Program area and demographic information

The project was implemented in UP and Gujarat between 2010 and 2014 and in Bihar between 2010 and 2015. In Gujarat and Bihar, the projects were initially implemented in 6 and 15 demonstration districts, respectively and subsequently scaled–up across the entire state by the respective state governments. In UP, the program was implemented in 12 districts under the Diarrhea Alleviation through Zinc and ORS Therapy (DAZT) project (Figure 1). The states and districts were selected based on high prevalence of childhood diarrhea and feasibility of program implementation. Table 2 further describes the intervention areas. The largest program was in Bihar with 15 demonstration districts and 23 scale–up districts, which reached an estimated population of 13 211 546 children aged 2–59 months.

Figure 1.  Map of intervention districts.

DAZT districts of Gujarat: In Gujarat, the demonstration project was implemented in six out of 26 districts: 1. Sabarkantha, 2. Patan, 3. Banaskantha, 4. Surendranagar, 5. Panchmahal, 6. Dahod.

DAZT districts of Uttar Pradesh: In Uttar Pradesh, the demonstration project was implemented in 12 out of 75 districts: 1. Ambedkar Nagar, 2. Kanpur Dehat, 3. Barabanki, 4. Lucknow, 5. Bareilly, 6. Shahjahanpur, 7. Budaun, 8. Sitapur, 9. Faizabad, 10. Sultanpur, 11. Unnao, 12. Hardoi.

DAZT districts of Bihar: In Bihar the demonstration project was implemented in 15 out of 38 districts: 1. Banka, 2. Bhagalpur, 3. Samastipur, 4. Sitamarhi, 5. Sheohar, 6. Munger, 7. Madhepura, 8. Sharsha, 9. Khagaria, 10. Supaul, 11. Nalanda, 12. Sheikhpura, 13. East Champaran, 14. Gaya, 15. Jehanabad.

Table 1 shows the situation of childhood diarrhea care seeking and treatment prior to the implementation of the DAZT programs across the three states. Care–seeking for diarrhea was at 65.6% in Gujarat, 73.8% in UP and 73.6% in Bihar [6]. ORS treatment rates were low at 17.4% in UP, 36.7% in Gujarat and 22% in Bihar [6]; whereas treatment with zinc was negligible in all three states [7].

As can be seen, the demonstration projects were initiated by MI in the three states against this backdrop of high prevalence of child diarrhea, low care–seeking and treatment coverage. In addition, across all three states, ORS and zinc distribution for childhood diarrhea treatment was hampered by budgeting and procurement issues, and there was a lack of systematic health worker training to effectively manage childhood diarrhea cases based on revised national guidelines.

Key program strategies

The main strategy was to strengthen public sector capacity to manage childhood diarrhea using zinc and ORS at both facility and community levels. Key program components included:

• Building capacity of facility level health providers, and frontline health workers including integrated child development services (ICDS) workers,

• Extending service delivery to communities through frontline workers and at health facilities,

• Ensuring supplies of ORS and zinc at all levels,

• Providing supportive supervision to community health workers,

• Conducting monitoring and evaluation activities.

Capacity building of health providers

One of the objectives of the program was to ensure enhanced knowledge of service providers on zinc and ORS. This included enabling providers to prescribe zinc and ORS for treating childhood diarrhea and to undertake necessary counseling of caregivers for using these products. A formative research study was conducted in five demonstration districts of Bihar as a part of the program to better understand issues pertaining to knowledge, attitude and practices (KAP) prevalent in the community and among service providers regarding childhood diarrhea management [8]. The Formative study was largely based on qualitative research methods including in–depth interviews with 22 mothers of children under five years, 18 caregivers (grandmothers and adolescent sisters), 21 influencers (experienced mothers and respected community members), 32 block–level health officials (Lady Health Visitors, Block Health Educators, and Medical Officer In–charges), 20 CHWs, 8 doctors and 26 medical store attendants, along with focus group discussions (FGDs) with 20 mothers of children under five years. The study findings reflect knowledge gaps among mothers and caregivers on causes and prevention of diarrhea. The caregivers and service providers found to have poor knowledge on use of zinc for child diarrhea treatment. The findings of this study in Bihar were also utilized in UP and Gujarat. One key gap identified in this qualitative research included knowledge of zinc use for the treatment of childhood diarrhea, and this finding informed the training curriculum for health providers. Specifically, the training curriculum and inter–personal communication (IPC) tools for increasing awareness among caregivers during interaction in one to one and smaller groups were designed for all three states and focused on zinc and ORS and improved case management of dehydration and other related complications. The training modules and methods were further developed for varying capacities of service providers at different levels, and included a training video CD in vernacular and pictorial job aids for conducting the trainings.

