Fluorosis Management in a DistrictReview and Monitoring System from Nalgonda DFMC

Srinivas Chekuri Regional Lead

FKAN

Overview the Problem:

National Level: High levels of Fluoride were reported in 230 districts of 20 States.>14000 habitations are affected with fluorosis. Population at risk being11.7 Million.

Telangana & A.P. • District: Nalgonda• Affected villages: 1108 (17 Mandals)• Affected Population: > 300000• Scope for scale up: 12 districts are affected by fluoride in A.P &

Telangana;

Therefore, Review & Monitoring System quite essential

Structure of the Presentation

I. Current System of Review and Monitoring • National Program for Prevention and Control Fluorosis

(NPPCF) • District Fluoride Monitoring Center (DFMC) II. Bottlenecks at various levels III. Proposed Review and Monitoring System

Directorate General of Health Services

•Advisor Nutrition/In Charge Nutrition & IDD

•National Nodal Officer ( NNO)

•State Nodal Officer (SNO)

• District Nodal Officer

•District Consultant

1. NPPCF Structure

NPPCF – R& M System

• Monthly Report : of activities and expenditure sent by District Nodal Officer to State Nodal Officer by10th of each month

• Quarterly Report: sent by the District Nodal Officer to the State Nodal Officer and to be forwarded to Central Fluorosis Cell by 15th of the subsequent month at the completion of the quarter

• Six Monthly Report: along with the cumulative progress should be sent to the Centre by 15th of October and 15th April every year by the State Nodal Officer. Utilization Certificate and statement expenditure to be forwarded to the Center every six months.

2. DFMC Structure

Chairman(Dist Collector)

Monitoring Officer

PartnershipsOther Stakeholders

17 Key Line DeptsHoDs & Point Persons

1. District Administration

2. Rural Water Supply and Sanitation (RWS)

3. Civil Supplies

4. Rajiv Vidya Mission

5. District Rural Development Agency (DRDA)

6. Health

7. Arogya Sri

8. District Water Management Agency (DWMA)

9. Social Welfare Department

10. Tribal Welfare Department

11. BC Welfare Department

12. Women and Child Welfare Department

13. Education

14. Horticulture

15. Animal Husbandry

16. Forest

17. Minor Irrigation

DFMC Key Line Department :

DFMC-Review MeetingsREVIEW MEETINGS:• Regular bi-monthly review meetings held

with 17 key line departments • Review done against performance indicators

embedded in Action Taken Report (ATR)• District Collector as Chairman, DFMC presides

over review meetings• All Heads of Depts (HoD) attend meeting

along with Point Persons• So far 4 such review meetings organised and

status updated in ATR• ATR submitted to District Collector &

circulated to all constituent departments• Monthly review meeting held with Point

Persons

Major Bottlenecks…

Community Level:• Water Distribution Issues: irregular and inadequate

supply, Pipe line leakages, no caps fixed on air walls, new taps not replaced timely in place of old taps, improper chlorination, water testing reports not sent to GP, Color coding of water sources not done, Krishna water and ground flow in one pipe only (mixing of water)

• No awareness on safe drinking water – Krishna water using for cooking and RO water for drinking

• Nutrition - improper distribution/lack of supply - milk, egg, fruits, full meal (children & pregnant women) – a month’s supplies are dumped at a time – leading to rotting.

• Health system: no referrals for re-surrective surgeries•  • No review done at GP

Pipe Leakage at Munugodu village opposite Govt High School

Major Bottlenecks…

• Capacity building of front-line workers - ASHA, AWW, VHSC,VWSC Teachers, SMCs, GP ward members 

• Awareness & SBCC - Drinking the same water in the fields/work sites

• No surveillance and listing of RO plants

• Schools, Aangan Wadi Centers, Model schools, Kasturiba schools, Residential hostels – Lack of access to safe drinking water – spread of water borne disease like diarrhea • No coordination between Krishna water lineman &

village waterman• Field Testing Kits (FTKs) – not put to proper use • Some of the Testing Labs – do not have Ion

Meters and reagents

Primary School, Sivannagudem,Marrigudem

Major Bottlenecks…

Mandal/block Level:• Fluorosis mitigation is not an agenda item in Mandal level meetings

even in severely affected mandals• Mandal level planning, review, monitoring is absent • No accountability at the mandal level• Data gaps and implementation gaps not attended at mandal level • Public representatives willing to involve in planning at the mandal

level, but there is no space for them • DFMC involved only at district level coordination

Major Bottlenecks…

District Level: • Absence of Intra-departmental and inter-departmental review • Every dept says there is no budget for F activities • 10 bedded Fluorosis ward in Head Quarters Hospital –non

functioning • Disabled Certificates in SADAREM Camps are not issued on time &

proper assessment of disability not done, inordinate delays • Convergence is brought by DFMC & it has to go a long way in term of

resource sharing • Involvement of Zilla Panchayat is not there • NGO/CSOs engagement

Suggested Model…

• Setting relevant performance indicators for R & M• Constant feedback from various level-

GP/Com/PHC/CHC/Mandal/District /State/National /media• Credibility of information• Sustainability process• Incentives • Role for other key stakeholders• Documentation of media information

Suggested Model…

District Level

State Level

National Level

Community Level

PHC/CHC

Mandal/Block Level

Suggested Model:

Community Level:• Monitoring & Surveillance by NGO/CSOs• PRI Functionaries, village water man • VWSC/VHSC/SHGs/Youth,SMCs• ASHA, AWWs• School Teachers,

PHC/CHC Level:• Medical functionaries – Doctors• AHSA, AWWs• VHSC/VWSC/SHGs• Referrals

Suggested Model…

Mandal/Block Level:• Mandal Development Officer• Public Representatives: MPP, MPTCs, GP Sarpanches• Line Departments • NGOs/CSOs/SHGs

District Level: • District Collector• Heads of line departments, point persons• District Consultant –NPPCF, District Nodal Officer-NPPCF• NGOs/CSOs,• Other stakeholders – technical & support agencies

Suggested Model…

State Level:

• NPPCF – State Nodal Officer, District Nodal Officer, District Consultants• Key stakeholders & line departments• District Collectors• ZP-CEOs and Chairpersons• MDOs& MPP• NGO/CSO representatives• Public Representatives –MLAs,MP, ZP Chairpersons• Involvement of technical, resource agencies

National Level: • Inter-state coordination• Involvement of technical, resource agencies • NGOs

Tools for Effective R& M

Rehabilitation Centers at endemic areasMIS & MESystems

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THANKS