A postulate of Proposed Gujarat State Plan of Operation RCH Phase - II

By

Project Director RCH

The Process

• • • • • Constituting the State Design Team Adapting Successful Practices Using Marginal Budgeting for Bottlenecks (MBB) tool for Resource Allocation Resource Mapping Exclusive Method to analyse priorities

The State Design Team

• The design team consists of • Experts within Govt. set up & SIHFW • • • NGO representatives UN agencies’ representatives Experts from IIM Ahmedabad as invitees

Approach of GoG

• Addressing specific needs in concern areas of: • • Rural, Urban and Tribal Health Environmental Health as a vital issue • Role of adequate nutrition

Approach of GoG

• Focused Strategies: • Analysing components of IMR, MMR and TFR dealing with bottlenecks.

Approach of GoG

• Holistic Approach: • Balanced integration with inputs received in IPD, BDCS, EC Sector Reform

Approach of GoG

• Health and Human Development: • Thrust for Human Development to maximise reproductive health and not just adopting target oriented approach.

• Gujarat Vision 2010 • Strong commitment

Our Vision 2010

Health Indicators

Sr. No.

1 2 3 4

Indicator

Total Fertility Rate Life Expectan cy at Birth (Male) Life Expectan cy at Birth (Female) Maternal Mortality Rate (1992-93)

Current Health

3.0

61.5

62.8

3.89

2005

2.5

65 68 1.5

2010

2.1

71 75 Below 1

Sr. No.

5 6 7 8 9

Indicator

Infant Mortality Rate Under 5 Mortality Rate (1996) Children Immuniza tion Rate Couple Protection Rate % Institution al Deliveries

Current Health

60 20.4

54 54.5

55

2005

40 15 80 65 70

2010

16 Below 10 100 70 80

Sr. No.

1 2

Indicator Current 2005 Health Infrastructure

Sub – Centers 7274 7274 1100

2010

7490 (Rural) 1200 (Urban) 1229 3 4 Primary Health Centers Community Health Centers Functional FRUs 1054 254 44 260 100 307 307

Marginal Budgeting for Bottlenecks

• An effort to identify the strengths and weaknesses of implementation of RCH program by means of HH study, Monitoring and validation study and Facility study in 5 districts • All 3 studies in 40 clusters in each district

Marginal Budgeting for Bottlenecks

• • • HH study: identified 6 families with infant in a cluster MV study:15 PHC, 30 SC (1village in each SC) in 40 cluster area Facility study: BEmOC, BEmPaedC and FW at PHC, CHC, DH

HH study

• • 40 Clusters by standard cluster sampling tech • Proportional allocation for Urban and Rural Municipal Corporation not included

HH study

• Information for ANC, INC, PNC, Breast Feeding practices, Weaning, FW, Awareness for hygiene, nutrition, Home based management for fever and Diarrhea.

HH study

• • A teams of 2 FHW, 2 MPHS (M/F) and 1 MO for each cluster • 8 teams in each district x 5 days ( 1 for each cluster) = 40 Orientation of all teams at SIHFW

HH study

• • Pre-tested in field Participatory planning by District teams • Data of about 7000 families entered and results are awaited [some results are available but yet to be validated]

Monitoring and Validation Study (MV study)

• • • • Team of 2 PG of Public Health/ Community Medicine 3 Teams in each district x 5 days (1 PHC/ day) = 15 PHC Orientation at SIHFW with faculties of Medical Colleges Questions related to PHC infrastructure, FHW and TBA skills and availability, accessibility and use of services.

Monitoring and Validation Study (MV study)

• • • Observations and suggestions by teams are included Field tested and includes validation for records and beneficiary Overview indicates good skills but need for refreshing

Facility Study

• Initial plans for CHC and DH, PHC included later • Information specifically for BEmOC and BEmPaedC, scope for assessing skills of personnel • Could be done in one pilot district

Facility Study

• • Planned for other districts also Overview indicates need for filling up the posts and updating the skills • Field work: 16 –26 January 2004

Some findings of Marginal Budgeting for Bottlenecks

602 32% 144 8% 58 3% 12 1%

Household Water Source

1087 56% Pipeline in house Public tap Open Public Well Other Sources Public tap/ Hand Pump

214 13% 165 10% 198 12% 226 14% 80 5%

Time required for collection of water

545 32% 1-5 minutes 6-10 minutes 11-15 minutes 16-20 minutes 21-25 minutes 26-30 minutes 31+ minutes 242 14%

