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Study Team. Bella Patel Uttekar Nayan Kumar Vasant Uttekar Jashoda Sharma Shweta Shahane
- Whitney Watkins
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2 Study Team Bella Patel Uttekar Nayan Kumar Vasant Uttekar Jashoda Sharma Shweta Shahane
3 PREFACE JSY, Janani Suraksha Yojana, is an integral component of the National Rural Health Mission, launched in April JSY aims to reduce maternal and neo-natal mortality by promoting institutional deliveries, focusing on women living below the poverty line (BPL). Another core strategy of the NRHM is to have a female Accredited Social Health Activist (ASHA) for every village with a 1,000 population to act as an interface between the community and the public health system. As a volunteer she receives performance-based compensation for promoting a variety of primary health care services such as referral and escort services for institutional deliveries, universal immunization, DOTS treatment for tuberculosis or construction of sanitary toilets. In response to a request by the Ministry of Health and Family Welfare (MoHFW) to assess JSY in West Bengal, the German Technical Cooperation (GTZ) partnered with the Centre for Operations Research and Training (CORT) to conduct the study. The aim was to assess the current status of the ASHA intervention and JSY in three districts of Assam, Jorhat, Goalpara and Nalbari. The present report documents the findings of the assessment, highlights evidence of success as well as points out areas that need to be addressed in order to further improve JSY. This document aims to provide useful information for policy makers and programme managers at the national and state levels for further strengthening the scheme as well as to develop training and IEC strategies and campaigns. It may also be pointed out here that the study was conducted in the initial stages of the programme being implemented in the state, which has been undergoing modifications, and the situation remains dynamic. As far as possible we have tried to incorporate all the themes, but in case of any lapses we are responsible for the same. We are very grateful to Mr. K. D. Maiti, Director, Ministry of Health and Family Welfare for his valuable inputs in framing the questionnaire and analyzing data. We would also like to acknowledge Dr. Dinesh Baswal, ASHA Training Coordinator at national level and Dr. J. B. Ekka, NRHM Mission Director and Dr. A. C. Baishya, Director North-East Regional Resource Centre, Assam, CMO of the selected districts and Managers of DPMU for all the support extended by them. At the outset, we take this opportunity to thank the GTZ Health Sector Support (HSS) for having entrusted the work of conducting the assessment to CORT. Our sincere thanks are due to Dr. J.P. Steinmann, Principal Advisor Health, Dr. Paula Quigley, Program Advisor, Ms. Judith Buesch, Project Manager, and Dr. Urvashi Chandra, Technical Specialist, for the cooperation extended to us during the various stages of the study. We appreciate their inputs in helping us develop the research tools, in administering the study in the field and commenting on the draft report. We are especially thankful to Ms. Judith Buesch and Dr. Paula Quigley for their meticulous work, quick replies and immense patience. We thank our respondents officers at the state, district and block levels, trainers of ASHA, PRI members, members of CBOs, ASHAs, ANMs, community members and of course the JSY beneficiaries without whose cooperation it would not have been possible to complete the study successfully. I wish to put on record my deep appreciation for Dr. Bella Patel Uttekar, the Principal Investigator of this project, and all the team members for contributing their might in the success of this project and thereby ensuring quality. Prof. M. M. Gandotra, Director Centre for Operations Research and Training (CORT), Vadodara
4 CONTENT Executive summary... i-vi Chapter 1: Introduction Background... 1 Objective of the study... 2 Study design... 3 Study area... 3 The sample... 3 Interviews of ASHAs... 4 Interviews of beneficiaries of JSY... 4 Other stakeholders... 4 Study tools... 5 Field operations... 5 Ethical considerations... 5 Data management and analysis... 5 Presentation of the report... 6 Chapter 2: Operationalization of ASHA Intervention and JSY in Assam State scenario... 7 Adaptation and operationalization of ASHA intervention... 7 Programme management processes... 8 Selection of ASHAs... 8 Training of ASHAs... 9 Adaptation of JSY guidelines and its operationalization Linkages and integration Accreditation of private institutions Monitoring and supervision Community s perception about ASHA and JSY Chapter 3: Involvement of ASHA in JSY Background characteristics of ASHA About ASHA: Their selection and motivation to work Training of ASHA Quality of Training... 21
