FIELD VISIT REPORT
September 29th to October 1st, 2009
SIVAGANGA DISTRICT, TAMIL NADU, INDIA
Author: Dr. M. Ganesan, Senior Project OfficerIITM’s Rural Technology and Business Incubator, ESB, # 331, Indian Institute of Technology Madras (IITM),
Chennai – 600 036, Tamil Nadu, India
1. Introduction
This field visit is the second after the technologytraining workshop that was held on May 4 – 5, 2009 at the Hotel Subhalakshmi Palace, Karaikkudi in Sivaganga district. The first field visit was made on June 19th – 20th, 2009. This time the field trip was organized for three days considering the amount of work on mhealth survey certification exercises among VHNs and demonstration of Tcube messaging and alerting tool for DDHS officials. Detailed agenda and itinerary was planned to maximize the outcome of this visit. The following gives you the detailed description of our fieldwork:
2. Field visits were made to the following places
2.1. Primary Health Centre (PHC) at Nerkuppai (Tuesday, September 29, 2009)2.2. Primary Health Centre (PHC) at Keelasevalpatty (Tuesday, September 29,
2009)2.3. Government Hospital (GH) at Thiruppathur (Wednesday, September 30,
2009)2.4. Primary Health Centre (PHC) at Thirukostiyur (Wednesday, September 30,
2009)2.5. Deputy Director of Health Services (DDHS) at Sivaganga (Wednesday and
Thursday, September 30 and October 1, 2009)
3. The field visits to each of the places focused on
3.1. Conduct/Observe VHN certification exercise with VHNs of Nerkuppai PHC3.2. Conduct/Observe VHN certification exercise with VHNs of Keelasevalpatty
PHC3.3. Meet with SHN at Thirukostiyur in regards to research methods on acquiring
records for the "replication simulation exercise". And to get information on other evaluation statistics such as actual patient counts etc.
3.4. Train the staff of IDSP at DDHS office on TCube and Messaging/Alerting3.5. Meet with Medical Officers and Nursing staff at GH of Thiruppathur to
understand the patients inflow and reporting mechanism
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4. Day One (September 29, 2009 Tuesday)
4.1. MHealthSurvey Certification Exercise
A certification exercise was conducted among four VHNs of Nerkuppai PHC and five VHNs of Keelasevalpatty PHC (In both the places, the SHNs were not available as they had some important meetings with their higher officials). The certification exercise was done in their respective PHC with the active participation. The list of VHNs who took part in this certification exercise is given in Table 1.
Table 1. List of VHNs participated
Sl. No. Name of VHN Name of PHC1. C. Maragatham Nerkuppai2. N. Umarani Nerkuppai3. V. Logamatha Nerkuppai4. N. Vanaja Nerkuppai5. Shanthi Keelasevalpatty6. Jayadhayabharathi Keelasevalpatty7. Vengadeswari Keelasevalpatty8. Sivagamu Keelasevalpatty9. S. Selvi Keelasevalpatty
A fourpage document titled “Standard Operating Procedures” in Tamil version was circulated to all the VHNs participating in this exercise prior to this through our field staff. The exercise was started after distributing the mhealth survey certification exercise format which consisted of three parts such as Install and Configure mhealth survey, Data Entry Submission and three general questions with multiple choice of answers related to standard operating procedures. The purpose was explained in detail and clear instructions were given to them to follow the rules strictly during the exercise. Time for each exercise was also allotted to them and they were asked to finish the exercise in the given time. At the end, they were asked to feel free to give any suggestions or feedbacks to improve further with regard to mhealth survey application.
4.2. Observations
• Five of them were able to download and configure the application and data entry submission. However, they were unable to complete this in the stipulated time.
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• The other two each from Nerkuppai and Keelasevalpatty PHCs were unable to down load and configure the application and in data entry submission. Later they were able to do this exercise with the help of Janakiraman and their colleagues.
• Janakiraman was trained in conducting this exercise with the purpose of replicating the same exercise for the remaining 15 VHNs.
After the completion of the exercise, we met with the Medical Officers, Dr. Shanmugapriya and Dr. Packiyalakshmi at Keelasevalpatty PHC with whom we discussed about the performance of VHNs on mobile phone data entry and current health information flow from HSC through PHC to DDHS.