586 31% 40 2% 11 1% 7 0%

Types of Toilet Facility

1247 66% No facility Personal drainage line Public toilet with drainage Common drainage well Common drainage line

NO 23%

Ante-Natal Care Recieved

YES 77%

% Distribution of ANC Service Provider

4% 44% 52% Doctor Nurse Dais

Un-trained 43%

Training Status- TBA

Trained 57%

Pregnancy period wise % distribution of the first ANC check-up

After 6 months, 26.54

First 3 months, 42.6

4-6 months, 30.86

% distribution of ANC check up received in times

Four times +, 0.2346

Don't remember, 0.0062

One time, 0.253

Two times, 0.2962

Three times, 0.21

% Distribution as per services provided at first, second and third ANC examination

None Foetal Heart Sound Weight Measurement Blood Pressure Abdomen Examination ANC 1 6.24% 2.51% 91.25% ANC 2 3.54% 0.0088

9.73% 85.84% ANC 3 1.26% 0.0506

0.0633

1.26% 86.10%

% Distribution of ANC cases examined by nurses and doctors in Private and Government sector

14 PRIVATE GOVT.

78 86 DOCTOR % 22 NURSE %

Other information made available under MBB study

• • • PROVIDER OF INC PLACE OF BIRTH Cleanliness of Place of delivery, environment offered to the new born • PNC Provision, number of visits and their timeliness

Other information made available under MBB study

• • • • BREAST FEEDING AND TIMING • Breast Feeding and use of Colostrums Period of Breast Feedin Method of Washing Hands Use of Mosquito Net

Other information made available under MBB study

• • • • • • Amount of Food and Liquid Given to Child and Knowledge Quotient Diarrhea episodes Source of ORS Pack Place of Purchase of Medicine H/O fever episode and Blood Smear Taken Vit A instituted and its frequency

Priority fixing

• Diligent use of community based link couple for family and community level care in rural areas and for family and community level care in urban areas.

• Promotion institutional deliveries by providing incentive to TBAs.

Priority fixing

• Increase in institutional deliveries. Staff nurses would be engaged on contractual basis in all PHCs for round the clock services.

Priority fixing

• 100 facilities will be identified (from among District Hospital, Sub district hospital, community health centers and labeled as FRUs) and upgraded for provision of comprehensive emergency obstetric care, New born care, laparoscopic sterilization operation and MTP service

Priority fixing

• Up gradation of 250 facilities (from among CHCs/PHCs) for provision of basic emergency obstetric care, new born care, abdominal TL, MTP and STI/RTI services

Priority fixing

• Up gradation of 1500 facilities (from among PHCs/SCs) for institutional deliveries, FP services, NSV and basic newborn care.

• 250 centers to be developed to provide STI/RTI diagnostic and treatment facilities

Priority fixing

• Strengthening State Project Management Unit and District RCH society thorough employing resource persons, consultants and other necessary human resources.

Priority fixing

• Advocacy for issues of PNDT act, NSV, adverse sex ratio and gender mainstreaming through creating state level forum with active participation of NGOs and other institutions.

Goal/ Outcome/ Output/ Activities GOAL: IMPROVING QUALITY OF LIFE OF PEOPLE OF GUJARAT THROUGH MAXIMISING WOMEN AND CHILD HEALTH AND ACHIEVING POPULATION STABILISATION OUTCOME: 1 REDUCED NUMBER OF MATERNAL DEATHS OUTPUT 1: PROPORTION OF WOMEN WITH DIRECT OBSTETRIC COMPLICATIONS DELIVERING AT EmOC FACILITIES INCREASED

Strategic Intervention 1.1

Comprehensive Emergency Obstetric Care facilities are operational

Goal/ Outcome/ Output/ Activities

Strategic Intervention 1.2

Basic EmOC facilities are operational during programme period on 24x7 with trained medical officer and 2 staff nurses

OUTPUT 2: INSTITUTIONAL DELIVERIES ’ RATE IS INCREASED

Strategic Intervention 2.1:

Essential Obstetric Care facilities are made available

Strategic Intervention 2.2:

Referral Transport for routine deliveries and for Referral of obstetric emergencies by planned transport options

Strategic Intervention 2.3:

Community support system is developed by community

Strategic Intervention 2.4:

As per Janani Suraksha Scheme, provide monetary incentive to families and TBAs for accompanying pregnant women for deliveries at institutions

