DOCC Project Report

IHAT Heath Action Trust

DOCC Project ReportAssessment and Gap Analysis of the PPTCT program and the efficacy of the interventions made by IHAT-PPTCT project in District-Pali through Case studies and Data analysisBy: Shounak Mitra (PGP-14-142) Center for Development of Corporate Citizenship S.P. Jain Institute of Management and Research

Contents

PREFACE4ACKNOWLEDGEMENT5EXECUTIVE SUMMARY6INTRODUCTION: INDIA HEALTH ACTION TRUST7GOALS:8MAIN STRATEGIES:8PPTCT PROJECT9HIV IN RAJASTHAN10IHAT OPERATIONS111.Main Activities:112.Reporting Systems:12ABOUT THE REPORT14METHODOLOGY:15FIELD VISITS AND INTERVIEWS:15District Hospitals (ICTC/ PPTCT/ ART)/ PHCs/ CHCs15PLHIV15Angandwadi16DATA ANALYSIS16OBSERVATIONS17At the ICTC/ PPTCT and ART centers17Meeting with the STI counselor (Sexually Transmitted Infection):17Meeting with the ICTC/ PPTCT counselors:17At ART centers:18Meetings with BPMs/ BCMOs19Meetings with the PLHIVs:19At the ANGANWADIs20Meetings with the IHAT ORWs20FINDINGS21IHAT ORWs21Anganwadi workers, ASHA and ANMs21At the ICTC/ PPTCT/ PHC/ CHC/ and ART centers22Meetings with PLHIV:22PROFILE OF CASES UNDER IHAT-PALI23Experiences in the life of an IHAT beneficiary:25GAP ANALYSIS OF PPTCT PROGRAM27THE BUBBLES FRAMEWORK28SWOT ANALYSIS OF PPTCT31SWOT ANALYSIS OF IHAT-PPTCT, PALI32KEY PERFORMANCE INDICATORS34RECOMMENDATIONS & CONCLUSIONS:37ABBREVIATIONS38APPENDIX-139

PREFACE

The project has been prepared as a part of the course Development of Corporate Citizenship (DOCC) at S.P. Jain Institute of Management & Research under the Post Graduate Diploma in Management (PGDM) program. The aim of this program is to sensitize MBA students, who are upcoming managers, towards the social sector and issues prevalent there. This program aims at developing sensitivity towards the underprivileged sections of the society and to understand the unstructured environment faced by the NGOs. This program is run with the NGOs across the countries, which are working in various social sectors like health, education, women rights, gender equality, etc. This program is running since 1993 and the college students have worked so far with 800 NGOs. This project was done in collaboration with the NGO IHAT (India Health Action Trust) in Rajasthan (Pali district). The organization is working on a project for Prevention of Parent to Child Transmission (PPTCT) of HIV AIDS. IHAT has two separate teams working on the PPTCT project in the two implementation districts of Dungarpur and Pali, backed by the senior team at the state office and the in the central office (Bangalore) level. The teams function under the leadership of Dr. Priyamvada Singh, Trustee and State Head, IHAT Rajasthan and the Project Director for the PPTCT project. IHAT strongly believes in a decentralized approach of functioning and is guided by the principle of honest commitment in realizing its objectives. I have evaluated their Operational and Data Management practices and have made actionable recommendations to induce long-term sustainability. I have consolidated a compendium of case studies based on interviews of the beneficiaries of the project. Based on the inputs from IHAT as well as my field exposure, the evaluation findings and the recommendations are made in the following sections. They are also based on the insights I gained from the meetings with service providers, health cadres/ stakeholders. Each of our meetings and visits were strategically planned having specific program area as focus of discussion/ observation as well as covering each category of the service providers/ officials, project team members and the beneficiaries / their families.

ACKNOWLEDGEMENT

I would like to express my deepest thanks and gratitude to all the members of India Health Action Trust (IHAT) for their help and time. I would also like to thank Dr. Priyamvada Singh, Trustee and State Head, IHAT Rajasthan (Project Director, PPTCT Project) for giving me an opportunity to work on this project and for her guidance, immense support and encouragement.

I want to extend my special thanks to Mr. Divakar Jharbade (District Coordinator, Pali-IHAT) for his insights about the processes of IHAT and administrative support. The field visits I had conducted as a part of this project would not have been possible without the help of IHATs team of Outreach Workers (ORW).

My heartfelt gratitude to Prof. Jagdish Rattani, my project guide, and to the DOCC Committee for giving me this opportunity to work with IHAT and to apply management principles in an unstructured environment thereby gaining immense knowledge throughout the course of this project.

EXECUTIVE SUMMARY

This report represents the project work carried out during the 6-week internship with India Health Action Trust (IHAT). IHAT in association with IMPACT is working on the PPTCT Program in two districts in Rajasthan- Pali & Dungarpur. IHAT aims to prove the effectiveness of its interventions and process design in the PPTCT program through its Conditional Cash Transfer strategy. The findings presented in this report are based on the field visits and interviews conducted with the stakeholders and data analysis carried out in the district of Pali in Rajasthan. Based on the findings and analysis, consolidated conclusions and recommendations have been put forward. The report carries a compendium of six case studies of PLHIV, who are beneficiaries of the IHAT-PPTCT program. The case studies give a glimpse in their lives and experiences as a PLHIV before and after meeting IHAT. They trace the process of accessing C&T services, medicines and social protection by the clients of IHAT and record their experiences. They record the frustrations of the beneficiaries at the knowledge of their HIV reactivity, the process delays, the red tape, how they have been overcome, and how things eventually work out.SWOT analysis has been done for the PPTCT program and IHAT-PPTCT project. The Bubbles framework, a behavior change framework, is summarized in terms of opportunity, ability and motivation, that can guide the decision making process for the communications strategy of IHAT in Pali and other districts.The framework identifies multiple factors which can have impact on behavior in terms of opportunity, ability and motivation to drive behavior change. By focusing on factors which can change and which cannot, IHAT can be more equipped to implement efficient campaigns that make the most of their little resources available (human. time and financial) as well as contact that the campaign has with target group members.It is not intended to generalize the PPTCT program efforts in the state of Rajasthan, but to give an insight into the various facets of the life of PLHIV under the PPTCT program from a beneficiarys perspective.The essence of the report is to strongly put forward the need to look at the long term processes and operations to sustain this project and scale it up. IHAT needs to aim at its target groups with a communication strategy which can make the most of its resources.

