RCH II AND FAMILY PLANNING PROGRAM IMPLEMENTATION PLAN
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RCH II AND FAMILY
PLANNING
PROGRAM IMPLEMENTATION PLAN
(PIP)
DEPARTMENT OF FAMILY WELFARE
MINISTRY OF HEALTH AND FAMILY WELFARE
GOVERNMENT OF INDIA
NIRMAN BHAVAN
NEW DELHI
CONTENTS
Section Number
"0
_I
£1.1
1.1.2
1.1.3
1.1.4““
1.1.5
1.1.6
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1.1.8
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Financial and economic
Analysjs__________
Family Welfare Program_____
Donor Financing______________
Economic Analysis of
Reproductive Health in India
Trends in Family welfare
Expenditure__________________
Economic analysis_________
Cost per capita/ year of protection
and birth averted_____________
Further Economic Analysis
42
1.4
Program Risks and the Factors
that may affect the success of
the same
55
2
2 1
Institutional Arrangements^
National Level Implementation
Organization___________ _ ___
State Level Implementation
Organization__
District Level Implementation
Organization_______________
CHC/FRU Implementation
57
57
£2/1
1.2.2
1.2.3
1.2.4
1.2.5
£3.1
1_31
1.3.3
1.3.4
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1.3.6
1.3.7
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I
The program
Background
__________ _
Policy Context
Socio-Economic Context
Demographic Features
Achievements of Family Welfare
Program
Burden of Diseases_______
Reproductive Morbidity
"Regional Variations___________
Public Health Care System
Page#
2~
~5
Program Objectives& Approach
Lessons Learnt from RCH I_
Appraisal of RCH I Interventions
Proposed Strategies for RCH II
Issues arising and Feasible
Actions in RCH II__
Linkages with other Programs
1.2
1.3
i
Section Title
Preamble
28
30
37
42
44
45
45
51
52
53
63
69
73
2.5
2.6
2.7
2.8
84
87
W3
120
T27
Behavior Change Communication
Strategy_______________ _ __
Training
180
4
Procurement and Logistics
196
5
5.1
5.2
5.3
5.4
Financial Management___
Financial Management_______
Budgeting and Flow of Funds
Disbursements______________
Accounting and Transactions
Information Flow________
Internal Checks and Controls
Staff Recruitment and Placement
Staff Training
_____
Audit Arrangements__________
Sustainability________________
Program Risks
200
200
201
201
201
3.5
3.6
3.7
3.8
3.9
3.10
t
F
—
74
75
76
79
Implementation Plan ______
Maternal health________ __ __
Newborn and Child Health____
Adolescent Health
________
Population Stabilization and social
marketing____________________
Urban Health_________________
Tribal Health________ ______
Infrastructure Mapping and
Strengthening______________
NGO Involvement
3
3.1
3.2
3.3
3.4
r
Organization________ _____
Primary Health Center_____
Sub-Center_______________
Village Level______________
Suggestions for Strengthening
Performance
5.5
5.6
5.7
5.8
5.9
5.10
147
157
165
174
186
202
202
203
203
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‘205
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6 5
Monitoring and Evaluation
Introduction________________
Review of RCH I Experience
Suggestions for RCH II
___
Key Development Indicators for
Measuring Progress
__
Key Progress Indicators
7
Costs
211
8
Donor Convergence
217
6
6.1
6.2
6.3
6.4
208
I
Section 0
Preamble
The Program Implementation Plan views RCH II as a program and not as a project per se. i
is an outcome-oriented initiative adopting a multi-pronged strategy to bring about the desired
outcomes in the program period. This is a program planned to be funded through a
combination of domestic funding, pool of donor funding and through developmental lending
institutions.
This program document and development of strategies has been governed by the following
•
•
•
The Millennium Development Goals (MDG)
The Tenth plan goals
Immediate and Medium Term Goals of National Population Policy 2000.
The program orientation and the achievement orientation are driven by the goals set out in
the above documents and the broad approaches these set out.
Millennium Development Goals (MDG)
The goals have been evolved as a result of several global summits that took place in the
1990s. These have culminated in seven International Development goals and the Millennium
General Assembly has provided the road map to the MDGs as follows:
Eradicate poverty and Hunger
Achieve Universal primary Education
Promote gender equality and empower women.
Reduce Child Mortality
Improve maternal health
Combat HIV/AIDS, Malaria and other major diseases
Ensure environmental sustainability
Develop a global partnership for development.