Goal/ Outcome/ Output/ Activities OUTPUT 3: UNIVERSALISE ANTENATAL COVERAGE FOR PREGNANT WOMEN

Strategic Intervention 3.1:

Ensure minimum 3 antenatal check ups of all pregnant women Involve ANM, TBAs, link couples and AWWs

OUTPUT: 4 HOME DELIVERIES ARE SAFE AND CLEAN (WHEREVER INSTITUTIONAL DELIVERIES ARE NOT FEASIBLE)

Strategic Intervention 4.1:

Remaining untrained TBAs are trained and skill attendance is encouraged for home delivered

Strategic Intervention 4.2:

TBA kits are periodically replenished

OUTPUT: 5 WOMEN RECEIVEIVING POST-PARTUM CARE ARE INCREASED

Strategic Intervention 5.1:

Contact on day 1, 2 and 7 and then at 6 th week and link with visits for neonates care for integrated mother-child care

Goal/ Outcome/ Output/ Activities

Strategic Intervention 5.1:

Conduct audit of maternal deaths in the community in transit or in the hospital

OUTCOME: 2 REDUCED NUMBER OF INFANT DEATHS Goal/ Outcome/ Output/ Activities OUTPUT: 1 IMPROVE CARE SEEKING AND REFERRAL OF SICK NEONATES WHO CANNOT BE MANAGED AT HOME

Strategic Intervention 1.1:

Improve facility-based care for complex newborn care with visiting specialist doctors, strengthen facilities and increase their utilization

Strategic Intervention 1.2:

Basic newborn care facilities are operational during programme period with trained medical officer and 2 staff nurses

Strategic Intervention 1.3:

Normal new born care is strengthened at all health care facilities through supply of essential life saving drugs, gloves etc.

Strategic Intervention 1.4:

Educate families, improve skills of AWWs, link couples and ANMs in diagnosing newborn sickness facilitate transport Community support system for referral of sick neonates is developed by village community

Goal/ Outcome/ Output/ Activities OUTPUT: 3 ROUTINE IMMUNIZATION AND OUTREACH SERVICES STRENGTHENED

Strategic Intervention 3.1:

Reaching out to every child through mobility support for ANM, strengthened cold chain and sterilisation facilities, and series needles through support fund

Strategic Intervention 3.4:

Strengthen Delivery System through refurbishing cold chain and sterilization equipment

Strategic Intervention 3.3:

Contracting ANMs on need base for outreach sessions and on specific vaccine days

Strategic Intervention 3.4:

Conduct social research/ participatory research with community and ANMs for increased efficiency of ANMs and immunisation

Goal/ Outcome/ Output/ Activities OUTPUT: 6 REDUCING THE GAP IN HEALTH SYSTEMS OF TRIBAL VS GENERAL PEOPLE

Strategic Intervention 6.1:

Orientation of Tribal Healers for childhood illnesses and their management through improved treatment seeking behaviours

Strategic Intervention 6.2:

Local folk artists of tribal areas are made capable of mobilising people to seek for treatment and understand childhood illnesses

Goal/ Outcome/ Output/ Activities OUTCOME 3: COUPLES HELPED IN ACHIEVING THEIR REPRODUCTIVE INTENTIONS OUTPUT 1: REDUCED CURRENT UNMET NEED FOR FP METHODS BY 75 % OF EXISTING LEVELS BY 2007

Strategic Intervention 1.1:

Comprehensive FP services with permanent methods of Sterilisation, NSV and spacing methods and safe MTP services are strengthened under one roof

Strategic Intervention 1.2:

Increased access to basic FP services of abdominal TL, safe MTP and IUD and other spacing methods Str

ategic Intervention 1.3:

Access to IUD insertion services improved at the sub centers and access to safe MTP services are increased

Strategic Intervention 1.4:

Access to non-clinical contraceptives increased through depot holders/link couples

Strategic Intervention 1.4:

Improved quality of care for client satisfaction

Goal/ Outcome/ Output/ Activities OUTPUT: 2 INCIDENT OF HIGH RISK SEXUAL BEHAVIOUR IN 15-49 YEARS REDUCED

Strategic Intervention 2.1:

Develop 250 health facilities (PHCs/CHCs) to provide quality RTI/STI case management

Strategic Intervention 2.2:

Awareness generated on RTI/STI/HIV-AIDS among adolescent and CBO members

OUTCOME: 4 URBAN POOR AND SLUM DWELLERS RECEIVE BASIC HEALTH FACILITIES FOR BETTER LIVING

Strategic Interventions:

Establish urban health centres in the towns not having any hospital, CHCs or PHC facilities Ensure staff, equipment and medicines are available at Urban Health Centres according to specifications Create community based female health volunteer to provide basic health services for minor illness and vaccinations

Resource Mapping

• Besides health statistics, it reveals: • • • • • Health and Medical Institutions Para Medical Training Medical Manpower Nursing Staff Various Health programmes in the State • • Workloads of FP activities Ongoing surveys of monitoring and validation and facility surveys will provide the latest information

Areas of concern

• • • • Rural Health Low utilisation Lack of maintenance Rural poor unable to afford Medical expenses • Lack of education/ awareness

Areas of concern

• • Inadequate blood banks Paucity of well organised referral system • • Urban Health Convergence of Health and Urban Dept.

• Poor Health Status of slum dwellers

Areas of concern

• • • • • BPLs unable to secure basic necessity and medical facilities Lack of planned efforts Over crowding of secondary and tertiary care In adequate infrastructure Environmental Health

Areas of concern

• • • • Difficulty in quality and quantity of ground water supply Excessive salinity, fluorides, nitrites in water Concentration of chemical industries Improper treatment of biomedical wastes

Areas of concern

• • • • Natural and man made disasters Irrigations Nutritional Health % relying on exclusive breast feeding is less

Areas of concern

• • Disparity in Nutritional status in various income levels • Poor awareness of healthy/ nutritious food More focus still requires in under 2 years and the lactating ones

Method Adopted to Analyse Priorities

• • Literature Review Prepared by various field organisations and institutions to reveal critical issues

Method Adopted to Analyse Priorities

• Carrying out practical studies in form of: • • Rapid Household Survey Monitoring and Validation Survey • Facility Survey

Other Data Sources

• • • • • Data Sources by GoI Rapid Household Survey by GOI NFHS Survey SRS Other State Specific information

Action Plan

• Thrust Areas for Human Development Index are reduction in: • IMR • MMR • TFR

Different Levels of Interventions

• • • Community level Awareness Generation Trainings & Skill Development • Strengthening CBWs including link couples and CBOs • Involving PRIs for a meaningful role

Different Levels of Interventions

• • • Clinical level Quality improvements Operationalising FRUs for Comprehensive EmOC

Different Levels of Interventions

• • Availing Basic EmOC at CHCs and PHCs • Skill based trainings for health providers Public Private Partnership: Need based out sourcing

Different Levels of Interventions

• • • • Outreach Field Visit RCH Camps Immunisation Sessions on fix days • Mobile Health Units for inaccessible areas

Broad Strategies to reduce IMR

• FOCUS is on URBAN SLUMS and NEWBORN CARE.

Strategic Interventions

• Neonatal Care: At community, household level as well as hospital for prevention of hypothermia and infection & to go for breast-feeding exclusively.

• Immunization, Diarrhoea, Treatment of ARI • Dealing with Malnutrition

Strategic Interventions

• • • Community Campaigns for nutritional goals including change in dietary behavior of community • Birth spacing as an IMR reducing strategy Intersectoral coordination Monitoring and supervision

Broad Strategies to reduce MMR

• Identifying Risk Causing Complications (like Bleeding, Eclampsia, Obstructed labour, Anemia, Sepsis): • Delay level 1: • Community identifies complications- family decides for Emergency Obstetric Care IEC Issues

Broad Strategies to reduce MMR

• • Delay level 2: • Availability of emergency transport-mobilization of community resources Delay level 3: • Starting the Emergency care at hospital level and make all FRUs functional

Areas of Strategic Intervention

Two Major thrust areas:

• Essential Obstetric Care • Emergency Obstetric care

Essential Obstetric Care

• • Comprehensive Antenatal care • Replacing Trained Birth Attendance by Skilled Birth Attendance • Quality obstetric services at primary Health Center Effective Supply management of DDKs

Essential Obstetric Care

• • • • Creating the right Infrastructure Training for early recognition of bleeding /prolonged labor / Infection /Abnormal presentation/Convulsions Incentive based approach for trained TBAs and early referral for EmOC Mobility support- Interest free moped loans to ANMs

Emergency Obstetric Care

• Effective Emergency Obstetric care management • Strengthening FRUs for effective service delivery with Blood transfusion facilities • BEmOC to be made available at CHCs and PHCs. • Skill development at all required stages

Emergency Obstetric Care

• • • Promoting timely referral by TBAs through training Expertise of Gynae and Anesthetists to be made available on panel and promote telemedicine for emergency.