INTRODUCTION: INDIA HEALTH ACTION TRUST

India Health Action Trust began its operations in 2003 to improve public health in India and abroad. IHAT specializes in providing comprehensive technical assistance and training in program planning and management. With emphasis on incorporating science in program design and monitoring, it aims to maximize both efficacy and efficiency of interventions. IHAT currently provides technical support to State AIDS Prevention and Control Societies and to NACO in designing and implementing evidence based HIV prevention and care programs. IHAT also implements HIV prevention and care programs in the State of Rajasthan to gain implementation experience. These implementation experiences enrich the technical support that IHAT provides in the country and outside. IHAT is working in the field of RMCHN in Rajasthan for last 3-4 years and recently initiated a large program in the state of UP. The Uttar Pradesh-Technical Support Unit (TSU) Project began in November 2013, is funded by the Bill & Melinda Gates Foundation. The TSU is established for the Government of Uttar Pradesh with the goal of providing techno-managerial support to improve the efficiency, effectiveness and equity of delivery of key RMCHNN interventions. The University of Manitoba is the prime recipient of the grant for the Project and India Health Action Trust (IHAT) has the overall responsibility for executing the TSU project in Uttar Pradesh. The John Snow International Research and Training Institute, Boston and Engender Health, New York are the other partners in this consortium.

The IHAT-PPTCT project runs in partnership with IMPACT. IMPACT provides the technical support (monitoring and evaluation), IHAT executes the field operations under the leadership of a Project Director. The IHAT Program Manager oversees the project in its two districts of implementation Pali & Dungarpur. Each district is under a District Coordinator who is in-charge of the activities carried out in the field by the Out-Reach Workers.

GOALS:The goals of IHAT-PPTCT project are as follows: Increase access to ICTC services by pregnant women; Ensure all HIV+ mothers and new born infant s receive ARV prophylaxis as per NACP guidelines; Ensure all babies born to HIV+ mothers are tested for HIV within 6 months and put on prophylaxis treatment as indicated, and; Demonstrate the effectiveness of Conditional Cash Transfer in PPTCT management.MAIN STRATEGIES:

Engage NRHM and WCD cadres to improve PPTCT referrals for HIV counseling , testing & services while having focused outreach and service linkage mechanism in place Use Vulnerability Assessment Checklist to screen pregnant women with high vulnerability to HIV and refer them for testing (a short term solution to universal testing for HIV in pregnancy) Reimburse travel cost to the most needy pregnant women availing HIV counseling and testing after referral Develop technology based MIS to minimize LFU (Loss to Follow Up) Contribute towards Integration of RCH and PPTCT services, while building capacities of ANMs, ASHAs, AWWs, Counselors and Lab Technicians (in line with the spirits of MoHFW & NACOs joint circular-Aug. 2010). Build capacities of PHC/CHC staff in Early Infant Diagnosis (EID) (govt. dependent) Build community support mechanisms for pregnant women living with HIV to avail full package of PMTCT (as recommended by NACP) Advocate with the government to ensure regular availability of supplies and quality counseling at PPTCT service delivery points Advocate with the government for scale up the PPTCT strategies as per( efficacy assessments)

PPTCT PROJECT

The NACO-UNDP-NCAER study on Socio-economic impact of HIV in India (2006), indicates that people living with HIV (PLHIV) and their households face severe economic consequences including exclusion, marginalization, and poverty. They are actively burdened by increased illnesses, loss of jobs and income, rising medical expenses, depletion of savings, and other resources, food insecurity, psychological stress and related morbidity, discrimination, social exclusion and imminent impoverishment that is often irreversible. Of the total PLHIV cases in India, women constitute 39% of all PLHIV while 4.4% are children. As on March 2012, 99,000 HIV positive children had been registered under the antiretroviral therapy (ART) program, 42,973 children ever started on Pediatric ART and 29,000 are receiving free ART. There has been a significant scale up of HIV counseling & testing, Prevention of Parent-to-Child Transmission (PPTCT) and ART services across the country over last five years.The main cause of transmission to children is from mother to child. Out of an estimated 27 million pregnancies in a year, only about 52.7% attend health services for skilled care during child birth in India. Of those who availed health services, 8.56 million pregnant women received HIV counseling and testing by March 2012.

According to WHO, without effective treatment, more than half of the babies born with HIV die before their second birthday. Prevention of parent-to-child transmission of HIV has been one of the most globally focused upon HIV prevention activities, encouraged by successful clinical trials of single-dose nevirapine and combination antiretroviral prophylaxis. The risk of mother-to-child transmission of HIV can be reduced to less than 5 percent througha combination of prevention measures including antiretroviral therapy (ART) for the expectant mother and her new-born child, hygienic delivery conditions and safe infant feeding. While the early realization and implementation of extensive programs have virtually eliminated pediatric HIV in many developed countries, the major challenge in developing countries such as India is to reach pregnant women at the right juncture to bring them under the net of PPTCT services. The government through the National AIDS Control Program (NACP) has been responsible for significant scaling up of HIV counseling & testing, PPTCT and ART services across the country over the last few years (the number of women tested under PPTCT program increased from 0.8 million to 8.8 million between 2004 to 2013). To enhance this coverage, a joint directive from the National AIDS Control Program (NACP) and the National Rural Health Mission (NRHM) regarding convergence of the two program components was issued in July 2010, explicitly stating that universal HIV screening should be included as an integral component of routine ANC check-up. In spite of the above government initiatives, the obstacles that the PPTCT program encounters are entangled in a mesh of issues ranging from lack of awareness and motivation (to get tested for HIV), economic backwardness to infrastructural inadequacies in the delivery of medical and health services. There is an urgent need of proactive facilitation, to bridge the gap between having the program and ensuring the delivery of the services through them.

India Health Action Trust (IHAT) in partnership with IMPACT and in collaboration with RSACS, NRHM and UNICEF, supported by ViiV Healthcare-PACF has taken upon the responsibility of being this facilitator through a Project presently running in two districts of Rajasthan with high risk of HIV Pali & Dungarpur. The way forward is to formulate and implement a sustainable plan for PPTCT, covering entire Rajasthan by leveraging the experience, findings and learning from the Project (2013-2015).

HIV IN RAJASTHAN

Rajasthan is the largest state in India with a population of 73.52 million (2015) and a literacy rate of 67.1 % (80.51% male and 52.66% female). Female literacy rate is the lowest in the country.In the context of HIV in India, Rajasthan is a highly vulnerable, high-priority state.HIV estimates for Rajasthan are erratic (0.32% in 2012) but given the current level of knowledge regarding sexual behavior and sexually transmitted infections (STI), particularly among vulnerable sub-populations, indications are strong that Rajasthan is a highly vulnerable state.A mapping exercise conducted in 2005-06 shows that there are 21,301 Female sex workers, 3,350 Men having Sex with Men, 1,431 Intra Venous Drug Users, 268911 Migrants, and 57342 Truckers. The Golden Quadrilateral, East West corridor and other major highways, passing through the state and existence of rural traditional sex work add to its vulnerability. The sero prevalence of Rajasthan is 0.25% among general population and 1.92% in STD patients. Rajasthan has equal HIV prevalence rates in both urban and rural areas.Many socio-economic factors are responsible for making the disease epidemic within the state. Statistically it has been seen that: A small increase in HIV rates can amplify in the state due to its large population. Thousands of people from Rajasthan migrate annually 0to higher prevalence states such as Maharashtra, Gujarat, and thousands are migrating in Rajasthan from other states like Bihar, West Bengal etc. Rajasthan accounts for 19 percent of all mines in India, employing over 500,000 workers, many of them are from other states.

