April-June School Health Programme initiated in 11 centres New batch of 22 lady CHVs to replace the ones who had dropped out PCC (Cement) road laid for 1 km from main road to the hospital by the Government 4-day VBS for 272 children from the neighbouring villages Joining of crucial new staff in administration Secondary Hospital Posting II from CMC Vellore for the first time and visits of students from various medical and other colleges for field exposure Initiation of RNTCP for TB patients Kala-azar programme in partnership with CRS.
Dr. Isac, Ms. Teresa & Mr. Francis attended a 3-day family get-together along with the missionaries of FMPB at Gangtok. Vacation Bible School was conducted for 4 days for the children of the neighbouring villages. This was along with the Padari Child Development Centre. 272 children participated enthusiastically. Ms. Sumathy (Staff nurse) was the VBS Director and 4 other staff helped out as teachers. Medical students: Five II year students from CMC Vellore spent 10 days with us to gain a perspective of Secondary Hospital care. We also had students visiting from Tirunelveli and Pondichery who came for a mission exposure trip.PROBLEMS FACED AND HOW THEY WERE MANAGED: Communication: During the last year, we enjoyed fairly good mobile coverage in the hospital area. So it was possible for central office or others to contact us on and off. In this last quarter, the coverage has drastically reduced, making it impossible for us to receive any calls. When we have an urgent call, we go to the neighbouring town (6 km away) and try. Internet connectivity is also nil since the last 8 months. We expressed this difficulty to various people and a church in UK has kindly sent us money to install V-Sat. This is in process. Once this is in place, we hope that we will also be able to make voice calls through skype. Pending financial dues: The dues carried over from 2008 plus pending bills to various suppliers amounted to over Rs. 12 lakhs (1,200,000) which is far beyond what we could raise through the hospital income. Our regional director advised us to include the old liabilities (Rs. 6 lakhs) in the budget. We started praying very specifically for this in July, inspired by George Mueller’s principle not to live on credit. By God’s grace, in two weeks we got a mail from EMMS, UK that they were sending 20,000 GBP – a little over our entire liability. We praise God for removing this “mountain” which had been towering before us for a long time! Standing up against the pressure to hide the truth: Another real struggle has been in the reporting of statistics of the hospital including deaths to the Government. They would prefer that we do not give specific causes for the deaths like malaria, TB etc. We feel strongly that we need to bring to light the very poor health status in the district, so that it gets the attention it deserves. Because of this and our stand never to pay bribes, some of our applications for Government schemes take a long time to get approved. We believe that God will move the files on our behalf! Urgent need to replace old jeep: The old jeep donated to us from Bhavan project of EHA in 2000 urgently needs replacement as the cost of maintenance is very high and the mileage is low.
Herbertpur Christian Hospital (EHA) has kindly offered to partly help us with this. We hope to put some more individual donations together and get this done by October. Electricity: Those who have visited us will know that we still do not have mains electricity and run the generator for limited hours in the day. The “electrify every village” scheme is moving slowly in our district. We praise God for the transformer that has been installed near our campus. We hope that we will actually have this luxury by November!ACKNOWLEDGEMENT TO SUPPORTERS: We are thankful to EHA Canada for supporting our Community Health Programme. We will be sending in our regular quarterly reports hereafter. Our apologies for this delayed report. We are grateful to EMMS, UK for supporting our key hospital staff, staff training and for helping clear our old liabilities. Some of our families and friends are supporting us too – financially and with their valuable prayers. One gentleman (whom we have never met) had heard about us and decided to send Rs. 1500/- every month to Prem Jyoti! And he faithfully deposits the amount in our account. We praise God for every support – big or small.JULy-OCT Spiritual retreats for staff Purchase of hospital equipment through help of Jiwan Jyoti Hospital, Robertsganj Joint screening camp for malaria and kala azar in Pandeni village and school along with the Government Training of Dr. Vijila – TOT for training district level trainers of Sahiyyas (Village Level Health Workers – Government recognized) at Gadchiroli Commencement of Global Fund TB project in Sahibganj District for ACSM – Advocacy, Communication & Social Mobilization Significant increase in the bed occupancy and number of deliveries
The gift of some much needed hospital equipmentfrom Jiwan Jyoti Hospital, Robertsganj is much appreciated. This included 1 delivery table, ECG machine,2 electric & 2 foot suction machines and an OT light.