An ‘NGO model’ was utilized for the trainings such that professional trainers from select NGOs were hired to train health providers at district and sub–district levels. This was done since medical officers working in the public sector may not have the time or inclination to conduct a large number of trainings in addition to their routine work, and could not necessarily be expected to carry out trainings on such a large scale. However, medical officers were engaged as an expert resource during training sessions. As a result, 144 246 health providers were trained in the intervention districts of UP, Bihar and Gujarat. These providers included medical officers, auxiliary nurse midwives (ANMs), child development program officers (CDPOs), supervisors and anganwadi workers (AWWs) from ICDS and accredited social health activists (ASHAs). All trainings were completed during 2011–2012 except in four UP districts. Table 3 presents information on the number and types of participants trained in project districts of the three states. Pre and post–tests for participants and monitoring of training sessions were done to ensure quality of the training program. Separate trainings were also conducted for assistant research officers (AROs) and data entry operators (DEOs) in order to improve their understanding on reporting childhood diarrhea cases.

Extending service delivery to communities

Prior to this program, childhood diarrhea management was predominantly carried out at the facility–level and CHWs were largely restricted to conducting community mobilization work.

One of the major objectives of the program was to enhance the use of zinc and ORS in the public sector for childhood diarrhea treatment. To achieve this, community level health workers including Accredited Social Health Activists (ASHAs) that work for the health department, and Anganwadi Workers (AWWs) that work for the department of woman and child development were involved in the program as service providers to increase public sector care seeking practices. During the program, ASHAs and AWWs were trained and supplied with zinc and ORS to manage diarrhea cases in communities, in addition to facility–based programs. The roles of CHWs included managing simple cases of diarrhea with ORS and zinc, identifying cases of moderate and severe dehydration for referral, and counseling of caregivers on appropriate diarrhea treatment and feeding practices during illness episodes. Thus, in the three states, service was delivered through a network of 66 418 ASHAs, 75 685 AWWs, 9516 health sub centers (HSCs), 918 primary health centers/community health centers (PHCs/CHCs) and 44 district–level hospitals in 33 demonstration districts.

Ensuring available supplies of ORS and zinc

Ensuring adequate and timely supplies of zinc and ORS was one of the major project strategies, which, along with supply chain management, are essential for ensuring continuous availability of zinc and ORS across all levels of the public health system.

In the beginning, MI introduced initial supplies in the form of combi–packs of zinc and ORS in 10 of the 15 demonstration districts of Bihar, 4 of the 6 districts of Gujarat and 8 of the 12 districts of UP. A total of 3 157 750 combi–packs were distributed. These combi–packs contained 14 tablets of taste–masked dispersible zinc (20 mg each), 2 packets of ORS, one measuring cup and an instruction leaflet. An additional 600 000 zinc tablets were distributed in the remaining 2 districts of Gujarat to be co–packaged with ORS supplies from the Gujarat government. Subsequently, in all the three states, MI facilitated incorporation of budgets under the National Health Mission (NHM) Project Implementation Plan (PIP) for procurement of ORS and zinc. After the first year, the government, in all three states, procured supplies. In Bihar, the state government procured and distributed zinc syrup for the treatment of childhood diarrhea. MI assisted the states to improve forecasting of zinc and ORS demand in order to strengthen procurement based on the child population estimates, diarrhea incidence, and care–seeking rates. It was ensured that states have rate contracts for zinc and ORS in place.

