Thinking big, thinking smart, scaling up fast
By Patralekha Chatterjee Mayurbhanj: A visit to Mankadia colony in Kaptipada block, Mayurbhanj, brings home the enormous challenges to saving babies in this vast, sprawling district .The ‘settlement’ is inhabited by the Mankadias--- nomadic food gatherers and hunters. There is no clean water nearby. Most adults in the colony are illiterate and live off forest produce. What instantly strikes an outsider about this remote, tribal settlement is the number of alarmingly emaciated children roaming around, carrying siblings barely a few months old. Many of these children may not live long. Mayurbhanj is the biggest district in Orissa, spanning 10, 418 sq km, with 26 blocks and a population of 2,221,782. Close to 60% of Mayurbhanj district’s population are tribals. Much of the terrain is hilly, forested and infrastructurally backward. Despite its beauty, the district is a tough place for outreach workers. But in this UNICEF-supported pilot district implementing the Integrated Management of Neonatal and Childhood Illness (IMNCI) strategy, amazing things are happening: 2504 out of 4,300 selected persons have already undergone training in IMNCI since its launch in the district in October 2004. 71% of young infants now receive three post natal visits within the first 10 days of their birth in those areas of Mayurbhanj where trained health and nutrition workers are deployed. And block-level data from local Child Development Project Officers (CDPO) suggest that IMNCI is contributing towards reducing malnutrition -- a key concern in the district. . “In 2001, 34% of the children in 0-5 age group in Udala block were what nutritionists would call ‘normal’. In 2005, that figure went up to 41.6%. IMNCI has contributed towards creating a greater consciousness about food and hygiene among communities and nutrition workers,” says Harapriya Patra, CDPO, Udala, reading out from a chart on the wall in her office. It is too early to say if IMNCI has impacted the district’s Infant Mortality Rate.
How did Mayurbhanj do it? Like other IMNCI pilot districts in the country, Mayurbhanj had its share of teething problems. But the deep conviction of key district officials who had already been trained in the IMNCI approach that this newborn-centric child survival strategy, with its emphasis on de-medicalising vital aspects of child care, and simple standards protocols for identification, classification, referral and treatment by community health and nutrition workers, could deliver results in Mayurbhanj eased the process. “The training was rigorous and practical. I was convinced that IMNCI, with its focus on newborns, could make an impact in Mayurbhanj, ” recalls Dr K K Mohapatra, Additional District Medical Officer (ADMO), Mayurbhanj. An enthused Mohapatra took the training module, and read it page by page with concerned programme officers in his district. Then, he invited a few IMNCI-trained nutrition workers and requested them to talk about the new skills they had acquired in front of the programme officers. A visiting high level UNICEF delegation to Mayurbhanj in early 2005 found a big change in the level of awareness among mothers in areas where IMNCI had been rolled out. “The experience was very heartwarming. Slowly, the top officials in the district began to be convinced about IMNCI’s potential”, says Mohapatra. The key to the success of IMNCI training and roll-out in Mayurbhanj has been innovative thinking and strategic partnerships. “To make an impact, we needed to do several things, and fast. We had multiple training sites. The accent was also on continuously creating a pool of trainers. As soon as IMNCI was launched in one block, we ensured that medical officers from adjacent blocks also got trained. This was a contingency measure factoring in that people get transferred frequently”, says Ashish Sen, Project Officer- Health in UNICEF’s Orissa office. In Mayurbhanj there are 6 training venues. Two are in adjacent districts -- Balasore and Keonjhar -- but have been chosen for logistical convenience such as availability of adequate number of sick babies for the clinical sessions. The starting point was the district hospital. Soon, three other sub divisional hospitals had been identified to ensure that all trainees had enough cases to examine during clinical sessions. These were sub-divisional hospitals at Udala, Karanjia and Rairangpur in addition to hospitals at Balasore and Keonjhar. Another major innovation has been the use of ‘freelance’ trainers and monitors. Local young men and women with grassroots experience have been recruited, and trained in IMNCI guidelines. These trainers now double up as monitors and are supervising community workers as they implement IMNCI in the villages. Currently, about 50% of IMNCI trainers (for health and nutrition workers) in Mayurbhanj are medical officers. This has reduced the pressure on existing personnel in the health services. In a vast district with a widely dispersed population, monitoring and supervision are central to the ultimate sustainability of IMNCI. To accelerate the IMNCI roll out in Mayurbhanj, UNICEF has supported introduction of another tier at the bottom – the Block Coordinator. Currently, 8 such locally recruited block coordinators are taking IMNCI forward in the district.
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