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RCH II

RCH II. STATE HEALTH SECRETARIES MEETING 15 th January, 2010 Amit Mohan Prasad Jt. Secy. ISSUES & SUGGESTED INTERVENTIONS. INFRASTRUCTURE AVAILABILITY Huge offtake of JSY, but facility strengthening slow

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RCH II

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  1. RCH II STATE HEALTH SECRETARIES MEETING 15th January, 2010 Amit Mohan Prasad Jt. Secy

  2. ISSUES & SUGGESTED INTERVENTIONS INFRASTRUCTURE AVAILABILITY Huge offtake of JSY, but facility strengthening slow Full complement of services not available in FRUs / 24x7 PHCs, e.g. Trained staff, equipment, adequate beds, quality of care, availability of blood No prioritisation of high load facilities for strengthening Existing staff not placed rationally, and selection of staff for skill-based training and their subsequent posting not adequate Prioritise high load facilities for strengthening, ensuring rational posting of staff, equipment, bed strength etc. TRAINING (LSAS, EmOC, SBA, IMNCI, NSSK, Sterilisation, MTP, IUD) Overall progress on various skill-based training needs to pick up Calculation of total training load; assessment of training capacity; steps to augment existing capacity through, e.g. PPP; linking training to facility operationalisation, ensuring adequate equipment and drugs/ supplies to trained personnel Monitoring utilisation of trained personnel

  3. ISSUES & SUGGESTED INTERVENTIONS (contd.) MICROBIRTH PLANNING Rolling out of name based tracking system Ensuring full antenatal care Identification of appropriate facility for delivery Ensuring referral arrangements, including transport back to the woman’s home after delivery QUALITY OF ANC, INC, PNC VHNDs still heavily focussed on immunisation, with inadequate provision of the full complement of services envisaged; microplanning and monitoring of sessions is essential Monitoring of quality of training, including post training adherence to protocols, e.g. Labour room protocols (maintenance of partographs, etc.) Ensuring trained providers at all deliveries (SBA, EmOC, NSSK, etc.) and available equipment, drugs, etc. Post delivery stay to ensure essential newborn care , and care of post partum complications

  4. ISSUES & SUGGESTED INTERVENTIONS (contd.) NEONATAL MORTALITY NMR continues to remain high, and has declined only by 1 point, from 37 (SRS 2004) to 36 (SRS 2007), contributing to nearly 2/3rd (65.5%) of IMR. Early NMR has in fact increased from 26 (SRS 2004) to 29 (SRS 2007), and accounts for 81% of NMR Strengthen facilities through provision of newborn baby corners in all labour rooms; adequate beds and hygienic environment and food to ensure 2-day stay. Ensure post natal care visits in homes through trained providers MALNUTRITION Greater linkages with the ICDS system at the ground level for early identification / referral of children to the NRCs and follow-up of the children in the community after treatment/ discharge from the facility

  5. ISSUES & SUGGESTED INTERVENTIONS (contd.) PROGRAM MANAGEMENT & MONITORING • Institutionalise facility and community based maternal death review • Ensure timely payment to JSY beneficiaries • Involvement of community in monitoring of payments, e.g. VHSCs, RKS, public disclosure of JSY beneficiaries at facilities • Ensure responsibilities of different levels of personnel for monitoring, eg. Prescribed percentage of physical and financial monitoring by CMO, PHC MO i/c , etc. • Strengthening supervision through, e.g. Trained public health nurses • Strengthening HMIS systems for better reporting

  6. OTHER COMMON ISSUES ACROSS STATES • Low institutional delivery rates in states like Chhattisgarh, Jharkhand, UP • High neo natal mortality in all the states; 2/3rd of the IMR • Anaemia during pregnancy and in early childhood is a problem across all states • Physical reporting on the HMIS needs attention • Delays in financial reporting from “spending centres”, e.g. Training, Urban Local Bodies, NGOs, infrastructure agencies, etc.