IHAT OPERATIONS

1. Main Activities:

Enrol & train HIV infected women as peer educators for the focused outreach, service referrals follow up with the HIV+ pregnant women (ANC, delivery, PNC) Follow up with mother-baby pair (till attaining 18 months age). Provide cash to support travel cost to pregnant women availing referral for HIV testing for self and further for their babies. Introduce client tracking system (manual as well as cell based) to ensure regular follow up for the PPTCT service delivery Orient ANMs, ASHAs and AWWs to screen pregnant women for HIV vulnerability and refer for testing and PPTCT counselling. Ensure institutional delivery & ART Prophylaxis for all identified HIV+ mothers/babies. Ensure regular follow up with identified HIV+ pregnant women through home visits till their babies attain 18 months of age. Train ICTC/PHC/CHC staff to collect, store and transport blood samples using DBS. Evaluate the role of conditional cash transfer in PMTCT management Document the experience and advocate with Government for scale up. Advocate with government to facilitate cash incentive using untied NRHM funds for HIV testing in pregnancy and EID.

2. Reporting Systems: The record keeping and reporting structure is as follows: Each ORW maintains these registers which are then fed to the district level monthly register. Referral Register: All clients met, referrals made and testing results and details are registered here; Client Tracking Register: If any client is tested positive, then her name and details are entered into the case tracking register and all details related to pregnancy, child birth, medications, tests and results are maintained till 18 months of age of the infant. Daily Activity Register covers the daily and routine activities of the ORWs which translates into the Monthly Progress Report to the District Coordinators Daily Output Register covers the main indicators of the project and serves as a daily tracking tool. This again will translate into a monthly progress report. CommCare, is a cell based MIS application designed into 4 modules i.e. Screening; Test Follow up; Pre-natal; and Post natal modules, is used by the ORWs. TheORWs have a daily and DCs have a monthly reporting system ORWs have a paper based format; for the DCs this is a computerised format. Both, the DCs and the M&E go through the reports looking at the progress, data discrepancies, and the quality of the reports submitted by the ORWs. The ORWs monthly reports are compiled by the M& E officer maintaining a soft as well as a hard copy and shares with the core project staff through e-mails. The core team members provide feedback to the M&E, required modification are made and report gets finalised and circulated again.

ABOUT THE REPORT

This project report is a compendium of six case studies of PLHIV who accessed PPTCT program and are beneficiaries of the IHAT project in PALI district. The stories give a glimpse of the lives of beneficiaries, their trials and triumphs, their worries and their hopes. They trace the process of accessing Counseling & Testing, medication and social protection by the beneficiaries and record their experiences. They record the frustrations of the beneficiaries at the knowledge of them being HIV positive, the delay in processes, the red tape, and how they have been overcome, how things eventually work out.This report provides a brief overview of the findings that emerge from the case studies. SWOT analysis has been done for the PPTCT program and IHAT-PPTCT project. The bubbles framework, a behavior change framework, is summarized in terms of opportunity, ability and motivation, that can guide the decision making process for the communications strategy.The framework identifies multiple factors which have impact on behavior in terms of opportunity, ability and motivation to drive behavior change. By focusing on what can change and what cannot, IHAT-PPTCT program managers can be more equipped to implement efficient campaigns that make the most of their little resources available (time, human and financial) as well as time/ contact that the campaign has with target group members.It is not intended to generalize the PPTCT efforts in the state of Rajasthan, but to give an insight into the various facets of the life of PLHIV under the PPTCT program from a beneficiarys perspective.All the respondents of the case studies are PLHIVs and most of the respondents are female. Most of the respondents are from the age group of 20 to 35.The case studies are attached at the end.

METHODOLOGY:

Field visits and interviews were the two key methods used to collect information and gain understanding on this project. Mr. Divakar, District Coordinator, IHAT PALI and his team of ORWs facilitated these field visits and helped in the my understanding on this project and PPTCT program.

FIELD VISITS AND INTERVIEWS:Field work is the core of IHATs operation. Thus field visits were conducted at various levels: district, block, village, and to various stakeholders of the IHAT-PPTCT project to understand the current operations and ensure that on-field work could be observed and practical observations could be gathered. District Hospitals (ICTC/ PPTCT/ ART)/ PHCs/ CHCsField Visits were conducted to the District Hospital of Pali, Community Health Centers of Bali and Jaitaran blocks and Public Health Centers of Bali, Jaitaran and Pali blocks. The District Hospital of PALI, Bangur hospital also hosts the PPTCT/ ICTC and ART centers. There are three ICTC centers in Pali, while Bangur hospital hosts the only ART and PPTCT center.The PPTCT/ ICTC and ART counselors openly discussed their daily operations, challenges and gaps in their work. Some of the observations are added in the later sections. At the block levels, I interacted with the Block Planning Managers and Block Medical Officers to discuss gaps and challenges faced by the PPTCT program. PLHIVThe major source of information in writing the case studies is the face-to-face interaction with the beneficiaries. These interviews were facilitated by the ORWs and Mr. Divakar. Prior consent was taken before each interview. The travel was made through local transport, so it was possible to understand the problems these PLHIVs can face while travelling to the ART centers each month for their medication. The Bubbles Framework has been analyzed using the questions and observations made during these interviews. The analysis and finding of the framework are added in the later sections. AngandwadiAnganwadis are the nodal points for the interaction and source of information for the ORWs. They collect critical information from the Anganwadi and ASHA workers to reach to their clients, i.e. the pregnant women. The ASHA, Anganwadi and ANM workers have helped from time-to-time in motivating the clients for the tests and travel to the district health facilities.I also attended the ANM meetings under the NRHM program chaired by the Block Planning Manager and Block Chief Medical Officer to understand the operations and challenges faced by the ANM workers. DATA ANALYSISData Analysis was carried out on the monthly reports submitted by the ORWs at the monthly meetings which take place on the 23rd and 24th of each month. I have analyzed the MPR PALI data from the inception till Dec 2014 and assessed the key performance indicators for this IHAT project in PALI. I have also added some insights on the demographic break-up of the beneficiaries and their families. Mr. Surendra of IMPACT and Mr. Divakar have been of great help in this regard.

OBSERVATIONSThis section will highlight the observations gathered during the field visits and interviews conducted. This section deals states the operations as they were observed and the later section on findings states the analysis of these observations.

At the ICTC/ PPTCT and ART centersMeeting with the STI counselor (Sexually Transmitted Infection):Patients suffering (or suspected to suffer) from sexually transmitted infections visit this counselor. The counselor gauges the responses of the patients and decides if the patient should be referred for a HIV test to the ICTC or not. The counselor talked about daily challenges, in which resistance offered during counseling and added lack of literacy were the biggest barriers.

Meeting with the ICTC/ PPTCT counselors:The ICTC counselor gets his clients through the following ways:1) Referred by the STI counselor2) Patients tested for HIV positive in their first (non-confirmatory) test at the PHC/ CHC/ other testing centers (like health camps). Such patients are directly referred to the ICTC.3) Patients who have been directly referred to the ICTC by the doctors or have come directly by themselves.4) Patients referred by NGOs (like the IHAT ORWs).

