable
improvement in the quality of service delivery which could be due to the interventions done during the
intervention phase.
The summary of interventions proposed under the project are:
1. Monitoring the quality of RI and IMNCI trainings being conducted at district and sub-district
level for the front-line health and WCD workers, such as, the ANM, AWW, LHV, BPOs, MOs
etc.
2. Facilitate in development of an integrated supervisory plan at sector and block level to monitor
the quality of service delivery

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3. Conduct regular field visits along with internal supervisors to monitor IMNCI, RI and VHND
sessions and report the findings in the prescribed formats on a monthly basis
4. Facilitate block and district level meetings with inter-departmental officials to ensure
intersectoral coordination
5. Provide hand-holding support to sector and block level officials in monitoring the programme
implementation, documenting best practices and conducting periodic reviews
6. Document case-studies, success stories and best practices from the field

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REVIEW OF LITERATURE
Supportive supervision in health care has proved to be an effective strategy to improve quality of
services and drive the programme towards its core objective. In supportive supervision regular
handholding support and capacity building of grass root level workers and solving the issues by
addressing the bottlenecks really strengthen the system as well as the programme. The most important
observation is to improve the motivation level of workers at all levels and increase their skills and
competencies. Small issues having greater effect on programmes can be identified and addressed easily
as well as effectively through supportive supervision.
Although convergence between nutrition and health has long been recognized as a barrier to improving
child under nutrition in India, actual convergence has been limited and somewhat ineffective. Some
factors underlying limited convergence include a range of multiple and diverse stakeholders; complexity
of the technical issue; determinants of under nutrition that lie outside technical domains; and the view,
based on an experiential understanding among implementers, that convergent action is an almost
insurmountable barrier. We postulate that three factors lie at the heart of this incomplete convergence
process: failure to include convergence in policy formulation, lack of attention to institutional
modifications to facilitate convergence, and lack of monitoring mechanisms to assess convergence of
programs on an ongoing basis. (Rajani Ved et al., 2012)
External monitoring for streamlining supportive supervision and capacity building of internal
supervisors has also been a proven strategy to combat the issues of poor supervision. Despite repeated
trainings, there is a lack of ability among supervisors to address the day to day issues and the underlying
causes to strengthen the system & programme effectively towards its goal. In such cases external
monitoring to strengthen the internal monitors/supervisors has proved to be an effective measure in
various programs.
Any project’s effectiveness must be evaluated simultaneously to ensure effective performance,
achievement of the objectives, visualize robust concurrent monitoring and course correction where ever
required. To achieve this, M & E is an efficient and effective tool, which helps in identifying problems
and its causes; suggests possible solutions to problems; raises questions about risks or assumptions and
strategy; encourages reflection on the progress and its directions; provides information and insight into
the programme; stimulates action on information and finally enhances the likelihood of positive and
sustainable impact.
Cornerstone of supportive supervision is working with health staff to establish goals, monitor
performance, identify and rectify problems, and proactively improve the quality of services. The
supervisor and health care personnel together identify and address weaknesses within the health care
service delivery system. Supervisory visits (external processes) also provide the opportunity to identify
and acknowledge best practices and successful approaches to motivating, training and enabling health
care personnel to effectively conduct self-assessment and peer assessment (internal processes). The

8
supervisory process explores how self and peer assessment with the inclusion of community input can
contribute to effective results-oriented supportive supervision (Government of the kingdom of Lesotho
Millennium challenge account. Supportive supervision system for district health management teams: a
guide to primary health care supervision. Health systems strengthening, technical assistance, HS-A-
012-09. 2010).
Supportive supervision by an external agent can lead to substantial improvement in the performance of
ASHAs as related to IMNCI. Under the current supervisory system, many line supervisors lack a clear
understanding of their roles and responsibilities as supervisors. In addition, they lack sufficient time and
training to provide supervisory support to ASHAs under IMNCI. We find that supportive supervision
has the greatest effect in improving ASHAs’ capacity, and hence their performance under IMNCI in the
following areas: record keeping, motivation, and knowledge and skills, such as the use of IMNCI
reference materials and techniques in home visit assessments. However, while external supportive
supervisors were effective in providing IMNCI materials, registers, and case sheets, we find less
evidence that they can improve access to medicine. Regardless of the presence of supportive
supervision, ASHAs continue to face resistance from their communities against institutional deliveries,
immunization, health checks for newborns, and referral to hospital facilities. (Martin Abel et. al. Effect
of Supportive Supervision on ASHAs’ Performance under IMNCI in Rajasthan. 2009)
Supervisory activities need to be budgeted and prioritized for community based project: Improving the
coverage and quality of village health and nutrition day. (USAID, Vistar project report).
Developing robust monitoring and evaluation methodologies can support performance improvement and
enable officials to better understand and advocate the contribution that convergence can make to
improved delivery of services.
Supportive supervision is a process that promotes quality at all levels of the health system by
strengthening relationships within the system, focusing on the identification and resolution of problems
and helping to optimize the allocation of resources, promoting high standards, teamwork and better two-
way communication.
In three of our national flagship programmes, such as, RI, VHND and IMNCI that aim to improve the
maternal and child health indicators in low performing areas, streamlining of supportive supervision has
received priority. Though there is a lack of related literature in the support of this strategy but the
findings from other programs indicate it might be effective in these programs. A recent study conducted
by IIPH-Bhubaneswar found that supportive supervision would be most effective when there is an
enabling policy environment at district and sub-district level to involve the supervisory cadre of health
workforce at work.

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AIMS & OBJECTIVES OF THE STUDY
Keeping the above findings in mind, we proposed the project, titled, “Evidence-based IMNCI, VHND
and RI service delivery through health system strengthening in Odisha – an external monitoring
demonstration project”, under which we would externally monitor services at session sites and
strengthen the health system preparedness. The overall purpose of this demonstration project is to assess
and compare the quality of maternal and child health services provided through community-based
service delivery programmes, such as, village health and nutrition day (VHND), integrated management
of neonatal and childhood illnesses (IMNCI) and routine immunization (RI) in Odisha.
1. In the first step, we proposed to conduct a baseline survey with respect to quality of VHND,
IMNCI & RI services. We will also assess the knowledge and opinion of supervisory cadre of
health workforce, namely, the medical officer (MO), AYUSH MO, lady health visitor (LHV),
ICDS supervisor and male health supervisors on these three key community-based MCH
programmes.
2. Over next one year, we will facilitate provision of a basket of interventions at session sites, block
levels, district and state level: monitoring of sessions, providing hand-holding support, assessing
quality of training programmes on IMNCI and RI, facilitating preparation of micro-plans and
integrated supervision plans and providing inputs in the block and district level meetings to
strengthen the service delivery of these three programmes.
3. At the end of one-year of intervention, we will conduct an end-line from the same sample
clusters, using same data collection tools for comparative analysis.
The specific objectives of this base-line study are:
I. To assess the coverage and quality of health and nutrition related services provided under the
VHND programme in Odisha.
II. To assess the skills of frontline health and ICDS workers trained in IMNCI, with respect to
assessment, classification, management and referral of sick neonates and children up till the age
of five years.
III. To assess the quality of RI services with respect to important quality parameters, such as,
coverage, logistics management, bio-waste management, behavior change communication and
interpersonal communication, etc.
IV. To assess the existing level of knowledge, opinions and skills of the supervisory staff at the
district and sub-district levels, with regard to VHND, IMNCI and RI services.

10
MATERIALS AND METHODS
Study Design and Setting
The land area of Odisha is 155,707 Sq. kms., which is 4.74 per cent of the total land area of India. In
terms of physical size, it is the 10th largest state in India. Amongst the districts in the state, Mayurbhanj
with the land area of 10,418 sq. kms ranks first position (6.69 per cent to the total area of the state) while
Jagatsinghpur with the land area 1,668 sq. kms ranks the lowest position - 1.70 per cent to the total area
of the state (Govt of Odisha).
It is one of the least urbanized states in India. As per the 2001 census, the rate of urbanization is 14.97%,
which is only higher than Assam and Bihar among the major States. Amongst the districts in the state,
the lowest degree of urbanization (having less than 5% urban population) is in the district of Nayagarh
4.29% and the highest degree of urbanization is in the district of Khurda 42.93 %. 15 districts have
urban population below 10% and 5 districts have urban population above 25% (Govt. of Odisha).
The state has been one of the most natural disaster-prone in India. Floods and droughts regularly
devastate the state and cyclones are common. Frequent occurrences of natural calamities stand as a
barrier to economic progress of the state. Agriculture sector absorbs about 80 per cent of the total work
force and contributes 50% of state’s domestic product. Paddy is the “principal” crop. Its cultivation is
the main occupation of 75% of the people. This is against all India average annual rate of growth of
7.4% in GDP during this period. The net state domestic product (NSDP) commonly known as state
income increased from Rs. 16,184.30 crores in 1993-94 to Rs. 25,178.31 crores in 2004-05. The per
capita income has increased to Rs. 6555 in 2004-05.
As per Census 2011 reports, the actual population of the state is 4.19 crores with a decadal growth rate
of 13.97 percent. Sex ratio of Odisha is 978 i.e. for each 1000 male, which is above national average of
940 as per census 2011. In 2001, the sex ratio of female was 972 per 1000 males in Odisha (Odisha
Population Census Data 2011, Provisional Population Totals 2011). Administratively, the state has 3
revenue divisions (also termed as revenue divisional commissioners or RDCs, 30 districts, 58 Sub-
divisions, 171 tehsils and 314 community development blocks. Out of total of 30 districts in the State,
broadly, the KBK category of districts (total =11) belong to the southern and western belt of the State,
while the non-KBK districts (total 19) are mostly from the coastal and northern belt. The State has
about 22% tribal population most of them residing in these KBK districts. The vital health indicators,
such as, infant mortality and maternal mortality data are skewed in favour of non-KBK districts. In
terms of health services delivery, the state has 6688 sub centres, 314 block PHCs, 310 24/7 facilities and
131 first referral units (FRU).