  7. STATE-SPECIFIC ISSUES

  8. (Rs. Crores) BIHAR

  9. BIHAR (CONTD..) MATERNAL HEALTH DLHS-3: 1st trimester ANC – 24%; At least 3 ANC – 26%; TT injection – 58%; BP taken – 17%; Full ANC – 5% Institutional delivery 28% and Safe delivery 32% Post natal visit within 2 weeks – 26% Anaemia during pregnancy – 60% (NFHS-3) • Only 3 FRUs reported to be fully functional in June 09. • Sub-optimal utilisation of trained personnel (LSAS, EmOC and SBA)

  10. BIHAR (CONTD..) CHILD HEALTH NMR at 31 accounts for 53% of the IMR, while early NMR at 27 accounts for 47% of the IMR (SRS 2007). JSY evaluation (December 2008) – only 16% beneficiaries surveyed stayed for at least two days in the health facility after delivery. DLHS-3 results: Early initiation of breastfeeding - 16%; Exclusive breastfeeding - 12%; ORS use in diarrhoea – 22% NFHS-3: Childhood anaemia – 88%; and 58% children <3 underweight FAMILY PLANNING DLHS-3 results: Total unmet need – 37%; use of modern contraceptives – 28% IUD insertions consistently decreasing: 1.00 lakh in 05-06 to 0.42 lakh in 08-09 Distt. Training centres / DHs lack facilities for skill based training (JRM-6) Lack of overall strategy to increase coverage of spacing methods (CRM-3)

  11. (Rs. Crores) CHHATTISGARH

  12. CHHATTISGARH (CONTD..) MATERNAL HEALTH • DLHS-3 results: 1st trimester ANC – 39%; BP taken – 39%; 100 IFA consumption – 38%; Full ANC – 14%; Institutional delivery – 18%. • JSY platform not sufficiently promoted and utilised to generate pressure on the system to strengthen the facilities (JRM-6) • Anaemia in pregnancy – 63% (NFHS-3) • Only 14 FRUs reported to be fully functional in June 09. • Certification of the LSAS trained MOs, as per GOI protocol, to be prioritised. • Establishing Blood storage units, and training of MOs and LTs not planned. • Poor quality of care in delivery rooms; with lack of protocols and training of staff, poor infection prevention practices (JRM-6)

  13. CHHATTISGARH (CONTD..) CHILD HEALTH NMR at 41 accounts for 70% of the IMR, while early NMR at 36 accounts for 61% of the IMR(SRS 2007) DLHS-3:ORS use in diarrhoea – 37% NFHS-3: Childhood anaemia – 81%; and 52% children <3 underweight Essential newborn care lacking, with lack of counselling leading to early discharge and poor newborn care practices(JRM-6) Equipment for neonatal management such as resuscitators and warmers - mostly out of order or not in use(CRM-3) FAMILY PLANNING DLHS-3: Total unmet need – 21% Fixed day services not available; FP outreach needs to be strengthened (JRM-6)

  14. (Rs. Crores) JHARKHAND

  15. MATERNAL HEALTH • DLHS-3: at least 3 ANC – 32%; BP taken – 22%; Full ANC – 9%; Institutional delivery – 18% (down from 21% in DLHS-2). • Anaemia in pregnancy – 68% (NFHS-3) JHARKHAND (CONTD..) • Rational use of existing personnel , especially specialists, a key issue. • Posting of LSAS and EmOC trained MOs needs to be done in FRUs. • Pace of setting up blood storage units (BSUs) needs to pick up - only procurement of equipments done for a few BSUs

  16. JHARKHAND (CONTD..) CHILD HEALTH NMR at 28 accounts for 58% of the IMR, while early NMR at 16 accounts for 57% of the NMR (SRS 2007). Post-delivery stay of at least two days not being ensured, and the concept of neonatal care as a planned intervention was missing (JRM-6). DLHS-3: ORS use in diarrhoea – 21%; care seeking in diarrhoea – 52%; care seeking in ARI – 56% NFHS-3: Childhood anaemia – 78% IMNCI - only 5634 persons trained FAMILY PLANNING No improvement between DLHS 2-3:Total unmet need – 35%; use of modern contraceptives – 31% Significant decrease FP performance between 07-08 and 08-09: Total number of sterilisation cases from 1.06 to 0.68 lakhs (36% decrease) IUD insertions from 0.85 to 0.72 lakhs (16% decrease)

  17. (Rs. Crores) MADHYA PRADESH

  18. MATERNAL HEALTH • DLHS-3: 1st trimester ANC – 34%; at least 3 ANC – 34%; BP taken – 30%; Full ANC – 9%; Safe delivery – 50%. • Anaemia in pregnancy – 58% (NFHS-3) MADHYA PRADESH (CONTD..) • SBA Training: Quality needs attention (CRM-3), including monitoring and supervision and practice of standard protocols. • LSAS Trg has not been initiated in the state, in spite of approval of 4 MCs long back and TOTs conducted twice. • No of private accredited institutions under Janani Sahayogi Yojana in 2009-10 and 2010-11 PIP – Figures have decreased from 206 to 15 needs clarification.

