IHAT Heath Action Trust

Contents
PREFACE.............................................................................................................................4
ACKNOWLEDGEMENT.........................................................................................................5
EXECUTIVE SUMMARY........................................................................................................6
INTRODUCTION: INDIA HEALTH ACTION TRUST..................................................................7
GOALS:...............................................................................................................................8
MAIN STRATEGIES:.............................................................................................................8
PPTCT PROJECT...................................................................................................................9
HIV IN RAJASTHAN............................................................................................................10
IHAT OPERATIONS.............................................................................................................11
1.

Main Activities:.......................................................................................................11

2.

Reporting Systems:................................................................................................12

ABOUT THE REPORT.........................................................................................................14

METHODOLOGY:................................................................................................................15

FIELD VISITS AND INTERVIEWS:.............................................................................15

District Hospitals (ICTC/ PPTCT/ ART)/ PHCs/ CHCs.................................................15

PLHIV......................................................................................................................15

Angandwadi...........................................................................................................16

DATA ANALYSIS.......................................................................................................16

OBSERVATIONS.................................................................................................................17
At the ICTC/ PPTCT and ART centers.............................................................................17
Meeting with the STI counselor (Sexually Transmitted Infection):................................17
Meeting with the ICTC/ PPTCT counselors:....................................................................17
At ART centers:.............................................................................................................18
Meetings with BPMs/ BCMOs.........................................................................................19
Meetings with the PLHIVs:.............................................................................................19
At the ANGANWADIs......................................................................................................20

Meetings with the IHAT ORWs.......................................................................................20

FINDINGS..........................................................................................................................21
IHAT ORWs....................................................................................................................21
Anganwadi workers, ASHA and ANMs...........................................................................21
At the ICTC/ PPTCT/ PHC/ CHC/ and ART centers...........................................................22
Meetings with PLHIV:.....................................................................................................22
PROFILE OF CASES UNDER IHAT-PALI...............................................................................23
Experiences in the life of an IHAT beneficiary:.................................................................25
GAP ANALYSIS OF PPTCT PROGRAM.................................................................................27
THE BUBBLES FRAMEWORK..........................................................................................28
SWOT ANALYSIS OF PPTCT...............................................................................................31
SWOT ANALYSIS OF IHAT-PPTCT, PALI...............................................................................32
KEY PERFORMANCE INDICATORS.....................................................................................34
RECOMMENDATIONS & CONCLUSIONS:...........................................................................37
ABBREVIATIONS................................................................................................................38
APPENDIX-1......................................................................................................................39

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 longterm 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:
TRUST

INDIA

HEALTH

ACTION

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 incharge 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 motherto-child transmission of HIV can be reduced to less than 5 percent through a 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
o focused outreach, service referrals
o follow up with the HIV+ pregnant women (ANC, delivery, PNC)

o 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.

The ORWs 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/ CHCs

Field 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.

PLHIV
The 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.

Angandwadi
Anganwadis 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 ANALYSIS
Data Analysis was carried out on the monthly reports submitted by the ORWs at the monthly
meetings which take place on the 23 rd 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.

OBSERVATIONS
This 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 centers

Meeting 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 counselor
2) 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 PREART 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 ANGANWADIs
The 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 ORWs

It 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.

FINDINGS
IHAT ORWs
It 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 ANMs

The 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 centers

There 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.

Age

ART

13 1
23
43
31

18-20

21-25

67

26-30

31-35

ON

PRE

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.

Husband's HIV status

BPL status

28

30
60

Positive

Negative

62

Yes

No

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

Caste
11
15

42

22
General

SC

ST

OBC

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 proactive 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 followup 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

Bubble

Concepts: Questions Summarized case interview findings

addressed
to
the
beneficiaries

Opportunity
Availability Where to go for HIV
testing and counselling?
Brand
Attitudes
Quality of
Care
Social
HIV testing is a routine
Norms
part of ANC
Brand
ANC staff and doctors
Appeal
are non-judgmental

Awareness of HIV and the availability of and need

for PPTCT services is low.
N/A
N/A

HIV testing has been made part of the MCH card

(Mamta card)
It 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 100% of the users of PPTCT services mention a
confidentiality of results fear of being disclosed to the public.
Willing to wait for the It is seen that many users have required constant
time
for
PPTCT motivation to take their medication and wait for
services.
testing kits when kits are unavailable.