11
Sampling
We selected five sample districts on the basis of priorities of the state government and UNICEF –
Odisha. In the second step, we adopted the WHO recommended thirty-cluster sampling technique for
data collection. Administratively, each district comprises of blocks; each block constitutes about 1.5 to
2 lac populations; and a block PHC, also termed as community health centre or CHC, caters to the health
needs of the block population as well as controls the functions of the PHCs-New. The block is further
divided for convenience of service delivery, into sectors. Each sector has a sector level primary health
centre - New (PHC-New) and about three to five sub centers. This way, one block usually has about
four to five PHCs-New and about 20 to 25 sub centres. For the purpose of our sampling a cluster
constituted a sector. Since thirty clusters were to be allocated to five districts, the number of clusters to
be assigned to each of the districts was decided on the basis of probability proportionate to size (PPS)
technique.
From each sample cluster (or sector), we focused on data collection for continuous six days. This
included observation of about 4 RI sessions, about 4 VHND sessions, about 8 IMNCI sessions; and
interviewing of about 4 supervisory staff. Therefore, the total number of events planned for observation
from each sector was 20. Given that there were thirty sample clusters, the events summed up to 600.
Against this, the achievement was 547 (Exhibit - 1).
Exhibit – 1: Summary of samples of RI sites, IMNCI sites, VHND sites, and supervisors, five
districts, Odisha
Sl.
No
District Name No of
clusters
allocated
RI sessions
observed
AWCs
observed
for IMNCI
VHND
sessions
observed
Supervisors
interviewed
P A P A P A P A
1 Bolangir 8 32 32 64 64 32 32 32 27
2 Nuapada 3 12 11 24 24 12 12 12 11
3 Koraput 8 32 27 64 64 32 32 32 23
4 Nabrangpur 7 28 24 56 52 28 28 28 14
5 Malkangiri 4 16 14 32 34 16 14 16 8
Total 30 120 108 240 238 120 118 120 83
(P=Planned; A=Achieved)
Data collection tools
For objective I, we used the government of Odisha recommended supervisory tool for collection of data
from the VHND site while the session was on. The tool comprised key quality parameters of VHND
programme, such as, availability of logistics, coverage and quality of services; and assessment of
children for growth monitoring.

12
For objective II, we used the IMNCI supervisory tool as recommended by government of Odisha. This
comprised a check-list on issues like coverage of services; skill level of IMNCI trained health providers
in assessment, management and referral of sick neonates and children under five. It also included
questions related to facility support, including availability of logistics.
For objective III, we used the government of India recommended supervisory format for data collection
from the RI session sites. It contained questions related to basic parameters of holding RI sessions,
quality of services, including availability of logistics, quality of vaccines, cold chain, waste management
and behavior change communication.
For objective IV, we developed a semi-structured interview schedule, field-tested it and used for data
collection from the supervisory cadre of health workforce working at sub-district level. It comprised of
questions on all three above mentioned community based child health service delivery programmes,
such as, the level of their involvement in planning and implementation of these programmes, the nature
and extent of support received from their supervisors, the kind of communication used in monitoring,
familiarity with the check-lists, the challenges and opportunities they face in supervising the sessions,
etc.
The baseline study was conducted over a period of three months; and data was collected from the
intervention districts through direct observation and interview. We also reviewed the existing literature
on external monitoring from the following databases: google, google scholar, PubMed Central and
Health Policy & Planning websites. The findings are reflected under literature review section.

13
Exhibit – 2: Matrix of objective-wise data collection tools
Sl
No
Objective Research Question Stakeholders Data Collection
Tool
I To assess the coverage and
quality of health and nutrition
related services provided under
the VHND programme in Odisha.
What is the coverage and
quality of the health and
nutrition services
provided under VHND
in Odisha?
 Beneficiaries
 Service Providers
Standardized
checklist for VHND
supervision, Govt. of
India, adapted by
Govt. of Odisha
II To assess the skills of frontline
health and ICDS workers trained
in IMNCI, with respect to
assessment, classification,
management and referral of sick
neonates and children up till the
age of five years.
How skilled are the
frontline workers in
implementation of
IMNCI programme?
 Beneficiaries
 Trained MPHW (F)
 Trained AWW
 Internal supervisors
Standardized
checklist for IMNCI
India, adapted by
Govt. of Odisha
III To assess the quality of RI
services with respect to important
quality parameters, such as,
coverage, logistics management,
bio-waste management, behavior
change communication and
interpersonal communication, etc.
What is the quality of
services provided under
routine immunization
programme?
 Beneficiaries
 ASHA
 AWW
 ANM
 Internal supervisors
Standardized
checklist for RI
India
IV To assess the existing level of
knowledge, opinions and skills of
the supervisory staff at the district
and sub-district levels, with
regard to VHND, IMNCI and RI
services.
What are the knowledge
& opinions of the
supervisory cadre on
programme
implementation and
supervision?
How skilled are the
supervisors in
programme supervision?
Supervisory health workers,
like
 MPHS-M
 MPHS-F
 ICDS Supervisor
 AYUSH-MO
 Sector-MO
Semi-structured
questionnaire
designed and field
tested by IIPHB

15
ROUTINE IMMUNIZATION (RI)
Table 1- Availability of vaccines at routine immunization session sites, Bolangir, Odisha
Vaccine availability
Bolangir (N=32) Total (N=108)
No. % No. %
BCG 31 97 105 97
BCG diluents 31 97 105 97
Measles 32 100 105 97
Measles diluents 32 100 106 98
tOPV 32 100 98 91
Hepatitis B 32 100 104 96
DPT 32 100 101 93
TT 32 100 97 90
With respect to availability of vaccines at immunization session sites in Bolangir district, we found that all
antigens except BCG and BCG diluents were available in 100 percent sites, while the later were available in 97%
sites.
Table 2-Availability of logistics at routine immunization session sites, Bolangir, Odisha
Logistics availability
No. % No. %
AD (0.1ml) syringes 32 100 106 98
AD (0.5ml) syringes 32 100 107 99
5ml reconstitution syringes 30 94 104 96
Vitamin A solution 32 100 105 97
Blank RI card 30 94 92 85
Counterfoils 23 72 83 77
ORS packet 32 100 105 97
Paracetamol 31 97 95 88
Plastic spoon/cap for Vitamin A 31 97 100 93
Tracking bag 23 72 56 52
Functional hub-cutter 26 81 91 84
AD syringes, Vit. – A solution and ORS packets were found to be available in all the sites visited for data
collection. Tracking bags and counterfoils was in less than 75% of the sites visited. In about 80% sites,
functional hub-cutters were found to be available. Blank RI cards (MCP cards) and reconstitution syringes were
found to be available in more than 94% sites. In 31 out of 32 sites, paracetamol tablets were available.

16
Table 3-Quality indicators-I at RI session site, Bolangir, Odisha
No. % No. %
Vaccines without label 0 0 1 1
Vaccines with unreadable label 0 0 1 1
Expired vaccine vial 0 0 0 0
Vaccines at VVM stage III or IV 0 0 1 1
Frozen vaccines 0 0 0 0
BCG/Measles reconstituted for more than 4 hrs 0 0 0 0
Sessions held as per plan 32 100 94 87
Vaccines brought to site by AVD 16 50 59 55
Vaccines brought to site by ANM 6 19 33 31
Vaccines brought to site by supervisor 0 0 1 1
Vaccines brought to site by others* 9 28 12 11
Vaccines & diluents kept in vaccine carrier 31 97 94 87
Vaccines & diluents kept in zipper bag 30 94 84 78
Four ice packs in the vaccine carrier 31 97 101 93
Vaccine batch no. recorded 28 87 89 82
Vaccine expiry date recorded 28 87 87 81
Diluent batch no. recorded 28 87 87 81
Diluent expiry date recorded 28 87 88 81
*Others=HW (M &F), MPW (M), Malaria Worker, MPHS (M)
We found that in all the session sites vaccines were correctly labeled and in readable form. There were no expired
vaccines or vaccines in stage III/IV of VVM or in frozen state. In all the sites, the sessions were held as per plan.
In 97% of the sites, we found that the vaccines were kept in vaccine carriers and zipper bags. Further, the
appropriate use of four ice packs was also found in 97% sites. In 50% sites, vaccines were brought by AVD, while
in 19% sites, it was brought by the ANM and in 28% sites other health workers delivered the vaccines to the
session sites. In more than 85% sites, the batch number and expiry date of both the vaccines and the diluents were
found to have been properly mentioned.