  19. MADHYA PRADESH (CONTD..) CHILD HEALTH Highest IMR in the country (70, as per SRS 2008) NMR at 49 accounts for 68% of the IMR, while early NMR at 39 accounts for 54% of the IMR (SRS 2007). JSY evaluation (December 2008) – only 68% of the beneficiaries surveyed stayed for at least two days in the health facility after delivery. DLHS-3: Exclusive breastfeeding – 31%; ORS use in diarrhoea – 30% NFHS-3: Childhood anaemia – 83%; 60% children <3 underweight State may look at quality milk being supplied in their NRCs instead of focusing on commercial RUTF FAMILY PLANNING CRM-3: IUD insertion training, especially post partum, and counselling skills needs strengthening

  20. (Rs. Crores) ORISSA

  21. MATERNAL HEALTH • DLHS-3: 1st trimester ANC – 48%; at least 3 ANC – 55%; BP taken – 42%; Full ANC – 23%; Safe delivery – 51%. • Anaemia in pregnancy – 68% (NFHS-3) ORISSA (CONTD..) • Sub-optimal utilization of training centers • Inadequate knowledge/ availability of GOI technical guidelines.

  22. ORISSA (CONTD..) CHILD HEALTH IMR (SRS 2008) at 69 is the 2nd highest in the country; however, a rapid decline in IMR in recent years NMR at 49 accounts for 69% of the IMR, while early NMR at 37 accounts for 52% of the IMR. JSY evaluation (December 2008) - only 27% of the beneficiaries surveyed, stayed for at least two days in the health facility after delivery (similar observation by the CRM-3 team in November 2009), clearly a missed opportunity to address early NMR NFHS-3: Childhood anaemia – 74% FAMILY PLANNING DLHS 2 to 3: Unmet need increased from 20% to 24%; and use of modern contraceptives decreased from 40% to 38% Significant decrease FP performance between 07-08 and 08-09: Total number of sterilisation cases from 1.21 to 0.91 lakhs (25% decrease) IUD insertions from 1.61 to 1.40 lakhs (15% decrease) CRM-3: Condom and OCP supply issues; low IUD awareness and retention.

  23. (Rs. Crores) RAJASTHAN

  24. MATERNAL HEALTH • DLHS-3: 1st trimester ANC – 33%; at least 3 ANC – 28%; BP taken – 30%; Full ANC – 7%; Safe delivery – 53%. • Anaemia in pregnancy – 61% (NFHS-3) RAJASTHAN (CONTD..) • 55 FRUs reported to be fully functional in June 09. • Quality of LSAS and EmOC training, and post training utilisation of skills, need monitoring. • Establishing blood storage centers needs priority attention at the FRUs. • State needs to prioritize the areas such as difficult, most difficult and inaccessible and make facility-wise strategies for such areas keeping the case load in mind.

  25. RAJASTHAN (CONTD..) CHILD HEALTH NMR at 44 accounts for 68% of the IMR, while early NMR at 34 accounts for 52% of the IMR (SRS 2007). JSY evaluation (December 2008) – only 43% of the beneficiaries surveyed stayed for at least two days in the health facility after delivery. DLHS-3: Exclusive breastfeeding – 25%; ORS use in diarrhoea – 31% NFHS-3: Childhood anaemia – 80% FAMILY PLANNING CRM-3: Family planning services are not fixed day but camp based. Very few providers available in the system. The training, esp. Minilap, needs to be up scaled. Post-delivery FP needs to be strengthened esp. IUD services

  26. (Rs. Crores) UTTAR PRADESH

  27. MATERNAL HEALTH • DLHS-3: 1st trimester ANC – 25%; at least 3 ANC – 22%; BP taken – 11%; Full ANC – 3%; Institutional delivery – 25%. UTTAR PRADESH (CONTD..) • Establishment of BSUs in designated FRUs needs attention. NIL FRUs reported functional in June 09, due to non-availability of blood (BSU, assured linkages to blood bank, etc.) • Slow Progress of skill based trainings (LSAS/ EmOC/ SBA) • No clear plan for operationalization of services/ training on safe abortion / RTI/STI • No progress on implementation of new training initiatives e.g. BEmOC for PHC MOs