5 Payments during training...22 Use of reading materials...22 Knowledge of ASHA about ANC and child care services...22 Pregnancy, delivery complications and actions...23 Knowledge about newborn care...24 Knowledge about responsibilities of ASHA...24 Organization of work by ASHAs...25 Availability and utilization of drug kits...26 ASHAs role in JSY...26 ASHAs awareness about cash assistance under JSY...27 Promoting JSY...27 Accompanying JSY cases and arranging for institutional delivery...28 Cooperation and cash assistance payment to JSY beneficiaries...28 Handling of delivery at natal place...29 ASHA s views about preference for home delivery among women...29 Beneficiaries of ASHAs...30 Networking of ASHA The role of other stakeholders...31 Panchayati Raj Institute...32 NGOs/CBOs...33 Block officials...33 Incentives received as ASHAs...34 Supervision and monitoring of ASHA...35 Opinion about the ASHA component...35 Difficulties and challenges faced by ASHA...36 Chapter 4: Beneficiaries of JSY in Assam Background information of JSY beneficiaries...39 Awareness about JSY Process of registration under JSY Utilization of ANC services by JSY beneficiaries Role of ASHAs in micro-birth planning...41 Intention versus actual place of delivery...42 Impact of JSY on institutional delivery...42 Motivation and decision making for institutional delivery...43 Process of arranging transport...43 Difficulties faced in reaching the place of delivery...44 Persons accompanying JSY beneficiaries to the health institution...44 Quality of services available at the place of delivery...44 Payments incurred for services at the health centre...45 Satisfaction with the services at the place of delivery...45
6 Persons who assisted delivery at home and views about TBA Child mortality Dynamics of delivery at home Who prefers delivery at home? Mode of payment and difficulties faced Use of cash assistance received for delivery Appreciation of JSY by the beneficiaries Role of ASHAs in helping JSY beneficiary Complications during delivery Chapter 5: Evidences of Success, Challenges and Policy and Programme Implications Programme management ASHA s contribution Cash assistance Increasing institutional delivery Community perceptions about ASHA and JSY Challenges Competency of ASHA Increasing institutional deliveries Lack of facilities Cash assistance Policy Implications Policy Programme management Demand generation Appendix 1: ASHAs tables Appendix 2: JSY tables
7 LIST OF TABLES Table 1.1: Sample covered for qualitative and quantitative components in Assam... 4 Table 2.1: Number of JSY beneficiaries by place of delivery from service statistics in Assam up to March Table 2.2 Number of ASHAs selected and trained in Assam up to January Table 2.3: Mother s cash assistance package for JSY beneficiaries in Assam Table 4.1: Intention versus actual place of delivery, Assam Table 4.2 Shift in the place of delivery before and after JSY, Assam Table 5.1 Table 5.2 Motivation factors leading to institutional delivery as against intension, Assam Pregnancy expenditure including cost incurred during ANC period, transport and delivery as against the amount received by JSY beneficiaries, Assam... 58
8 LIST OF FIGURES Figure 3.1: Scoring knowledge of ASHAs in Assam Figure 3.2: ASHAs awareness about her responsibilities Figure 3.3: Networking of ASHA with stakeholders Figure 4.1: Time when the beneficiary heard about the JSY Figure 4.2: Sufficiency of cash incentives as perceived by JSY beneficiary Figure 4.3: Role of ASHAs in helping JSY beneficiary... 49
9 APPENDIX TABLES Appendix 1: ASHAs Tables ASHAs interviewed in Assam Table A1: Profile of ASHAs in Assam, Table A2: Work history of ASHAs in Assam, Table A3: Number of living children and place of previous delivery for ASHAs in Assam, Table A4: Source of information and selection of ASHAs in Assam, Table A5: Topics covered and arrangements made in the training of ASHAs in Assam, Table A6: ASHAs views on logistic arrangements at the place of training, Assam, Table A7: Views about the training among ASHAs in Assam, Table A8: Payments received during training by ASHA in Assam, Table A9: Utilization of guidelines by ASHA in Assam, Table A10: Scoring of knowledge of ASHAS in Assam, Table A11: Knowledge of ASHAs about ANC care in Assam, Table A12: Knowledge about complications during pregnancy among ASHAs in Assam, Table A13: Knowledge about common complications during pregnancy / delivery that can result into death of a woman, Assam, Table A14: Knowledge about immunization and child care among ASHAs in Assam, Table A15: Responsibilities, recognition and feelings about being an ASHA in Assam, Table A16: Functioning of ASHAs in Assam, Table A17: Knowledge about care for pregnant women, Assam, Table A18: Availability and utilization of drug kits by ASHAs in Assam, Table A19: Awareness about JSY and its benefits among ASHAs in Assam, Table A20: Cash assistance available under different schemes for ASHA and JSY beneficiaries in Assam, Table A21: ASHA s role in promoting JSY in Assam, Table A22: Role of ASHAs in accompanying JSY cases and arranging for institutional delivery in Assam Table A23: Average time taken to reach the institution by distance of the facility from residence of JSY beneficiary, Assam, Table A24 Cooperation and cash assistance received at the place of delivery as perceived by ASHA in Assam Table A25: Handling of women visiting natal place (other village) for delivery in Assam, Table A26: Reasons for preferring home delivery despite cash assistance for institutional delivery, Assam,