Providing supportive supervision to CHWs

CHWs require continuous support and guidance to sustain their knowledge levels in order to effectively manage diarrhea cases. To this end, a mechanism of supportive supervision was envisaged through a network of supportive supervisors at the sub–district level. A ‘partnership model’ was followed in UP and Gujarat, where supportive supervision was implemented in partnership with NGOs having a state–level presence, whereas in Bihar this support was provided using the existing cadre of government functionaries at PHCs called Block Community Mobilizers (BCMs) . Supportive supervisors visited CHWs and provided one–on–one support to them and interacted with caregivers to understand their level of adherence to zinc treatment. In addition, they also addressed gaps in CHW capacities during group meetings. Supportive supervisors were provided with a checklist to be completed during supportive supervision visits in order to identify existing knowledge gaps. This checklist captured data on CHW knowledge, skills and availability of supplies.

During each visit, a supportive supervisor was expected to meet at least three field workers and one or two caregivers who had visited CHWs with sick children. In the three states the number of ANM, ASHA, AWWs and caregivers reached through supportive supervision visits is shown in Table 4.

The sites visited for supportive supervision were planned each month and priority was accorded to poor performing frontline workers. The findings from supportive supervision visits were used to give one–to–one feedback as well as group feedback during monthly meetings with the frontline workers. Data was analyzed and findings were shared at national, state and district levels to understand program issues and to suggest mid–course corrective actions.

Conducting monitoring and evaluation activities

A Health Management Information System (HMIS) exists in the public health system for all three states in order to report on public health service delivery. However, HMIS captures data reported by ANMs at health sub–centre and above facilities but do not have a formal reporting tools for CHWs who were also involved in service provision under the project. Hence simple pictorial formats were developed to facilitate childhood diarrhea reporting by semi–literate CHWs. In addition, HMIS did not include indicators to track progress of key program aspects, such as dehydration levels and the number of diarrhea cases treated with both zinc and ORS. Therefore, a project reporting mechanism was developed to effectively track performance from all service delivery points, including CHWs using pictorial formats.

Trainings were provided to health care providers at all service delivery levels, including the CHWs who received close support through the supportive supervision mechanism previously described. A large number of cases were reported through this system from the beginning of the project in all three states. The Government of Bihar has involved CHWs for service delivery in the scale–up districts and has also introduced simple pictorial reporting tools based on the utility of this program reporting mechanism.

In Bihar, the government has added the following new HMIS indicators in that state:

• Number of cases of childhood diarrhea with no dehydration,

• Number of cases of childhood diarrhea with some dehydration,

• Number of cases of childhood diarrhea with severe dehydration,

• Number of cases of childhood diarrhea treated with both zinc and ORS,

• Number of cases of childhood diarrhea referred,

• Number of ASHAs reported ORS stock–out (lack of ORS availability),

• Number of ASHAs reported zinc stock–out (lack of zinc availability).

Currently the program is attempting to streamline and sustain the government HMIS reporting. In addition to reporting, data collected under supportive supervision and research studies also contributed to overall program monitoring in order to understand its progress and to take corrective actions as required. Program evaluation studies planned under this program were conducted by The Johns Hopkins School of Public Health (JHSPH) and results are reported elsewhere [10].

Ensuring regular availability of zinc and ORS supplies is critical for program performance and needs sustained efforts