17
Table 4-Quality indicators-II at RI session sites, Bolangir, Odisha
Quality Indicators
No. % No. %
Due list available with ANM 32 100 106 98
Due list available with mobilize 29 91 100 93
Reconstitution time written on vials by ANM 31 97 101 93
AD syringe used by ANM to inject vaccines 32 100 107 99
DPT vaccine given on antero lateral aspect of mid thigh 32 100 105 97
Route of measles (sub-cutaneous) 32 100 102 94
Measles given on right upper arm 32 100 101 93
ANM touching any part of needle while injecting 5 16 8 7
ANM following no recapping procedure 32 100 66 61
Syringe cut with hub cutter after use 26 81 91 84
Red & black bags used to segregate immunization waste 26 81 92 85
Tally sheet used to keep record after vaccinating each child 15 47 80 74
4 key messages delivered to caregivers 26 81 79 73
Beneficiaries ask to wait for 30 mins after vaccination by ANM 10 31 48 44
Vaccinate a child with mild fever 24 75 85 79
Vaccinate a child with loose motion 26 81 75 69
Immunization waste carried to PHC 23 72 88 81
Health supervisor visited you in last three months 18 56 85 79
MO visited you in last three months 7 22 15 14
Availability of due list, correct use of AD syringe by the ANM and correct site of administration of
measles and DPT was found in 100% sites. Also, ANMs followed no recapping procedure in all the
sites. In about 80% sites the syringes were being cut with hub cutter after use, red and black bags were
used to segregate immunization waste, four key messages were delivered to caregivers and ANMs said
that they would vaccinate a child with loose motion. Tally sheets were used to keep record after
vaccination in 47% sites. In 30% of the sites, beneficiaries were asked by ANMs to wait for 30 minutes
after vaccination. In the last three months, health supervisors had visited to 56% sites whereas MOs had
visited to 22% sites.

18
Table 5-Health supervisors visited in the last three months v/s 4 key messages delivered to caregivers,
Bolangir, Odisha
Health supervisor visited you in last three months
Bolangir Total
Yes No Yes No
All 4 key messages delivered to
caregivers
Yes 15 11 61 18
No 3 2 21 2
With respect to delivery of four key messages and its relationship with the frequency of supervisory
visits, we found that out of 18 sites where the supervisors had made visits in the last three months, in 15
sites all four key messages were being delivered to the caregivers by the front-line health workers.

19
VILLAGE HEALTH & NUTRITION DAY (VHND)
Table 6-Availability of logistics at VHND site, Bolangir, Odisha
Logistics Availability
Bolangir
(n=32)
Total
(N=118)
No. % No. %
Examination table 21 66 69 58
Screen for privacy 10 31 35 30
BP Instrument 29 91 106 90
Stethoscope 29 91 108 91
Foetoscope 1 3 16 14
Inch tape 17 53 76 64
MUAC tape 31 97 113 96
Weighing scale (adult) 29 91 105 90
Weighing scale (baby) 30 94 86 73
Haemoglobin testing 30 94 86 73
Needle/Lancet 31 97 81 69
Nischay kit 3 9 71 60
ORS sachets 30 94 112 95
Zinc tablets 0 0 31 26
Albendazole tablets / Syrup 29 91 91 77
Anti-malarial tablets / Syrup 28 87 89 75
Cotrimoxazole tablets 26 81 81 69
Paediatric Paracetamol 24 75 64 54
IFA tablets (large) 26 81 94 80
IFA tablets (small) 14 44 58 49
IFA syrup 21 66 68 58
Urine testing kit / Uristix 17 53 69 58
RDK kit 20 62 79 67
Condoms 19 59 88 75
Oral contraceptives 17 53 74 63
Emergency contraceptive pills 18 56 87 74
Gentian violet lotion 25 78 62 52
Test tubes 1 3 18 15
Hand gloves 20 62 42 36
Toilet 4 12 17 14
Water supply 17 53 37 31

20
Bolangir
(n=32)
Total
(N=118)
No. % No. %
Soap 26 81 71 60
Red bag for disposal 11 34 36 30
Cotton bandage 13 41 50 42
Absorbent cotton 23 72 64 54
IMNCI chart booklet 31 97 93 79
Blank MCP cards 27 84 99 84
Referral cards 30 94 100 85
Monthly topic calendar 23 72 87 74
Duelist of beneficiaries 20 62 81 69
Reporting format 28 87 102 86
BP instrument, stethoscope, haemoglobin testing kit, weighing scale (adult and baby), MUAC tape,
referral cards, IMNCI chart booklets and needles were found to be available in more than 90% sites.
Foetoscope & test tubes, and pregnancy testing kits were available in just 1 and 3 sessions respectively.
Zinc tablets were conspicuous by their non availability in any of the sample sessions. Examination
tables and screens for privacy were available in 66% and 31% sites, respectively. IFA tab – large and
small were available in 81% and 44% sites, respectively. Availability of RDK kits was found in 62%
sites and contraceptives were available in about 60% sites.
Table 7-Session site of VHND, Bolangir, Odisha
Session Site Bolangir (N=32) Total (N=118)
Sub center 2 10
AWC 24 87
Others 6 15
Total 32 112
24 out of 32 sessions visited were conducted at AWCs, while only 2 were being held at sub centres. 6
sessions were held in other places including school buildings, community halls etc.

21
Table 8- Availability of health workers at VHND site, Bolangir, Odisha
*Others=BPO, AYUSH MO, PHEO, etc.
With respect to availability of different types of health workers at VHND session sites, we found that in
66% sessions the MPHW (F) also known as the ANMs were present while the session was on. The
comparable percentages for male health workers, AWW and ASHAs were found to be 31%, 78% and
91%, respectively. Further, the presence of supervisory cadre of health workforce at session sites was
found to be ranging from 3% (ICDS supervisor) to 37% (health supervisors). The sessions where the
ANMs were not present were being conducted by the MPHW (M) and LHV.
Table 9-Maternal health service delivery at VHND sites, Bolangir, Odisha
Maternal Health Service Delivery
Bolangir
(N=32)
Total
(N=118)
No. % No. %
Relevant history taken 23 72 91 77
Privacy during examination ensured 12 37 54 46
BP recorded 30 94 103 87
Hemoglobin test done 26 81 93 79
Urine examination done 4 12 54 46
Pregnant women weighed 29 91 101 86
Abdominal palpation done 12 37 26 22
Fetal heart sound recorded 12 37 26 22
IFA for antenatal woman provided 30 94 112 95
Relevant counseling done 27 84 80 68
Danger signs communicated 18 56 51 43
PPTCT counseling done 29 91 61 52
Health workers at site
Bolangir
(N=32)
Total
(N=118)
No. % No. %
MPHW(F) 21 66 103 87
MPHW(M) 10 31 62 52
Health supervisors 12 37 42 36
AWW 25 78 107 91
ASHA 29 91 102 86
ICDS supervisors 1 3 3 2
AWH 22 69 75 64
GKS/PRI members 5 16 7 6
Others* 9 28 17 14

22
Weighing of pregnant women, their BP recording, availability of IFA for ANC and PPTCT counseling
was found to be done in more than 90% sites. Hemoglobin testing was done in about 80% sites.
However, privacy during examination, fetal heart sound recording and abdominal palpation was done
only in 37% sites. Urine examination was done in as low as 12% sites.
Table 10-Child health & family planning service delivery at VHND session sites, Bolangir, Odisha
Child Health Service Delivery & Family Planning
Bolangir
(N=32)
Total
(N=118)
No. % No. %
Advice on breast feeding given 17 53 88 75
Dietary counseling on children done 14 44 71 60
Need for supplementation with IFA communicated 26 81 86 73
Danger signs of new born communicated 13 41 41 35
Weight of infants recorded 8 25 40 34
ORS demonstration done 13 41 42 36
Advice on hand washing /hygiene given 22 68 58 49
FP counseling provided 25 78 108 91
Contraceptives provided 25 78 101 86
ANM & ASHA conduct meeting with women 26 81 70 59
ANM & ASHA conduct meeting with men 0 0 1 1
With regard to delivery of child health & family planning services, we found that ANM and ASHA
conducted meeting with the lactating mothers in about 80% instances. But meeting with their husbands
was not found in any of the sessions. Advice on breastfeeding, dietary counseling to mothers, weighing
of infants and assessment of danger signs of newborns was done in less than 50% samples. Family
planning counseling was found to be done in 78% sites and contraceptives were provided in an equal
percentage of sites.