SPIRITUAL MINISTRY: The team starts the day with prayer and a short devotion in the chapel followed by ward prayer in which the gospel is shared individually with patients before praying for them. Every Saturday, the team gathers for half day of prayer and Bible study On Sundays, we worship together in the chapel. 5 small outreach teams have been formed. They go to selected villages to conduct church service and encourage the Malto believers. The staff children have Sunday school in the afternoon. This quarter we started the Firm Foundation syllabus for them. There is a chain prayer on the first Monday of the month to pray for areas of special concern where breakthrough is urgently needed. As a team we have experienced the power of prayer over and over again. In July, we had a 3-day retreat for married couples. This was conducted by Rev. Prakash and Dr. Mrs. Jameela George. It was a very meaningful and interactive time which helped to enrich our families as we serve the Lord together. In August, all our single staff attended a 2 day retreat conducted by Mr. Barua. He taught on pre- marital issues and about deeper Christian life. Many of our staffs were blessed by this retreat.OTHER DEVELOPMENTS / EVENTS / VISITORS Dr. Benedict Joshua could help out in Madhipura Christian Hospital for 2 weeks to replace the doctor who was on sick leave Mr. Jason (Finance Director, EFICOR) visited for 4 days to train Mrs. Pancy and to give his expert advice regarding financial procedures Dr. Sam David (Prem Jyoti trustee) visited for 2 days to encourage the team. Mr. Anil Sinha joined as District Coordinator for the Global Fund TB Programme.
CHALLENGES / PROBLEMS FACED AND HOW THEY WERE MANAGED: High maternal mortality: This has been a quarter when we have seen more maternal deaths happening right before our eyes than in any other previous period. All these patients came very late and they collapsed before we could do anything. It is clear that the primary health care system in our district is very wanting and the awareness of the community at large is very poor, whereas we are able to see a noticeable improvement in the target Malto villages because of improved awareness. We have been trying to get recognized as a Government authorized centre for safe delivery for the last 3-4 years because that would entitle poor women to get a health cost reimbursement. By the grace of God and after much prayer (and without paying a single rupee as bribe), we have had a break-through during this quarter and it is hoped that the scheme could be implemented from the next quarter. This facility would enable pregnant women to come earlier for help – thereby reducing maternal mortality. Sudden increase in bed occupancy: During this quarter, we had epidemics of severe diarrhea and later encephalitis as well as an increase in the number in deliveries. So patients had to be accommodated on stretchers and benches in the verandah. We anticipate that this increase in bed occupancy will continue and that it is not just a seasonal trend. So we are discussing and planning about the next phase of hospital expansion.Oct-Dec 15-day Surgical Camp Celebration of Hospital 14th anniversary
3-day CHV Mela (Festival) Initiation of EHA TB global Fund and related training programmes Significant increase in the number of deliveries, especially in the month of October the total number of deliveries were 64 (an all time high) 2-day Trustees meeting at the hospital Long-awaited relief for the communications problem in the form of Internet Purchase of much needed assets: new Jeep, LCD projector, new computer for the RSBY programme Final signing of MOU for JSY and initiation of the programme in the hospital Christmas programme was conducted for the hospital childrenNETWORKING:With the Government: 1. After trying for about 3 years, we finally signed the MOU with the District Rural Health Society for Janani Suraksha Yojanna (delivery benefit scheme). In this scheme BPL (below poverty line) women who deliver in hospital get a cash payment of Rs. 1400/-. We hope that as people come to know of this, more and more poor women would come earlier for safe delivery to the hospital before they develop serious complications. 2. RSBY- Rashtriya Swasthya Bima Yojanna – Health Insurance scheme: The software has been set up and Mr. Francis has been oriented by the District in-charge regarding the processes involved. The smart cards are yet to be distributed in the neighbouring blocks. In this scheme the BPL families receive medical reimbursement up to Rs. 30000/- per year for 5 members per family. Once the cards are distributed and people are aware, this scheme will enable the poor to access health services for medical / surgical emergencies without the fear of expenses.OTHER DEVELOPMENTS / EVENTS / VISITORS The trustees meeting was held on November 9th and 10th and we could review the various aspects of the Community Health and Hospital programmes and plan future directions. We are thankful to Dr. Santhosh, Rev. Kennedy, Mrs. Carol Motuz, Dr. Sam David & Mrs. Margaret Kurian for sparing their valuable time to be with us and give us their inputs and insights. We appreciate their willingness to be involved…