  28. UTTAR PRADESH (CONTD..) CHILD HEALTH NMR at 48 accounts for 70% of the IMR, while early NMR at 36 accounts for 52% of the IMR (SRS 2007) JSY evaluation (December 2008) – only 27% of the beneficiaries surveyed stayed for at least two days in the health facility after delivery. CRM-3: 48 hour stay after delivery was seen only in the DH. At the HSC and PHC level, adequate facilities for patients staying - not available, women leave with their families after a few hours of delivery; No emergency transport system, with ambulances seen to be used for transport of drugs & supplies DLHS-3:Early initiation of breastfeeding – 15%; exclusive breastfeeding – 8%; ORS use in diarrhoea – 17%; at least one dose of Vit A supplementation in children 9 months or above – 32% NFHS-3: Childhood anaemia – 85%

  29. UTTAR PRADESH (CONTD..) FAMILY PLANNING DLHS-3: Total unmet need – 34%; use of modern contraceptives – 27% Significant decrease FP performance between 07-08 and 08-09: Total number of sterilisation cases from 4.72 to 3.94 lakhs (17% decrease) IUD insertions from 19.43 to 13.42 lakhs (31% decrease) JRM-6: No focus on IUD insertion; service not even available at the Medical College Post partum counselling and contraception not provided in most of the facilities

  30. (Rs. Crores) UTTARAKHAND

  31. MATERNAL HEALTH • DLHS-3 results: 1st trimester ANC and at least 3 ANC – 34%; BP taken – 25%; 100 IFA consumption – 34%; Full ANC – 16%; Institutional delivery – 30%. UTTARAKHAND (CONTD..) • 37 FRUs reported to be fully functional in June 09. • CRM-3 visit: Many of the DHs even do not fulfill FRU criteria. • Sub-optimal deployment of specialists / trained personnel at DH / CHCs. • 20 doctors have been trained in LSAS; however as per GoI records only 7 doctors are trained. Are 20 doctors trained as per GOI norms? If yes are they posted at designated FRUs?

  32. UTTARAKHAND (CONTD..) Child Health DLHS-3: Exclusive breastfeeding – 37%; ORS use in diarrhoea – 44% NFHS-3: Childhood anaemia – 62% CRM-3: Inadequate attention to neonatal care FAMILY PLANNING DLHS-3: Total unmet need – 21% Sharp decrease in IUD insertions – 1.41 lakh in 06-07 to 0.81 lakh in 08-09.

  33. (Rs. Crores) HIMACHAL PRADESH

  34. MATERNAL HEALTH • DLHS-3: Institutional deliveries – 48% HIMACHAL PRADESH (CONTD..) • LSAS training for MBBS doctors has been initiated since the last 2 years but the state has not yet been able to provide details of their posting & service utilization. • No clear Training plan for interventions on Safe Abortion and RTI/STI. • CHILD HEALTH • DLHS-3: Exclusive breastfeeding – 40% • NFHS-3: Childhood anaemia – 59% • FAMILY PLANNING • DLHS-3: Total unmet need increased to 15% (from 12% in DLHS-2) • Regular decline in IUD users between 05-06 and 08-09 (0.30 lakh to 0.28 lakhs)

  35. (Rs. Crores) JAMMU & KASHMIR

  36. MATERNAL HEALTH JAMMU & KASHMIR (CONTD..) • Slow progress of LSAS; sub-optimal utilisation of training institute capacity. • State has not shared training plan for EmOC Training, even though master trainers have been trained. • No details shared on quality certification/accreditation of health facilities as reflected in 2009-10 PIP. • Maternal deaths reported from facilities are negligible as complicated cases are being referred, often verbally and no documentation of the same exists in registers.

  37. JAMMU & KASHMIR (CONTD..) CHILD HEALTH J&K’s IMR (SRS 2008) at 49 is lower than the national average of 53, yet the IMR has increased by 4 points over the past five years NMR at 39 accounts for 77% of the IMR, while Early NMR at 31 accounts for 61% of the IMR. Further, Early NMR has steadily increased from 23 (SRS 2004). CRM-3: Most delivery cases do not stay in the facility beyond a few hours post delivery FAMILY PLANNING DLHS-3:Total unmet need – 22% Decline in number of sterilisations and IUD insertions, in the past 3 years. CRM-3: Any systematic efforts to improve performance of terminal methods (especially post partum sterilization) and spacing methods were nonexistent; Counselling for family planning by ANMs & clinical providers, appears to be lacking.

