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

A postulate of Proposed A postulate of Proposed Gujarat State Gujarat State

Plan ofPlan of Operation Operation RCH Phase - IIRCH Phase - II

ByProject 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 2010Our Vision 2010

Health Indicators

Sr. No. Indicator Current 2005 2010

Health1 Total

Fertility Rate

3.0 2.5 2.1

2 Life Expectan

cy at Birth

(Male)

61.5 65 71

3 Life Expectan

cy at Birth

(Female)

62.8 68 75

4 Maternal Mortality

Rate (1992-93)

3.89 1.5 Below 1


Health5 Infant

Mortality Rate

60 40 16

6 Under 5 Mortality

Rate (1996)

20.4 15 Below 10

7 Children Immunization Rate

54 80 100

8 Couple Protection

Rate

54.5 65 70

9 % Institution

al Deliveries

55 70 80


Health Infrastructure1 Sub –

Centers7274 7274 7490

(Rural)1200

(Urban)

2 Primary Health Centers

1054 1100 1229

3 Community Health Centers

254 260 307

4 Functional FRUs

44 100 307

Marginal Budgeting forBottlenecks

• 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 findingsSome findingsofof

Marginal BudgetingMarginal Budgetingforfor

BottlenecksBottlenecks

Household Water Source121%

583%144

8%

60232% 1087

56%

Pipeline in house

Public tap

Open Public Well

Other Sources

Public tap/ Hand Pump

Time required for collection of water

54532%

24214%

22614%

16510%

21413%

19812%

805%

1-5 minutes

6-10 minutes

11-15 minutes

16-20 minutes

21-25 minutes

26-30 minutes

31+ minutes

Types of Toilet Facility

124766%

58631%

111%

70%40

2%

No facility

Personal drainage line

Public toilet with drainage

Common drainage well

Common drainage line

Ante-Natal Care Recieved

YES77%

NO23%

% Distribution of ANC Service Provider

52%44%

4%

Doctor

Nurse

Dais

Training Status- TBA

Trained57%

Un-trained43%

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

After 6 months, 26.54

4-6 months, 30.86

First 3 months, 42.6

% distribution of ANC check up received in times

Don't remember, 0.0062

Four times +, 0.2346

Three times, 0.21Two times, 0.2962

One time, 0.253

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

None 6.24% 3.54% 1.26%

Foetal Heart Sound 0.0506

Weight Measurement 0.0088 0.0633

Blood Pressure 2.51% 9.73% 1.26%

Abdomen Examination 91.25% 85.84% 86.10%

ANC 1 ANC 2 ANC 3

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

86

14

22

78

DOCTOR % NURSE %

PRIVATE GOVT.

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 INCREASEDStrategic Intervention 1.1Comprehensive Emergency Obstetric Care facilities are operational


Strategic Intervention 1.2Basic 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 availableStrategic Intervention 2.2:Referral Transport for routine deliveries and for Referral of obstetric emergencies by planned transport optionsStrategic Intervention 2.3:Community support system is developed by communityStrategic Intervention 2.4:As per Janani Suraksha Scheme, provide monetary incentive to families and TBAs for accompanying pregnant women for deliveries at institutions


OUTPUT 3: UNIVERSALISE ANTENATAL COVERAGE FOR PREGNANT WOMEN Strategic Intervention 3.1: Ensure minimum 3 antenatal check ups of all pregnant womenInvolve 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 deliveredStrategic Intervention 4.2:TBA kits are periodically replenished

OUTPUT: 5 WOMEN RECEIVEIVING POST-PARTUM CARE ARE INCREASEDStrategic Intervention 5.1:Contact on day 1, 2 and 7 and then at 6th week and link with visits for neonates care for integrated mother-child care


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


OUTPUT: 1 IMPROVE CARE SEEKING AND REFERRAL OF SICK NEONATES WHO CANNOT BE MANAGED AT HOMEStrategic Intervention 1.1:Improve facility-based care for complex newborn care with visiting specialist doctors, strengthen facilities and increase their utilizationStrategic Intervention 1.2:Basic newborn care facilities are operational during programme period with trained medical officer and 2 staff nursesStrategic 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 transportCommunity support system for referral of sick neonates is developed by village community


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 daysStrategic Intervention 3.4:Conduct social research/ participatory research with community and ANMs for increased efficiency of ANMs and immunisation


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 behavioursStrategic Intervention 6.2:Local folk artists of tribal areas are made capable of mobilising people to seek for treatment and understand childhood illnesses


OUTCOME 3: COUPLES HELPED IN ACHIEVING THEIR REPRODUCTIVE INTENTIONS

OUTPUT 1: REDUCED CURRENT UNMET NEED FOR FP METHODS BY 75 % OF EXISTING LEVELS BY 2007Strategic 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 methodsStrategic 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 couplesStrategic Intervention 1.4:Improved quality of care for client satisfaction


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 managementStrategic 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 LIVINGStrategic Interventions:Establish urban health centres in the towns not having any hospital, CHCs or PHC facilitiesEnsure staff, equipment and medicines are available at Urban Health Centres according to specificationsCreate 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


• Clinical level

• Quality improvements

• Operationalising FRUs for Comprehensive EmOC


• Availing Basic EmOC at CHCs and PHCs

• Skill based trainings for health providers

• Public Private Partnership: Need based out sourcing


• 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 Increasing the Involvement of Involvement of StakeholdersStakeholders

Type of Organization Role in Health Activities

Academic Institutions Basic and applied researchOperationsTrainingMonitoring and evaluationPolicy guidance/advice

NGOs Providing servicesIEC and Community mobilisationProviding community inputs in planningProviding feedback of government servicesTraining

Professional Bodies (e.g. IMA, Nurses Associations)

Providing support to national health programmesGiving input in planning and policy makingHelping in staff recruitmentPutting forward view of the professionals

Women’s organizations Supporting the programmePutting forward women’s issues and gender issuesHelping monitor programmeHelp in IEC and services delivery

Youth organizations (e.g. NSS, NCC NYK etc.)

Support programme implementationIEC and community mobilizationYouth involvement

Community based organization

IEC and mobilizing communityHelping in service delivery Advice and referralTransport

Religious organizations Helping in promoting healthy lifestylePromoting health by inculcating religious and cultural valuesHelping in services delivery and community mobilisation

Press and Media Projecting the correct and balance image of the health servicesProviding feedback on health service functioningGiving voice to people’s needs and feelingsIEC and mass mobilisation

Voluntary and philanthropic organizations

Providing volunteer time and money for health work

Services Clubs (e.g. Rotary, Lions, JC)

Supporting health awareness and services by volunteer time and money

Corporate Support health activities for employees and families and neighboring villages and help IECProvide funds and help in management development in health department

Judiciary Provide balanced judgments where public interest is developed with individual interestsProvide effective and quick resolution of public grievances

Consumer organizations 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/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 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

ThanksThanks

Documents

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