It can be observed from the above that most of the objectives relate to the ROH framework
and the others are inter connected with the achievement of RCH goals. The analysis of these
goals facilitate in capturing the understanding of the outcomes jointly determined by policies
in multiple sectors. It would be useful to develop strategy based on outcomes, identify the
capacity building areas and bring about a holistic approach to program planning by linkages
through research and practices to the outcomes through appropriate actions The framework
adopted in developing this program document follows this approach
I i
Tenth Plan Goals
• Reduction of decadal growth rate of population between 2001-2011 to 16.2
• Reduction of Infant Mortality Rate to 45 per 1000 by 2007 and 28 per 1000 by 2012
• Reduction in Maternal Mortality Ratio to 2 per 1000 live births by 2007 and 1 per 1000
live births by 2012.
• Reduce Total Fertility Rate to 2.3 by 2007
• Improve coverage of full Ante-Natal Care from 31.8% to 89% in 2007
• Improve coverage of Institutional deliveries/safe deliveries from 34%/40.2% to 80% in
2007
• Improve Couple Protection Rate from 48.2% to 65% in 2007
National Population Policy Objectives
•
•
Immediate objective is to address unmet needs of contraception, health care
infrastructure (especially in the Empowered Action Group states), and health
personnel and provide integrated service delivery for basic RCH
The medium term objective is to bring the Total Fertility Rate to the replacement level
by 2010 through coordinated implementation of inter-sectoral linkages.
Linkages among the the different goals
Tenth Plan
RCH II Goals
Goals
(2004-9)
(2002-2007)
Indicators
Population
Growth
Infant
Mortality Rate
Under 5
Mortality Rate
16.2%
(2001-11)
45/1000
16.2%
(2001-11)
35/1000
National
Population
Policy 2000
(By Period
2010)
30/1000
Millennium
Development
Goals
r
i i
Tenth Plan Goals
• Reduction of decadal growth rate of population between 2001-2011 to 16.2
• Reduction of Infant Mortality Rate to 45 per 1000 by 2007 and 28 per 1000 by 2012
• Reduction in Maternal Mortality Ratio to 2 per 1000 live births by 2007 and 1 per 1000
live births by 2012.
• Reduce Total Fertility Rate to 2.3 by 2007
• Improve coverage of full Ante-Natal Care from 31.8% to 89% in 2007
• Improve coverage of Institutional deliveries/safe deliveries from 34%/40.2% to 80% in
2007
• Improve Couple Protection Rate from 48.2% to 65% in 2007
National Population Policy Objectives
•
•
Immediate objective is to address unmet needs of contraception, health care
infrastructure (especially in the Empowered Action Group states), and health
personnel and provide integrated service delivery for basic ROH.
The medium term objective is to bring the Total Fertility Rate to the replacement level
by 2010 through coordinated implementation of inter-sectoral linkages.
Linkages among the the different goals
Tenth Plan
RCH II Goals
\
Goals
(2004-9)
V
(2002-2007)
Indicator
National
Population
Policy 2000
(By Period
2010)
Millennium
Development
Goals
30/1000
-
Population
Growth
Infant
Mortality Rate
Under 5
Mortality Rate
16.2%
(2001-11)
45/1000
Maternal
Mortality ratio
2/1000
150/100000
100/100000
Total fertility
rate
Couple
Protection
rate
2.3
2.2
2.1
65%
65%
Meet 100%
needs
16.2%
(2001-11)
35/1000
Reduce by 2/3
from 1990
levels
Reduce by 3a
between
1990-2015
Ii
The above Table clearly brings about the convergence of objectives of the different policy
documents and clearly sets the tone for the RCH II
Nomenclature
The other important issue that has come to light while carrying out the design for RCH II is
the issue regarding the nomenclature to be applied to the program. The European
Commission Technical Assistance (ECTA) has brought to light the issues surrounding the
understanding of the different program managers at different levels. Further it has also
brought to light the consequences arising due to the absence of conceptual clarity and
terminological inexactitude. This has given rise to administrative proliferations in
microscoping the scope and coverage of RCH.
This view projected by the ECTA is also reflected in the letter received from an officer in Uttai
Pradesh clearly bringing about the drawbacks of calling the second phase as RCH II. The
contention that has been put forward is that the RCH II will be based on minor tinkering of
RCH I activities and the shortcomings of the RCH I would be carried forward into RCH II.
