Nexus of Good: Life-saving endeavour

What the Pune district achieved in terms of controlling infant mortality under the inspired leadership of Aayush Prasad, Chief Executive Officer of Zila Parishad, is truly remarkable. It brought down the gross estimated infant mortality rate to less than 2 per cent. This is also significant in the context of a district that is spread over 16,000 sq. km with the mountainous terrain of the Sahyadri Ranges in 7 of the 13 blocks. The population of the district is 44 lakhs, with 3.28 lakh infants. There are particularly vulnerable tribal groups, nomadic tribes, and migrants inhabiting slums and vast tracts of the rural hinterland. The diversity of the district makes the model worth studying and replicating for the rest of the country.

The Zila Parishad in Pune resolved to focus on child health on February 25, 2020. As a first step, they finalised the indicators that they would focus on: preventing infant mortality and eliminating malnourishment. There were many more indicators but these two indicators covered all aspects of child health. These were outcome indicators whose achievement would mean multiple smaller targets would be achieved.

A 'whole government' approach was adopted to overcome the challenges. Health and Women and Child Departments have their systems and targets that ultimately focus on the health and nutrition of children. Both these departments end up replicating their efforts. They also work in silos even though they aim at achieving the same outcomes. In villages, the field functionaries of these departments, ASHAs and Aanganwadi Sevikas don't usually collaborate. The state and central-level schemes also overlap. Pune's Zila Parishad converged Rashtriya Bal Suraksha Karyakram from Health Department and Raj Mata Jijau Mission from the Women and Child Development Department to achieve the mission. They created a common Standard Operating Procedure (SOP) and jointly oriented officials at all levels: district, block and village. Responsibilities were assigned in a manner to prevent replication and for bringing greater efficiencies. While creating the SOPs, experts took the lead. The administrative staff focussed on bringing experts together and supporting micro-planning.

With the help of the Maharashtra Emergency Medical Services, the Zila Parishad created a Management Information System to track each child. The ABA ID under the National Digital Health Mission is going to be the same system for the entire population of India. The software system was linked to an auto-diagnostic support software system. The software is like a search engine that finds a probable illness when entered with observations. Software like this has been used by many large hospitals to support doctors make a better diagnosis. By using such software, the Zila Parishad enhanced the ability of BAMS Doctors working as Community Health Officers and MBBS Doctors working as Medical Officers to identify problems in a much better manner. For example, the number of children identified as malnourished went up by over 3 times when calculation errors were removed.

Repeated screenings were carried out in rounds. The Health Department has the expertise to work in programmatic mission mode thanks to Polio Vaccination Drives and other drives focussed on Tuberculosis, Leprosy etc. Schemes and programmes are better executed if they are aligned with the work culture of those implementing them. Four rounds of health screenings were carried out in anganwadis, in play schools, hospitals, homes and camps of migrant communities. These repeated screenings over the year helped track the health of the child, compare with development charts, weed out errors in data and identify children in need of specialised care. Automated identification by the software using the big data and the reference by screening doctors ensured all children in need of care were identified.

Children identified in need of specialised care were brought to block-level community health care centres where in collaboration with medical colleges, six departments were roped in to examine each child. The departments were paediatrics, ophthalmologist, dermatology, orthopaedics, neurology and surgery. Necessary blood tests and body scan facilities were made available at these camps. Dieticians were also made available. Such camps have been held twice. Over 400 children have undergone surgeries under the Rashtriya Bal Suraksha Karyakram, many of whose parents were unaware that their children required surgery. Several children were admitted to the Nutritional Rehabilitation Centre.

Consumption of medicines that were given to the children was monitored using ASHA workers as is done in the TB Dots Program. Of the malnourished children who underwent VCDC programs in Anganwadis, 60 per cent showed improvement after the first two months, and after three rounds, just 169 children remain malnourished. The remaining children are undergoing treatments at BJ government medical college and Sassoon Hospital.

Water- and vector-borne diseases are also major killers of children. Thanks to the implementation of Gadge Baba Abhiyan and the Swachh Bharat Mission, Pune District has not lost a single person to diarrhoea in the last 7 years. The health care workers and mothers are all well-trained in the use of Oral Rehydration Solutions. The procurement of FTK Kits under the Jal Jeevan Mission and water quality monitoring are helping in preventing water-borne diseases. The integrated disease surveillance program under the National Health Mission has helped identify any health outbreaks and to contain and prevent them. There was just one death due to Dengue in rural areas this year and no localised outbreaks. Measles has also been contained to five cases and no outbreaks. There was one case of Zika and it was contained. Malaria deaths have not occurred in nine years now.

The health of mothers has been given top priority to ensure that the health of children remains good. Over 98 per cent of pregnancies are registered within 12 weeks. ASHA workers are playing a critical role in this regard.

The social factors that may lead to the death of a girl child have also been checked. 525 villages have been identified with a child sex ratio below 912. Intensive IEC drives and surveillance activities have been conducted by the woman and child development department by mobilising 21,000 volunteers in all villages. 48 child marriages have been prevented this year thereby leading to fewer pregnancies in the teenage age groups. Preventing child sexual abuse and neglect has been enlisted as a priority area for these villages. The child sex ratio for the entire rural areas of the district is 948 girls for every 1,000 boys which is a biological norm.

Pune presents an excellent example of Nexus of Good. Their experience shows that a focussed program, implemented systematically and consistently through convergence between departments and schemes, can bear good results. The Pune model can be replicated by other districts in the country.

Views expressed are personal