The counselor explained that patients generally reach him in a state of confusion. The awareness on HIV is low. Those who have some idea on HIV are in a state of depression. The counselor guides them to the next two rounds of testing and if the patient is confirmed HIV positive, he counsels the client on HIV and its treatment. If the patient is pregnant, then she is referred to the PPTCT counselor.The reactive client is referred to the ART (Anti-Retroviral Therapy). For a pregnant lady, it is recommended to go ON-ART irrespective of the CD4 count.The PPTCT counselor counsels an HIV+ pregnant woman up to child birth. It is the responsibility of PPTCT counselor to make sure the new-born receives the right dosage of NEVIRAPINE in accordance with the weight of the child. Once this process is over, the records are handed over to ART center where the woman and child receive proper medication and testing.He showed us the registers and the format in which he recorded the details of the patients counseled and also for those who are detected positive. The format has been designed to ensure follow up post-delivery also, till all 3 DBS (Dried Blood Sample) tests have been conducted for the infant.These testing kits are procured by the RSACS and there is monthly reporting format which includes the kit inventory details that must be adhered to by the PHCs/ CHCs.

At ART centers:

I met both the Pre-ART and ON-ART counselors as well as the lab technicians. While the PRE-ART counselor counsels the patient on the importance of a healthy diet, avoidance of alcohol/ tobacco/ doda-post and other such addictive substances; the ON-ART counselor in addition to these notes the suitability of the drug combination to the patient. It has been observed that patients have had side-effects on taking the drugs like itching, rashes, nausea, vomiting, etc. Both the counselors are also responsible to counsel on the behavioral aspects.The significance of CD4 count was explained. It is mandatory to start ART for a pregnant woman as per the new guidelines. However, there are cases where the patient is not on ART because of healthy CD4 counts. A CD4 count above 350 is considered OK. As per the guidelines CD4 counting should be done every 6 months.

Meetings with BPMs/ BCMOs

I met the BCMOs of Bali and Jaitaran blocks. The agenda for the meetings was to conduct a health camp in the block and integrate a mass HIV testing for pregnant women. Both the BCMOs were ready to provide any help required. The date for conducting the health camp is yet to be decided in these two blocks.The ORWs of the respective blocks also raised the topics of unavailability of testing kits at the PHCs and CHCs. The BCMOs acknowledged that a weak supply chain is the key challenge they are facing. Ensuring timely supply of the kits come under the domain of ICTCs but the record of the inventory has to be matched by the PHCs and CHCs. There was found a gap in the correspondence between these two bodies.I met the Block Planning Managers of Bali, Jaitaran, and Sumerpur blocks. They explained how ASHA manages the funds allocated to them. The BPM of Jaitaran block showed the software packages installed by the Govt. of Rajasthan. One such software is the PCTS (Parent-Child Tracking System), online software which is available at every PHC/ CHC and sub-centers. The PCTS software is adept at knowing the complete database on each pregnancy and follow-up data till child birth. The ASHAs are paid on a referral basis only when they submit the final details on the pregnancy. Another software E-Aushadhi was shown to me. It is a drug-inventory management system given at each PHC/ CHC/ sub-centers. I also attended the NRHM-ANM meeting chaired by the BCMO and the BPM, Jaitaran. This helped me in understanding the operations and guidelines related to ANMs.

Meetings with the PLHIVs:The observations made during the visits to the beneficiaries have been recorded as case studies, which are shown at the end of the document. Some of the observations have also been recorded in the section: Experiences in the Life of an IHAT beneficiary.

At the ANGANWADIsThe AWWS and the ASHA are the nodal points to reach the unstructured social network in villages. The AWWs and ASHA appointed have to be a resident of the village. For every 1000 families, there exists an Anganwadi. The nature of their work enables them to build close contacts with the women in the village.The IHAT ORWs are able to leverage the network built by the AWWs and ASHA to seek timely information on the pregnant women which enables them to reach and contact them. In many cases, the AWWs/ ASHA and even ANMs help in building the first contact with the client.

Meetings with the IHAT ORWsIt is delightful to see these ORWs work so hard to reach their clients and motivate them for tests and later for treatment. While taking the interviews with the clients, I found that most of the ORWs are taken as friends to the families of the clients. They have a built a comfort zone and trust base with the clients.It was a surprise to know that most of the IHAT ORWs are themselves reactive. It is delightful to see how knowledge and proper counseling have enlightened their lives and now they are taking the torch forward.The dissemination of the information (to the pregnant woman or her family) about HIV at the time of referral is important. The ORWs attempt to provide sufficient knowledge to the clients to make them willing to get tested. Sometimes they only tell the patient that she has some infection in blood and must see the doctor. The importance of HIV and counseling is given keeping in mind the behavior of the client.The decision to give CCT (conditional cash transfer) to the clients lay solely on the ORWs. It was told during the monthly meetings to keep proper proof of the CCT given and that it should be given only after approval by the District Coordinator. Mobile phones have been given to the ORWs so that they can communicate at will. IHAT has also provided a software to keep data updated.

FINDINGSIHAT ORWsIt was found that irrespective of the VAC (Vulnerability Assessment Card), the ORWs referred all pregnant women for C&T services. The utility of VAC comes into question here. As per IHAT guidelines, even if one question is answered positive as per the VAC, the client should be referred for testing. But questions like, Does your husband go out of state for work for more than 2-3 months have yes as an answer for most of the residents in a place like Phalna, Bali. At such places, then everyone should be vulnerable as per VAC and should be referred for testing.It was found that there was greater reception and acceptance to questions in VAC when women were in groups. However, certain questions related to sexual habits of their spouses cannot be addressed in a group.The ORWs not only motivate the clients to go for HIV tests, they also act as facilitators. They make sure test kits and personnel are available before sending a client. Fixed-day testing and health camps have been good strategies to ensure that both client and health staff are ready. There is adequate support from the government for the health camps.Coverage is an issue for the ORWs. There are 28 ORWs working in 10 blocks. Owing to large distances and scanty transportation, it is tedious task for these ORWs to reach each and every client. However they do a good job in the follow-up through visits and phone calls. Each ORW is paid an amount Rs. 1200 per month as travelling allowance.Anganwadi workers, ASHA and ANMsThe ASHA and AWWs can potentially serve as the first counselors to motivate pregnant women take the HIV test. By leveraging their close connections to the village women, they can surpass the barrier of stigma associated with the word HIV. The MCHN day serves as an extremely valuable forum to reach the lactating mothers who have not yet tested for HIV. Inclusion of HIV test in the MCH (Mamta card) has been the first step to make HIV testing a usual norm for pregnant women. On the MCHN day, ANM can enlighten the women on HIV, its medication and its prevention. However, in some cases, I have found that ANMs are themselves not aware of HIV. In one particular case, the ANMs denied vaccination to the reactive woman and her infant. Such cases add to the stigma of HIV and acts as a barrier to open dialogue and communication.There is an urgent need to build consensus among the various stakeholders of the PPTCT program starting from the base of the pyramid. Capacity building of the ASHAs/ ANMs is one step towards this.At the ICTC/ PPTCT/ PHC/ CHC/ and ART centersThere is a big difference in the number of pregnant women referred to the ICTC in the government registers and in the IHAT registers. IHAT has the referral slips for each referral made. While talking on this issue to the BPM of Jaitaran, he proudly showed the government softwares for tracking pregnancies and HIV tests done. However, during the NRHM ANM meeting, the true state of affairs came out. Most of these softwares were not even opened at the PHC level for as high as 500+ days. Even the most up-to-date PHC had not opened the software for over a month.The reason that came up was that the ANM were responsible for filling the data and many ANMs were not even aware that such software existed. This showed that even though there is sufficient infrastructure and funds made available by the government, there is lack of communication at the grass-root level.The second finding was the unavailability of test kits. The DBS test kits were not available for more than 6 months at a stretch. The PPTCT counselor on this issue said that the test kits come from RSACS Jaipur. PHC/ CHC data on the number of HIV tests performed is an important statistics for RSACS and is not received by ICTC.Meetings with PLHIV:The findings are shown in the form of a framework, which is shown in the later sections.