5. Day Two (September 30, 2009 Wednesday)
5.1. Interview with Two Candidates for mobile phone data entry at PHC level
On the morning of Sept 30, the two candidates namely Mr. Nagarajan and Ms. Kasthuri Bai were interviewed for the post of field assistants on part time basis in mobile phone data entry work at PHC level. They were found to be suitable candidates. They were informed that we would let them know on the outcome of interview shortly. Details of their contract will be further discussed and if the candidates accepted the proposed assignment, one of them (Kasthuri Bai) will be stationed at Keelasevalpatty PHC and the other one (Nagarajan) at Nerkuppai PHC.
In order to capture all the patient information in the respective PHC, the following responsibility chart has been prepared:
Table 2. PHC wise responsibility chart
Sl. No. Name of PHC Responsibility for specific activity1. Sevanipatty Janakiraman for both past and present data entry2. Thirukostiyur Kaliyammal, SHN for present data entry and
Janakiraman for past data entry3. Keelasevalpatty Kasthuri Bai for both past and present data entry4. Nerkuppai Nagarajan for both past and present data entry
5.2. Visit to Government Hospital, Thiruppathur
GH visit was made with the purpose of understanding the number of patient and health information flow system. We ourselves introduced by showing the consent letter of Health Secretary, Tamil Nadu Government to Dr. Shanmugam, Medical Officer who in turn asked us to meet with Nursing superintendent and senior staff member. They explained to us the daily patients’ inflow and reporting formats being adopted by them. It
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was observed that approximately 500 patients are visiting this GH daily and in addition 56 patients are already occupying the available beds as inpatients. After the meeting, we went around the hospital and visited the various wards in this premises. The outcome of this visit will be considered when a proposal to scale up the current RTBP project will be developed.
5.3. Discussion with SHN/VHNs on the replication simulation exercise and actual patient counts
We met with the SHN Ms. Kaliyammal and the VHNs, Ms. Dhanalakshmi and Karuppayee at the PHC, Thirukostiyur to discuss the records for the "replication simulation exercise" and other evaluation statistics such as actual patient counts etc. We further spent time to understand the registry work involved at the PHC. We went through the registers being maintained at the PHC and had a detailed discussion on method of data updation and formats used.
Based on the available registers, it was decided that the actual patients inflow record counts on daily basis under the following heads will be collected by Janakiraman along with the support of the concerning SHNs.using the format given on Table 4 and the total should be arrived on monthly basis for the respective PHC and HSC starting from June 2009. This would help the analysis and monitoring team to identify the gap between the actual number of data entered and patients visited daily.
Table 3. Serial number wise heading available in the register
Sl No. in the Register
Heading
3 High risk mother reference6 New Born Referred14 ARI treated15 ADD16.1 Vaccine Preventable Disease (Causes)16.2 Vaccine Preventable Disease (Death)18 Medical Terminal Pregnancy
Minor ailments
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Table 4. Model format for Location wise actual number of patient inflow by month starting from June 2009
Sl. No. Location Jun ‘09 Jul ‘09 Aug ‘09 Sep ‘091.2.3..28.
Apart from this, we found that before entering the diseasewise cumulative total counts in the register, they also collect patient information in two registers at PHC level. These are as follows:
• OPD register contains OPD No., Name of the Patient, Village Name and Sex. This information will be entered by the person who is in charge of maintaining this register before the patient meets with Medical Officer for checkup.
• Nominal Register contains Location, Date & Time, Diagnosis (Disease), Symptoms, Sign, Sex, and Age. This information is actually collected in this register when the patients meet with MO.
When we were discussing about mandatory option for the fields of patients name and status we observed that it takes more time in entering data for each patient and also it is not required as per the objectives of the project. At the end of our meeting, we also discussed the disease outbreak details.
Table 5. Disease outbreak details in the past oneyear
Sl. No. Disease Period No of persons affected1. Malaria May, 2009 12. Dengu Fever July, 2009 13. ADD September, 2009 54. Viral Fever September, 2009 155. Mumps April, 2009 5
To know more details about disease outbreak by PHC and HSC, please click on the following website http://intra.tn.nic.in/dph/pcm/ and request for password from the project team.
5.4. Meeting with Dr. Raghupathy, DDHS, Sivaganga
In the late afternoon of the second day, we went to DDHS office, Sivaganga to meet with Dr. Raghupathy, Deputy Director of Health Services. We discussed the performance of
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VHNs/SHNs who are part of the project and also about the tool of Tcube messaging and alerting.