23
CROSS-TABULATIONS
Table 11- Quality attributes of VHND services, Bolangir, Odisha
Bolangir Total
ICDS supervisors present at site
Yes No Yes No
Beneficiaries mobilized to site
by ICDS workers
Yes 1 17 3 79
No 0 14 0 36
Beneficiaries mobilized to site by ASHA
Health Supervisors present at
site
Yes 10 2 36 7
No 14 6 64 11
Examination table present at site
GKS/PRI members present at
site
Yes 5 0 5 2
No 16 11 65 46
Abdominal palpation done and recorded
Screen for privacy present at
site
Yes 3 7 10 17
No 9 12 25 63
Abdominal palpation done and
recorded
Yes 6 6 16 11
No 15 4 53 35
Cross tabulation of key attributes of quality of services revealed that only in one session wherein the
ICDS Supervisor was present in the session site were the beneficiaries mobilized by the ICDS workers.
In 12 sessions the health supervisors were present out of which in 10 sites the beneficiaries were
mobilized by the ASHAs. Examination tables were available in 21 sites out of which in five sites the
GKS/PRI members were present. Abdominal palpations were carried out in 12 sites though the screens
for privacy were available only in 10 sites. On the other hand, examination tables were available in 21
sites against which only in 12 sites abdominal palpations were carried out. In other words, in 9 sites
despite of availability of an examination table, abdominal examinations were not carried out.

24
INTEGRATED MANAGEMENT OF NEONATAL &
CHILDHOOD ILLNESSES (IMNCI)
Table 12-Review of IMNCI records, Bolangir, Odisha
Record review
Bolangir
(N=64)
Total
(N=238)
Total no. of live birth in last 3 months 484 1830
Total no. of newborns in last 3 months who have received home visits 462 1533
Average no. of newborns per AWC/SC in last 3 months who have received home visits 7.2 6.4
Home visits conducted as per IMNCI guidelines 8 (12%) 41 (17%)
IMNCI assessment sheets correctly filled up 16 (25%) 55 (23%)
All sick cases referred 12 (19%) 30 (13%)
Referral Slips filled up 12 (19%) 27 (11%)
IMNCI monthly reporting formats filled up 17 (27%) 42 (18%)
On an average, 7 newborns had received home visits in last three months. The study found that all key
parameters of IMNCI implementation, such as, home visits as per IMNCI guidelines, filling-up of
assessment sheets, filling-up of referral slips and reporting formats were abysmally low, lesser than
30%.
Table 13-Assessment of skills of IMNCI trained workers, Bolangir, Odisha
A. NEW BORN (0-2 months)
Bolangir
(N=64)
Total
(N=238)
No. % No. %
Correctly assessed a young infant 27 42 70 29
Correctly classified the young infant 25 39 98 41
Correctly treated the young infant 27 42 83 35
Correct counseled the infant 22 34 59 25
Infant needing referral is referred 18 28 41 17
Correctly assessed the immunization of infant 17 27 54 23

25
B. CHILD (2 months – 5 yrs)
Bolangir
(N=64)
Total
(N=238)
No. % No. %
Correctly assessed a child 28 44 71 30
Correctly classified the child 18 28 46 19
Correctly treated the child 12 19 35 15
Correctly counseled the child 14 22 39 16
Child needing referral is referred 4 6 30 13
Correctly assessed the immunization of child 33 52 75 31
With respect to the skills of IMNCI trained workers on key parameters of IMNCI programme
implementation we found that both in the case of 0-2 months and 2 months-5 yrs age group of infants
and young children the assessment skills were poor, a little over 40%. On correct classification,
counseling, management and referral their skills were also equally poor. It ranged from 6% to 42%.
Table 14-Availability of logistics at AWC, Bolangir, Odisha
FACILITY SUPPORT
Bolangir
(N=64)
Total
(N=238)
No. % No. %
IMNCI board 3 5 35 15
Salter scale / child weighing scale 62 97 196 82
One litre jar, cup and spoon 12 19 40 17
Ped Cotrimoxazole tab/syp 39 61 92 39
Ped Paracetamol tab/syp 38 59 90 38
ORS 50 78 188 79
IFA tablets 44 69 155 65
Gentian violet paint/ powder 34 53 73 31
IMNCI module 64 100 212 89
IMNCI photo booklet 62 97 206 87
IMNCI forms for 0-2 mon 52 81 217 91
IMNCI forms 2 mon to 5 yrs 52 81 217 91
Referral slips 46 72 208 87
Reporting forms 42 66 175 73
With respect to availability of various logistics at AWCs on the days of conducting this survey, we
found that certain key components of the programme, such as, IMNCI chart booklets and IMNCI
modules were available in all the sites. Photo booklet and Salter scales were available in 97% sites.

26
Among IMNCI drugs, ORS was found to be available in most of the sites (78%) and Zinc tablets were
available in the least (2%). Availability of other drugs, such as, Cotrimaxazole, Paracetamol, IFA
tablets, Gentian violet ranged from 53% to 69%.
Table 15-Skill assessment of IMNCI trained workers on assessment, classification & management of sick
neonates, Bolangir, Odisha
Bolangir
(N=64)
Total
(N=238)
No. % No. %
Assessing possible serious bacterial infection
Convulsion 19 30 89 37
Fast breathing 31 48 117 49
Chest in-drawing 24 37 109 46
Nasal flaring 23 36 95 40
Pustule 10 16 74 31
Temperature 44 69 138 58
Decreased movement 22 34 83 35
Assessing diarrhea
Blood in stool 32 50 96 40
Lethargic or unconscious 17 27 78 33
Restlessness/irritability 21 33 84 35
Sunken eyes 26 41 118 50
Skin pinch 32 50 128 54
Assessing breastfeeding
Difficulty feeding 34 53 110 46
Not able to feed 20 31 70 29
Less than 8 breastfeeds in 24 hours 34 53 109 46
Received other foods or drinks 21 33 74 31
Attachment 22 34 92 39
Suckling 25 39 97 41
Oral thrush 29 45 99 42
Assessing immunization 40 62 117 49
Assessing other problems 11 17 41 17
Classification 23 36 80 34
Treatment/Management
Referral of severe cases 16 25 60 25
Given antibiotic for local infection 13 20 32 13
Given ORS solution in facility 15 23 51 21

27
Bolangir
(N=64)
Total
(N=238)
No. % No. %
Advise on home care 39 61 86 36
Explained signs for when to return immediately 20 31 34 14
Advised follow-up care 24 37 65 27
Counseled on breastfeeding 42 66 80 34
Next date for immunization 23 36 65 27
Checking mother’s/caretaker’s understanding 5 8 18 8
The survey assessed the skills of IMNCI trained health workforce on assessment, classification and
management of sick neonates by using the state government advocated format. We found that with
regard to assessment of sick neonates the skills of health workers ranged from 16% to 69%. On
classification aspect, 36% respondents had the correct skills, while effective management skills ranged
from 8% (checking understanding of mothers) to 66% (counseling on breastfeeding).
children of 2 months to 5 years, Bolangir, Odisha
Bolangir
(N=64)
Total
(N=238)
No. % No. %
Assessed general danger signs
Not able to drink or breastfeed 9 14 17 7
Vomit everything 8 12 17 7
Convulsion 3 5 14 6
Asked for cough or difficult breathing
Chest indrawing 8 12 40 17
Asked for diarrhea
Restless and irritable 10 16 33 14
Able/ not able to drink/ drinking eagerly/ thirsty 6 9 15 6
Skin pinch 10 16 43 18
Diarrhoea for 14 days or more 9 14 21 9

28
Bolangir
(N=64)
Total
(N=238)
No. % No. %
Assessed fever
Stiff neck 8 12 17 7
Fever present for more than 7 day 9 14 26 11
Assessed malnutrition
Visible severe wasting 8 12 28 12
Oedema of both feet 8 12 23 10
Grade of malnutrition (red/ yellow/ green) 8 12 38 16
Assessed anaemia
Severe palmar pallor 9 14 21 9
Some palmar pallor 7 11 20 8
Assessed immunization 9 14 40 17
Assessed feeding
Not Exclusive breastfeeding (for less than 6 month infant) 9 14 31 13
Using bottle to feed to child 8 12 19 8
Child is not fed actively 9 14 25 10
Child is fed less frequently 8 12 20 8
Child is fed less quantity of food 7 11 9 4
During illness child is fed less quantity of food 7 11 9 4
Assessed other problems 8 12 21 9
Given antibiotic for pneumonia 8 12 20 8
Advise home care 10 16 34 14
Counseling on feeding 11 17 34 14

29
With regard to the technical skills of health workers on implementation of IMNCI programme for 2
months to 5 years children, the assessment skills ranged from 5 to 17%. About 16% of respondents
could correctly classify. About 5% workers were confident in checking the understanding of
mothers/caretakers as against 17% workers who could correctly counsel the mothers on appropriate
feeding practices.

