Opinion

Maharajganj, a district of 22 lacs population has a single surgeon who can perform sterilizations; 40% of primary health centres and two-thirds of sub centres in Uttar Pradesh do not have buildings; districts are without even a single female doctor; and to top it all 42% of frontline health workers do not show up for their duties on any given day! This is the scenario in which the reproductive and child health programme (RCH) is functioning in UP. In this dismal situation, though it is possible to reach out to a sick child here or a pregnant woman there, a huge population, often the poorest and most at risk, remains unserved.

The RCH challenge is gigantic to carry family planning & immunization services to the farthest village. Like for most problems, a number of easy solutions have been tried out over the years. Usually they have been neat, plausible and wrong! However in the last five years, with the help of SIFPSA's Innovations Project, some success has been achieved in making good quality family planning and immunization services reach remote areas. The strategy has been to work through camps and campaigns.

The camp & campaign approach requires a pragmatic mindset. The strategy here is to marshal resources to optimize results; to pick battles big enough to matter but small enough to win!

Reproductive and child health (RCH) camps are organized twice a month at every tehsil and block level hospital. Organization of each camp involves detailed planning related to publicity, manpower deployment, camp arrangements, availability of equipment, consumables and medicines. These camps provide services like gynaecological check ups, immunizations, counseling for child spacing & sterilizations. The availability of lady doctors in a large number of these camps, much better quality of services and their assured availability has made these camps extremely popular.

About 6000 such camps are organized every year in the 39 SIFPSA Project districts and one sure indicator of their success has been that 53% of all sterilizations are now being performed in these camps. On an average112 persons avail RCH services at each camp which is closer to their homes thus obviating the inconvenience and cost of traveling to district headquarters. On popular demand, it has been decided to double these camps to one a week from October 2003.

Another successful intervention is the tetanus toxoid (TT) immunization campaign for pregnant women which was devised as an accelerated strategy for reducing maternal and child mortality in UP, which remains the highest in the country. From 1999 to 2002 SIFPSA, organized these campaigns to reach out to all pregnant women. This involved a week long statewide enumeration of pregnant women, communication efforts to spread awareness about campaign dates and immunization centres through mass media as well as group meetings. Family welfare machinery as well as NGOs pitched in to organize thousands of group meetings in villages and distributed specially designed handbills.

Micro planning to set up booths and provide door to door vaccination and fine tune the logistics of arranging vaccine, ice packs , syringes, needles, consumables like cotton wool, kerosene, spirit were worked out. The involvement of the village community was sought and obtained. In large number of cases villagers provided stoves and pressure cookers for sterilizing needles.

A whopping 30 lac women were immunized in each campaign after 2000 and by 2002 the percentage of pregnant women protected from tetanus jumped up from 13% to 62%. This was a remarkable achievement in 2 years considering that it had never gone up above 15% in the 50 years since the programme started! The impact this will have on reduction of tetanus among mothers and infants is likely to be huge. The most heartening aspect of this campaign was its cost effectiveness, the incremental expense on each statewide campaign being less than Rs.1 crore.

The UP TT campaign received worldwide acclaim and was recognized as a wonderful innovation. It was commended as a best practice at the Global Health Council meeting at Washington in June 2001 and the WHO Conference at Cairo in February 2002. This campaign was discontinued by the government after July 2002. But considering the fall in immunization coverage since, it has been decided to restart it this year. The camp & campaign approach has to continuously contend with the proponents of improving routine services.

However the gaps in infrastructure and inability to deploy personnel in rural facilities severely limits government's ability in providing health services on a daily basis. Today, routine services, are a lot like chastity. They are widely praised, but alas, too little practiced. One lesson that clearly needs to be learned is that in the context of UP, for a long time to come camps and campaigns will remain the only feasible accelerated strategy for carrying essential health care to the rural poor. The RCH camps & the TT campaign have proved this beyond doubt