10 Table A27: Brief details of ASHA s interaction with her last client in Assam, Table A28: Details of ASHAs when last accompanied women for delivery in Assam, Table A29: Networking of ASHAs with other stakeholders in Assam, Table A30: The roles of other stakeholders in the implementation of ASHAs in Assam, Table A31: Process of receiving cash incentive money as ASHA in Assam, Table A32: Average amount received from government (other than training) by ASHA in the last three months Table A33: Reported satisfaction with the cash incentive in Assam, Table A34: Supervision and monitoring of ASHA in Assam, Table A35: Knowledge and opinion of ASHAs about their work with the government in Assam, Table A36: Suggestions of ASHA for further strengthening their work in Assam, Table A37: Difficulties and challenges faced by ASHA in carrying out activities in Assam, Appendix 2: JSY Tables Coverage of sample in Assam Table J1: Background information of JSY beneficiary, Assam, Table J2: Source and type of information heard about JSY, Assam, Table J3: Process of registration, Assam, Table J4: Awareness about index pregnancy, Assam, Table J5: Contacts with health personnel during index pregnancy, Assam, Table J6: Frequency and place of antenatal check-ups during index pregnancy, Assam, Table J7: Persons who motivated JSY beneficiaries for antenatal check-ups, Assam, Table J8: Persons who accompanied the beneficiary and cost incurred for ANC visits, Assam, Table J9: Reasons for not seeking ANC services, Assam, Table J10: Role of ASHA to JSY beneficiary during index delivery, Assam, Table J11: Intentional and actual place of delivery among JSY beneficiaries, Assam, Table J12: Intention versus actual place of delivery, Assam, Table J13: Shift in the place of delivery before and after JSY, Assam, Table J14: Process of arranging transport to reach health institution, Assam, Table J15: Difficulties faced in reaching the place of delivery, Assam, Table J16: Persons accompanying JSY beneficiaries to the health institution, Assam, Table J17: Quality of services available at the place of delivery, Assam, Table J18: Payments made for services at the health centre, Assam, Table J19: Satisfaction with the services at the place of delivery, Assam, Table J20: Persons who assisted delivery at home, Assam,
11 Table J21: Views about TBA, Assam, Table J22: Perceived reasons for women to deliver at home despite cash assistance paid under JSY for institutional delivery, Assam, Table J23: Background information of JSY beneficiaries, Assam, Table J24: Contact with health personnel during index pregnancy by place of delivery, Assam, Table J25: Utilization of ANC services during index pregnancy by place of delivery, Assam, Table J26: Payment made to JSY beneficiaries, Assam, Table J27: Difficulties faced by JSY beneficiaries in getting cash assistance for delivery, Assam, Table J28: Opinions of beneficiaries about JSY in Assam, Table J29: Complications during index pregnancy, Assam, Table J30: Profile of last and last but one child, Assam,
12 EXECUTIVE SUMMARY Towards achieving the objectives of the National Rural Health Mission (NRHM), Janani Suraksha Yojana was launched in April 2005 to promote institutional deliveries among the BPL population through provision of referral, transport and escort services. JSY integrates cash assistance with delivery and post delivery care for women to have healthy outcomes of pregnancy and childbirth. The NRHM aims to have a villagebased female Accredited Social Health Activist (ASHA) in 18 high focus states, which are low performing with respect to institutional deliveries, to act as the interface between the community and the rural public health system and negotiate health care for poor women and children. ASHAs would reinforce community action for universal immunization, safe delivery, newborn care, prevention of water borne and communicable diseases, improved nutrition and promotion of household toilets. They would inform, interact, mobilize and facilitate improved access to preventive and promotive healthcare, and have drug kits to provide basic curative care. The Ministry of Health and Family Welfare (MoHFW) decided to undertake an assessment of JSY. The Centre for Operations Research and Training, CORT, based at Vadodara conducted this assessment of the JSY for GTZ and the MoHFW to understand the process of implementation of the programme, involvement of ASHAs and experiences of JSY beneficiaries. This report is based on the qualitative and quantitative assessment of JSY in Assam covering three districts of Goalpara, Jorhat, and Nalbari. Using semi-structured study tools, 181 ASHAs and 240 JSY beneficiaries were interviewed through a quantitative survey. In-depth interviews were conducted with key persons associated with the implementation of JSY. Implementation of ASHA Intervention and JSY As per the national guidelines, with 18 percent institutional deliveries as per NFHS-2 Assam is categorized as a low performing state. The implementation of the ASHA intervention is taking place in a phased manner; in phase 1, eleven districts were covered while the remaining 13 districts would be taken up in phase 2. Around 26,000 ASHAs, one for every 1,000 population, were required. In 11 districts of phase 1, selection and first round of training of ASHAs was completed by January The selection process and training of ASHAs in 12 districts of phase two was ongoing at the time of fieldwork. At the state level, the State Programme Management Unit (SPMU) supported by the North-East Regional Resource Centre gives directives to implement the programme. At the district level, District Programme Management Units (DPMUs) implement the trainings and programme activities, monitor the programme and bring in intersectoral convergence. A team comprising of Block Medical Officers, Health Supervisory staff, District public Health Nurse, and NGOs was involved in implementing the scheme at block level. At the village level, under the leadership of sarpanch, ANM, AWW and ASHAs worked together to provide ANC and PNC services. ASHAs were paid performance-based payment of Rs. 600 under JSY by the ANM of the concerned sub-centre and PRI.