PROFILE OF CASES UNDER IHAT-PALI

Diagram 1 captures the age-wise distribution of the 90 cases under IHAT PALI accessing PPTCT services. 50% of the women under this program are in the age group of 21-25. Out of the 90 cases, 74% of the cases are ON-ART, i.e. under medication.

The occupations of the husbands are varied. They range from laborers, government servicemen to businessmen. Out of the 90 cases, 60 beneficiaries husbands are HIV+ and a major portion of them (77%) are laborers. Of the 90 cases, 86% of the families under BPL status (31%) are HIV positive and their husbands are laborers.

Caste wise distribution shows that OBC as the biggest chunk of the cases. (47%)

Block wise distribution shows that Bali has the most number of cases followed by Desuri.

Experiences in the life of an IHAT beneficiary:Based on the interviews of the beneficiaries and the ORWs (most of themselves are PLHIV), it is evident that PLHIV have a mixed experience in accessing social support and protection. While on one hand they receive support and encouragement from organizations like IHAT and some pro-active government officials, on the other hand they also need to deal with corrupt practices, red tape, and perceived and enacted stigma.Based on the case interviews, the beneficiaries have received support from IHAT in accessing their entitlements. IHAT ORWs provide information on schemes like PALANHAR YOJNA, BPL card, etc. and help fill the applications. Some beneficiaries have been informed by pro-active government officials and ASHA workers or NGO workers like IHAT ORWs informing them of their eligibility for certain schemes and helping them apply. Beneficiaries share that approvals have been timely. A few report inordinate delays in getting benefits or need to follow-up constantly before the benefits accrue.Beneficiaries expressed exasperation over the stigma and unfair practices towards PLHIV. One respondent from Bali block shares her story on how she and her child were denied vaccination by ANM workers. The reason was that ANM workers believed they would get HIV if they touch and provide vaccination to her baby. Such myths and stigma even among government workers like ANMs and ASHAs are adding to the miseries of PLHIV. Divakar, District Coordinator, IHAT PALI, says that the beneficiaries find it difficult to access the social welfare schemes addressed to them. Many local government officials arent even aware of these schemes. Some schemes like the PALANHAR scheme require verification by the gram panchayat. Perceived or actual stigma are barriers that inhibit these beneficiaries from accessing the entitlements under HIV-sensitive (modified) or exclusive schemes.Based on these case interviews, there is unanimity on the need for social protection. There is also perceived need of support in accessing schemes and addressing stigma and confidentiality issues. The study finds that in-spite of the government initiatives, the obstacles that the PPTCT program encounters are entangled in a mesh of issues ranging from the lack of awareness and motivation (among government personnel to push people to get tested and among people to get tested), economic backwardness to infrastructural inadequacies in the delivery of medical and health services. There is an urgent need of proactive facilitation, to bridge the gap between having the program and ensuring the delivery of services though them. India Health Action Trust (IHAT) in partnership with IMPACT and in collaboration with RSACS, NRHM and UNICEF, supported by ViiV Healthcare-PACF has taken upon the responsibility of being this facilitator through a Project presently running in two districts of Rajasthan with high risk of HIV Pali & Dungarpur. The way forward is to formulate and implement a sustainable plan for PPTCT, covering entire Rajasthan by leveraging the experience, findings and learning from the Project (2013-2015).

GAP ANALYSIS OF PPTCT PROGRAM

I have used the Bubbles Framework as an audit tool to ensure that the findings from the case interviews and filed visits are translated into components for behavior change. By using a summary of case study findings by bubble, IHAT can better understand the determinants behind the behavior. Under each determinant category, concepts are ranked low (red), medium (orange) and high (green) based on how well the target group is on the determinant. IHAT can use this framework to assess which of these bubbles is likely to be correlated to the update to counseling and testing services.Desired Behavior Change: To increase the utilization of the ANC-based C&T services among pregnant women and follow-up with the PPTCT services if they are diagnosed HIV+.Primary Target Group: Pregnant women and their male partners.Secondary Target Group: Men and women (esp. PLHIV) in the 20 to 44 in the age bracket who are planning to have children.Justification: While HIV prevalence in Rajasthan is still lower than other states in India, the heavy burden of stigma and the case research findings on the motivating factors for getting tested recommend the best way to increase utilization of ANC-based C&T and PPTCT services for HIV+ pregnant women is to promote among pregnant women and their partners in the general population. Once the foundation has been set and ANC-based C&T is accepted by the general population, more targeted interventions with high risk vulnerable women will be possible. Women who are supported by their husbands and communities are more likely to seek out HIV counseling and testing services and follow-up with the PPTCT services if they are diagnosed HIV+. While men are less involved in the details of the ANC services utilization, they do accompany their wives to these services and have the potential to convince some otherwise unwilling wives to agree to the HIV test.

THE BUBBLES FRAMEWORK

BubbleConcepts: Questions addressed to the beneficiariesSummarized case interview findings

Opportunity

AvailabilityWhere to go for HIV testing and counselling?Awareness of HIV and the availability of and need for PPTCT services is low.

Brand AttitudesN/A

Quality of CareN/A

Social NormsHIV testing is a routine part of ANCHIV testing has been made part of the MCH card (Mamta card)

Brand AppealANC staff and doctors are non-judgmentalIt is seen that ANM and ASHA staff gossip about the reactive status of HIV positive pregnant women.The women are more concerned with what ASHA and ANM workers would think of them if they agreed for test and found positive.

Realistic expectations of confidentiality of results100% of the users of PPTCT services mention a fear of being disclosed to the public.

Willing to wait for the time for PPTCT services.It is seen that many users have required constant motivation to take their medication and wait for testing kits when kits are unavailable.

