Strengthening monitoring systems and inter-departmental convergence to drive program improvements

Description of the problem : VHNDs are an initiative to provide 15 integrated MNCHN outreach services at a fixed day, place and time through convergent actions by the health and WCD departments. Though guidelines had been issued by the state health department for conducting VHNDs, they had not been disseminated. As a result, workers lacked role clarity and services were limited to immunization. Systems were not in place for regular and structured monitoring and feedback. No functional forums existed for a systematic review of VHND performance and problem solving by both the key line departments involved. Methods : The IntraHealth-led Vistaar Project provided technical assistance to the Government of Uttar Pradesh to expand the quality and coverage of VHNDs in 8 districts. The project worked with district staff of the ministries of health and women and child development by: orientating district officials and frontline workers on VHND guidelines and creating role clarity Promoting structured monitoring through an observation checklist and orienting supervisors on its use. Designing an auto analysis package for regular analysis of observation and related capacity building to the system Facilitating joint micro-planning Activating convergence platforms to meet regularly, with VHND review on the agenda using data from monitoring visits to review program performance and drive improvements in access, coverage and range of service Orienting Panchayats and Village Health and Sanitation Committees on their roles Main Findings : Strengthened inter-departmental convergence is reflected in joint micro-planning, the presence of all 3 workers at VHND sessions to provide an expanded range of services and joint review of program performance. Findings from the Project MIS indicate that between July-September 2009 to April-June 2011: % VHND sessions at which ASHAs, AWWs and ANMs were present increased from 61% to 81% the mean number of services offered during VHND increased from 5.6 to 8.1 Blocks where monthly convergence meetings were held increased from 58% to 94%. In terms of improved monitoring, the Project MIS findings for the same period are that % VHND sessions at which supervisors from Health/WCD were present increased from 21% to 26%. Observations by supervisors resulted in immediate feedback to frontline workers as well as data to be shared with decision-makers on key gaps. These results are consistent with endline survey (Jan-Mar 2012) findings. Additionally, endline data shows that among currently pregnant women, awareness of VHND is widespread (88%) and they know both the date and location of VHNDs in their area (67%). More than three quarters of pregnant women reported presence of all the front line workers at the VHND site. Discussion including recommendations : Improving monitoring of VHNDs was critical at two levels. At the field level, it resulted in feedback for improving the quality of services. At the managerial level, the review of data from monitoring visits resulted in improved worker deployment and ensuring equipment and supplies to provide an expanded range of services. Increasing ownership through orientation on guidelines and joint planning and using data during regular review meetings create opportunities for successful program delivery. While data is collected for most government programs, it is passed on to the state and national level and rarely used locally to assess and improve program performance. In order for data to be used at the block and district, capacity building was required for collection, verification, randomization and analysis. The Project had maintained the MIS throughout the life of the Project and in its sustainability phase it has initiated capacity building at the block and district levels. Another learning is that if just top level indicators are tracked, it does not serve the data needs of program implementers who may require more complete information on which gaps to address. A comprehensive checklist is more useful at the district and block levels. VHND is a priority under the National Rural Health Mission in India and the lessons learned about convergence, improved monitoring and use of data has potential for replication and wide scale-up.