Mitanin Programme- an introduction

1. Mitanin Programme- an introduction The Integration of Training, Deployment, Support and Monitoring of Community Health Activists ( Mitanins) to yield measurable outcomes .

2. Objectives of the Mitanin Programme: Improve awareness of health and health education. Improve utilisation of existing health care services Provide a measure of immediate relief to health problems. Organise community ,especially women and weaker sections on health care issues Sensitise panchayats and build capabilites

3. Operational Objectives 1. Select a Mitanin in every hamlet of the state- 60,000 in all. A mitanin is a woman and -fully voluntary - selected by the community and approved by the panchayat. 2. Train the Mitanin over 18 months- 20 days of camp based training and 30 days of on the job training at the village. 3.Provide support to her in her work and closely coordinate with ANM and AWW for maximal effectiveness.

4. What are the Compulsions for a Community health volunteer? 4000 subcenters, 26,000 villages and 54,000 hamlets- If infant mortality must fall further then in every hamlet every newborn, every diarrhoea, every ARI, every case with fever- must be seen on Day One. Health education requires someone from within the community who knows the local idiom and perceptions,

5. How is increased utilisation of health care services effected? By providing information on health care services By creating awareness on key health care services- as an entitlement- the rights based approach. By facilitating the delivery of healthcare services- coordination with TBA,ANMs ,anganwadis and PHC By local advocacy- pressure for ensuring access to these services: IN PARALLEL IMPROVEMENTS IN HEALTH CARE DELIVERY

6. What are the special features of the Mitanin Programme( as compared to earlier such programes) The volunteer is a woman � and so are all her trainers( 59,000 women require approx. 2900 trainers) The selection is hamlet/village based The selection is through a 3 to 6 month process where the community makes the choice but facilitated by a trained prerak drawn (largely from but not necessarily) from NGOs. While selecting a Mitanin four guidelines to remember Preferably be a married woman Should be able to give time( supportive family circumstance) Preferably Should have been involved in some social work Education not a must but preference to good literacy level

7. Special features of the Mitanin/ASHA Programme Curative care is complementary and essential � but not central part of the programme. Continued training and support for the entire duration of the programme � not merely an initial effort. Parallel strengthening of public health systems- not a substitute to strengthening public health systems � but forms a context in which it becomes more accountable and functional. State- civil society partnership at all levels.

8. Selection Problems- Who speaks for the community? Method 1: ANMs/AWWs made selections- declared per Mitanin selection rate of compensation: Too many got selected, the selected were familiar/obedient to ANMs/sarpanch. They had expectation of wage; Little community acceptance or motivation. Method 2: Collector gives deadlines to panchayats. Entire selection completed within a month. All sarpanches do the selection in expectation of wage/influence. Little knowledge of programme. Even ANMs do not own it � leave alone community. Weaker section representation poor.

9. Selection Problems- Who speaks for the community? Method 3: The anganwadi worker and helper selected as Mitanin. Programme took off very well- as they did not want a competitive cadre to emerge- but in 3 months programme started flagging, and in 9 mnths they declared that if imposed more work they could go to court!!! Zero community ownership Method 4: Contracted out to NGOs- selected persons familiar/associated to them. ANMs refused to own selection. Sarapanches variable on support. Weaker sections well represented but negotiation poor.

10. Approach to selection: Faciliation has four aspects- Informing the community of the programme Ensuring that women and weaker sections are consulted in the choice.. Ensuring that the panchayat approves the choice of the gram sabha. Ensuring that there is enough preceding community mobilization to generate participation and number of volunteers to choose from. Kalajathas were used extensively to convey /explain three key messages: Hamar Swasthya Hamar Haath Swasthya hamar adhikar hawai Mitanin is a volunteer of the community

11. How to facilitate selection: Identify one person (prerak)per cluster of villages � about 10 to 15 persons for a block.Maybe ANM/AWW worker or from NGO or from any other source. Insist on consulation meeting between different stakeholder groups( prereak) Orient them on this programme- 3 to 5 day workshop Help them( training and mentoring) to develop insights on gender, caste and power equations.- same 3 days Ensure/monitor no.of meetings, at least 3 in each hamlet. Hold some public events(kalajatha, aam sabha) to explain the programme. The formal gramsabha selection . Then written endorsment by panchayat. Documents all of these, verify and then only confirm. Block level coordination of selection by an active ICDS persons and one Active ANM/MPW and two or three NGO members or one lead NGO.

12. What actually happened in Mitanin Only 30% selected in this way. But the first four wrong types of selection were less than 20% . Even where ANM and AWW chose they chose better then they would have done otherwise. So in effect 80% effective Mitanins. Assembly questions and political protests easily faced!!! With written endorsements. AND LESS THAN 5% DROPOUTS

13. The training programme- first round- Approach, Objectives and specific activites of Mitanin programme, An understanding of the health and related services available/should be available in their area. An understanding of how to improve access to and utilisation of health services � An understanding of child health � why we are focussing on it, what are its causes and how to tackle it.( nutrition including breast feeding, diarrhoea, ARI and immunisation). A brief introduction to issues involved in women�s health