Assessment of child health services under Reproductive, Maternal, Neonatal, Child and Adolescent (RMNCH+A) strategy at primary health care level in Doiwala block of Dehradun District, Uttarakhand, India - A cross – sectional study

ABSTRACT

Background:

The reproductive, maternal, newborn, child + adolescent health (RMNCH+A) strategy was launched by the Indian government in the year 2013 to remain in the lead of the global war against child and maternal mortality and morbidity. Under RMNCH+A program in Uttarakhand state, according to the State public health policy, various provisions are needed to be done for maintenance of downtrend in infant mortality rate (IMR). There are various thrust areas under the child health program. The purpose of our study is to monitor the program implementation in terms of Input and Process indicators and to identify if there are any gaps in the child health services provided by RMNCH+A in the PHCs and subcentres of Doiwala block of Dehradun district, Uttarakhand.

Aim:

To evaluate Input and the process indicators of child health services under RMNCH+A strategy at Primary health care level in Doiwala block of Dehradun district, Uttarakhand.

Methods:

This Cross-sectional study was carried out in Doiwala Block of Dehradun district, Uttarakhand in 3 randomly selected Primary health centres (PHCs) and their 6 subcentres using a validated standard checklist for PHCs and subcentres.

Results:

In PHCs, mean obtained score for Input indicators was 56% and for Process indicators was 35%. The mean obtained score in subcentres for Input indicators and Process indicators was 53% and 51%, respectively.

Conclusions:

Both the input and the process indicators for child health services in PHCs and subcentres of Dehradun district were inadequate. Most indicators scored less than 50% at both the PHCs and subcentres.

Introduction

Mother and child health care always persisted as the crucial component of health-care delivery system in India since the time of independence.[1]

Each and every person strives to enhance their quality of life. But most people in developing countries live in overcrowded houses with inadequate sanitation and unsafe water supply.[2]

Every year in India, around 26 millions of children are born. The share of children (0–6 years) accounts 13% of the total population in the country as per census 2011.[3] Infectious disease and malnutrition are common in children. The under-5 child death rate is high that is 34.3 per thousand live births in India.[4] To decrease it, primary health care came into being.[5]

WHO considers the central role of primary health care for attaining health and well-being for all, at all ages.[6] The primary health care (PHC) has been globally promoted as a comprehensive approach to achieve optimal health status and ‘Health for all’.[7]

Reproductive, maternal, newborn, and child health (RMNCH) covers the health concerns and interventions across the life course involving women before and during pregnancy; newborns, that is, the first 28 days of life; and children to their fifth birthday.[8]

The reproductive, maternal, newborn, child + adolescent health (RMNCH+A) strategy was launched by the Indian government in the year 2013 to remain in the lead of the global war against child and maternal mortality and morbidity.[9]

Under RMNCH+A program in Uttarakhand state, according to the State public health policy, various provisions are needed to be done for maintenance of downtrend in Infant mortality rate (IMR).[10] There are various thrust areas under the child health program which includes- neonatal health, nutrition of children, management of childhood diarrheal diseases and Acute respiratory infections along with intensification of routine immunization.[11]

Uttarakhand, the 27^th state of the Republic of India and was carved out of Uttar Pradesh on November 9, 2000. There are 13 districts in Uttarakhand which are grouped into two divisions—Kumaun and Garhwal. The Kumaun division includes six and Garhwal division includes seven districts.[12] Dehradun is one district of Garhwal division out of 7 and is also the capital of Uttarakhand state. There are 6 blocks in Dehradun District, totally.[13] The RMNCH+A program is running in all blocks of Dehradun district.[14]

The purpose of our study is to monitor the program implementation in terms of Input and Process indicators and to identify if there are any gaps in the child health services provided by RMNCH+A in the PHCs and subcentres of Doiwala block of Dehradun district.

Primary care physician who is the backbone of the health care system and also the first contact point with patient, result of this study will be helpful for them for improving input and process components of child health services at primary care level.

Methodology

A cross-sectional study was carried out in Doiwala block of Dehradun district, Uttarakhand, India. The Doiwala block is having 5 PHCs out of which the study was conducted in 3 PHCs (PHC Raiwala, PHC Bhaniyawala and PHC Chidderwala) and 6 subcentres (2 from each PHC) of Doiwala Block. The PHCs and subcentres were selected through simple random sampling.

The study was started after taking ethical approval from the institutional ethics committee. (Letter No- AIIMS/IEC/21/348).

The study included various indicators (Input and Process indicators) for assessment of child health services under RMNCH+A strategy in the selected PHCs and subcentres.

Input indicators refer to the resources needed for the implementation of an activity or intervention. Policies, human resources, materials, financial resources are examples of input indicators.

Process indicators refer to indicators to measure whether planned activities took place. Examples include distribution of medicines, development, and testing of health education materials.

In the present study, Input indicators included various components like—Provider availability and training, Infrastructure and facilities, essential protocols and guidelines, availability of equipment’s, availability of drugs and consumables and they were assessed by facility survey.

