TABLE 4: DISTRICT WISE HUMAN DEVELOPMENT INDEX OF ODISHA

District Health _Index Education _Index Income _{Index Value}HDI _RankHDI

Nabarangapur 0.516 0.178 0.249 0.283 30 Malkangiri 0.512 0.388 0.247 0.366 29 Koraput 0.550 0.301 0.301 0.368 28 Rayagada 0.571 0.379 0.321 0.411 27 Bargarh 0.738 0.305 0.330 0.420 26 Kalahandi 0.618 0.414 0.324 0.436 25 Kandhamal 0.590 0.548 0.256 0.436 24 Baudh 0.562 0.545 0.277 0.439 23 Nuapada 0.631 0.444 0.324 0.449 22 Balangir 0.668 0.418 0.334 0.454 21 Mayurbhanj 0.708 0.515 0.260 0.456 20

Gajapati 0.592 0.479 0.336 0.457 19 Kendujhar 0.646 0.481 0.316 0.461 18 Debagarh 0.699 0.487 0.295 0.465 17 Sambalpur 0.734 0.372 0.404 0.480 16 Dhenkanal 0.651 0.554 0.361 0.507 15 Nayagarh 0.633 0.605 0.357 0.515 14 Sonapur 0.711 0.619 0.346 0.534 13 Jharsuguda 0.792 0.523 0.383 0.542 12 Anugul 0.700 0.588 0.386 0.542 11 Ganjam 0.645 0.532 0.466 0.543 10 Sundargarh 0.735 0.631 0.355 0.548 9 Bhadrak 0.700 0.646 0.368 0.550 8 Jajapur 0.746 0.704 0.353 0.570 7 Baleshwar 0.758 0.735 0.394 0.603 6 Kendrapara 0.721 0.712 0.429 0.604 5 Cuttack 0.723 0.734 0.466 0.628 4 Puri 0.714 0.784 0.461 0.637 3 Jagatsinghapur 0.768 0.810 0.450 0.654 2 Khordha 0.675 0.796 0.532 0.659 1

Source: (Article) Development of Human Development Index at District Level for EAG States, Volume 14, Nos. 1 & 2, 2016 (New Series) pp. 43-61

Measuring Distribution of MCH Services in both the Sample Districts:

Distribution of Maternal and Child Health care entails with reaching the services at the doorstep of the community provided under public domain and ensures universal accessibility. It results in optimum utilization of MCH services and reducing mortality and morbidities among mother as well as children. In this present study it is observed that district Rayagada has poor performance in MCH services in comparison to Bhadrak. This gap indirectly shows lack of universal distribution of MCH services among the beneficiaries. Singh et al. (2013) reported that the increasing coverage of maternal, newborn and child health care services is intrinsically associated with the expected improvement in the maternal and child health by using Composite Coverage Index (CCI)6_{. However Barros et al. (2013) viewed} 6 Composite Coverage Index (CCI) analysis on distribution of MCH services is a tool

that there is no single best measure of inequality and have recommended that at least one absolute and one relative measure must be presented when describing inequality at a given point of time. Attempt has been made in this study to gauge the coverage of MCH interventions by measuring key indicators. The term ‘coverage’ is defined here as the percentage of people receiving specific interventions related to these indicators. The CCI is calculated as:

CCI = 0.25 × (FPS + 0.5 × [SBA + ANCS] + 0.25 × [2DPT3 + MSL+ BCG] + 0.5 × [ORT + CPNM]7₎

The CCI comprises of four different intervention areas under maternal and child health care. These are family planning, maternal and newborn care, immunization and treatment of sick children which composed of the continuum of care covering reproductive, maternal, newborn and child health. The value used to calculate CCI is brought from DLHS 38. After putting the value it is observed that CCI for Rayagada and Bhadrak are 38 & 54 respectively. The analysis of both HMIS data and evaluated data of DLHS3, shows that the performance of Rayagada is poor in comparison to Bhadrak district.

Table-5: Definition of Indicators used to construct the CCI

Sl.No _{tion Areas Indicators}Interven- Definition Indicators used from _{DLHS 3}

1 _PlanningFamily Family Planning Need Satisfied Percentage of currently married women do not want any more children or they want to wait 2 or more years before having another child and using

contraception

Total unmet need for family planning

7 care seeking for pneumonia.