Mr. Ravee, finance Manager, Duncan Hospital (Raxaul) visited us and helped the Accounts staff to sort out issues. He studied the cash-flow from various sources and recommended that we could proceed to implement the new salary scale. Mr. & Mrs. Paul & Sue East visited us in December which was an encouragement. V-Sat was installed after a long wait; we appreciate Dr. Sam David who took much efforts for this and the church in UK who provided the support We could get a new jeep (Bolero – 7 seater with 4 wheel drive), thanks to the help of Herbertpur Christian Hospital, EHA Central Office and Vehicle recovery fund contributions from EHA Canada & EMMS. We could implement the October 2009 (EHA) salary revision from November 2010; we praise God who cleared our debts and stabilized us financially; this decision is a step of faith – trusting Him to keep us going The construction of the training hall (approx 2000 square feet) was commenced with Government funds; we praise God for the continued support of the District Collector; Mr. Dinesh from Nav Jivan Hospital, Satbarwa came to help us regarding the technical details of this hall. 6 theological students (2 from Marthoma Seminary, Kottayam and 4 from Bishop’s college, Kolkata) spent a few weeks with our team for mission exposure. They conducted a children’s retreat for our staff children for 2 days. Jan-Mar Surgical Camp from Feb 21st to Mar 4th 2011 2-day Workshop on Community health evangelism (CHE) Initiation and successful implementation of RSBY program (Insurance scheme for below poverty line people) Implementation of JSY (Maternity benefit scheme) New MoU signed with CRS, Ranchi for kala-azar elimination program.
A road rally and TB awareness meeting conducted in Sahibganj as a part of global TB fund program.SPECIAL PROGRAMMES: Evaluation of Prem Jyoti Programmes – Drs. Beulah Jeyakumar & Jeevan Kuruvilla conducted a week-long programme review with the aim of enabling the CHP team to identify a way forward. A summary of the same is given in the annexure. 2-day Workshop on Community health evangelism (CHE): A 2-day Envisioning Workshop was conducted by Dr. David Sorley and Mr. Prabat for representativesof FMPB (Malto & Santal), ECI and Prem Jyoti. This addressed the following crucial areas: i. Integrating evangelism & discipleship with home-to-home health and development teaching ii. Showing the importance of development and contrasting it with relief. Teaching others to do things themselves rather than having outsiders do things for them. iii. Using the communitys own God-given resources instead of relying on outside "help". iv. How to develop community ownership of CHE for sustainability. v. Seeking God’s guidance for this whole processAt the end of the workshop, all agreed that there is an urgent need for such a holistic and sustainableapproach. Further steps in this direction would be decided in the coming months. RSBY programme: This is part of a project that EHA has undertaken with UNDP and the Ministry of Labour & Employment (MoLE) to strengthen the National Health Insurance Scheme (RSBY – Rastriya Swasthya Bhima Yojana). It broadly has two components a) Community based component, which is to be implemented through the CH project teams. The main purpose of this component is to educate and engage the community and various other stakeholders at the village and district level so that the cardholders will be able to benefit from this scheme. This will involve training the Village Health & Sanitation Committees and the ASHA’s and to develop a mechanism by which the community monitors the programme. b) Hospital based component: The purpose of this objective is to ensure that the RSBY card holders / clients are able to get quality health care at a reasonable costs. The programme also aims to establish benchmarks/standards and a mechanism of monitoring this in a systematic manner and on a regular basis. Mr. Ajeesh from the Central office visited Prem Jyoti to initiate the community survey in order to find out the present level of knowledge and attitude of the community regarding RSBY. Global fund TB Round 9 Project (GFTBR9): Prem Jyoti is the facilitator of this project in the district with Mr. Anil Sinha as the District Coordinator. During this quarter, the following programmes were conducted as part of GFTBR9:
o Meetings were held with partner NGOs (EFICOR, Mariam Pahad, Sona Santhal Samiti, Prem Jyoti) in the district; implementation strategy was finalized and MOU was signedo 1-day training about TB was conducted for rural health practitioners – this was very well received with excellent participation of the 25 RHPso The NGOs started conducting sensitization meetings in their respective blocks using flash cards on TB designed by Prem Jyotio 2-day training was conducted for 20 representatives of CBOs (Community Based Organizations) from the 5 target blocks in the district. This training focused on the role of CBOs in controlling the spread of TB.o 4 sets of 1-day training were conducted for health staff working in various positions in the Government health department. The main focus of this training was on good communication with patients, DOTS providers and other stakeholders in the control of TBo A special rally with street play was conducted on March 24th - World TB day at Sahibganj.o Mr. Anil Sinha – the district coordinator has translated most of the power- points and hand-outs from English to Hindi, rendering them much more effective in training.
OTHER DEVELOPMENTS / EVENTS / VISITORS 1. Training centre construction – roof casting is over and finishing work is going on 2. Dr. Adeline Sitther, missionary doctor in Papua New Guinea visited us for 4 days. It was good to hear about missions in another country, also among tribals. There are so many similarities. 3. Dr. & Mrs. Abraham Ninan visited us for a day – though the time was very short, we were much encouraged by their first visit. 4. Dr. Aletta Bell – Canadian missionary doctor to India for several decades and a great support to Prem Jyoti especially in the first 7 years of its inception, visited us for 3 days. It was a joy to fellowship with her again and we were mutually encouraged. 5. Mr. Jan and Ms. Maresa, elective medical students from Germany spent 3 weeks with us. They shared that it was a new experience for them. 6. 4 medical students from Tirunelveli Medical College visited for 4 days. These were boys who are seriously considering missions and it was good to spend time with them.CHALLENGES / PROBLEMS FACED AND HOW THEY WERE MANAGED: CHV supervision: Finding CHV supervisors and retaining them has always been a struggle. For efficient functioning of CHVs, supervisors play a vital role. But the work they need to do is very tough - constantly moving from village to another, traveling in rugged roads, climbing hills and so on. Daniel Malto joined as CHV supervisor during this quarter, to replace Patras Malto. Also we started new concept of having part time supervision. These part time supervisors are male CHVs who are very active in their work. They are given a certain number of villages in their neighbouring cluster of villages and they are to supervise the CHVs in those villages. Inputs are being given in Chandragodda and also by full time supervisor. As of now we have chosen two- Markose and Reuben. We need to wait and see the effectiveness and acceptance by CHVs of this new concept.Annexure: Extracts from the draft report of the evaluation:A program review of Prem Jyoti CHP was undertaken in January 2011 with the aim of enabling the CHP team toidentify a way forward. Three specific objectives helped address this overall aim: 1. To assess the current status and changes that have occurred over the past nine years (2002 to ’11) in key areas that influence the program: a. Health status, health services and household behaviors. b. Socio cultural and economic changes
c. Christian witness to and by Malto communities 2. To assess the current socio political and health services environment and their future course 3. To assess value addition by the CHP, its core strengths and passion, and viabilityHealth services were assessed for Maternal and Child Health (MCH), TB and malaria as these areas represent most-at-risk populations and cover significant portions of mortality and morbidity in Malto communities. Householdbehaviors assessed were care seeking for fever, use of bed nets, complementary feeding for infants aged 6-9months, institutional deliveries and immunizations. These behaviors were chosen for their critical impact on themortality and morbidity of mothers and young children, who are most vulnerable.Stakeholders included the Prem Jyoti CHP team, Malto communities, district Ministry of Health (MOH), EHA andlocal units of partner organizations EFICOR and FMPB and their local program staff.The review was designed to be participatory, client centered and based on primary data.The