Process indicators included various components like—New-born Care, Immunization, Management of sick children and Growth Monitoring and they were assessed by actual observation of service, review of records and interview of service providers and clients.

Data collection

A validated standard checklist for PHCs and subcentres was used for getting information regarding the Input and the Process indicators of child health services under RMNCH+A strategy in the PHCs and subcentres.[15,16] The period for the study was 4 months.

Data analysis

Data entry was done in MS Excel sheet for coding. Collected data was then exported to IBM SPSS version 25.0 for data analysis. Descriptive statistics were calculated for all the study variables regarding the input and the process indicators. Mean score was calculated for each indicator.

Scores were given to each component of the indicator in the checklist ranging from one to maximum three. A high score (3) was given to the items considered very essential, a middle score (2) was given to those that were necessary, and a lower score (1) to those that were less important or necessary for providing a particular service. The scores were added up at the end to get the total score for each subsection. Weighted mean was used to arrive at the total section score.

Results

Overall mean score obtained for the Input section for PHCs was 56%. About 2 PHCs were managed by single MBBS Medical Officer (MO), whereas remaining 1 had both MBBS and AYUSH MO. In all PHCs, MO (MBBS) was available round the clock. No medical officer was trained in IMNCI, and essential new born care in the past 1 year. Regarding training, only two PHCs had paramedical staff trained in essential newborn care [Table 1].

Table 1.

Status of input indicators of Child Health Services under RMNCH+A strategy in selected three PHCs

Input indicators	Mean Score Obtained (%)	Maximum Score
Provider availability and Training	5.7 (47)	12
Infrastructure and Facilities	12 (57)	21
Essential Protocols and guidelines	6 (43)	16
Availability of Equipments	23.6 (79)	30
Availability of Supplies: Drugs and Consumables	22.6 (54)	42

In the element on infrastructure, the score for cleanliness was 93.3%, essential amenities and other essential facilities scored 50%. The information and communication facilities scored the least i.e. 39%. With regard to the transport services at PHCs, no PHC had their own ambulance and driver and they all were utilizing 108 services for referring the patient to the referral centre [Table 1].

The guidelines on immunization chart were available at all PHCs. Essential new born care (ENBC) guideline was not available at any of the PHCs. Equipments for cold chain were available at all the centres [Table 1].

Newborn care was based on review of records and actual observation of the service. There were no functional labour room and no deliveries were conducted at any of the three PHC [Table 2].

Table 2.

Status of process indicators of Child Health Services under RMNCH+A strategy in selected three PHCs

Process indicators	Mean Score Obtained (%)	Maximum Score
Newborn Care	0 (0)	41
Immunisation	37.3 (72)	52
Management of sick children	3 (43)	7
Growth Monitoring	3.7 (23)	16

The cold chain management was appropriate at all three PHCs and the sessions. Nearly 80– 100% of the observed children received vaccination at appropriate age with correct dose, route and site. Correct segregation of biomedical waste was done at only two PHCs [Table 2].

Almost all children were correctly weighed at all three PHCs but the weight was not plotted among those who were offered growth monitoring. Nearly, 80–100% of the mothers were informed regarding current weight of their child; and no mother was told regarding their child’s progress [Table 2].

All Subcentres were located near a main habitation. The overall general cleanliness was good at all facilities [Table 3].

Table 3.

Status of Input indicators of child health services under RMNCH+A strategy in selected six subcentres

Input indicators	Mean Score Obtained (%)	Maximum Score
Physical Infrastructure	5.1 (40)	13
Human Resource	1 (33)	3
Equipments	10 (56)	18
Essential Drugs	5.3 (76)	7
IEC Display	4.1 (60)	7

One ANM was present at all subcentres but the post was vacant for 2^nd ANM and MPW-male at all subcentres [Table 3].

Almost all equipment’s were present at all six subcentres but the new born care equipment’s were non-functional. The color-coded bins were present at 4 Subcentres out of 6 but were functional at only 1 subcentre. The RBSK pictorial toolkit and height chart were absent at all subcentres [Table 3].

Almost all essential drugs were available at all subcentres. All subcentres were having approach roads having directions to the sub centre. Immunisation schedule was present at almost all subcentres except one [Table 3].

All subcentres were providing with vaccination to the children. Nearly 80–100% of the children who were observed for the vaccination process received vaccination at appropriate age with correct dose, route and site. Correct segregation of biomedical waste was not done at any of the Subcentre. Not all mothers were given four key messages viz. the vaccine given, side effects, follow-up date and card safety [Table 4].

Table 4.

Status of process indicators of child health services under RMNCH+A strategy in selected six subcentres

Process indicators	Mean Score Obtained (%)	Maximum Score
Immunisation	33.5 (84)	40
Growth Monitoring	3.1 (18)	18

Only one subcentre was offering almost complete growth monitoring to the eligible children. Almost all children were correctly weighed and the weight was correctly plotted among those who were offered growth monitoring. Out of remaining 5, only 2 subcentres were offering growth monitoring but not plotting the weight [Table 4].