Dr. Raghupathy highlighted the following important points in the meeting:
• 46 PHCs and 265 HSCs are available in this district
• 10 lakhs people are getting benefit from the existing PHCs and 2 lakhs people from GH
• In order to show the advantage of RTBP, Cost Benefit analysis has to be worked out (present reporting cost vs RTBP cost). The cost could be associated with reporting, analysis and notification system to VHNs
• He pointed out that during November to January every year, there is a chance of emerging malaria disease outbreak due to water affluent in the “Vaigai” river basin
• With regard to duration for final data analysis preparation at DDHS level, it currently takes 3 days
• PHC has been submitting the cumulative records using the standard format to DDHS through Health Inspector at weekly interval and DDHS will consolidate all the information collected from each PHC and submit it to DPH on monthly basis
• Finally, he along with Mr. Nuwan mentioned that If RTBP project is successful, more funds have to be sought for scaling up this project in the same district
5.5. Meeting with IDSP unit staff
We met with Mr. Ramesh, District Entomologist and Mr. Jaiganesh, Data Manager of Integrated Disease Surveillance Programme (IDSP). We discussed the Form S – Weekly Reporting Format for Syndromic Surveillance by HSC level and Form P – Weekly Reporting format by PHC level. The collected data using this format would be entered in an excel sheet before they are being entered on the website: www.idsp.nic.in.
Auton Lab software was downloaded on the IDSP unit computer after installing the java
programme from www.java.com. This was done in keeping with our next day’s programme on the demonstration of Tcube analysis and messaging/alerting for IDSP staff.
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6. Day Three (October 1, 2009 Thursday)
6.1. Training of DDHS staff on TCube Messaging/Alerting tool
This tool will be useful for IDSP unit as they are already involved in doing the health data analysis for detecting disease outbreak and giving message/alert and disseminating the situation reports. Keeping this in view, four staffs of IDSP unit at DDHS office were trained on TCube and Messaging/Alerting system. The training was conducted with the purpose of orienting health category alerts (situational reports), conducting surveys and other messaging. The following participants were present:
• Mr. K. Ragavendran, District Health Educator• Mr. Jaiganesh, Data Manager• Mr. Ravi, Data Entry Operator• Ms. Mahalakshmi, Data Entry Operator
The participants were given an overview of RTBP project followed by practical demonstration of mobile phone data entry by Janakiraman. As soon as they understood about the project, Mr. Nuwan described the standard operating procedures step by step before demonstrating the Tcube and Messaging/Alerting system. The training was mainly focused on how do we analyse the health data and detect the event by location and period. They were also taught the situational reporting involving the Messaging/Alerting Module (MAM) and dissemination of situational reports. All the participants were actively involved and raised the following important questions related to Tcube analysis.
• Can we see the diseases with a threshold count of one (i.e. Malaria) in neighboring villages or districts?
• What is the probability rate that was given on the graph of TCube analysis? They have also asked us to mention the formula that was used for calculation of probability rate.
• Can we use the messaging and alerting tool for other than health project activities?
• They were exploring the differences between the existing data analysis system and Tcube analysis tool.
After clarifying their queries, we mentioned that a manual on TCube Messaging/Alerting would also be prepared and sent to them. Finally, the
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participants were given Mr. Janakiraman’s contact details to keep in touch with him if they need any trouble shooting support.
7. Follow up • The certification exercise for the remaining 15 VHNs and one SHN will be
conducted by Janakiraman. He will have to finish this task in one week’s time (The 15 copies of questionnaire incorporating English name for each disease, which were earlier only in Tamil, have been sent to Field).
• We will be analyzing the certification exercise data to know their improvement of skill and knowledge level in downloading and configuration and data entry submission. This will be done once the exercise was over from all the 24 VHNs.
• We need to take final decision on removing mandatory option for the fields of patient name and status
• Monthly patient records starting from June 2009 should be collected to identify the gap between the actual number of patients visits daily and actual number of records entered on the mobile phone (A model format has been prepared and incorporated in this document)
• Janakiraman should make weekly visit to DDHS office to meet with the staff of IDSP unit to give timely support
• On completion of the certification exercises with the VHNs, it has been highlighted that the VHNs are still dependent on Janakiraman to complete certain functionalities of the mobile phone application. This has to be further improved on.
• We should get regular feedback from the IDSP unit staff to improve further on the tool of TCube Messaging/Alerting
Field visits undertaken by Mr. Nuwan WaidyanathaDr. M. Ganesan and Mr. N. Janakiraman
Field trip organized byMs. Suma Prashant, Mr. N. Janakiraman and Dr. M. Ganesan
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