30
INTERVIEW OF SUPERVISORS
Table 17 – Profile of supervisors, Bolangir, Odisha
No. % No. %
Designation of
supervisor
MPHS-F 8 30 21 25
MPHS-M 2 7 17 20
ICDS supervisor 7 26 20 24
AYUSH MO 7 26 22 26
Sector MO 3 11 3 4
The table above reflects the profile of our respondents. Out of the total 27 supervisors interviewed, 30%
were lady supervisors (LHV), 7% were male supervisors, 26% were ICDS supervisors, 26% were
AYUSH MOs and 11% were Sector MOs.
Table 18 – Supervisory visits made by internal supervisors in last one month, Bolangir, Odisha
Total Avg Total Avg.
No. of supervisory visits made last month on IMNCI 48 2 149 2
No. of filled in supervisory checklists submitted to block level on
IMNCI last month
8 0 32 1
No. of supervisory visits made last month on RI 101 4 287 3
RI last month
52 2 161 2
No. of supervisory visits made last month on VHND 95 3 313 4
VHND last month
43 2 127 2
Support from supervisors while providing services in hard
to reach areas
13 48 (%) 41 49 (%)
With reference to all the three programmes, the number of supervisory visits made during last one
month was found to be maximum for RI, followed by VHND. For IMNCI the supervisory visits were
the least. The supervisors were filling up on an average 2 supervisory checklists, each for VHND and
RI programmes; whereas, for IMNCI, the comparable figures were close to nil. When asked whether
they were getting support from their supervisors for providing services in hard to reach areas, 13 (48%)
respondents gave an affirmative answer.

31
Table 19 – Frequency, method and place of feedback received on IMNCI from higher officials, Bolangir,
Odisha
IMNCI
No. % No. %
Frequency of feedback
from supervisors on
IMNCI
Always 6 22 26 57
Sometimes 18 67 32 39
Never 3 11 22 26
Method of feedback from
supervisors on IMNCI
Verbal 7 26 31 37
Written 11 41 25 30
Both verbal & written 6 22 7 8
Place of getting feedback
from supervisors on
IMNCI
Sector meeting 1 4 18 22
Block meeting 6 22 9 11
OJ training 4 15 4 5
Block meeting & OJ training 3 11 3 4
Sector meeting & block
meeting
0 0 2 2
Sector meeting, block meeting
& OJ training
0 0 2 2
22% supervisors received feedback on IMNCI from their higher officials, regularly, while 11% of them
never received it at all. The method of feedback was in written form (41%), followed by verbal (26%)
and both verbal and written (22%). Block meetings (22%), followed by OJ training (15%) and both
block meetings & OJ trainings (11%) were the platform of getting the feedback. Only 4% respondents
said that they received feedback from their higher officials in sector meetings also.
Table 20 – Programme management of IMNCI by the supervisors, Bolangir, Odisha
IMNCI
No. % No. %
Familiar with IMNCI supervision checklist 13 48 33 40
Role in preparing integrated supervision plan 10 37 21 25
Aware of reporting system under IMNCI 16 59 48 58
Aware of referral services under IMNCI 21 78 54 65
Transportation support for IMNCI supervision 6 22 11 13
Instances of IMNCI drug stock out during last 3 months 14 52 41 49
Regular indenting for IMNCI in your sector 5 18 19 23
Verifying centers supervised v/s planned in the sector 8 30 19 23

32
IMNCI
No. % No. %
Weekly review at sector level meetings 25 93 54 65
Monthly review at block level meetings 25 93 44 53
Received FUS training on IMNCI 10 37 28 34
Use of supervisory checklist
Always 7 26 14 17
Sometimes 4 15 5 6
Rarely 0 0 3 4
Never 16 59 50 60
Components of programme
supervised during visits
Registers 12 44 46 55
Assessment forms 15 56 54 65
Drugs 13 48 44 53
Other logistics* 8 30 26 31
*Other logistics like booklets, IMNCI board, weighing machine, home visits, etc.
93% supervisors informed that they were conducting weekly and monthly reviews on IMNCI. Regular
indenting of IMNCI drugs was done by the supervisors only in 18% cases. 22% Supervisors received
transportation support. 37% of them were involved in preparing the integrated supervision plans. Equal
percentage of them was trained on FUS training. 48% of supervisors were familiar with the IMNCI
supervision checklist; whereas, 26% supervisors always used IMNCI supervisory checklist against 59%
who never used it. While supervising, they most often check the assessment forms (56%), while other
logistics (booklets, IMNCI board, weighing machine, home visits, etc) were being supervised the least
(30%).
Table 21 - Frequency, method and place of feedback received on RI from higher officials, Bolangir, Odisha
RI
No. % No. %
from supervisors on RI
Always 8 30 47 57
Never 4 15 5 6
Method of feedback
Verbal 3 11 37 45
Written 11 41 27 32

33
RI
No. % No. %
Place of getting
feedback from
supervisors on RI
Sector Meeting 0 0 28 34
Block Meeting 4 15 10 12
OJ Training 2 7 2 2
Block Meeting & OJ training 9 33 10 12
Sector Meeting & Block Meeting 1 4 3 4
Sector Meeting, Block Meeting &
OJ Training
1 4 3 4
30% supervisors received feedback on RI from their higher officials, regularly, while 15% of them never
received it at all and 48% said that they receive feedback from their higher officials sometimes. The
method of feedback was in written form (41%), followed by both verbal and written (30%) and only
verbal (11%). 33% of supervisors said that block meetings & OJ training were the most common
platform of getting feedback from higher officials. Sector meetings were not used as a platform for
giving feedback to the supervisors.
Table 22- Programme management of RI by the Supervisors, Bolangir, Odisha
RI
No. % No. %
Involvement in preparation of micro plan 15 56 53 64
Providing OJ training to ANM on micro plan preparation 17 63 50 60
Verifying sub centre level RI micro plan during final compilation 18 67 51 61
Verifying sessions planed v/s held in your sector 19 70 69 83
Monitoring counterfoils in the session site 24 89 68 82
Verifying session logbook of ANM at the session site 19 70 51 61
Regular indenting in the sector for RI 15 56 44 53
Conducting review meetings at block level 27 100 68 82
Conducting review meetings at district level 18 67 37 45
Monitoring cold chain maintenance system at session site 21 78 57 69
Monitoring cold chain maintenance system at ILR point 14 52 38 46
Transportation support for supervision 15 56 27 32
Financial incentives for supervision 3 11 10 12
Left out/drop out cases of RI 7 26 30 36
Vaccine/Equipment stock out in last 3 months 4 15 10 12

34
RI
No. % No. %
Always 15 56 42 51
Rarely 0 0 2 2
Never 7 26 13 16
Familiarity with RI
supervision checklist
Poorly 5 18 8 10
Somewhat 2 7 7 8
Fairly 5 18 21 25
Very Well Familiar 15 56 39 47
Factor for drop out
Illiteracy 1 4 11 13
Improper programme planning 0 0 3 4
Poor quality services 0 0 1 1
Cultural barrier 1 4 5 6
Others* 17 63 42 51
*Other factors majorly include migration, lack of communication, poor awareness, etc.
100% supervisors informed that they were conducting RI review meetings on block level against 67%
who conducted review meetings at district level. 78% supervisors monitored cold chain maintenance
system at session site and 52% at ILR points. 56% Supervisors received transportation support and 11%
received financial incentives for supervision. 56% of them were involved in preparing of micro plan.
26% supervisors informed that there were left out/drop out cases of RI and 63% of them agreed that the
major factors for drop out were migration, lack of communication, poor awareness, etc. 56% of them
always used the supervision checklist and were very familiar with the same, while 26% never used the
checklist and 18% were poorly familiar with the RI supervision checklist.
Table 23- Frequency, method and place of feedback received on VHND from higher officials, Bolangir,
Odisha
VHND
No. % No. %
from supervisors on
VHND
Always 7 26 37 45
Never 5 18 8 10
Method of feedback
from supervisors on
VHND
Verbal 10 37 52 63
Written 4 15 10 12