8 District Level Households and Facility Survey conducted by Ministry of Health & Family Welfare, Government of India. It designated International Institute of Population Science (IIPS), Mumbai as the nodal agency to conduct this survey. Till date four rounds of survey has been completed by IIPS. These are DLHS -1 (1998-99), DLHS -2 (2002-04), DLHS – 3 (2007-08), DLHS-4 (2012-13).

2 Mater- nal and newborn Care Skilled Birth At- tendance Percentage of Livebirth attended by skilled health personnel (Doctor,

Nurse, midwife and auxiliary midwife)

Delivery at home & other places assisted by a doctor/nurse /

LHV/ANM (%)

Antenatal Care

Percentage of women attended at least once during pregnancy by skilled health personnel

Mothers registered in the first trimester when they were pregnant with last live birth/still birth

(%) 3 Immuni-_zation Measles Vaccina- tion Percentage of Children aged 12-23 months who were immunized against

Measles

Children (12-23 months) who have

received Measles Vaccine (%) Diphthe- ria, Per- tussis and Tetanus Vaccina- tion Percentage of Children aged 12-23 months who received three doses of Diphtheria, Pertussis and

Tetanus vaccine

Children (12-23 months) who have received 3 doses of DPT Vaccine (%) BCG Vac-

cination

Percentage of Children aged 12-23 months cur- rently vaccinated against

BCG

Children (12-23 months) who have received BCG (%) 4 Treatment of Sick Children Oral re- hydration therapy Percentage of children under 5 with diarrhea in

the preceding 2 weeks who received Oral Rehy- dration Therapy (Packets

of oral rehydration salts, recommended home solution or increases fluid) and continued

feedings

Children with Diar- rhea in the last two weeks who received

ORS (%) Care Seeking for Pneu- monia Percentage of children aged 0-59 months with suspected Pneumonia (Cough and Dyspnea) who sought care from a

health provider

Children with acute respiratory infection/ fever in the last two weeks who were given treatment (%)

Civil Society and MCH Services

Civil Societies are advocacy groups engaged for public interest. Civil society is a broad concept which encompasses the NGOs, professional as well as ethnic association, community based organizations, professional autonomous organizations etc. Unlike NGOs, the pressure groups which

exert pressure on the policy makers on various areas like health, education, microfinance and livelihoods etc. are only for expanding the control of community. Involvement of NGOs in health sector for ensuring health equity is crucial. NGOs like CARE, Save the Children, OXFAM, World Vision, Voluntary Health Association of India (VHAI), Path Finder, Population Services International and Doctors without Borders etc. are some of the example of NGOs which are actively engaged in ensuring accessibility of poor communities to public health services. They extended technical expertise to government in planning and implementation also. They are like social change agents increasingly involved in social development and gradually success if visible. Alma Ata Declaration, Right to Information, Mahatma Gandhi National Rural Guarantee Act are some of the bright examples of these successes. The basis of these successes is deeply rooted in the community in the form of action, organization and information. Civil Society Organizations and the NGOs are fulfilling the needs of the people where the government fails to deliver. According to World Bank, Civil Society organizations are “a wide array of organizations: community groups, non-governmental organizations (NGOs), labour unions, indigenous groups, charitable organizations, faith based organizations, professional associations and foundations”. However Civil Society is a wide array of formal and informal associations and organizations that advance public interests and ideas and are independent of the public and for-profit sectors. This definition differentiates civil society from the for-profit private sector. However, the private sector may include both civil society organizations and for-profit service provider. Involvement of CSOs in enhancing the utilization of MCH care among the disadvantaged groups is crucial. Their informal approach and small scale target oriented interventions helps them to enhance acceptability among the community.

For making public health more community friendly, World Health Organization has engaged with non-governmental organizations as a part of wider civil society organizations. The meaning used by United Nations (UN), “civil society is a term used to refer to the wide array of non–governmental and not-for-profit organizations that have a presence in public life, expressing the interests and values of their members or others, based on ethical, cultural,

political, scientific, religious or philanthropic considerations”. Community largely derives maximum benefits from this type of engagement when their voice is placed in the right forum through NGOs.