13 Centre for Operations Research and Training, Vadodara Besides, they were paid under the respective national programme as per the services provided by them including family planning, DOTs treatment for tuberculosis, and promotion of sanitary latrines. JSY is administered by the state JSY nodal officer. CMO and BMO in-charge are responsible for JSY intervention at district and block level. The scheme was publicized widely through print and electronic media, however, TV propaganda cannot be viewed as the ideal means to promote the scheme as only 56 percent households in rural areas have access this medium, even less so with the target group of JSY, the BPL population. Newspaper advertisements were circulated in local language showing the roles and responsibilities of ASHAs. ANMs, Anganwadi workers and ASHAs worked for creating awareness about the scheme. Organizing immunization weeks and Village Health Days is used as a conversion point where AWW, ASHAs, ANM, PRI, SHGs, and NGOs work together on issues related to health and development of the village. Instead of offering JSY benefits to only BPL women Assam decided to give cash assistance to all pregnant women delivering in Government health centres like subcentres, PHC, CHC, FRU and general wards of District and state hospitals or accredited private institutions are eligible for getting JSY benefits of Rs. 1,400 if from a rural area and Rs 1,000 for those belonging to urban areas. Further, BPL women delivering at home receive Rs PRI managed untied fund of Rs. 10,000 at the Village Panchayat level along with ANMs. The process of accreditation of private institutions has just begun and partnership with existing Tea Garden and Red Cross hospitals is being sought. Monitoring and supervision is happening at all levels, with DMUs playing a key role. Yet, there is a need to develop a simple and sustainable monitoring system. Involvement of ASHA in JSY Most of the ASHAs are middle-aged, educated and married staying in the same village where they were functioning. Seventy percent of the ASHAs belonged to SC/ST or other backward classes. Of the 181 ASHAs interviewed, one-fourth of the ASHAs did not fulfill one or the other eligibility criteria. Before JSY, 68 percent of the ASHAs had opted to deliver their child at home. On average, the respondents worked as ASHA for 7.4 months. The study shows that 26 percent of ASHAs did not receive any payment until the date of survey. On average, ASHAs who were paid received Rs monthly from working as ASHA. Forty-six percent of the respondents first came to know about the ASHA from ANM and 13 percent from Gram panchayat. Hoardings, pamphlets, radio, TV, health personnel, anganwadi workers, and Sugam workers also informed them about the ASHA. ANMs, sarpanch, local political leader, mahila samiti, PHC staff and sugam worker also played a role in selection of ASHAs. In most cases (76 percent) Gram Sabha approved their name. The main motivation for being an ASHA was to serve the community (90 percent), save the children (57 percent), earn money (56 percent) and remove misconception (24 percent). ii
14 Executive Summary In Assam, training of ASHAs was done, on average, 7.2 months ago for seven days. Most (94 percent) of the ASHAs attended trainings conducted at PHCs, while logistic arrangements were poor. Food arrangements accommodation and sitting arrangements need to be improved. However, ASHAs appreciated the training sessions and regarded trainers and training methods as good and useful. However, only 77 percent of the ASHAs received their allowance during training and only 14 percent of the ASHAs received the total due amount. On average, they received Rs Informal discussions with the stakeholders revealed that the ASHAs were given transport allowance depending on the distance they travelled (instead of Rs. 100 irrespective of the distance travelled as per the guidelines). Ninety-four percent of the ASHAs received reading materials/guidelines while 75 percent of them were largely able to follow the materials. Seventy percent of the ASHAs scored Grade A or O for answering 8-10 out of 10 questions correctly. Scoring knowledge of ASHAs in Assam Grade A Grade 45% 'O' 25% ASHAs claimed to know about complications during pregnancy, but only percent talked about weak or no foetal movement and abnormal position of the foetus. In such situation, ASHAs said that they would Grade C 5% Grade B 25% immediately refer the pregnant woman to the nearest functional FRU or accompany them, while surprisingly 48 percent said that they would ask the pregnant woman to consult the ANM the next day. ASHAs mentioned that their main responsibilities were to support the immunization programme (85 percent) and accompany delivery cases (82 percent). While every second ASHA mentioned registration of birth and death, provision of ANC care, awareness creation on health and every third ASHA mentioned working with ANM/AWW, awareness creation regarding basic sanitation and hygiene, and mobilization of the community to utilize health services as their responsibilities. Family planning, village health planning, counseling, promoting good health practices and providing basic curative care were mentioned by few ASHAs. ASHAs visit house to house (98 percent), besides attending immunization session and accompanying women for delivery. ASHAs provided constellation of services and played a potential role in providing primary medical care as their last client came seeking services related to get advice about place of delivery, immunization, ANC care, registration of vital events, for receiving IFA tablets, post natal care, and procuring spacing family planning methods. Eighty-eight percent of the ASHAs had accompanied an average of 4.4 JSY cases (ranging from 1 25) for institutional delivery, mainly to PHC and government hospital. ASHA accompanied the last case around 35 days ago and 80 percent of them stayed with JSY beneficiaries at the place of delivery. iii