Ability
Knowledge

Social
Support

Understands that an
HIV negative child can
be born to an HIV
positive mother

There 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 While respondents understand that a child can get
practices.
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.
The doctor recommends Doctor recommendation has a great deal of
that I take PPTCT weightage in a persons decision to get tested.

services

SelfEfficacy

Motivation
Attitudes

Beliefs

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 A good number of the respondents state that their

that I get tested
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.
Can take the trip to the Most women questioned stated that their husbands
ART during operating went to the ART center for counselling and getting
hours.
the medicines. Barriers included lack of time and
money to visit the ART centers.
Can ask for C&T Pregnant women have difficulty accepting offered
services at the ANC
HIV testing and ART and very few ask for it
without prompting from the doctor. Building selfefficacy 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.
HIV testing is a routine The majority of pregnant women attending ANC
part of ANC for centers accept tests like sonography and urine-test
everyone.
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 Expecting parents want a healthy baby, one without
very important to me.
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.
Belief that everyone There is not only poor knowledge on the
needs to know about availability of the ARV therapies, but that others

PPTCT
Even
though
the
partners live wholesome
lives and look healthy,
they can be at risk of
HIV

Threats

Outcome
Expectation

The husband is faithful

Care and support will be

available
if
found
positive

Locus
control

of Who makes the ANC

decisions

Willingness
to Pay

Can C&T be afforded

Subjective
norms

Others will think that I

or we (husband & wife)
have risky behavior if I
agree for test.

other than only PLHV need to know about it.

Both partners feeling and looking healthy act as a
barrier and they feel confident of their seronegative 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.
Women 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.
Fear 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.
The ANC decisions rest in the domain of wife,
however, husbands support can help accessing
these ANC services.
C&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.
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.

OPPORTUNITY

ABILITY

MOTIVATION

Key:
Brand Attitudes
Availability

Quality of Care
Brand Appeal
Appeal

Social Norms

Knowledge

Attitudes

Social Support Locus of Control

Beliefs

Outcome Expectation

Self-Efficacy Subjective NormsThreatWillingness to Pay

Orange=medium
Green=High (already okay)
No Color= Not Applicable

SWOT ANALYSIS OF PPTCT

Red=low
(bad)

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:

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.

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.

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: Concept
SWOT 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

Level

Statement

Key
Performance Results
Indicators
(%)

Goal

Minimize
Parent
to
Child
Transmission
of HIV
To ensure all
HIV positive
mothers
receive
prophylactic
treatment
during
pregnancy and
beyond
To ensure all
babies born to
HIV positive
mothers are
tested for HIV
within
6
months
and
put
for
prophylaxis
treatment

Percentage of children
born to HIV positive NA
mothers, tested negative
for HIV

Objective 1

Objective 2

3-year
Target
(%)
80.00

Baseline
(%)

Percentage
of
HIV 74.44
positive pregnant women
who
receive
recommended
prophylactic
treatment
and full ANC package
during pregnancy

95.00

75

Percentage of babies born 45.10

to HIV positive mothers
tested for HIV within 6
months of their lives

95.00

56

73

Objective 3

Impact

Outcomes

Percentage of babies born 82.36

to HIV positive mothers
received
recommended
prophylactic
treatment
through follow up till 18
months of their age.
Percentage of referred 91.24
vulnerable women report
get tested for HIV at
ICTC