35
VHND
No. % No. %
Place of getting
feedback from
supervisors on VHND
Sector Meeting 0 0 28 34
Block Meeting 8 30 18 22
OJ Training 1 4 1 1
Block Meeting & OJ
training
7 26 9 11
Sector Meeting & Block
Meeting
3 11 6 7
Sector Meeting, Block
Meeting & OJ Training
0 0 2 2
26% supervisors received feedback on VHND from their higher officials, regularly, while 18% of them
never received it at all and 52% said that they receive feedback from their higher officials sometimes.
The method of feedback was in verbal form (37%), followed by both verbal and written (18%) and only
written (15%). 30% of supervisors said that block meetings were the most common platform of getting
feedback from higher officials followed by 26% who agreed that block meetings and OJ training were
used as a platform for giving feedback on VHND by their higher official. Only 4% of respondents said
that OJ training was used as a platform for feedback.
Table 24- Programme management of VHND by the supervisors, Bolangir, Odisha
VHND
No. % No. %
Availability of VHND micro plan at sector level 22 81 60 72
Training to ANM/AWW on VHND micro plan preparation 20 74 53 64
Verifying sub center level VHND plan & guiding as per need 22 81 55 66
Compiling & finalizing VHND micro plan at sector level 20 74 53 64
Reviewing VHND reports in the sector 23 85 69 83
Verifying sessions planed v/s held 20 74 68 82
Transportation support for monitoring 10 37 22 26
Weekly review of programme at sector level review meetings 26 96 75 90
Monthly review of programme at block level review meetings 26 96 56 67
Familiarity with supervision checklist
Not aware at all 5 18 15 18
Somewhat familiar 2 7 17 20
Fairly familiar 2 7 17 20
Very well familiar 16 59 31 37

36
VHND
No. % No. %
Use of supervision checklist
Always 14 52 29 35
Rarely 0 0 10 12
Never 8 30 20 24
Components of VHND supervised
Registers/records 23 85 74 89
Availability of drugs 17 63 61 73
Availability of other logistics 22 81 72 87
Others* 15 56 45 54
*Other components include due list, equipment, MCP cards, Danger signs in mothers, adolescent health, etc.
96% supervisors informed that they were conducting weekly & monthly reviews on VHND and 85% of
them reviewed the VHND reports in the sector. 81% supervisors were involved in verifying the sub
center level VHND plan and 74% trained the ANM on VHND micro plan preparation. 74% of
supervisors also verified the sessions planned v/s the sessions held. Only 37% supervisors received
transportation support for monitoring. 59% of supervisors were very well familiar with the VHND
supervision checklist against 18% who were not aware of it at all. 52% supervisors always used the
VHND supervisory checklist against 30% who never used it. While supervising, they most often
checked the registers/records (85%), while other components (due list, equipment, MCP cards,
adolescent health, danger sign in mothers, etc) were being supervised the least (56%).

38
ROUTINE IMMUNIZATION (RI)
Table 1- Availability of vaccines at routine immunization session sites, Nuapada, Odisha
Vaccine availability
Nuapada (N=11) Total (N=108)
No. % No %
BCG 11 100 105 97
BCG diluent 11 100 105 97
Measles 11 100 105 97
Measles diluent 11 100 106 98
tOPV 11 100 98 91
Hepatitis B 11 100 104 96
DPT 11 100 101 93
TT 11 100 97 90
With respect to availability of vaccines at immunization session sites in Nuapada district, we found that
all antigens were available in 100 percent sites.
Table 2-Availability of logistics at routine immunization session sites, Nuapada Odisha
Logistics availability
No. % No %
AD (0.1ml) syringes 11 100 106 98
AD (0.5ml) syringes 11 100 107 99
5ml reconstitution syringes 11 100 104 96
Vitamin A solution 11 100 105 97
Blank RI card 9 82 92 85
Counterfoils 5 45 83 77
ORS packets 11 100 105 97
Paracetamol 7 64 95 88
Plastic spoon/cap for Vitamin A 11 100 100 93
Tracking bag 11 100 56 52
Functional hub-cutter 5 45 91 84
AD syringes, reconstitution syringes, Vit. – A solutions and ORS packets were found to be available in
all the sites visited for data collection. In about 45% sites, functional hub-cutters and counterfoils were
found to be available. Blank RI cards (MCP cards) were found to be available in 82% sites. Zinc tablets
were available in 27% and Paracetamol in 64% sites.

39
Table 3-Quality indicators-I at RI session site, Nuapada, Odisha
No. % No. %
Vaccines without label 0 0 1 1
Vaccines with unreadable label 0 0 1 1
Expired vaccine vial 0 0 0 0
Vaccines at VVM stage III or IV 0 0 1 1
Frozen vaccines 0 0 0 0
BCG/Measles reconstituted for more than 4 hrs 0 0 0 0
Session as per plan 11 100 94 87
Vaccines brought to site by AVD 6 54 59 55
Vaccines brought to site by ANM 2 18 33 31
Vaccines brought to site by supervisor 0 0 1 1
Vaccines brought to site by others* 3 27 12 11
Vaccines & Diluents kept in vaccine carrier 11 100 94 87
Vaccines & Diluents kept in zipper bag 11 100 84 78
Four ice packs in the vaccine carrier 11 100 101 93
Vaccine batch no. recorded 11 100 89 82
Vaccine expiry date recorded 11 100 87 81
Diluent batch no. recorded 11 100 87 81
Diluent expiry date recorded 11 100 88 81
*Others=HW (M &F), MPW (M), Malaria Worker, MPHS (M)
We found that in all the session sites vaccines were correctly labeled and in readable form. There were
no expired vaccines or vaccines in stage III/IV of VVM or in frozen state. In all the sites, the sessions
were held as per plan. In 100% of the sites, we found that vaccines were kept in vaccine carriers and
zipper bags. Further, the appropriate use of four ice packs was also found in 100% sites. In 54% sites,
vaccines were brought by AVD, while in 18% sites, it was brought by the ANM and in 27% sites other
health workers delivered the vaccines to the session sites. In more than 100% sites, the batch number
and expiry date of both the vaccines and the diluents were found to have been properly mentioned.

40
Table 4-Quality indicators II at RI session sites, Nuapada, Odisha
Quality Indicators
No. % No. %
Due list available with ANM 11 100 106 98
Due list available with mobilizer 11 100 100 93
Reconstitution time written on vials by ANM 11 100 101 93
AD syringe used by ANM to inject vaccines 11 100 107 99
DPT vaccine given on antero lateral aspect of mid thigh 11 100 105 97
Route of measles (Sub-cutaneous) 11 100 102 94
Measles given on right upper arm 11 100 101 93
ANM touching any part of needle while injecting 1 9 8 7
ANM following no recapping procedure 11 100 66 61
Syringe cut with hub cutter after use 5 45 91 84
Red & black bags used to segregate immunization waste 11 100 92 85
Tally sheet used to keep record after vaccinating each child 8 73 80 74
4 key messages delivered to caregivers 9 82 79 73
Beneficiaries ask to wait for 30 mins after vaccination by ANM 3 27 48 44
Vaccinate a child with mild fever 9 82 85 79
Vaccinate a child with loose motions 11 100 75 69
Immunization waste carried to PHC 8 73 88 81
Health Supervisor visited you in last three months 10 91 85 79
MO visited you in last three months 0 0 15 14
The following indicators were found to be available in all the sites: due list available with ANM,
reconstitution time written on vials by ANM, AD syringe used to inject vaccines, DPT vaccines given
on anterolateral aspect of thigh, route of Measles administration, Measles given on the right site, ANM
following no recapping procedure, red and black bags used to segregate immunization wastes,
vaccinating child with loose motion. 27% of respondents asked the beneficiaries to wait for about 30
minutes after vaccination. In 45% sites, syringes were found to be cut with hub-cutter. In 73% sites,
tally sheets were used for record keeping. On the other hand, in none of the sites we found the medical
officers visited the session in last three months.

41
Table 5-Health supervisors visited in the last three months v/s 4 key messages delivered to caregivers,
Nuapada, Odisha
Health supervisor visited you in last three months
Nuapada Total
Yes No Yes No
All 4 key messages delivered to
caregivers
Yes 8 1 61 18
No 2 0 21 2
With respect to delivery of four key messages and its relationship with the frequency of supervisory
visits, we found that out of 10 sites where the supervisors had made visits in the last three months, in 9
sites all four key messages were being delivered to the caregivers by the front-line health workers.