Regular supplies increase diarrhea cases appropriately treated. Regular availability of zinc and ORS in the public sector is critical for the treatment of diarrhea cases with both zinc and ORS. Program data report that 593 030 childhood diarrhea cases received treatment in 6 demonstration districts of Gujarat between November 2011 and September 2014. More than 99% of these cases were treated with both zinc and ORS. In 12 demonstration districts of UP, 907 295 diarrhea cases reportedly received treatment between December 2011 and September 2014, and 86% of these cases were treated with both zinc and ORS. In Bihar, 1 796 563 cases were reported to have received treatment in 15 demonstration districts between August 2011 and September 2014, and 77% were treated with both zinc and ORS. Importantly, public sector service providers in intervention districts reported only those cases of childhood diarrhea that were provided with any treatment and cases not given treatment were not reported. In Gujarat, the higher percentage of childhood diarrhea cases treated with both zinc and ORS was largely due to the uninterrupted availability of zinc and ORS in that state compared to UP and Bihar that had supply interruptions (Table 5). A baseline study on caregiver’ knowledge, attitude and practice on the use of zinc and ORS for childhood diarrhea in Bihar also reflects that availability of zinc and ORS with service providers is one of the reasons that prevents treatment seeking by caregivers for childhood diarrhea from such service providers [11].

These findings suggest that availability of regular supplies of zinc and ORS helps in treating a higher percentage of diarrhea cases with both zinc and ORS.

Ensuring regular supplies needs sustained efforts. The maintenance of regular zinc and ORS availability at different service delivery points has proved a challenge in the public sector, and particularly in states with relatively poor governance. In Bihar, supply audit studies were periodically conducted to assess zinc and ORS availability among CHWs. The supply audits indicated that there were no stock–outs in the first six months of supply distribution but thereafter 28% of ASHAs on average experienced stock–outs of both zinc and ORS between June 2012 and February 2014. After April 2014, there was a zinc stock–out at most service delivery points due to expiry of existing zinc syrup and other challenges faced by the state during the process of ensuring new procurement mechanisms. Similarly, in UP, ORS was unavailable at many of the services delivery points at different time periods between November 2013 and October 2014 due to procurement challenges.

MI and other development partners made sustained efforts to restore supplies in both Bihar and UP, such as through advocacy for placement of procurement orders, providing technical support for accurate demand forecasting, advising on product specifications, and providing close support in supply distribution to service delivery points. Gujarat already had an improved supply chain mechanism that resulted in fewer ASHAs experiencing zinc and ORS stock–outs (Table 5).

Indeed, ensuring regular supplies is one of the biggest challenges in the public health system not only in India but across the countries for treating childhood diarrhea with both zinc and ORS [12]. The important gaps that need to be addressed to ensure regular zinc and ORS availability include:

• Lack of knowledge among program managers in the public health system for forecasting the required quantity of drugs: In general, public sector supplies are procured without accurate demand calculations and therefore training and technical support for proper forecasting is important for procuring the adequate supply quantities [13].

• Complicated and time–consuming procurement processes: procurement is carried–out by the state government, for which getting the information on quantity required from various levels, placing procurement orders, testing drug quality and appropriate distribution is cumbersome and time–taking. Recognizing this problem, some of the states have engaged a dedicated corporation for their drug procurement and distribution. However, in some states such corporations are either newly established or not fully operational. Therefore technical support provided at different procurement stages could facilitate the process until these procurement corporations become fully functional.

• Lack of proper warehousing facilities at district and sub–district levels: Due to lack of proper storage facilities the districts and blocks (sub–districts) are unable to store supplies required for replenishing unanticipated stock–outs [14].

• Lack of an effective mechanism of tracking availability of supplies with CHWs and timely replenishment of stocks at service delivery points in the case of stock outs: The HMIS and drugs logistic management system (DLMS) does not track CHW supply availability, which is a major impediment for replenishing CHW stocks [15].

Regular supplies promotes caregiver confidence in CHWs and public health sector

Lack of available zinc and ORS weakens caregiver trust and reliance in the quality of public health care services, which adversely affects care–seeking at the public sector. A recent study [16] on care–seeking for childhood diarrhea and acceptance of CHWs as credible service providers in the demonstration districts in Bihar, found reduced trust among caregivers on the quality of care and services provided by CHWs, as a result of lack of zinc and ORS availability with them. In public health sector, frequent stock–outs also weaken the confidence of CHWs to provide treatment of child diarrhea. Similar findings were also observed in a study on health care reforms involving the introduction of user fees and drug revolving funds and their influence on health workers’ behavior in Nigeria [17].