95.00

72

95.00

68.05

97.00

NA

55.55

92.00

NA

91.24

95.00

90.27

95.00

82.00

To
demonstrate
the
effectiveness
of conditional
cash transfer
in
PPTCT
management
Improved
Percentage
of
HIV
pregnancy and positive pregnant women
newborn
deliver live baby
survival
among HIV
positive
women
Percentage of babies born
to HIV positive mothers
survive till 18 months of
their lives
Pregnant
Percentage of referred
women
vulnerable women report
vulnerable to get tested for HIV at
HIV
avail ICTC
testing
facilities
Pregnant HIV Percentage
of
HIV
positive
positive women having
mothers opt institutional deliveries
for
institutional
deliveries

Percentage
of
HIV 82.81
positive pregnant women
having
institutional
deliveries receiving cash
support from government
schemes

95.00

NA

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
ANC
ANM
ART
ASHA
AWW
BCMO
BPM
CCT
CHC
CPT
DBS
F-ICTC
ICTC
IHAT
MCHN
NACP
NRHM
ORW
PHC
PPTCT
RSACS
VAC
WHO

Antenatal Care
Auxiliary Nurse Midwife
Anti-retroviral therapy
Accredited Social Health Activist
Anganwadi Worker
Block Chief Medical Officer
Block Planning Manager
Conditional Cash Transfer
Community Health Centre
Co-trimoxazoleprophylactic treatment
Dried Blood Spot
Facility integrated ICTC
Integrated Counselling & Testing Centre
India Health Action Trust
Mother and Child Health and Nutrition Day
National AIDS Control Programme
National Rural Health Mission
Outreach Worker
Primary Health Centre
Prevention of Parent to Child Transmission
Rajasthan State AIDS Control Society
Vulnerability Assessment Checklist
World Health Organization

APPENDIX-1

DOCC-IHAT,
Pali

Work
Report
Feb-Mar, 2015
Subject/Activit
y

Meeting with Dr.

Priyamwada
Singh, Project
Director, IHAT
and Mr. Devki
Nandar, Program
Manager, IHAT,
Rajasthan.

Date

23/02/201
5

Agenda

Comments

1) 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.

IHAT Office, Pali

24/02/201
5

IHAT Office, Pali

25/02/201
5

Visit to
Beneficiary at
Bhatund, Pali

26/02/201
5

Visit to the
Anganwadi
Center, Bhatund,
Pali

26/02/201
5

Bangar Hospital,
Pali

27/02/201
5

Bangar Hospital,
Pali

27/02/201
5

IHAT Office, Pali

02/03/201
5

IHAT Office, Pali

03/03/201
5

1) A brief function of IHAT and its

supporting bodies like IMPACT,
1) Meeting with
RCACS, NRHM, and PACF was
Divakar, DC, Pali
explained.
2) Attending the
2) Met the ORWs from different
monthly ORW
blocks. Noted their names and
meeting.
phone numbers regarding visits to
the beneficiaries.
2) Studied previous case studies.
1) Preparation for
3) Studied the Case writing
Case Visits.
instructions given by Divakar
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.
1) Preparing Case
4) Interaction with the beneficiary and
study based on
her husband.
this visit.
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.
1) Interacted with Anganwadi workers
1) Understanding
and helpers.
the role of
2) Learnt about their work and role of
Anganwadi
Anganwadi and ASHA in the lives of
workers and
the villagers.
their interaction 3) Learnt how IHAT ORWs interact
with IHAT
with Anganadi workers and ASHAs
to get their work done.
1) Met and interacted with ICTC
counsellor Mr. Satyanaran Mathur
1) Interaction with
and PPTCT counsellor Mr. Suresh
the PPTCT &
Tiwari.
ICTC counsellors.
2) Understood the referral system at
the ICTC and PPTCT centers.
1) Interacted with an RCACS
1) Interaction with
employee and ART lab technician.
the ART
2) Understood the difference between
counsellor
Pre-ART and ON-ART process.
3) The counsellor was not present.
1) Studied the annual report, 2013 of
1) Understanding
IHAT.
of operations
2) Studied the referral system at IHAT,
and processes at
the differences between white slips
IHAT.
and pink slips.
1) Writing the Case 1) Discussed the case visit and my
study based on
observations and understanding.
the visit with
2) Wrote the case study based on the
ORW Mamta.
voice recording and interaction
with the beneficiary.