Ability

KnowledgeUnderstands that an HIV negative child can be born to an HIV positive motherThere is a lack of understanding that it is possible for a HIV negative child be born to HIV positive mother. Both the female and male respondents had low awareness of the availability of drugs and methods to dramatically reduce chances of a HIV positive child born to a mother living with HIV.

Knows the best feeding practices.While respondents understand that a child can get HIV from mother to child, they dont seem to understand that breast feeding can transmit HIV if blood flows into the milk feed. Also they arent aware of the best practices of feeding.

Social SupportThe doctor recommends that I take PPTCT servicesDoctor recommendation has a great deal of weightage in a persons decision to get tested. There is high regard and trust in health providers, and most individuals felt that they would follow the recommendations and advice of health providers without questioning as it is in the best interest of both mother and the child.

My husband supports that I get testedA good number of the respondents state that their husbands accompanied them to their ANC checkups. The women agree that their husbands support and encouragement is important. Men can with the right communication approach play a positive role in encouraging women to get tested for the health of their baby.

Self-EfficacyCan take the trip to the ART during operating hours.Most women questioned stated that their husbands went to the ART center for counselling and getting the medicines. Barriers included lack of time and money to visit the ART centers.

Can ask for C&T services at the ANCPregnant women have difficulty accepting offered HIV testing and ART and very few ask for it without prompting from the doctor. Building self-efficacy for the pregnant women to be comfortable accepting or asking for C&T as part of their concern for the overall health for the child has potential for behavior change.

Motivation

AttitudesHIV testing is a routine part of ANC for everyone.The majority of pregnant women attending ANC centers accept tests like sonography and urine-test without resistance. By linking the HIV test to the MCH (Mamta) card, as part of the routine checklist for every pregnant woman, C&T will become more acceptable to pregnant women.

The health of the baby is very important to me.Expecting parents want a healthy baby, one without birth defects, malnutrition, and disease. Rather than addressing the stigma and low risk perception head on, a review of case studies supports normalizing HIV test as just one of the many necessary tests to ensure a healthy baby.

BeliefsBelief that everyone needs to know about PPTCTThere is not only poor knowledge on the availability of the ARV therapies, but that others other than only PLHV need to know about it.

ThreatsEven though the partners live wholesome lives and look healthy, they can be at risk of HIVBoth partners feeling and looking healthy act as a barrier and they feel confident of their sero-negative status. Migrant nature of jobs of husbands have been identified as a risk, because most indulge in extra-marital affairs, esp. during abstinence of sex during their wives pregnancy.

Outcome ExpectationThe husband is faithfulWomen report that they have trust on their husbands. Men agree with their partners that women are at lower risk because they have small social circles.

Care and support will be available if found positiveFear of positive result was the biggest barrier. Reducing the stigma surrounding HIV and making people aware of the availability of the treatment, and also care and support for PLHIV, has the potential to increase C&T utilization.

Locus of controlWho makes the ANC decisionsThe ANC decisions rest in the domain of wife, however, husbands support can help accessing these ANC services.

Willingness to PayCan C&T be affordedC&T services and ART is given free of cost by the government. The main issue is that there are only 3 ICTC, 1 PPTCT and 1 ART center at PALI. Accessing these centers requires long distance travel from different blocks, which can be costly for most. Most beneficiaries are come under the BPL scheme.

Subjective normsOthers will think that I or we (husband & wife) have risky behavior if I agree for test. There is a great deal of stigma against agreeing to a HIV test in ANCs. This may be because agreeing to a test may infer that they or their husbands engage in socially stigmatized behavior. Also the gossips that can spread if found positive is another barrier.

The bubbles are coded in terms of the concepts they represent, based on the results from case studies.

OPPORTUNITYABILITYMOTIVATIONAvailabilityBrand Appeal AppealSocial SupportSelf-EfficacyBeliefsAttitudesSocial NormsKnowledgeThreatSubjective NormsQuality of CareOutcome ExpectationWillingness to PayLocus of ControlBrand Attitudes Key: Red=low (bad)Orange=mediumGreen=High (already okay)No Color= Not Applicable

SWOT ANALYSIS OF PPTCT

Strengths:

Adequate funds available. Policy and guidelines readily available. Infrastructure available like the PCTS software, for keeping every pregnancy updated. Free medicines through systems like E-Aushadhi. Weakness:

Weak supply chain. Medicines and test kits are unavailable for long periods. Lack of consensus on approaches. Strong emphasis on health facility rather than community. Communication strategies (feedback) not in place between the community and the health center. Time taken at health center to complete the process. Lack of personnel and C&T centers. No effective mechanism of follow-up (of child also). A large proportion of deliveries are conducted at private, but the program is not able to involve private partners in an effective manner.

Threats:

Stigma arising from awareness programs. Cultural norms/ behaviors that are dominant, e.g. socio-cultural issues. Incoherent message among health providers. Misinterpretation or misinformation by those who are not involved. Opportunities:

Devise wider strategies and build linkages with programs in other sectors and within health sector. Adopting one message with many voices consensus building. Involvement of leaders at all levels - national, district, community. It has been seen that the gram panchayats and local govt. bodies are insensitive towards PLHIV.

SWOT ANALYSIS OF IHAT-PPTCT, PALI

Strengths:

Flat hierarchy. There is strong communication between the District Coordinator and ORWs. The DC has sufficient freedom. ORWs have the freedom to decide whom to give CCT or not give. This makes decisions quick. Most ORWs are themselves HIV positive. So they understand the right questions to ask and right points to trigger to motivate another vulnerable person to get tested. IHAT has good connections and rapport with all government stakeholders. Proper follow-up of the clients right from testing to the birth of child and then till 18 months of age of the infant. Such personal service is commendable and has shown good results.Weakness:

There are at max. 3 ORWs per block. Travelling and coverage becomes a barrier. Short-term v/s long term decisions: The project is at present working with privately hired ORWs. However, if this project has to be integrated in the government infrastructure, ASHAs and ANMs have to be included. There is scope of improvement in data analysis. The data in the case tracking records are incoherent and even making a pivot table is quite difficult.

Threats:

Lack of understanding on HIV and its related knowledge among the ANMs and AWWs. Lack of consensus among the public on HIV test as a regular test during pregnancy. Mismatch in the data recorded between RSACS and IHAT. Inadequacies in the PPTCT services infrastructure like shortage of kits.Opportunities:

Capacity building and training of ASHA and AWWs for the long run. Adopting one message with many voices consensus building. Involvement of leaders at all levels - national, district, community. It has been seen that the gram panchayats and local govt. bodies are insensitive towards PLHIV.

How IHAT is/ can filling the gaps.

Determinant: ConceptSWOT Comments

Availability: IHAT ORWs in co-ordination with the ASHAs and ANMs have drastically improved the referral and testing rate for HIV. 14047 pregnant women were tested out of a total of 15395 vulnerable women referred to the C&Ts in 2014.

Brand Appeal: Complicated environment makes this difficult to address. However each ORW visits a beneficiary twice to thrice a month and are always in touch through phone. Capacity building of ORWs and ASHA workers can help in this direction. ANMs can be integrated as ORWs.