15 Centre for Operations Research and Training, Vadodara ASHAs network with the various stakeholders in the village to implement JSY. All ASHAs met ANMs, followed by AWW (98 percent), PHC staff (87 percent) and PRI members (65 percent). They also met block facilitators, Village mandals, Health and Sanitation Committee, as well as NGO staff. Eighty percent of the ASHAs received some cash incentive money, mainly for attending JSY beneficiaries, antenatal care, immunization of children and DOTs treatment. The mean monthly amount received for attending JSY beneficiary in three months varied between Rs (ranging between ) and for immunization of children between Rs (ranging between ). Sixty-two percent of the interviewed ASHAs were satisfied or somewhat satisfied with the cash incentives mainly because they were able to serve people and received payment. Thirtyeight percent ASHAs were unsatisfied with the cash assistance as it was too much work and too little money (53 percent), or because of delay in payment (37 percent). ASHAs spent on average 3.9 hours every week in preparing various registers while their work was mostly monitored by the ANMs and MO PHC. Supervisory support from other officials was lacking. Beneficiaries of JSY in Assam The JSY beneficiaries were young (mean age, 23.8) and mostly those who had schooling up to primary, middle or secondary level. Fifty-two percent of the JSY beneficiaries belonged to SC/SC and 14 percent to the other backward classes. The average monthly family income of the JSY beneficiaries is only Rs It can be said that JSY reached to the socio-economically lower strata women covering poor segment of the society, as at least two-thirds of the JSY beneficiaries belonged to this group. The beneficiaries learnt about JSY during various stages of pregnancy, however, nine percent learnt about the scheme only after delivery. The majority of beneficiaries (77 percent) got registered in the first or second trimester, and on average, women had 4.4 antenatal check-ups during their index (JSY) pregnancy. Since ANC card showing that the women had taken full ANC is required for claiming payment of cash assistance, women ensured that they had at least 3 or more ANC check-ups done. ASHAs (71 percent) and husbands (50 percent) accompanied the beneficiary for ANC visit(s). Fifty-four percent of the women received antenatal care at PHC and another 22 percent at the sub-centre. The majority (83 92 percent) of JSY beneficiary received advice about diet, delivery care and newborn care and breast-feeding, but advice regarding danger signs and family planning was mentioned by only 71 and 48 percent respectively. Two-thirds of the beneficiaries were told about four or more aspects (out of 5) of micro-birth planning. The cross-tab of intention vs. actual place of delivery shows interesting results. Of the total JSY beneficiaries interviewed, five percent (n=12) women delivered at home though they intended to deliver institutionally because of lack of time and nonavailability of transport facilities. iv
16 Executive Summary Twenty-five percent of the total sample intended to deliver at home, out of which 16 percent (n=39) changed their mind and finally delivered in institutions because of Intended place for last delivery Institutional At home Intention versus actual place of delivery Place where last delivery of JSY beneficiary took place Institutional At home Total 70.4 (169) 16.3 (39) 5.0 (12) 8.3 (20) 75.4 (181) 24.6 (59) Total 86.7 (208) 13.3 (32) 10 (240) support provided by ASHAs (77 percent), safety of mother and child (36 percent), complications (26 percent), more facilities at the institution (21 percent) and previous child born in an institution (8 percent). Majority (76 percent) of the institutional deliveries took place in PHC and district/sub-district hospital. Among all the beneficiaries who opted for institutional deliveries support provided by ASHAs (81 percent), safety of both mother and child (38 percent), and cash assistance (31 percent), better care at hospital, and previous experience of complicated delivery were the motivating factors. Out of the 100 JSY beneficiaries who had two or more children, 57 percent of the previous deliveries were reported as home deliveries. Forty-three percent of the women with two or more children delivered their last (JSY) baby at the institution while 18 percent continued to prefer home delivery. Nevertheless, between two deliveries, 39 percent (n=41) of the beneficiaries shifted from home to institution due to support provided by ASHAs (n=32, 80 percent), safety of the child (n=18), cash assistance available (n=16) and better facilities at the institution (n=10). It shall be pointed out here that at the state level, as per the services statistics for April 06 February 07, 72 percent of JSY beneficiaries delivered in an institution, a very encouraging trend. The demand for institutional delivery calls for upgrading of the public health infrastructure to provide quality care, especially in the realm of subcentres and PHCs. In Assam, JSY beneficiaries had to travel, an average of 6.6 kms to reach the ultimate place of delivery. Women spent approximately 1 hour and 9 minutes to arrange transport and reach the ultimate place of delivery and another 40 minutes after reaching the institution on registration and administrative processes as well as waiting time until someone attend to them. Thirty-seven percent of the JSY beneficiaries did not receive their cash assistance, while 99 percent of those who received cash got payment in one go (but much later or a week after the delivery, 77 percent) from the CHC/PHC MO, accountant or ANM. The JSY beneficiaries spent an average of Rs during ANC period, Rs for transportation to the place of delivery and Rs for delivery, against which they received an average of Rs. 796 from the government as cash assistance. The study evidently shows the cash assistance is not enough to cover all the expenses for institutional deliveries with women spending a substantial amount out of their own pockets. For those, who delivered at home, only 6 percent had negative balance and others gained Rs. 30 on average. While in the case of institutional deliveries, 70 percent spent more than what they received and on average, those who had v