3) Picked up the topic on lack of DBS

kits.

10 Pali

Bangur Hospital,

04/03/201
5

1)

11 IHAT Office, Pali

09/03/201
5

1)

Visit to
12 beneficiary at
Bali, Pali

1)
10/03/2015

1)
Meeting with

13 BPMO, Bali with

10/03/2015

Divakar

14 Visit to Jaitaran

2)

11/03/2015

1)

Block, Pali

2)

1) Met and interacted with the ART

counsellor.
Visit to the ART
2) Met the PPTCT counsellor and saw
center.
the Dried Blood Sampling kit and
understood its significance and
process.
1) Interacted with Divakar and
discussed the agenda for the week.
2) Discussed on the questions and
Agenda for the
responses that should be recorded
week
during a case interview.
3) Showed the video of ORW Mamta,
how her life has changed after
joining IHAT.
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
Preparing case
were visiting.
study based on
4) Interaction with the beneficiary and
the visit and
her husband.
observations.
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.
1) Interacted with BPMO of Bali.
2) We talked on the current status of
Interaction with
HIV in the block and he assured his
the BPMO and
full support to IHAT for their
knowing his
operations.
roles and
3) A few ground level problems at the
responsibilities.
PHC level were brought up ORW
Taking BPMOs
Sartaj, which the BPMO promised to
permission for
address.
health camp.
4) BPMO acceded to start a health
camp for that includes HIV testing.
Understanding
1) Interacted with the Block Planning
the health
Manager, Jaitaran, Pali.
services at the
2) Understood his roles and
Block level.
responsibilities and role and
Attending the
operations of NRHM.
ANM meeting
3) Saw a few softwares made by the
under CMHO and
Government of India like PCTS
BPM.
(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.

12/03/2015

1) Preparing case
study based on
the visit and
observations.

13/03/2015

1) Writing the Case

study based on the
visits with ORW
Sartaj Banu.

Visit to
16/03/2015
17 Beneficiary at
Raipur Block, Pali

1) Preparing case
study based on
the visit and
observations.

18 IHAT Office, Pali

17/03/2015

1) Writing the Case

study based on
the visit with
ORW Pooja.

Visit to Bangar
19 Hospital, Pali

17/03/2015

1) Interaction with
an HIV patient
referred by a
beneficiary.

20 IHAT Office, Pali

18/03/2015

Visit to
15 beneficiary at
Bali, Pali

16 IHAT Office, Pali

1) Understanding
the data
management by
IMPACT.

5) Attended ANM meeting under BPM

and BPMO. Understood the ground
reality of the NRHM project and
issues faced by ANM workers.
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.
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.
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.
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.
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.
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

Visit to
19/03/2015
21 Beneficiary at
Raipur Block, Pali

1)

1)
Visit to Bangur

22 Hospital, Pali

20/03/2015

23 IHAT Office, Pali

23/03/2015

24 IHAT Office, Pali

24/03/2015

25 Jaipur

25/03/2015
31/03/2015

1)

1)

1)

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.
1) Met and interacted with ORW Kiran.
2) Understanding of her work and
problems related to it.
3) Case history of the beneficiary we
Preparing case
were visiting.
study based on
4) Interaction with the beneficiary and
the visit and
her children.
observations.
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.
1) Saw a new born baby for the first
To visit a
time. The baby was only 2 hours
beneficiary from
old.
Sumerpur who
2) Ensured that the PPTCT counsellor
recently
gave the dose of Nevirapine.
delivered a baby.
3) Ensured the health of the mother.
1) Met the ORWs from different
Attending the
blocks.
monthly ORW
2) Listened to the recommendations
meeting.
given by the Ms. Swati Singh and
team.
Attending the
2) Discussed on the Key Performance
monthly ORW
Indicators with Ms. Swati Singh, the
meeting.
consultant for IHAT.
1) Assimilated the data and findings.
2) Applied various frameworks to
Report Writing
analyze the data.
3) Wrote the report and made the
presentation.

INDIA HEALTH ACTION TRUST