Knowledge:IHAT ORWs have not only been counsellors but friends to the pregnant mothers and their husbands. They have shared and enlightened them on the subject of HIV, baby care, baby feeding, etc. 49/ 72 (HIV+ women delivered) cases under IHAT PALI delivered a live baby and 45% of the babies born to HIV positive mothers were tested for HIV within 6 months of their birth, while 82.35% were given recommended prophylactic treatment through follow-up.

Self-Efficacy: Self-Efficacy has been improved through IHATs CCT strategy (Conditional Cash Transfer). 19 out of 60 cases under IHAT PALI were given CCT for testing of their babies in the year 2014.

Beliefs & Threats:IHAT ORWs have been able to educate their clients on HIV, child care, and clear various myths and stigma related to HIV.

Outcome Expectation:IHAT ORWs help their beneficiaries not only through CCT, but also helping them to access various government schemes available for them. For e.g. the BPL card, Palanhar Yojna, roadways pass, etc.

Willingness to Pay:This problem has been sorted out by the CCT strategy. ORWs mostly accompany their cases for their first visits to the C&T centers and ART at Pali.

Subjective Norms: While women make their own ANC decisions, there is stigma to saying yes to an HIV test, the connotation is that she or her husband practices high risk behavior. IHAT ORWs have been successful in this domain as well through various behavioral change strategies. For e.g., they address the childs health rather than health of the mother or pregnant woman.

KEY PERFORMANCE INDICATORS

LevelStatementKey Performance IndicatorsResults (%)3-year Target (%)Baseline (%)

GoalMinimize Parent to Child Transmission of HIVPercentage of children born to HIV positive mothers, tested negative for HIVNA80.0073

Objective 1To ensure all HIV positive mothers receive prophylactic treatment during pregnancy and beyondPercentage of HIV positive pregnant women who receive recommended prophylactic treatment and full ANC package during pregnancy74.4495.0075

Objective 2To ensure all babies born to HIV positive mothers are tested for HIV within 6 months and put for prophylaxis treatmentPercentage of babies born to HIV positive mothers tested for HIV within 6 months of their lives45.1095.0056

Percentage of babies born to HIV positive mothers received recommended prophylactic treatment through follow up till 18 months of their age.82.3695.0072

Objective 3To demonstrate the effectiveness of conditional cash transfer in PPTCT managementPercentage of referred vulnerable women report get tested for HIV at ICTC91.2495.000

ImpactImproved pregnancy and newborn survival among HIV positive womenPercentage of HIV positive pregnant women deliver live baby68.0597.00NA

Percentage of babies born to HIV positive mothers survive till 18 months of their lives55.5592.00NA

OutcomesPregnant women vulnerable to HIV avail testing facilitiesPercentage of referred vulnerable women report get tested for HIV at ICTC91.2495.000

Pregnant HIV positive mothers opt for institutional deliveriesPercentage of HIV positive women having institutional deliveries90.2795.0082.00

Percentage of HIV positive pregnant women having institutional deliveries receiving cash support from government schemes82.8195.00NA

The table above summarizes the important achievements as against the baseline numbers. Some of the most significant achievements of the project during the period 2013 to Dec 2014, especially when compared with the baseline are:The intervention has been an effective mechanism to screen the vulnerable women and then referring them for testing. About 32% of the women have been provided cash benefits in the year 2 (till Dec 2014) through the projects innovative strategy of CCT, which has directly improved the rate of testing and counselling for pregnant mothers. While all women are not eligible for cash support, there are women who are found to be extremely vulnerable to HIV coupled with the lack of economic support to be able to avail services. The projects ORWs have been given the responsibility and freedom to refer such women and provide them the support for testing.Through the projects intervention there has been an improvement in the prophylactic treatment that pregnant women receive. While the baseline reported to 75% of HIV positive pregnant women receiving, ART, the progress report shows that 74.44% of women are following the recommended ART regimen. The low values of HIV testing of new-born infants are due to the unavailability of testing kits at the ICTCs.

RECOMMENDATIONS & CONCLUSIONS:

There is a great opportunity to reach PLHIVs in sympathy groups and though other PLHIV networks with important information they need to know when making decisions about pregnancies or intentions to have a family. Doctor recommendation has a great deal of weightage in persons decision to get tested. Doctors need better communications support to better inform ANCs attendees on PPTCT issues. Counselors need communications support to fill gaps between them and ANMs, including information that those counseled can take with them. Overall awareness of the availability of the C&T services as part of the normal checklist of the ANCs should be promoted among the general population with an emphasis on pregnant women and their partners. The motivating factor that is most likely to influence them is the health of the baby. There is a lack of understanding that it is possible for a HIV negative child to be born to HIV positive mother. Both female and male partners have low awareness of the availability of drugs and methods to dramatically reduce chances of a reactive child. Streamlining Data Management Integration of e-Aushadhi portal & PCTS (Parent Child Tracking system) into PPTCT program via CMHO Office.

ABBREVIATIONS

ANCAntenatal Care

ANMAuxiliary Nurse Midwife

ARTAnti-retroviral therapy

ASHAAccredited Social Health Activist

AWWAnganwadi Worker

BCMOBlock Chief Medical Officer

BPMBlock Planning Manager

CCTConditional Cash Transfer

CHCCommunity Health Centre

CPTCo-trimoxazoleprophylactic treatment

DBSDried Blood Spot

F-ICTCFacility integrated ICTC

ICTCIntegrated Counselling & Testing Centre

IHATIndia Health Action Trust

MCHNMother and Child Health and Nutrition Day

NACPNational AIDS Control Programme

NRHMNational Rural Health Mission

ORWOutreach Worker

PHCPrimary Health Centre

PPTCTPrevention of Parent to Child Transmission

RSACSRajasthan State AIDS Control Society

VACVulnerability Assessment Checklist

WHOWorld Health Organization

APPENDIX-1

Work ReportDOCC-IHAT, PaliFeb-Mar, 2015

Subject/ActivityDateAgendaComments

1Meeting with Dr. Priyamwada Singh, Project Director, IHAT and Mr. Devki Nandar, Program Manager, IHAT, Rajasthan.23/02/20151) Scope of the project.2) Timelines, responsibilities & deliverables.Key Responsibilities & Deliverables:1) Understanding the context and the project.2) Taking part in the project activities/ meetings.3) Analysis of the project data/ information and presenting the progress on the key result indicators.4) Assisting project team in the project documentation through making case studies on the visits to the beneficiaries.

2IHAT Office, Pali24/02/20151) Meeting with Divakar, DC, Pali2) Attending the monthly ORW meeting.1) A brief function of IHAT and its supporting bodies like IMPACT, RCACS, NRHM, and PACF was explained.2) Met the ORWs from different blocks. Noted their names and phone numbers regarding visits to the beneficiaries.