Civil Society Organizations are basically known for services to the poor community. They can reach the targeted community more effectively, compassionately and efficiently than the public services (Pfeiffer, 2003). From a broader sense, civil society can play various roles in the national health system. Shanklin et al. (2016) has listed eight basic roles that are to be played by the CSO. Those are Public information, advocacy and policy development; Public oversight; Participatory governance; Direct service provision; Capacity development; Resource mobilization; Research and innovation; and Networking. In the area of public information, advocacy and policy development the CSOs are actively engaged in advocacy to transform public understanding and attitudes on health and represent public and community interests in policy discussions. Not only are the CSOs engaged in policy development but they also play a role in public oversight where they make governments accountable for development of public health outcomes. Here, CSO can be seen as a “watchdog” playing an independent role to monitor the outcome of health interventions by the Government. Apart from their independent roles, CSOs participate in and contribute to developing policy so as to implement the program at grass root levels especially in remote rural areas where the service delivery systems usually fail to render the desired MCH services. CSOs are direct service providers to the community also. It is a widely accepted that CSOs are pioneers in providing services to the marginalized and the disadvantaged sections of the society in their own habitat whereby they are able to integrate cultural preferences into service delivery and are able to test unconventional approaches to service provision and aim for success. To play the role of capacity development, CSOs are providing training and developing human capital, as well as building organizational capacity in both civil society and public sectors. Developing training modules for services providers, imparting training to the grass root level workers, organizing training are the activities conducted by CSOs for capacity development. Civil Society also has the ability to mobilize resources for a given task or a specific goal from external sources.

They can mobilize funds from individual and public sources for fulfilling the public health objectives. Civil Society has also played significant role in research and innovation particularly as the CSOs are able to be unique in trying and testing innovative methods and tools to improve service delivery. A number of experiments like Home Based New Born Care (in Gadchiroli of Maharashtra in India), deploying community link workers (in Gadchiroli of Maharashtra in India), developing clean home delivery kit (in Nepal) and using cell phones by community health workers to share message among pregnant and post partum mothers (in rural Afghanistan) etc., are the examples of innovations undertaken by CSOs which are gradually being replicated by public health service delivery systems. Lastly CSOs contribute considerable social capital for successful implementation of various MCH services. They build and maintain a range of trusting relationships to achieve shared goals. The following Case Studies provide better insight into the scope of engagement of CSOs. Names mentioned in the case studies have been changed.

Case Study -1

(Background: SHAKTI is one of the NGOs working in Rayagada district. It is involved in various MCH interventions. It is also managing Maternity Waiting Home in PPP mode with the district health administration under NHM. Apart from this it is also managing one CHILDLINE for safety and security of the children who are in need.)

On 14.12.2015 at about 1.30 am CHILDLINE managed by SHAKTI received a phone call from Padmini Singh, AWW of Kunguli regarding a mentally challenged widow who had given birth to a female child at an open place of Aduguda village under Kalyansingpur Block of Rayagada District. Immediately both mother and child were rescued and admitted to SNCU of DHH, Rayagada. In the mean while CWC, Rayagada was also intimated. Next day in the early morning, the mother of the child ran away from the SNCU leaving her child behind. After five days the case was referred to MKCG, Berhampur on 19.12.2015 so that the newborn could be provided better treatment and necessary protection.

After improvement of the health condition of the child, the pediatrician discharged the child on 23.12.2015 when the child was again admitted to SNCU of DHH, Rayagada and after proper health checkup the child was produced before the CWC, Rayagada for proper action. Following the instructions of CWC, Rayagada, officials of SAA, Koraput received the child Amrita from CWC, Rayagada in the presence of DCPU staff of Rayagada for rehabilitation. It was only due to the timely intervention of an NGO like SHAKTI that an abandoned child got life with proper medical attention and a new identity as Ansupa.

