Focus group discussions with the providers

At the discussions with the frontline health workers, we found that all were aware of their job responsibility and had knowledge of services supposed to be provided at the VHND session. Major concern raised was lack of suitable venue and basic amenities for a VHND session. VHND sessions were held at Anganwadi Centers, school premises and at club houses. All venues had poor infrastructure and lack of basic amenities. The result was a decrease in attendance of beneficiaries to the VHND sessions. Most of the participants perceived this to be a reason for low turnout rate of beneficiaries to the VHND sessions. They also added the poor involvement of members of the local administrative body, Panchayat Raj Institution as another reason compounding the low turnout. There was differential attendance by people of different castes owing to socio cultural taboos and caste barriers. For instance, in situations where VHND sessions were being held in a general caste locality, there was a low attendance by the beneficiaries of scheduled caste and tribe. Lack of privacy and proper examination facilities were quoted as major hindrance in doing health check-up of pregnant women and adolescent girls. Especially the mobilization of lactating women to the session and referral of high risk pregnant women were mentioned as key practical problems. Participants mentioned a status of inadequate medicine supply, difficulty in timely repair and replacement of instruments affected quality of services. Further, participants found it difficult to discuss the health topics at VHND sessions since beneficiaries were reluctant to stay for long due to lack of proper waiting place and snacks provision. Time constraint was cited as a problem to carry out all services as per guidelines.

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Regular supervision by higher authorities was suggested as a useful means to promote beneficiary participation and improve quality of services. Further, provision of snacks to the beneficiaries while attending VHND session, organizing motivational activities like prize distribution, healthy baby show, increase in remuneration for referral of high risk pregnant women and advanced malnourished children were cited as a few key strategies for improving the beneficiary participation.

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Discussion

Odisha is one of the States in India with low literacy and high infant mortality (12;13). The malnutrition prevalence of this state is among the highest in the country (14). Against this backdrop, VHND program was initiated with an aim to provide primary health care services to pregnant women, lactating mother, children under five years and adolescent girls with the help of village level workers. Effective implementation of VHND is therefore important to address the issues related to nutrition, early identification of health problems and high risk individuals through focusing at different stages of the life cycle (adolescence, pregnancy, lactation, Under-5 children). The present study aimed to assess the quality of VHND implementation and identify demand and supply gaps if any. Low participation of the beneficiaries and suboptimal quality of services were the salient findings. Notable gaps identified were poor infrastructure, inadequate availability of logistics, minimal supportive supervision, and low involvement of community leaders/ the local administrative body Panchayat Raj Institution members in service delivery.

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VHND program provides a community level platform for making different health services available and accessible to different categories of beneficiaries. To avail the maximum benefit of the services, commensurate utilization by the beneficiaries is the foundational requirement. However, during the present study, it was observed that the turnout rate of enrolled beneficiaries is very low, about one-third (30.7%). Knowledge of the facilities available at VHND session was low. 34 percent of the participants were not aware of the single facility. Findings are in congruence with an earlier study conducted in Odisha, where this percentage was 24 percent (15). Among different categories, the participation of lactating mothers and adolescent girls were the lowest. Both beneficiaries and providers mentioned poor infrastructure and amenities to be the main reasons for low attendance. Our facility assessment also observed the lack of privacy for examination, no waiting space, non-availability of basic amenities like drinking water, fan in the venue thus posing practical difficulties for the beneficiaries to participate and remain at the session site for the whole duration. Further, a majority of the health workers believed that inadequate availability of medicines at the session site discouraged the beneficiaries to attend, while some indicated less involvement of the community leaders as another contributing factor.

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Surprisingly, we observed a limited awareness among the beneficiaries about the venue and time of VHND. One reason could be lack of permanent display board informing the date, time and place of the session. This is further compounded by low community mobilization owing to less involvement of members from Panchayat Raj Institution and deficient coordination between health workers and community leaders. As there is no regular and routine supervisory visit, neither health workers nor the local Panchayat Raj Institution members felt motivated for ensuring beneficiary mobilization. The impact of involvement of the Panchayat Raj Institution has already been documented (16;17). At the same time this also hampers timely and adequate provision of medicines and equipment for the sessions. Nevertheless, all these cumulatively result in a low beneficiary turn out rate. Moreover, the caste difference amongst the participants was another key observation. As quoted by the health workers, when the session is organized in an area dwelled by a particular caste, the people of other castes are reluctant to attend and share the same venue. However, we did not observe any mechanism in place for counselling the beneficiaries against this social barrier.

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Timely and adequate availability of logistics and equipment is integral to ensure quality services in any health program. However from the study it was noticed that in none of the sites, measuring tapes were available thus leading to incomplete nutritional assessment. In a majority of the sites, examination table and basic medicines for minor ailments were lacking, resulting in low quality service delivery as well as low attendance by the beneficiaries. These findings are in line with the earlier studies done at VHND sessions in Uttrakhand, India (18).

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Services like early registration of the pregnant women, per-abdominal examination and IFA supplementation were being provided in all the sessions while haemoglobin estimation, blood pressure measurement, weight measurement, urine examination for albumin of pregnant women were not done in many of the sessions. As blood pressure and weight measurement, urine examination for albumin are early identifiers of high risk pregnancy, there is a risk of missing out on some of those women with urgent need for referral. Studies from other parts of India have highlighted similar findings (15;19). Limited evidence exists regarding training and supervision of health workers for provision of integrated outreach. A dialogue on integrated outreach services provided under India’s National Rural Health Mission program reported that health workers were not fully aware of services to be offered and lacked appropriate skills to deliver the package of additional services, such as family planning (20).

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A component on Nutrition Health Education and Demonstration (NHED) is incorporated into each VHND session to impart knowledge and awareness among the beneficiaries (21). However, we observed that in three quarters of the session sites this was not being followed. The beneficiaries declared that even though being interested to learn, it was difficult for them to wait till the end of the session because of time constraint as they also had to take care of domestic work. Some also expressed that non availability of waiting space in the venue and absence of any refreshment (snacks, tea) arrangement makes it difficult to wait for the NHED session. The health providers were of the view that with limited human resources, they were over occupied to deliver other VHND services and hardly found any time to carry out the educational activity. They also felt the lack of waiting space and refreshment as major barrier for women to wait through NHED session. Conducting and attending NHED was found to have the lowest priority both among health workers and beneficiaries respectively. This needs timely attention and intervention as nutrition education is a key factor for fostering healthy nutritional practices. Considering the time constraint with the beneficiaries as well with health provider, developing visual aid and printed material with key messages which are easy to understand can be distributed during the VHND session or prior to that. This may contain photo stories, dos and don’ts etc. through graphics so that the beneficiaries with minimal education status can easily comprehend the message. Also, funds from local panchayat can be utilized to addressing the issue of refreshments etc.

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Supportive supervision plays a vital role in successful implementation and bringing quality improvement through on job training, onsite supervision. Significance and effectiveness of supportive supervision is well documented from the other health programmes (22;23). While each VHND session should ideally be supervised by designated health officials, in reality it was found to be happening rarely. This has multifold effect across all levels contributing to low beneficiary participation, inadequate logistic supply, incomplete service delivery, deficient basic amenities and insufficient community involvement (Figure 1). Our study emphasizes on developing a systematic supportive supervision inbuilt into the VHND program. Similarly, the role of the community leaders is very important in mobilization, assisting the service providers and support each VHND session. However, our study found limited involvement of community leaders as gathered through direct observation and health worker interviews. This could be due to low perceived importance of VHND among these individuals. Proper coordination with the community leaders and making them understand the importance of the programme should be considered.