Discussion

India comes under the top 10 countries with highest number of death in under-5 children. Therefore, it is important to strengthen the primary healthcare level to achieve the sustainable development goal 3.2.1.[17]

With regard to the Input indicators of PHCs in the present study, the highest score was obtained by availability of equipments followed by infrastructure.

The availability of drugs and consumables is an essential component for child health care under input section but it was worst performing component in the present study. On the contrary, in the study conducted by Chavda P et al.,[15] the drugs and consumables component obtained the highest score among all input elements.

Other input components e.g. essential protocols and guidelines and provider availability and training were not up to the mark at all PHCs. Our study finds that all the studied PHCs had a Medical officer available round the clock but none of them was residing at the PHC. A similar study by Sriram S assessed many deficiencies in the infrastructure and manpower in the PHCs studied, there were none availability of AYUSH medical officers and female health workers.[18]

With regard to the process indicators of PHCs, in the present study, the immunization service is better than other services which was consistent with the studies conducted by Chavda et al. and Agarwal et al.[15,19] In the process indicators, management of sick children component was also scored satisfactory score. The new born care was poor all PHCs because there was no functional labour room available in any of the PHCs. Growth monitoring was also not up to mark at any of the studied PHC in present study. On the contrary, in similar studies conducted by Chavda et al.[15] the newborn care and growth monitoring components were satisfactory at studied PHCs. Study conducted by Agarwal et al., also observed poor scores under services available for management of sick child as well as growth monitoring.[19]

The issue of New-born care component is worth alluding as adequate emphasis on this was found to be lacking for all PHCs in this study. Also, in the present study, so much of furtherance is needed in the component of growth monitoring which is in line with the study done by Pedraza and Santos.[20] which also found that child growth monitoring is an action not yet consolidated, with significant deficiencies in the process. Also, similar study by Olugbenga-Bello et al. found that despite of high level of awareness about growth monitoring, there is a poor knowledge of the procedures and interpretation of growth monitoring. Training and re-training of PHC workers was recommended by this study.[21]

So, it was observed that input indicators, which deals with the structural attributes, was better than the process indicators in all studied PHCs which was similar to the study done by Chavda et al.,[15] Agarwal et al.[19] and Khan et al.[22]

In subcentres, among input indicators, availability of essential drugs and IEC material display were satisfactory performing components which was consistent with the study done by Sugunadevi G in the subcentres in a district in Tamil Nadu.[23] Physical infrastructure was not satisfactory at all studied subcentres. It was observed that approximately 83% of the subcentres were functioning in a government building with building in a good condition which was similar to the study done by Sugunadevi G in which 80% of the subcentres were functioning in government building.[23] In the Human resource section, only 1 ANM post was filled at all six subcentres in the present study. According to the RMNCH+A guidelines, there is a provision of 2 ANMs and 1 multi-purpose male health worker at each subcentre.[16]

In our study among process components, the highest score was obtained by immunisation services at all studied subcentres, however, there was a loophole in vaccine delivery services that message regarding side effects of vaccines was not conveyed to most of the population unless asked by the beneficiaries themselves. It was similar to the study conducted by Salunke et al.[24] in Beed district, they found that availability of logistics for vaccination sessions was more than 80% at all vaccination sessions but the major problem was that the information about side effects were not provided to people.

Like PHCs growth monitoring component was not satisfactory in all studied subcentres. A similar study by Barua et al.[25] conducted in Assam found that growth monitoring charts provided in the MCP card were not found to be satisfactory and the deficiency was found in the ANMs regarding their applied methods and interpretations of the growth charts. Like PHCs in the sub centres also, input indicators were performing better than the process section. The main loopholes were found in the process section. There were no functional labour room and improper growth monitoring services at the subcentres. So, overall Input section was performing better than the process section in all the PHCs as well as Subcentres of our study area.

There are several limitations to this study: To assess any program, 3 indicators are needed- input, process and output. But, this study used only input and process indicators. We could not assess the output indicators due to the limited time of study. Also, this study may not be representing adequate sample of PHCs and subcentres as the number of PHCs and subcentres were taken as per convenience.

Conclusion

At both PHC and Subcentre level, from all the Input indicators, three components scored more than 50% whereas two components scored less than 50%. And, from all the process indicators of the PHCs and the subcentres, the maximum score was obtained for Immunisation services. The unavailability of a functional labour room is a serious concern for new-born health as due to this no deliveries are conducted at primary healthcare level. So, it can be concluded that both the Input and the process indicators for child health services in PHCs and Subcentres of Dehradun district were inadequate. So, the infrastructure gap of subcentres and the PHCs should be met, the available untrained manpower should be trained and there must be periodical orientation of the ANMs and ASHA workers for different sectors of child health like growth monitoring, newborn care etc., A functional labour room must be incorporated to take care of the newborns at the facilities, essential protocols and guidelines should be provided at all the PHCs and the subcentres for the patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.