42
VILLAGE HEALTH & NUTRITION DAY (VHND)
Table 6-Availability of logistics at VHND site, Nuapada, Odisha
Nuapada
(N=12)
Total
(N=118)
No. % No. %
Examination table 11 92 69 58.
Screen for privacy 7 58 35 30
BP instrument 12 100 106 90
Stethoscope 11 92 108 91
Foetoscope 2 17 16 14
Inch tape 8 67 76 64
MUAC tape 12 100 113 96
Weighing scale (adult) 12 100 105 90
Weighing scale (baby) 12 100 86 73
Haemoglobin testing 12 100 86 73
Needle/Lancet 12 100 81 69
Nischay kit 4 33 71 60
ORS sachets 12 100 112 95
Albendazole tablets / Syrup 12 100 91 77
Anti-malarial tablets / Syrup 11 92 89 75
Cotrimoxazole tablets 12 100 81 69
Paediatric Paracetamol 7 58 64 54
IFA tablets (large) 12 100 94 80
IFA tablets (small) 7 58 58 49
IFA syrup 11 92 68 58
Urine testing kit / Uristix 6 50 69 58
RDK kit 9 75 79 67
Condoms 10 83 88 75
Oral contraceptives 9 75 74 63
Emergency contraceptive pills 10 83 87 74
Gentian violet lotion 11 92 62 52
Test tubes 1 8 18 15
Hand gloves 6 50 42 36
Toilet 1 8 17 14
Water supply 6 50 37 31
Soap 11 92 71 60

43
Nuapada
(N=12)
Total
(N=118)
No. % No. %
Red bag for disposal 7 58 36 30
Cotton bandage 7 58 50 42
Absorbent cotton 9 75 64 54
Blank MCP cards 12 100 99 84
Referral cards 8 67 100 85
Monthly topic calendar 10 83 87 74
Duelist of beneficiaries 5 42 81 69
Reporting format 12 100 102 86
BP instrument, stethoscope, haemoglobin testing kit, weighing scale (adult and baby), MUAC tape, ORS
sachets, Albendazole, Cotrimaxazole, IFA tab (large), IMNCI chart booklets, blank MCP cards,
reporting formats and needles were found to be available in 100% sites. Test tubes and Zinc tabs were
found in one site, while foetoscope in two sites, and pregnancy testing kits were available in just 4 sites.
Zinc tablets were conspicuous by its availability in only one site. Paracetamol and IFA (small) were
available in 58% sites. Urine testing kits were found in 50% sites. Examination tables and screens for
privacy were available in 92% and 58% sites, respectively. Availability of RDK kits was found in 75%
sites and contraceptives were available in about 80% sites.
Table 7-Session site of VHND, Nuapada, Odisha
Session Site Nuapada (N=12) Total (N=118)
Sub Center 0 10
AWC 9 87
Others 3 15
Total 12 112
9 out of 12 sessions visited were conducted at AWCs, while no sessions were being held at sub centres.
3 sessions were held in other places including in school buildings, community halls etc.

44
Table 8- Availability of health workers at VHND site, Nuapada, Odisha
*Others=AYUSH MO, BPM, PRI members
With respect to availability of different types of health workers at VHND session sites, we found that in
100% sessions the MPHW (F) also known as the ANMs were present while the session was on. The
comparable percentages for Male health workers, AWW and ASHAs were found to be 67%, 75% and
75%, respectively. Further, the presence of supervisory cadre of health workforce at session sites was
found to be ranging from 0% (ICDS Supervisor) to 42% (Health supervisors).
Table 9-Maternal health service delivery at VHND sites, Nuapada, Odisha
Maternal Health Service Delivery
Nuapada
(N=12)
Total
(N=118)
No. % No. %
Relevant history taken 6 50 91 77
Privacy during examination ensured 8 67 54 46
BP recorded 12 100 103 87
Hemoglobin test done 11 92 93 79
Urine examination done 0 0 54 46
Pregnant women weighed 6 50 101 86
Abdominal palpation done 0 0 26 22
Fetal heart sound recorded 2 17 26 22
IFA for antenatal woman provided 12 100 112 95
Relevant counseling done 12 100 80 68
Danger signs communicated 2 17 51 43
PPTCT counseling done 11 92 61 52
Health workers at site
Nuapada
(N=12)
Total
(N=118)
No. % No. %
MPHW(F) 12 100 103 87
MPHW(M) 8 67 62 52
Health supervisors 5 42 42 36
AWW 9 75 107 91
ASHA 9 75 102 86
ICDS supervisors 0 0 3 2
AWH 10 83 75 64
GKS /PRI members 0 0 7 6
Others* 5 42 17 14

45
Weighing of pregnant women was done in 50% sites. Their BP recording, relevant counseling and
availability of IFA for ANC was found in 100% sites. PPTCT counseling and haemoglobin testing was
found to be done in more than 90% sites. However, privacy during examination, fetal heart sound
recording were done in 67% and 17%, respectively. Urine examination and abdominal palpation was
done in none of the sites.
Table 10-Child health & family planning service delivery at VHND session sites, Nuapada, Odisha
Child Health Service Delivery & Family Planning
Nuapada
(N=12)
Total
(N=118)
No. % No. %
Advice on breastfeeding given 11 92 88 75
Dietary counseling on children done 10 83 71 60
Need for supplementation with IFA communicated 12 100 86 73
Danger signs of new born communicated 0 0 41 35
Weight of infants recorded 2 17 40 34
ORS demonstration done 5 42 42 36
Advice on hand washing /hygiene given 11 92 58 49
FP counseling provided 12 100 108 91
Contraceptives provided 12 100 101 86
ANM & ASHA conduct meeting with women 12 100 70 59
ANM & ASHA conduct meeting with men 0 0 1 1
With regard to delivery of child health and family planning services, we found that ANM and ASHA
conducted meeting with the lactating mothers; availability of contraceptives; counseling on family
planning and the need for supplementation with IFA in about 100% instances. But meeting with their
husbands and describing danger signs of newborns was not found in any of the sessions. Advice on
breastfeeding and on hand washing was found in 92% sites; dietary counseling to mothers was found in
83% sites, while ORS demonstration in 42%, and weighing of infant in 17% sites.

46
CROSS-TABULATIONS
Table 11-Quality attributes of VHND services, Nuapada, Odisha
Nuapada Total
ICDS supervisor present at site
Yes No Yes No
Beneficiaries mobilized to site by
ICDS worker
Yes 0 11 3 79
No 0 1 0 36
Beneficiaries mobilized to site by ASHA
Health Supervisor present at site
Yes 3 2 36 7
No 6 1 64 11
GKS/PRI member present at site
Yes 0 11 5 2
No 0 1 65 46
Screen for privacy present at site
Yes 0 7 10 17
No 0 5 25 63
Yes 0 11 16 11
No 0 1 53 35
Cross tabulation of key attributes of quality of services revealed that in 11 out of 12 sites, the beneficiaries were
mobilized by the ICDS workers, though in none of the sites the ICDS supervisors were present. In 5 sessions the
health supervisors were present, whereas in 9 sites the beneficiaries were mobilized by the ASHAs. Examination
tables were available in 11 sites, whereas GKS/PRI members were present in none of the sites. Abdominal
palpations were carried out in none of the sites, though the screens for privacy were available only in 7 sites. On
the other hand, examination tables were available in 11 sites but no abdominal palpations were carried out in any
of those sites.

47
INTEGRATED MANAGEMNT OF NEONATAL &
CHILDHOOD ILLNESS (IMNCI)
Table 12-Review of IMNCI records, Nuapada, Odisha
Record Review
Nuapada
(N=23)
Total
(N=238)
Total no. of live birth in last 3 months 248 1830
Total no. of newborns in last 3 months who have received home visits 203 1533
Average no. of newborns per AWC/SC in last 3 months who have received home visits 8.8 6.4
Home visits conducted as per IMNCI guidelines 3 (13%) 41 (17%)
IMNCI assessment sheets correctly filled up 14 (61%) 55 (23%)
All sick cases referred 5 (22%) 30 (13%)
Referral Slips filled up 0 (0%) 27 (11%)
IMNCI monthly reporting formats filled up 0 (0%) 42 (18%)
On an average, 9 newborns had received home visits in last three months. The study found that all key
parameters of IMNCI implementation, such as, home visits as per IMNCI guidelines, filling-up of
referral slips and reporting formats were abysmally low, lesser than 25%, while filling up of assessment
sheets were found in about 60% sites.
Table 13-Assessment of skills of IMNCI trained workers, Nuapada, Odisha
A. NEW BORN
Nuapada
(N=23)
Total
(N=238)
No. % No. %
Correctly assessed a young infant 15 65 70 29
Correctly classified the young infant 13 56 98 41
Correctly treated the young infant 10 43 83 35
Correctly counseled the young infant 3 13 59 25
Infant needing referral is referred 7 30 41 17
Correctly assessed the immunization of infant 0 0 54 23

48
B. CHILD
Nuapada
(N=23)
Total
(N=238)
No. % No. %
Correctly assessed the child 15 65 71 30
Correctly classified the child 3 13 46 19
Correctly treated the child 1 4 35 15
Correctly counseled the child 8 35 39 16
Child needing referral is referred 0 0 30 13
Correctly assessed the immunization of child 12 52 75 31
With respect to the skills of IMNCI trained workers on key parameters of IMNCI programme
implementation we found that both in the case of 0-2 months and 2 months-5 yrs age group of infants
and young children the assessment skills were poor, a little over 65%. On correct classification,
counseling, management and referral their skills were also equally poor, figures ranged from 4% to 56%.
Table 14-Availability of logistics at AWC, Nuapada, Odisha
FACILITY SUPPORT
Nuapada
(N=23)
Total
(N=238)
No. % No. %
IMNCI board 17 74 35 15
Salter scale / child weighing scale 18 78 196 82
One litre jar, cup and spoon 3 13 40 17
Ped Cotrimoxazole tab/syp 12 52 92 39
Ped Paracetamol tab/syp 9 39 90 38
ORS 19 83 188 79
IFA tablets 18 78 155 65
Gentian violet paint/ powder 16 70 73 31
IMNCI module 23 100 212 89
IMNCI photo booklet 23 100 206 87
IMNCI forms for 0-2 mon 19 83 217 91
IMNCI forms 2 mon to 5 yrs 20 87 217 91
Reporting forms 22 96 175 73
With respect to availability of various logistics at AWCs on the days of conducting this survey, we
found that certain key components of the programme, such as, IMNCI chart booklets, IMNCI photo
booklets and IMNCI modules were available in all the sites. Referral slips and reporting formats were

