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

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

• By
• Project Director
• RCH

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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

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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

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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

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Approach of GoG

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

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Approach of GoG

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

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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

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Our Vision 2010

• Health Indicators

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Sr. No. Indicator Current 2005 2010
Health Health Health Health Health
1 Total Fertility Rate 3.0 2.5 2.1
2 Life Expectancy at Birth (Male) 61.5 65 71
3 Life Expectancy at Birth (Female) 62.8 68 75
4 Maternal Mortality Rate (1992-93) 3.89 1.5 Below 1
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Sr. No. Indicator Current 2005 2010
Health Health Health Health Health
5 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 Institutional Deliveries 55 70 80
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Sr. No. Indicator Current 2005 2010
Health Infrastructure Health Infrastructure Health Infrastructure Health Infrastructure Health Infrastructure
1 Sub Centers 7274 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
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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

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Marginal Budgeting for Bottlenecks

• HH study identified 6 families with infant in a
  cluster
• MV study15 PHC, 30 SC (1village in each SC) in
  40 cluster area
• Facility study BEmOC, BEmPaedC and FW at PHC,
  CHC, DH

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HH study

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

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HH study

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

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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

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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

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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.

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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

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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

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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

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Some findingsofMarginal BudgetingforBottlene
cks
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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

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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

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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

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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.

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Priority fixing

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

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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

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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

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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

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Priority fixing

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

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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.

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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
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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
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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 6th week and link with visits for neonates care for integrated mother-child care
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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
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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
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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 Strategic 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
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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
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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

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Areas of concern

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

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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

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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

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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

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Areas of concern

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

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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

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Method Adopted to Analyse Priorities

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

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Method Adopted to Analyse Priorities

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

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Other Data Sources

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

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Action Plan

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

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Different Levels of Interventions

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

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Different Levels of Interventions

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

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Different Levels of Interventions

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

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Different Levels of Interventions

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

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Broad Strategies to reduce IMR

• FOCUS is on URBAN SLUMS and NEWBORN CARE.

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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

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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

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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

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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

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Areas of Strategic Intervention

• Two Major thrust areas
• Essential Obstetric Care
• Emergency Obstetric care

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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

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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

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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

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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.

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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

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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

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Overarching Issues

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

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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

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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

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Increasing the Involvement of Stakeholders
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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

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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

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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

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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

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Budget for Service provision

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

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Budget for IEC activities

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

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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

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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

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Budget for Service provision

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

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Budget for IEC activities

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

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Thanks