These results indicate the importance of regular zinc and ORS availability for increased public sector care seeking by improving the credibility of CHWs among caregivers and boosting confidence of the CHWs to act as well–equipped service providers.

Quality capacity building activities ensures sustained knowledge and skills of the health functionaries

A large number of health providers were trained in the program as previously described. These trainings were conducted with the help of external trainers who were supported technically by government medical officers, which facilitated the completion of trainings within the stipulated short timeline and with quality assurance. Though baseline data on CHW knowledge level is not available, data collected during supportive supervision visits provide information on knowledge levels of CHWs. During supportive supervision visits, information on CHW knowledge and capacity was collected using a checklist by block community mobilizers (BCMs) in Bihar and by NGO partners in Gujarat and UP. In Bihar nearly 100 BCMs placed at block level in 10 districts undertook a maximum of four supportive supervision visits each month. In Gujarat and UP, 20 and 27 supportive supervisors, respectively, undertook field visits for approximately 20 days in each month. During each visit, a supportive supervisor was expected to meet and collect data from at least three field workers (1 ANM, 1 ASHA and 1 AWW) and to meet with one or two caregivers who attended CHW services. These data were analyzed on a monthly basis and generally showed sustained CHW knowledge and skills, which indicates the good quality of training provided under the program (Table 6). Table 6 highlights ASHA awareness level regarding the definition of diarrhea (three or more watery stool within 24 hours) was either sustained or improved. Similarly, there was sustained or increased ASHA awareness about the age–wise correct dosage of zinc across the three states (Table 7). An end–line evaluation study of caregivers’ knowledge, attitude and practice on the use of zinc and ORS for childhood diarrhea, carried out in 11 blocks of five districts of Gujarat, where trainings were conducted using similar methods that were adopted under the DAZT program districts, also show a high and sustained knowledge of ASHA on identification of childhood diarrhea and its management protocols [18].

Involvement of CHWs strengthens service delivery and performance reporting

Enhances percentage of cases treated at community level. A key program strategy was to involve CHWs in the management of child diarrhea cases and to report program performance. Availability of services increased at the community level by involving CHWs in service delivery. In Bihar, 62% of non–facility cases seen by ANMs and CHWs were treated and reported by CHWs. This indicates better availability of services and easy access by caregivers near their homes. A similar pattern of CHW treatment and reporting was also found in UP and Gujarat (Figure 2). Evalutation of DAZT program in Gujarat reflects increased coverage of diarrhoea treatment by CHWs [10].

Figure 2.  Proportion of cases treated and reported by community health workers (CHW) and auxiliary nurse midwives (ANM) in Bihar, May 2013.

Improves tracking program performance and increases reporting of child diarrhea cases. Along with service delivery, CHWs were also involved and trained for performance reporting. The public health system has traditionally focused on facility–based data and reporting. In this program, CHWs were also involved in reporting in order to track the treatment of cases at the community level. As previously described, a simple pictorial format was developed to facilitate CHW reporting and CHW capacities for reporting were reinforced through supportive supervision visits. The number of reported cases increased after involving CHWs in the reporting process. Figure 3 shows the increased number of childhood diarrhea cases in Bihar both before and after CHW reports were integrated into HMIS in that state.

Figure 3.  Diarrhea cases reported in 15 demonstration districts of Bihar before and after integrating the community health worker (CHW) reporting system into Health Management Information System (HMIS).

Reporting by CHWs however requires further strengthening. Reporting completeness exercises conducted in the three states indicated that only 41% of ASHAs in Bihar (May 2013), 57% in UP (July 2013) and 82% in Gujarat (June 2013) were able to report cases using the standard form, and the remaining were not able to submit the report. CHW report submission can be further improved by streamlining the reporting mechanism, ensuring availability of reporting tools and close supervision to enhance their capacity on case reporting. A review of integrated community case managemnt in sub Sahara African countries also highlights that involvemnt of reporting by CHWs can strngthen HIMS, if CHWs are provided simple reporting tools and have a few selective indicators to report [19].