49
available in 96% sites. Among IMNCI drugs, ORS was found to be available in most of the sites (83%)
and Zinc tablets were available in none of the sites. Availability of other drugs, such as, Cotrimaxazole,
Paracetamol, IFA tablets, Gentian violet ranged from 39% to 78%.
neonates, Bolangir, Odisha
Nuapada
(N=23)
Total
(N=238)
No. % No. %
Assessing possible serious bacterial infection
Convulsion 16 70 89 37
Nasal flaring 8 35 95 40
Pustule 10 43 74 31
Temperature 18 78 138 58
Decreased movement 0 0 83 35
Assessing diarrhoea
Restlessness/irritability 3 13 84 35
Skin pinch 14 61 128 54
Assessing breastfeeding
Difficulty feeding 19 83 110 46
Not able to feed 3 13 70 29
Less than 8 breastfeeds in 24 hours 13 56 109 46
Received other foods or drinks 9 39 74 31
Attachment 5 22 92 39
Suckling 6 26 97 41
Oral thrush 12 52 99 42
Assessing immunization 20 87 117 49
Assessing other problems 7 30 41 17
Given antibiotic for local infection 0 0 32 13

50
Advise on home care 13 56 86 36
Counseled on breastfeeding 17 74 80 34
The survey assessed the skills of IMNCI trained health workforce on assessment, classification and
management of sick neonates by using the state government advocated format. We found that with
regard to assessment of sick neonates the skills of health workers ranged from 4% to 87%. On
classification aspect, 70% respondents had the correct skills, while effective management skills ranged
from nil (giving antibiotic for local infection and ORS solution in facility) to 74% (counseling on
breastfeeding).
children of 2 months to 5 years, Nuapada, Odisha
Nuapada
(N=23)
Total
(N=238)
No. % No. %
Assessed general danger signs
Not able to drink or breastfeed 0 0 17 7
Vomit everything 1 4 17 7
Convulsion 1 4 14 6
Asked for cough or difficult breathing
Asked for diarrhoea
Restless and irritable 0 0 33 14
Able/ not able to drink/ drinking eagerly/ thirsty 0 0 15 6
Skin pinch 0 0 43 18
Diarrhoea for 14 days or more 1 4 21 9
Assessed fever
Stiff neck 0 0 17 7
Fever present for more than 7 day 0 0 26 11

51
Nuapada
(N=23)
Total
(N=238)No. % No. %
Assessed malnutrition
Visible severe wasting 0 0 28 12
Oedema of both feet 1 4 23 10
Grade of malnutrition (red/ yellow/ green) 1 4 38 16
Assessed anaemia
Severe palmar pallor 1 4 21 9
Some palmar pallor 0 0 20 8
Assessed immunization 0 0 40 17
Assessed feeding
Not exclusive breastfeeding (for less than 6 month infant) 1 4 31 13
Using bottle to feed to child 1 4 19 8
Child is not fed actively 0 0 25 10
Child is fed less frequently 0 0 20 8
Child is fed less quantity of food 1 4 9 4
During illness child is fed less quantity of food 1 4 9 4
Assessed other problems 0 0 21 9
Given antibiotic for pneumonia 0 0 20 8
Advise home care 0 0 34 14
Counseling on feeding 1 4 34 14
With regard to the technical skills of health workers on implementation of IMNCI programme for 2
months to 5 years children, the assessment skills ranged from nil to 4%. None of the respondents could
correctly classify. About 5% workers were confident in checking the understanding of
mothers/caretakers as against 17% workers who could correctly counsel the mothers on appropriate
feeding practices.

52
INTERVIEW OF SUPERVISORS
Table 17-Profile of supervisors, Nuapada, Odisha
No. % No. %
Designation of
supervisor
MPHS-F 2 18 21 25
MPHS-M 2 18 17 20
ICDS supervisor 4 36 20 24
AYUSH MO 3 27 22 26
Sector MO 0 0 3 4
The above table reflects the profile of our respondents. Out of the total 11 supervisors interviewed, 36%
were ICDS supervisors, 27% were AYUSH MOs, 18% were lady supervisors (LHV) and the rest 18%
were male supervisors.
Table 18-Supervisory visits made by internal supervisors in last one month, Nuapada, Odisha
Nuapada
Total Avg.
Total Avg.
No. of supervisory visits made last month on IMNCI 32 3 149 2
IMNCI last month
2 0 32 1
No. of supervisory visits made last month on RI 31 3 287 3
No. of filled in supervisory checklists submitted to block level on RI last
month
4 0 161 2
No. of supervisory visits made last month on VHND 44 4 313 4
No. of filled in supervisory checklists submitted to block level on VHND
last month
5 0 127 2
Support from supervisors while providing services in hard to
reach areas
6 54 (%) 41 49 (%)
With reference to all the three programmes, the number of supervisory visits made during last one
month was found to be maximum for VHND, followed by IMNCI. For RI the number of supervisory
visits made was comparatively low. The supervisors were filling up on an average 3 supervisory
checklists, each for IMNCI and RI programmes; whereas, for VHND, the average was found to be 4.
When asked whether they were getting support from their supervisors for providing services in hard to
reach areas, 6 (54%) respondents gave an affirmative answer.

53
Table 19-Frequency, method and place of feedback received on IMNCI from higher officials, Nuapada,
Odisha
IMNCI
No. % No. %
from supervisors on
IMNCI
Always 11 100 26 57
Sometimes 0 0 32 39
Never 0 0 22 26
supervisors on IMNCI
Verbal 0 0 31 37
Written 11 100 25 30
from supervisors on
IMNCI
OJ Training 0 0 4 5
Block meeting & OJ training 0 0 3 4
meeting
0 0 2 2
Sector meeting, block
meeting & OJ training
0 0 2 2
All the supervisors received feedback on IMNCI from their higher officials regularly and the method of
feedback was always in written form. None of the supervisors mentioned about the place of receiving
feedback.
Table 20-Programme management of IMNCI by the supervisors, Nuapada, Odisha
IMNCI
Nuapada (N=11)
Total (N=83) %
No. %
Familiar with IMNCI supervision checklist 6 54 33 40
Role in preparing integrated supervision plan 2 18 21 25
Aware of reporting system under IMNCI 10 91 48 58
Aware of referral services under IMNCI 11 100 54 65
Transportation support for IMNCI supervision 0 0 11 13
Instances of IMNCI drug stock out during last 3 months 10 91 41 49
Regular indenting for IMNCI in your sector 4 36 19 23
Verifying centers supervised v/s planned in the sector 0 0 19 23
Weekly review at sector level meetings 11 100 54 65
Monthly review at block level meetings 11 100 44 53

54
IMNCI
No. % No. %
Received FUS training on IMNCI 4 36 28 34
Always 3 27 14 17
Sometimes 0 0 5 6
Rarely 1 9 3 4
Never 7 64 50 60
Components of programme
supervised during visits
Registers 6 54 46 55
Assessment forms 9 82 54 65
Drugs 5 45 44 53
Other logistics* 4 36 26 31
*Other logistics like booklets, IMNCI board, weighing machine, home visits, etc.
100% supervisors informed that they were conducting weekly and monthly reviews on IMNCI. Regular
indenting of IMNCI drugs was done by the supervisors only in 36% cases. None of the supervisors
received transportation support. 18% of them were involved in preparing the integrated supervision
plans. 36% of them were trained on FUS training. 54% of supervisors were familiar with the IMNCI
supervision checklist; whereas, 27% supervisors always used IMNCI supervisory checklist against 64%
who never used it. While supervising, they most often check the assessment forms (56%), while other
logistics (booklets, IMNCI board, weighing machine, home visits, etc) were being supervised the least
(36%).
Table 21-Frequency, method and place of feedback received on RI from higher officials, Nuapada, Odisha
RI
Nuapada (N=11) Total
(N=83)
%
No. %
Always 7 64 47 57
Never 0 0 5 6
supervisors on RI
Verbal 2 18 37 45
Written 9 82 27 32
OJ training 0 0 2 2
Block meeting & OJ
training
0 0 10 12
meeting
0 0 3 4
Sector meeting, block
meeting & OJ training
0 0 3 4

Baseline Report-Evidence Based RI, VHND and IMNCI Service delivery through Health system strengthening in Odisha

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