target population of the CHP was divided into three groups1 based on their geographic accessibility, and thefollowing data collection exercises were carried out in each group: • Focus group discussions with men • Focus group discussions with women • Interviews with mothers of young children • Interview with family of a recent maternal death • Interview with family of a recent child death • Interview with a current/recently completed TB patient • Interviews with Anganwadi Workers (AWWs) of the Integrated Child Development Scheme (ICDS) • Interviews with Sahiyyas, a volunteer cadre of NRHMIn addition to the above, focus group discussions were carried out in neighboring Santhal communities to drawcomparisons and also to assess their needs.The following data collection exercises were carried out with other stakeholders: • Focus group discussion with staff of Parivartan Child Survival Project of EFICOR • Interviews with missionaries of FMPB • Interviews with Medical Officers in Charge (MOICs) of PHCs • Interview with District Program Manager of the National Rural Health Mission (NRHM) • Focus group discussion with CHP staff • Focus group discussion with CHVs1 The three groups are: Communities in Sahibganj district with poor access, communities in Sahibganj district with better access,target communities in Pakur district
ConclusionsThe CHP has intervened in the health status of one of the country’s most impoverished and underservedcommunities, bringing about significant reductions in the burden of disease. It has introduced these communitiesto preventive and treatment interventions, many of them right where they live. In its implementation area theprogram has contributed to the achievement of Millennium Development Goals (MDGs) 4, 5 and 62.Overall, the CHP and Prem Jyoti have changed the power, visibility and opportunities for the weakest. Working inan extraordinarily constrained context, the team has endeavored in humility and commitment to bring health andhope to those at the very “end of the road”.The CHP and the hospital are complementary by design, which has ensured that the supply side of the equation ismet for target communities in the context of a very weak public health infrastructure. A culture of learning andimprovement has enabled the program to maximize its reach and effectiveness in the midst of significantconstraints.Given the virtual absence of development work, geographic remoteness of their residence, very low literacy as wellas their reclusive nature that is slow to warm up to external influence, Malto communities have taken long torespond and that, in a patchy manner. It has taken longer and has cost more to reach where the CHP currently is,compared to what it generally takes in other rural/tribal locations. Uptake of facility-based services by Maltocommunities has not kept pace with that of other poor communities in the district. In fact, many Maltocommunities are yet to experience for themselves what low-cost, high-quality health interventions such asdelivering routinely in a well-equipped facility, or a behavior such as early and exclusive breastfeeding can do to thesurvival of the mother and the newborn. Most Maltos continue to accept the high neonatal, infant and maternaldeaths as inevitable, and do not yet have reason to hope that the situation could be different. However, cases suchas Mukri demonstrate that such change is possible. A critical mass of success needs to build up amongst them forhopelessness to revert to the hope that more things are more possible, and to enable Maltos enter and participatein mainstream society.A two-pronged approach will help build such critical mass: strengthen existing interventions to maximize theiroutcome, and scale up the geographic reach to match the size of the problem. Both of these can only beaccomplished by intentionally and meaningfully co-opting others, including the government, by identifying pointsthat create leverage and by bringing in the right mix of interventions which connect and amplify one another.The scope and size of the problems in health status of the Maltos demand a response that is ambitious, well-designed and cognizant of what we already know about what it takes to reach this people group. However, all ofthese changes are only possible with a significant increase in staff strength from current levels, and dedicated stafffor the CHP.Recommendations 1. Implementing the two-pronged approach mentioned in section E above will require a deeper understanding of the current health status, in quantitative, qualitative/formative terms. A quantitative2 MDGs 4, 5 and 6 are: Reduce child mortality, Improve maternal health and Combat HIV/AIDS, malaria and other diseases.
