Quality in RCH September 04, 2009 Bubaneshwar

1. Quality in RCHSeptember 04, 2009Bubaneshwar V. Srinivas, IAS Secretary Family Welfare & Mission Director, NRHM Government of Rajasthan

2. The Status of Health Infrastructure in the State Norms for Sub- center – 3000 to 5000, PHC- 20000 to 30000 CHC- 80000 to 120000

3. Status of Major Health Indicators

4. Quality Assurance Cell 1. Genesis 2. Operationalisation 3. QA field visits 4. Lessons Learned 4. Next Steps

5. Experiences of implementing Quality Assurance in Rajasthan • Initiated from September 2008 under the tripartite agreement between Government of Rajasthan, UNFPA and Prayas. In the Pilot Phase :- • Carried out in four districts – Ajmer, Nagaur, Sikar & Udaipur • 25 sub-centres, 5 PHCs and 1 CHC in each block i.e. 4 blocks in each district. • A total of 100 sub-centres, 20 PHCs & 4 CHCs in each district and Overall 400 sub- centres, 80 PHCs and 16 CHCs in four districts

6. Genesis of QA Objective- • To facilitate the continuous monitoring of quality for reproductive health services at Sub centers, CHCs/ PHCs and outreach services • To improve the service quality by focusing on and addressing the gaps identified during the assessment process.

7. Quality Assessment • Strengthening of already existing QA committees at State level and District level • Workshop to Review the QA Tools- • Pretesting of the Tools • Identification of Health Facilities for QA Interventions • Formation of Quality Assessment Groups for Assessing the Health Facilities. • Finalize the quarterly visit schedule Review the findings of assessment.

8. Selection Criteria of the Health Facilities • 4 FRU from each district. Performance indicators are Institutional Deliveries and IPD Load • 50% CHC are good performing & 50% are average performing 1 CHC 1 CHC 1 CHC 1 CHC • 5 PHCs from each identified blocks. Performance indicator is OPD Load. • 50% PHC are good performing & 50% are average performing 5 PHCs 5 PHCs 5 PHCs 5 PHCs • 25 SCs from each identified blocks. Performance indicator is Immunization status. • 50% SCs are good performing & 50% are average performing 25 SCs 25 SCs 25 SCs 25 SCs

9. Key Features • District QA group constitution : CMHO as chairperson and RCHO as Nodal officer, 8-10 members including specialist • Quality assessment using standardized checklists, periodic visits by the members of DQAG • Quality Improvement is an integral component: on going and also through PIP route • Covers MH, RTIs /STIs, FP and Immunization • Covers CHCs /PHCs /SCs and RCH Camps; all CHCs, 50 percent PHCs, 10 percent SCs and camps

10. Key Features . • Focus largely on Inputs, processes and some outputs • Debriefing at the end of the visit in facilities • Revamping monitoring visits in the districts • Grading of facilities on the basis of Scores • Supportive supervision at the same time

11. Operationalizing QA in Rajasthan Initial bottlenecks • Delay in QA committee finalization • Elections delayed quality assessments • Detailed operational guidelines under preparation

12. Operationalizing QA

13. QA Field Visits in Rajasthan • First round of field visits is completed in all the four districts • Base line assessment provides conclusion that 70% problems can be solved at district level

14. Baseline Assessment findings

15. Baseline Assessment findings

16. Findings of the Pilot testing- CHC SalumberDist. Udaipur Facility Grade: (Grade A = 76 % and above score, B = 51 % - 75 % score, C = 26 % - 50 % score, D = Up to 25 % score)

17. An insight into the initial grading of PHCs in Ajmer

18. Findings of field visit, PHCs- District AJMER

32. Baseline Assessment findings

33. Baseline Assessment findings Dist. Nagaur has initiated field visits late Dist. Nagaur has initiated field visits late

34. Baseline Assessment findings Dist. Nagaur has initiated late

35. Improvement After QA InterventionsBlock Salumber & Bhinder

36. Improvement After QA InterventionsBlock Mavli (Udaipur)

37. Improvement After QA InterventionsBlock Kherwar (Udaipur)

38. Actions to be Initiated-An Illustration

39. AREA OF ACTION TAKEN • Infrastructure & Cleanness • Purchasing of the required and essential equipments • Develop the baby corner • Improvement in labor room with privacy • Cold chain maintenance • Use of partograph • Record keeping • Supply of the RTI/STI drugs at PHC level also • Improvement in the area of the counseling regarding ANC, PNC, Family planning, Child health care and immunization • Follow up of IUD cases

40. Lessons Learned

41. CHALLENGES • Fund utilization , Record keeping • Time management • Vacant / transfer of staff position • Untrained staff in some areas ( LT not trained for RTI/STI test , MTP, BEmOC/ EmOC) • Operatinalisation of the FRU • Supply and refilling of the medicine , equipments (disposable) and regarding lab functioning • Facility incharges always demand each instruction in written order • Sustainability of the service quality • Continues monitoring of the each parameter • Unutilized furniture and material lying dumped • Running water and power supply or power backup

42. JSY

43. Distribution of Total Institutional Deliveries

44. DISTRIBUTION OF INSTITUTIONAL DELIVERIES

45. DISTRIBUTION OF INSTITUTIONAL DELIVERIES

46. DISTRIBUTION OF INSTITUTIONAL DELIVERIES

47. TREND OF INSTITUTIONAL DELIVERY & JANANI SURAKSHA YOJANA JSY

48. Bed strength Total bed strength has been added periodically in various govt./ district/ satellite hospitals, CHCs

49. Assessment of JSY by GoI (UNFPA) Evaluation Study carried out by GOI through UNFPA

50. CHC Monitoring SystemKey indicators for Fortnight CHC Monitoring are:- No. of OPD cases No. of IPD cases No. of Deliveries No. of C- section Deliveries No. of Sterilization No. of Laboratory test No. of X-Rays