17 Centre for Operations Research and Training, Vadodara institutional deliveries spent Rs additional to the cash assistance. A JSY beneficiary said, it is better to deliver at home as we get Rs. 500 against no expense, whereas in the case of institutional delivery we spend more than what we get. Fortyfive percent of the JSY beneficiaries felt that the cash assistance received was not sufficient. While JSY is evidently reaching out to poorer segments of society it can be assumed that the poorest of the poor cannot take advantage of the services simply because their economic situation leaves them with no option but to opt for home deliveries. It is encouraging that husbands and ASHAs each accompanied the majority (83 percent) of women for delivery. Other family members, mothers, mothers-in-laws and neighbours also accompanied the women. On average, after normal delivery (n=186) women were discharged after 24 hours, for assisted delivery (n=13) after 36 hours and for caesarean (n=6) after 7 days. Most of the women were satisfied with JSY and would recommend relatives or friends/ neighbours to benefit from it, mainly because of courteous hospital staff, clean health facilities, counseling received for breastfeeding/immunization, follow-up visits, newborn care/diarrhoea management and safety of children. JSY beneficiaries perceived that despite cash assistance paid under the JSY, women still prefer to deliver at home because of extreme poverty, hospital expenses, fear of doctors, and nurses, Illiteracy, lack of transport facilities, shyness and opposition from family members. On the success side, the process of programme implementation such as selection and training of ASHAs has progressed well as per plan, and involvement of other parallel departments, PRI, and AWWs is evident. The state needs to nurture and further intensify this network. In Assam, ASHA s contribution is significant. They are enthusiastic and motivated to serve the community, save children and earn some money. They also got the opportunity to learn new things, move out of the village and meet many people. ASHAs have been able to generate demand and mobilize clients for reproductive and child health services. ASHAs informed women about JSY, contacted them first, registered for JSY, advised during pregnancy, explained benefits of institutional deliveries, and accompanied women for institutional deliveries. Fiftynine percent of all interviewed beneficiaries said that it was actually the ASHA who decided to go for institutional delivery on behalf of the JSY beneficiary, while 37 percent of ASHAs arranged for transport and 83 percent accompanied women to the health institution. Beneficiary interviewees would also recommend JSY to others. The communities have heard about the scheme but lack knowledge about its detail. It can be said that JSY has shown impact in Assam. However, the quality of care at the hospitals and particularly at PHC and sub-centres needs to be improved to provide services for normal deliveries. The state needs to reach the unreached and motivate the poorest of the poor for institutional delivery by proper campaigning, addressing their fears regarding hospital setting and staff, making arrangement for transport and making due payments on time to the beneficiaries. vi
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Warning: This blog may contain minor spoilers for those not up to date with Fairy Tail's Manga. It's only certain characters you may not know about but anyway just be careful as these guys sound pretty cool.
Even stronger then Jura... now that's something. Also what you are about to read is probably crap. You have been warned.
Now for the real message
It's good to be back, who missed me?... Anyone? Really? Not a single person? Oh come on! Anyway I made a little play below inspired by the newest chapter (please take note of the date to avoid confusion). Well the reason for this is that I got bored after my exams and going into town, to celebrate the end of my estimate exams in an attempt to wash away our sorrows, so I fought I make a little something to signal my return. Anyway I hope you enjoy the crappy piece of crap below. There are also some ideas I had if you want to give them a read to.
|Death of a Sales-God
|The following events take place after the closing of the Grand Magic Games arc. We see Lahar of the Magical Council's Custody Enforcement Unit sitting in his office working through some paperwork he had left over. Outside, it is dark as rains falls like the world is weeping because of a great tragedy. Suddenly the Communication Lacrima on Lahar's desk receives a message.
Communication Lacrima: (urgently and stressed) Lahar? Are you there? Lahar!?
Lahar: (slightly worried) Hmm, I wonder what this could be about.
The Lacrima flickers as a picture of Doranbolt's sweaty and fearful face appears.
Doranblot: Lahar, you have to come to us quickly the unthinkable has just Happened! We need you down here now!
Lahar: Calm down Doranblot, you're speaking too fast. Explain to me fully what has happened.
Doranbolt: (with a worried and saddened look on his face) It's the deities from Ishval. They've been...
Lahar: (shocked) No it can't be... That's ridiculous...
Doranbolt: I'll be there to take you to the scene shortly. I hope you have a strong stomach...