cross-sectional population based survey of key areas such as maternal and child health, malaria and TB will provide a picture of the scope and size of the problem, and qualitative/formative studies will be required to gain insight into what keeps behaviors from changing and how current behaviors in care- seeking, infant feeding and maternal care can be replaced by appropriate ones. Before we decide where to get to, it is absolutely critical to know where we are.2. One of the two areas of work to create a critical mass of success in health interventions among Maltos is to strengthen the existing community-based intervention by improving their technical and operational rigor. These steps will help maximize their output (and impact: a. Current interventions for household level behavior change can benefit from a strategic and targeted approach with a structured follow up that will increase the chances of improved knowledge and awareness resulting in changed behavior. The CHP’s plans to partner with EFICOR Child Survival Project (CSP) for training CHVs in communicating key behaviors should be pursued as a high priority as it includes a package of interventions targeting areas of high vulnerability such as newborn care and infant/child malnutrition and diarrhea management. b. Treatment adherence for TB can dramatically improved by adopting DOT, and by identifying a DOT provider for every patient who is started on anti TB treatment. This will require the prior identification and training of an army of DOT providers across Malto communities, who could be drawn from CHVs, church elders, missionaries, school teachers and Sahiyyas. DOT provision from the Prem Jyoti hospital should be limited to those who can reach the facility by foot. c. Initiatives for economic development within current target area will help make household economies more robust and enable communities gain a foothold on the development ladder. This can be done by leveraging available resources and by mobilizing communities, especially women. Examples of such initiatives are seed banks, microcredit and entrepreneurship development. d. Uptake of CHV-based interventions has much scope for improvement and this deserves to be taken up as an activity in and of itself. Services of the CHV need to be promoted in a sustained manner through the local church or other leaders in each community. The interface of the CHV with each household should also be intentionally increased through use of the CSP’s behavior change method and other such means. e. The current reach and spread of the mobile outreach program needs to be reviewed/rehashed in the light of the current reach of government health services, remoteness of locations, client-patterns of Prem Jyoti hospital (communities that use Prem Jyoti extensively but are remote, as well as those that do not use Prem Jyoti’s or other facilities could both be targeted). Also the range of services offered by these outreach clinics need be modified based on those provided by the government in each locality, such as immunizations. Working towards complementarities with government services will send a strong affirmative message across to communities that will help uptake of both the services and increase value for money. Presence and work of both the CHV and NRHM’s Sahiyya is another area for clearly mapping areas of duplication and working to complement government services.3. The other area for the program to consider is geographical scale up. It is evident from the review that there are communities of Maltos that are in even greater need than ones being reached through the current intervention. This applies to community-based interventions as well as provision of secondary-
level care. Inequity in development amongst Malto communities could derail gains made in some of the areas, as Martin Luther King, Jr famously said, “Injustice anywhere is a threat to justice everywhere”. This scale up is only possible if we co-opt government services and work closely and intentionally with them to identify areas where Prem Jyoti can add greatest value.4. Integration and coordination with government services come at the cost of higher administrative burden and longer delays and so they need to be weighed carefully with the need and urgency to achieve results in critical areas. Prem Jyoti has already demonstrated willingness, wisdom and agility in this area and this effort needs to be carried forward with greater vigor.5. All of the recommendations above can only be made feasible if there is a significant increase in staff strength and capacity. Bold and game-changing innovation will be required to recruit, train and retain the right people for this endeavor.