  38. (Rs. Crores) ANDHRA PRADESH

  39. MATERNAL HEALTH ANDHRA PRADESH (CONTD..) • Only 87 FRUs reported to be fully functional in June 09. • Training of MOs in LSAS Training not initiated despite TOT of Master trainers 2 years back. • Inadequate knowledge/ availability of GOI technical guidelines • CHILD HEALTH • NFHS-3: Childhood anaemia – 79%

  40. (Rs. Crores) GUJARAT

  41. MATERNAL HEALTH • Effect of Chiranjeevi Yojana is not visible on indicators (institutional delivery has increased marginally from 52.2% to 54.9% between DLH-2 and DLHS-3). • In spite of comprehensive MamtaDiwas in place, full ANC has declined between DLHS-2 (25%) and DLHS-3.(19%) GUJARAT (CONTD..) • Quality of care is an issue in Chiranjeevi scheme. Further, no attempts seen to make beneficiaries aware of their entitlements in the scheme (CRM-3) • SBA/ LSAS/ EmOC Training needs proper monitoring and supervision especially quality parameters.

  42. GUJARAT (CONTD..) CHILD HEALTH State has one of the highest rates of IMNCI & facility based care implementation, in the country, yet reduction in IMR is slow; 1.4 points per year between SRS 2003 and SRS 2008. NMR at 37 accounts for 71% of the IMR, while early NMR at 29 accounts for 56% of the IMR (SRS 2007). FAMILY PLANNING NSV progress remains very slow in 08-09 (compared to 07-08); 11530 cases of male sterilisation have been carried out in 08-09; however, in 07-08 this was around 21000.

  43. (Rs. Crores) HARYANA

  44. MATERNAL HEALTH • Only state besides Punjab where MMR has increased – Steps to address this? • DLHS-3: Full ANC – 13%; Institutional delivery – 47% • Anaemia in pregnancy – 70% (NFHS-3) HARYANA (CONTD..) • 17 FRUs reported to be fully functional in June 09. • State may share the details of Janani Suvidha Yojana for e.g. payment to the private provider/ Incentive to Sakhi etc, Delivery Hut Scheme/JacchaBaccha Scheme? • No Training plan for intervention on Safe Abortion and RTI/STI. • BEmOC Training for MOs not planned • Except in DH, no partographs or baby corner observed by the CRM team

  45. HARYANA (CONTD..) CHILD HEALTH 19 (out of 21) districts of the state implementing IMNCI, Breastfeeding is promoted by establishing counselling centres in each district hospital,46 FRUs and 160 PHCs are providing newborn care services Yet one point decline per year in IMR for past five years NMR at 34 accounts for 62% of the IMR, while early NMR at 23 accounts for 42% of the NMR (SRS 2007). Wherever enquired by the CRM team, mother and baby were kept for 6 hrs only following delivery. DLHS-3: Early initiation of breastfeeding – 17%; exclusive breastfeeding – 6%; ORS use in diarrhoea – 32% NFHS-3: Childhood Anaemia – 83% FAMILY PLANNING Increase in total unmet need between DLHS-2 (15%) and DLHS-3 (16%)

  46. (Rs. Crores) KARNATAKA

  47. MATERNAL HEALTH • Highest MMR among the southern states - 213 • Anaemia in pregnancy – 50% (NFHS-3) KARNATAKA (CONTD..) • 71 FRUs reported to be fully functional in June 09. • SBA Training needs to be expedited. • Sub-optimal deployment and utilization of specialists (anesthesia & OBG) already available in the system.

  48. KARNATAKA (CONTD..) CHILD HEALTH 1 point reduction of IMR per year (52 in 2003 to 45 in 2008 as per SRS) a cause of concern DLHS-3: Early initiation of breastfeeding – 47%; exclusive breastfeeding – 38%; ORS use in diarrhoea – 46% NFHS-3: Childhood anaemia – 83% Home Based Newborn Care, SEARCH model is being implemented in 6 districts, is the Gentamycin injection and asphyxia management part also being implemented, evaluation of the initiative needs to be done

  49. (Rs. Crores) KERALA

  50. MATERNAL HEALTH KERALA (CONTD..) • State may clarify its position whether it needs LSAS/EmOC Trained doctors or it has sufficient number of specialists available in public heath system. • Maternal death review conducted by the State for many years. No sharing of the report with GOI. • CHILD HEALTH • Need to introduce initiatives to increase access to care for CH initiatives (ORS use rates declining) improve the nutritional status- continued breastfeeding rates, anaemia management • DLHS-3: exclusive breastfeeding only 22.3% • FAMILY PLANNING • Use of any modern method for family planning has decreased from 54.7% to 53.1% (DLHS 2-3), while total unmet need has increased by 1.7% points (15.1% to 16.8%).

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