Case Study-2

(Background: SHAKTI VARTA is one of the IEC activities with well- designed training modules implemented by TMST-DFID through NGOs in districts having poor MCH indicators. It is a module based training program provided to WSHG members intended to develop positive health seeking behavior. In district Rayagada, SHAKTI NGO is the implementing agency. )

Smt. Arpita Himirika about 22 years belonging to the Scheduled Tribe category lives at Pujariguda village of Suri GP under Kolnora Block. It is a remote village situated at the foot of a hill and is almost 5 Km away from the main road. Her financial condition is very poor and her family depends on cultivation. Her education is only up to class-II. She had conceived for the first time and had no idea about prenatal, perinatal and postnatal care. By the time when she came in contact with Mrs. Saipriya Hikaka, a SHG motivator in her village, she joined a SHG and attended the SHAKTI VARTA meetings.

After completion of SHAKTI VARTA module-8, she learnt about the 3 primary causes and factors responsible for maternal mortality and learnt about the steps about birth preparedness (delivery kits) & their necessity. She also learnt about the care of new born child such as wiping, chord cutting, wrapping, and initiation of early breast feeding, bathing the child, exclusive breast feeding,and positioning, attachment and burping of the child. During SHAKTI VARTA module-12 meeting, it came to the notice of the SHG facilitator that Smt. Arpita had already prepared the delivery kit,

started to save money, had noted the phone number of HW (F) & ASHA. She had also persuaded her mother-in-law to accompany her to the hospital before time for safe institutional delivery. She was practicing hand wash with soap in 6 steps as per instructions. She was very happy with the training and praised SHAKTI VARTA program for bringing empowerment within her and developing positive health seeking behavior. Not only Arpita, but also a lot of mothers who attended SHAKTI VARTA meetings have utilized MCH care services better.

In most of the cases the activity of Civil Society Organizations basically means to ensure realization of fundamental rights by the members of community. They join hands for a common cause and are playing vital roles in bringing about social movement. Civil Society Organizations are raising the voice of the people to policy makers. To differentiate between CBO and NGO, Lombard, 2015 viewed CBO as membership based and NGO as non-profit but not membership based. CSOs are largely membership-driven focusing on core issues and NGOs are mostly donor based. Generally NGOs are implementing various programs by forming Community Based Groups in the community. Women Self Help Groups (WSHG) are the platforms they are using for implementing various women and child related programs. WSHG are the groups of 10-20 individual women from among the neighbors of the same community. Civil Society takes many forms where WSHGs are one of them. These groups are generally engaged in microfinance activity. Financial literacy among WSHGs members is being promoted for enhancing credit linkages with a view to reduce poverty; because poverty is a limiting factor in leading a just human life in general and leading to a reduction in the utilization of MCH care among women in particular. Now WSHG is envisaged as a tool for community mobilization. WSHGs are not just a formal group but it is also regarded as institutional mechanisms for implementing various government programs. They are playing an important role in implementation of Mid-Day Meal Scheme, Supplying Take Home Ration to ICDS, and construction of toilets under Swachh Bharat Abhiyan are some of the examples. WSHGs could be a vehicle for translating better MCH services by increasing the utilization pattern among rural women. Mahindra, 2003 in his study conducted in Kerala has observed the positive

role of WSHGs in promotion of health services. He described that there are two main components in health promotion by a WSHG member i.e. female autonomy at an individual level and social solidarity at the community level.

Conclusion

Though Odisha has improved in its MCH indicators it still requires maintaining the consistency of its progress so as to be at par with the developed states like Kerala, Tamil Nadu and Maharashtra, etc. Besides this, the development of Odisha is not uniform across the districts. There are perceived gaps exist among the districts as well as between rural and urban areas. For minimizing the gaps, leveraging human capital is essential. So the involvement of Civil Society organizations (CSOs) especially Community Based Organizations (CBOs) like Women Self Help Groups (WSHGs) are critical. Engagement of civil society in improving the utilization of MCH care services among the most underprivileged is a strategy for leveraging human capital. Realizing this, National Health Policy 2017 supports that the voluntary services like NGOs or CBOs, available in remote rural areas or with under-serviced communities, can play effective role in efficiently serving the community in a better way. The unique strategies of implementation of public health programs especially for preventive and promotive health care by the NGOs are much more effective than the government machineries and particularly Women SHGs in a particular area could be the harbinger of change and their involvement in maternal child health care is very crucial in maternal child health care.

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