3IHAT Office, Pali25/02/20151) Preparation for Case Visits.2) Studied previous case studies.3) Studied the Case writing instructions given by Divakar

4Visit to Beneficiary at Bhatund, Pali26/02/20151) Preparing Case study based on this visit.1) Interacted with the ORW Mamta of Bali Block.2) Understanding of her work and problems related to it.3) Case history of the beneficiary we were visiting.4) Interaction with the beneficiary and her husband.5) Talked about their life, their problems, their awareness on HIV and how IHAT is helping them through its ORW.6) Other problems and stigma they face.

5Visit to the Anganwadi Center, Bhatund, Pali26/02/20151) Understanding the role of Anganwadi workers and their interaction with IHAT1) Interacted with Anganwadi workers and helpers.2) Learnt about their work and role of Anganwadi and ASHA in the lives of the villagers.3) Learnt how IHAT ORWs interact with Anganadi workers and ASHAs to get their work done.

6Bangar Hospital, Pali27/02/20151) Interaction with the PPTCT & ICTC counsellors.1) Met and interacted with ICTC counsellor Mr. Satyanaran Mathur and PPTCT counsellor Mr. Suresh Tiwari.2) Understood the referral system at the ICTC and PPTCT centers.

7Bangar Hospital, Pali27/02/20151) Interaction with the ART counsellor1) Interacted with an RCACS employee and ART lab technician.2) Understood the difference between Pre-ART and ON-ART process.3) The counsellor was not present.

8IHAT Office, Pali02/03/20151) Understanding of operations and processes at IHAT.1) Studied the annual report, 2013 of IHAT.2) Studied the referral system at IHAT, the differences between white slips and pink slips.

9IHAT Office, Pali03/03/20151) Writing the Case study based on the visit with ORW Mamta.1) Discussed the case visit and my observations and understanding.2) Wrote the case study based on the voice recording and interaction with the beneficiary.3) Picked up the topic on lack of DBS kits.

10Bangur Hospital, Pali04/03/20151) Visit to the ART center.1) Met and interacted with the ART counsellor.2) Met the PPTCT counsellor and saw the Dried Blood Sampling kit and understood its significance and process.

11IHAT Office, Pali09/03/20151) Agenda for the week1) Interacted with Divakar and discussed the agenda for the week.2) Discussed on the questions and responses that should be recorded during a case interview.3) Showed the video of ORW Mamta, how her life has changed after joining IHAT.

12Visit to beneficiary at Bali, Pali10/03/20151) Preparing case study based on the visit and observations.1) Met and interacted with ORW Sartaj Banu.2) Understanding of her work and problems related to it.3) Case history of the beneficiary we were visiting.4) Interaction with the beneficiary and her husband.5) Talked about their life, their problems, their awareness on HIV and how IHAT is helping them through its ORW.6) Other problems and stigma they face.

13Meeting with BPMO, Bali with Divakar10/03/20151) Interaction with the BPMO and knowing his roles and responsibilities.2) Taking BPMOs permission for health camp.1) Interacted with BPMO of Bali.2) We talked on the current status of HIV in the block and he assured his full support to IHAT for their operations.3) A few ground level problems at the PHC level were brought up ORW Sartaj, which the BPMO promised to address.4) BPMO acceded to start a health camp for that includes HIV testing.

14Visit to Jaitaran Block, Pali11/03/20151) Understanding the health services at the Block level.2) Attending the ANM meeting under CMHO and BPM.1) Interacted with the Block Planning Manager, Jaitaran, Pali.2) Understood his roles and responsibilities and role and operations of NRHM.3) Saw a few softwares made by the Government of India like PCTS (Pregnancy and Child Tracking System) and E-Ashaudhi (procurement software for free generic medicine)4) Interacted with the BPMO for his sanction on health camp.5) Attended ANM meeting under BPM and BPMO. Understood the ground reality of the NRHM project and issues faced by ANM workers.

15Visit to beneficiary at Bali, Pali12/03/20151) Preparing case study based on the visit and observations.1) Met and interacted with ORW Sartaj Banu.2) Case history of the beneficiary we were visiting.3) Interaction with the beneficiary and her husband.4) Talked about their life, their problems, their awareness on HIV and how IHAT is helping them through its ORW.5) Other problems and stigma they face.

16IHAT Office, Pali13/03/20151) Writing the Case study based on the visits with ORW Sartaj Banu.1) Discussed the case visit and my observations and understanding.2) Wrote the case study based on the voice recording and interaction with the beneficiary.

17Visit to Beneficiary at Raipur Block, Pali 16/03/20151) Preparing case study based on the visit and observations.1) Met and interacted with ORW Pooja.2) Understanding of her work and problems related to it.3) Case history of the beneficiary we were visiting.4) Interaction with the beneficiary and her children.5) Talked about her life, problems, and awareness on HIV and how IHAT is helping them through its ORW.6) Other problems and stigma she faces.

18IHAT Office, Pali17/03/20151) Writing the Case study based on the visit with ORW Pooja.1) Discussed the case visit and my observations and understanding.2) Wrote the case study based on the voice recording and interaction with the beneficiary.

19Visit to Bangar Hospital, Pali17/03/20151) Interaction with an HIV patient referred by a beneficiary.1) Interacted with the patients mother and son.2) Enquired about her medical history and medication routine.3) Met the Doctor on Round and assisted him in knowing the patients medical history and ART medication till date. We told about her pervious Tuberculosis, on which the Doctor checked the X-Ray and referred her for a TB test.

20IHAT Office, Pali18/03/20151) Understanding the data management by IMPACT.1) Interacted with Mr. Surendra of IMPACT and understood his roles and responsibilities in this project.2) He showed me the data collection methods and how they are analyzed on a monthly basis.3) We talked on some discrepancies on the use of Vulnerability Assessment Card and data sampling biases that may arise due to improper or fake visits.

21Visit to Beneficiary at Raipur Block, Pali 19/03/20151) Preparing case study based on the visit and observations.1) Met and interacted with ORW Kiran.2) Understanding of her work and problems related to it.3) Case history of the beneficiary we were visiting.4) Interaction with the beneficiary and her children.5) Talked about her life, problems, and awareness on HIV and how IHAT is helping them through its ORW.6) Other problems and stigma she faces.

22Visit to Bangur Hospital, Pali20/03/20151) To visit a beneficiary from Sumerpur who recently delivered a baby.1) Saw a new born baby for the first time. The baby was only 2 hours old.2) Ensured that the PPTCT counsellor gave the dose of Nevirapine.3) Ensured the health of the mother.

23IHAT Office, Pali23/03/20151) Attending the monthly ORW meeting.1) Met the ORWs from different blocks.2) Listened to the recommendations given by the Ms. Swati Singh and team.

24IHAT Office, Pali24/03/20151) Attending the monthly ORW meeting.2) Discussed on the Key Performance Indicators with Ms. Swati Singh, the consultant for IHAT.

25Jaipur25/03/2015 - 31/03/20151) Report Writing1) Assimilated the data and findings.2) Applied various frameworks to analyze the data.3) Wrote the report and made the presentation.

INDIA HEALTH ACTION TRUST