Emergency transport for cases with complications and needing referral.

Broad strategy for population stabilization

• • • CNA approach and focusing on unmet needs Volunteerism and informed choices as basis of population policy Community behavioral change through IEC

Broad strategy for population stabilization

• • Community based contraceptive availability • Skill based training for doctors and paramedics Monitoring and supervision: Ensuring filling up all posts of ADHOs, DIECOs and strengthening MIS

Overarching Issues

• • • • • Emphasizing Adolescent Health Harnessing Technology Increasing the Involvement of Stakeholders Mainstreaming Gender Meaningful role of PRIs

Overarching Issues

• • • • • Enhancing Performance of Health Delivery Systems Promoting Indian Systems of Medicine & Homeopathy Qualitative Improvements in Family Planning Establishing Effective Monitoring Mechanisms Increasing Awareness among Women

Harnessing Technology

• • • Harnessing opportunities created by IT revolution for health services through networking of district health offices with the health directorate The establishment of GIS Implementation of the telemedicine application

Increasing the Involvement of Stakeholders

Type of Organization Academic Institutions NGOs Professional Bodies (e.g. IMA, Nurses Associations) Women ’ s organizations Youth organizations (e.g. NSS, NCC NYK etc.) Community based organization Role in Health Activities Basic and applied research Operations Training Monitoring and evaluation Policy guidance/advice Providing services IEC and Community mobilisation Providing community inputs in planning Providing feedback of government services Training Providing support to national health programmes Giving input in planning and policy making Helping in staff recruitment Putting forward view of the professionals Supporting the programme Putting forward women ’ s issues and gender issues Helping monitor programme Help in IEC and services delivery Support programme implementation IEC and community mobilization Youth involvement IEC and mobilizing community Helping in service delivery Advice and referral Transport

Religious organizations Press and Media Helping in promoting healthy lifestyle Promoting health by inculcating religious and cultural values Helping in services delivery and community mobilisation Projecting the correct and balance image of the health services Providing feedback on health service functioning Giving voice to people ’ s needs and feelings IEC and mass mobilisation Voluntary and philanthropic organizations Providing volunteer time and money for health work Services Clubs (e.g. Rotary, Lions, JC) Corporate Supporting health awareness and services by volunteer time and money Support health activities for employees and families and neighboring villages and help IEC Provide funds and help in management development in health department Judiciary Consumer organizations Provide balanced judgments where public interest is developed with individual interests Provide effective and quick resolution of public grievances Protect consumer interests in health with long term view

Enhancing Performance of Health Delivery Systems

• Enhancing productivity and accountability within the department through training programme and systemic changes • Developing capacity among senior personnel for strategic planning and health systems management

Enhancing Performance of Health Delivery Systems

• • Improving logistics and supplies including improvements in the Central Medical Stores Organization Optimum utilization of equipments and maintenance of infrastructure

Budget for Human Resource

• • • • • Specialists at 100 Comprehensive BEmOC centers (Obstetrician/Pediatrician/Anestheti st on contractual basis) Contractual Staff Nurse at All PHCs State and district level consultants and support staff Village level link couples Community based health volunteers in urban areas

Budget for facility improvement

• • Civil works Repair/renovation at CHCs / PHCs / SCs • Equipment / Instrument based on facility survey for Comprehensive and basic BEmOC • Capacity building

Budget for Service provision

• Drugs/ Consumables for EmOC/STI/RTI • Iron supplement for Adolescent population • Institutional deliveries

Budget for IEC activities

• • • • Mass Media Family and self care Educational material Mahila Swasthya Sangh Print media

Budget for Human Resource

• • • • • Specialists at 100 Comprehensive BEmOC centers (Obstetrician/Pediatrician/Anesthetist on contractual basis) Contractual Staff Nurse at All PHCs State and district level consultants and support staff Village level link couples Community based health volunteers in urban areas

Budget for facility improvement

• Civil works repair/renovation at CHCs /PHCs / SCs • Equipment/Instrument based on facility survey for Comprehensive and basic BEmOC • Capacity building

Budget for Service provision

• Drugs/ Consumables for EmOC/STI/RTI • Iron supplement for Adolescent population • Institutional deliveries

Budget for IEC activities

• • • • Mass Media Family and self care Educational material Mahila Swasrthya Sangh Print media

Thanks