Enhances caregiver access and reach of public health services for childhood diarrhea management. Involving CHWs in service provision for childhood diarrhea management helps increase caregivers access to services and the reach of the public health system. A rapid assessment study conducted by MI in Gujarat and UP suggested that caregivers prefer receiving free–of–cost services closer to home from CHWs [20]. Making the community aware about the availability of zinc and ORS with CHWs, coupled with strong CHW skills and training in the management of child diarrhea, can further enhance the acceptability of CHWs by the community. This in turn will help increase zinc and ORS coverage through the public sector.

Probably a component of behaviour change communication as a part of program strategies would have contributed to increase in caregivers’ awareness thereby resulting in greater demand for zinc and ORS for management of childhood diarrhea.

Continuous engagement with government and sharing early evidences of program performance facilitated government decision–making for scale–up

In order to ensure government ownership from the program outset, attempts were made to continously engage the government at all levels. At the start of the program, Memoranda of Understanding (MOUs) were signed with the state governments of Gujarat and Bihar. The program was also reviewed regularly at the block, district and state levels, which helped strengthen service delivery. In addition, information on program performance was also shared regularly with districts and state level authorities. This continuous engagement with the government and regular sharing of progress achieved has been important for ensuring government ownership, and has paved the path towards the program scale–up.

For the purpose of scale–up, the program have focused since its outset in generating evidence of program performance, ensuring buy–in from the government on program strategies, and enhancing capacity of government functionaries. Generating early evidence on effectiveness and regularly sharing these updates with government counterparts has facilitated the government’s decisions for scale–up of specific program strategies. Despite the challenges in procurement, affecting the program achievements, in UP and Bihar the following strategies have been scaled–up by all the three states to facilitate program expansion across districts [21]:

• CHW involvement in service delivery is now implemented across the entire states of UP, Bihar and Gujarat

• Estimation of zinc and ORS stocks and supply provision to all service delivery points

• Regular reporting mechanisms of cases through the HMIS in Bihar

• Service provider trainings in childhood diarrhea treatment using ORS and zinc

The state governments have earmarked budgets for the procurement of zinc and ORS across districts in order to scale–up program strategies. Bihar, Gujarat and UP governments have incorporated these program activities in their annual plans and have submitted budget proposals to the Government of India for implementation across all districts. The Government of India has approved these proposed budgets for 2012–2013 and subsequent years [22].

Regular technical support and evidence–based policy advocacy leads to policy changes and release of implementation guidelines

The advocacy efforts undertaken and technical support provided by MI and other development partners at national levels have resulted in the development of operational guidelines by the Ministry of Health and Family Welfare, Government of India [23]. These guidelines include strategies used in the demonstration districts that will help facilitate roll–out of program strategies across all states of India. The advocacy efforts of MI and other partners have also facilitated the following policy changes that will enhance the availability of zinc supply in India:

• Zinc specifications included in the Indian pharmacopeia: Due to this change more Indian pharmaceutical companies can start production of therapeutic zinc [24]

• Zinc included in the essential drug list: The Government of India has included zinc in the list of essential medicines [25]. This will help to ensure zinc availability at service delivery points in the public health sector

• Indicators on zinc usage included in large–scale national surveys (eg, Annual Health Survey of India) [26] and District Level Health Survey–4 [27]): This will help the government track the use of zinc for child diarrhea management at the national and sub–national levels

Limitations

Information on certain aspects of program has been collected only during the implementation of the projects across the three states and detailed information on these aspects, like stock out of zinc and ORS, reporting of the cases treated with zinc and ORS, cases of childhood diarrhea treated by CHWs, knowledge level of CHWs on management of childhood diarrhea is not available prior to the initiation of the project implementation. Since data collected during the evaluation studies is being published as a separate paper on evaluation findings in this same issue of the journal, hence evaluation data has not been used in this paper. This paper is largely based on program monitoring and data collected through government functionaries which may have some limitations.