Lahar falls back into his chair, horrified by the news had just heard.
Lahar: That's just insane... Somebody couldn't have done this, not alone. I can't believe they're really dead...
Lahar and Doranbolt arrive in a large room decorated with prestigious items and magnificent paintings. A number of council mages scattered looking for evidence. In the centre is a large table covered in delicious food and fine silverware all stained in blood. A body lies on the ground, covered by a large sheet to hide the mess. Smeared across above the fireplace is blood which makes out the saying "There is only one true God, Ishvala."
Doranbolt: As you can see each of them were killed in different rooms yet the conditions of the bodies are all the same. It appears the murderer was able to separate each of them and take them out one by one, avoiding direct confrontation with each of the four Saints.
Lahar: (worried) What do you mean murderer? You're saying one single person did this?
Doranbolt: Apparently so. They were having a meal between themselves to discuss affairs I am currently unaware of; however one of the servants witnessed the murder in the upstairs bathroom. The murderer appeared to have snuck in unnoticed through an upstairs window left open from when he entered. The servant saw the murderer's first victim as he left the bathroom and was gasped around the mouth with the murderer's right arm. The servant, fearful for her life, hid as fast as he could while the rest was quickly taken out.
Lahar: So we have a witness?
Doranbolt: Yes, the woman over there. She just witnessed something horrible so we have to leave the full questioning for later but we were able to get a brief summary of what she was doing before and what murderer looked like, before she went into hiding. Poor thing was so terrified she couldn't even scream all she could do was run and hope for her own safety.
Lahar: (slightly annoyed) Alright then... let's get a look at the bodies. I want to see if there any clues to how they were killed.
Doranbolt: (worried, while trying to convince Lahar otherwise) Are you sure about this? You are aware that this might be too much for you.
Lahar: (determined) I'm fine, we've seen many things during or work so I think I can handle this.
Doranbolt: (hesitant) ...Very well.
Doranblot lifts the cover off the corpse, revealing the bloody figure in pieces. One council mage in the background vomits at the sight of what's left of the corpse.
Lahar: Somebody get him out of here and while you're at it give him a glass of water too! We can't have men react like that on this scene, but to be honest I can't blame him. To think somebody is capable of making such a mess to mages of their caliber.
Doranbolt: They were in pieces... or getting that way... as if they were blown apart from the inside.
Lahar: (with a fearful look on his face) You don't think that Zeref could be behind this?
Doranbolt: (swallowing his fear) I've seen his magic... though the victim end ups in the same result as these guys, Zeref's powers are instant... The only similarity is the result of death. Also I believe they would have sensed such a massive amount of magic and the description just doesn't match that of the Zeref I saw all those years ago.
Lahar: Sense the magic... (horrified) are you implying that the murderer didn't have any form of magic? This couldn't have been done with mere weapons... just look at this body, the mess is too great and I don't even think weapons would have worked on these guys knowing their power! How could this happen! Doranbolt: Yes, I think we're dealing with something completely different here...
Lahar: ...This is ridiculous. What does the murderer look like and how can he do such a thing...?
Doranbolt: Not much is given but apparently he is a rather tall muscular man with a dark complexion but, most noticeably is his red eyes and large X-shaped scar across his forehead... it looks like a religious attacked if anything and for all I know his powers are something that should be taken lightly...
Meanwhile under a street lamp in an unknown location a large dark complexioned man with a scar on his forehead stands beside a young man with short hair in the rain.
Scarred Man: So the heretics are eliminated... to think somebody could stray so far that they would even claim themselves to be gods... Such a disgrace.
Young Man: Well with what they've done it doesn't surprise me. At least the world will be better off without them. Some of things they were allowed to get away with and the council just turned a blind eye to it all. Do you truly believe they deserve forgiveness?
Scarred Man: That's not for me to decide. All I can say for them is that they are at the mercy of God. Four new souls have returned to him.
Young Man: Pfft, if you say so. I don't get why they are considered Gods anyway. If anything they should be known as "devils" instead of "deities". What a joke. Scarred Man: One thing I must ask you though. Young Man: Well if I answer that then you have to answer mine.
Scarred Man: Very well, now tell me what other reason did you have for wanting me to eliminate these so-called deities? You're not the kind to go out your way and plan such an act just for the sake of it?
Young Man: Huh, so you figured it out? Well let's just say I'm helping a "friend" work his way to the top. Now my turn, a man such as yourself has gone through a lot and must be someone of interest. What I want to know is that man's name.
Scarred Man: Well I can't say I have one; people just label me as Scar.
Young Man: Interesting enough but I guess we're quite similar in that case.
Scar: How so?
Young Man: Well people here seem to label me as Kong.
Now here are a few extra's if you want to have a read of them as well.
|The Best Sitcom Ever!
|Scar: Huh, by the way didn't you think it was a bit much to write that message on the wall?
Kong: (confused) What message?
Scar: The one in blood.
Kong: I have no idea what you're talking about. I just needed to check if they were actually dead.
Scar: Then who was it?
Then out of the darkness, a b*tch appears.
Minerva: It was me of course.
Everybody: Oh Minerva, you sadistic b*tch.
The audience laugh and applaud as the screen rolls on to the credits.
Make sure to tune in next week to see how Minerva deals with cooking a dinner for her hot date! Who knew children tasted on B*tches Be Crazy!
|The Council Really are Useless
|Suddenly Doranbolt and Lahar walk on to the street. They notice the two men in the distance.
Doranbolt: Wait as second that man describes the description of the murderer! We need to stop him!
Lahar: Don't worry, I have a plan.
Doranbolt: Let's hear it them.
Lahar: We are going to stand and watch him walk away.
Doranbolt: S... se... seriously?
Lahar: What? It worked with Jellal on the third day of the GMG.
Doranbolt: Oh for the love of God! We have been over this so many times before! That was the most stupid decision of your career!
Lahar: You're just Jealous because you didn't think of it first.
Doranbolt: You let the country's worst criminal just walk away! How was that a good idea!
Lahar: Well why didn't you chase after him then?
Doranbolt: It's Jellal! The man who deceived the council and constructed the Tower of Heaven! I couldn't take out a stripper and a sex pest, how do you think I would fair against... you know screw this I'm going to get drunk again.
Doranbolt then teleports to a bar and begins drinking to his heart's content. He later found himself in a similar situation like that movie, Dude Where's My Car? That was a funny movie.
Lahar: (feeling smug a the potential suspects leave off to their next killing spree) Hehehe, I always win.

subset: commoncrawl


text:
About the Book
Features & Details
- Category Wedding
Large Format Landscape, 13×11 in, 33×28 cm
66 Pages
- Publish Date Oct 05, 2008
- Tags Majorca, mallorca, mediterranean, Deia
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About the Creator
Sharon Boyse
Primrose Hill, London, United Kingdom
I work in the music industry, but am passionate about photography. I hate the posed pics that most people have, but like to capture the moments when people are behaving naturally, oblivious of the camera, but being themselves. Hope you like my photographs
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text: Peach Lady Ingredients Edit vodka peach liqueur orange and peach juices grenadine Directions Edit Mix the ingredients to prepare the cocktail, then serve it with ice. Retrieved from "http://cocktails.wikia.com/wiki/Peach_Lady?oldid=14380" Ad blocker interference detected! Wikia is a free-to-use site that makes money from advertising. We have a modified experience for viewers using ad blockers Wikia is not accessible if you've made further modifications. Remove the custom ad blocker rule(s) and the page will load as expected. Categories: Vodka recipes Grenadine recipes Peach liqueur recipes Peach juice recipes Orange juice recipes Add category Cancel Save


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You probably before now cognise that your credit, or FICO, win is premeditated independently by the Big Three commendation reportage agencies: Experian, Equifax, and TransUnion. However, utmost empire do not cognise almost the 4th Credit Agency and the large vigour it wields done whether you receive golden appreciation offers in the mail.
The 4th Agency that maximum population are not cognisant of is Innovis. This authority deposit comparatively down below the radar of common municipal consciousness because it does not resource an proper FICO rack up. (As you are aware, it is this valuation that lenders check when decisive your eligibility for golden tax on for mortgages, car loans, or new recognition cards). This evident removal of generic unexclusive fluency something like this 4th Agency certainly makes its influence done your business form potentially even more regnant.
Just like the Big Three agencies, Innovis keeps copious collection of any lost payments and other approval gen roughly speaking all U.S. consumers. However, they use the large indefinite amount otherwise than do the Big 3 Agencies. Here is how they operate:Post ads:
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Innovis compiles post lists for all mode of respect paper companies, security interest lenders, and separate monetary institutions. As constituent of their service, they use their own respect rating arrangement to filter out and remove the calumny and addresses of family they deems to be a respect danger from the mail lists of their monetary clients, regardless of what the FICO gain shows. Effectively, Innovis keeps favorable thanks offers previously earmarked for FICO score-qualified consumers out of their keeping by removing them from the post lists at the finishing insignificant. This is dispossessed for populace who may have errors on their Innovis thanks papers but do not even cognise that this news more or less them exists.
When this 4th Agency basic came on the scene time of life ago, they did not property any hearsay on their Web position to let consumers like-minded you to get their own Innovis commendation ranking. Presently, they do let consumers to do so, either via cellular phone or uniform letters. More niceties going on for order your word can be saved on their Web site: honourable hunt for their base camp via your favorite query motor.
By periodically ordering your thanks evaluation from the Big 3 approval agencies, you will be organized to argue any errors. In addition, I proposition going the ancillary pace and requesting you Innovis appreciation chalk up as resourcefully. By doing so, you will be aware of what could feat involving you and golden appreciation offers. And, you will cognize more than the majority of U.S. consumers do give or take a few this 4th bureau which rest for the most part a "secret" to this day.Post ads:
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