The issues of framing RCH II and taking into account the gaps in RCH I has been addressed
through the design process but further clarity is perhaps required in the nomenclature. To
quote the ECTA paper “anything can be called by any name, provided the meaning is clearly
defined and unique.” Conceptual clarity can enhance better management of the program
through a common understanding. Though in this design it has not been possible to evolve a
nomenclature to clearly designate the program but it can adopt a name, which is easily
understood by both providers and users. This needs to be worked upon through a
consultation.
This issue has been addressed in this document by designating the program as RCH & FP
program and this has been reflected in the design of this document. Any reference to RCH-II
as made in this document implies RCH+FP.
Approach
The performance levels of the different states show variations ranging from very high levels
to low levels of achievement. This has an effect of lowering the overall performance levels of
the country as a whole. The reasons for the variations in performance are based in the deeprooted socio-cultural and geographic features that are very peculiar to a country like India. To
take into account the variations it has been realized that ‘one-size fit all’ strategy may not
suffice and hence a differential approach for a group of states at homogenous levels of
achievements have been taken in the design of the program.
I i
Section 1
The Program
1.1 Background
1.1.1 Policy Context
India, currently the second most populous country in the world, sustains 17 percent of world’s
population in less than three percent of earth's land area. Realizing the need to check its
growing population, in 1951 India became the first country in the world to launch a famil .
planning program. The successive five-year plans have provided the policy framework and
funding for the development of nationwide health care infrastructure and manpower. After being
re-christened as Family Welfare Program in 1978, maternal and child health services began tc
receive greater attention under the program’s plan of action. The 100% centrally funded
program has been providing the states additional infrastructure; manpower and consumables
needed for the delivery of services.
In the 1990s, Government of India began to reorient the programme in the light of
recommendations made by a subcommittee of the National Development Council, an expert
group headed by Dr. M. S. Swaminathan, and more specifically, to address the concerns
expressed at the International Conference on Population and Development held at Cairo in
1994. Following a major review undertaken with the support of the World Bank and other
agencies in 1994-95, method-specific contraceptive targets were abolished and the emphasis
shifted to decentralized planning at district level based on community needs assessment, and
implementation of programs aimed at fulfilling unmet needs. The first phase of the Reproductive
and Child Health Program was launched in 1997 as a flagship program that covered the entire
gamut of safe motherhood, child heath and RTI/STI diagnosis and care. A National Population
Policy was announced in 2000 that articulated the new broad-based approach towards
population stabilization, and set long-term policy goals. A National Population Commission was
also set up under the chairmanship of the Prime Minster of India to review, monitor and give
directions for the implementation of the NPP, and to promote intersectoral coordination.
Activities under RCH II are being formulated to realize the professed goals under the NPP and
the tenth five-year plan.
1.1.2 Socio-Economic Context
Seventy two percent of India's population live in about 600,000 villages where agriculture is the
main livelihood of the people. But in the gross national product, which is estimated at Rs. 19
trillion in 2000-01, agriculture's share is only one-fourth. Nonetheless, agricultural production
increased nearly fourfold between 1950-51 and 2000-01, largely due to the success of green
revolution. Although the area under cultivation of food grains has remained virtually unchanged
since the beginning of 1970s, India has emerged as a marginal exporter of food grains, thanks
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to an increase of nearly 20 percentage points in the agricultural land under irrigation, and a rise
of 65 percent in the yield per cultivated area. In the meanwhile, the percentage of population
living below the poverty line has declined from 55 to 26 percent.
India had a weak industrial base at the time of independence. Following a concept of mixed
economy, the policy framework reserved some areas for the exclusive development in the
public sector, while permitting private activity in other sectors. India today possesses a broad
based industrial sector, comprising food, textiles, metallurgical, mechanical, chemical, electronic
and software industries. During 1950-90, industrial production expanded at an average rate ol
six percent compared to less than three percent in agricultural production. Production of coal
crude oil and electricity has increased manifold. Electricity generation grew at an average rate oi
11 percent during 1950-90. The percentage of villages electrified increased from less that
percent in 1960-61 to 83 percent in 1990-91.
But, what was accomplished in the first four decades is far below the potential envisaged at the
time of independence. During 1950-90, gross domestic product grew at an average rate of -i
percent while population grew, on an average, by 2.1 percent. Thus the per capita income
could increase at a rate of 1.7 percent only. Since the early 1990s, India has embarked on a
phased programme of structural reforms for liberalization and globalisation. It aims at simplifying
the licensing system, disinvesting loss-making public enterprises, introducing tax reforms,
liberalization of exchange rate and import duties. Spurred by these reforms and rapidly
expanding market for knowledge-based industries, the growth in gross national product crossed
6 percent for the first time during the eighth-plan period of 1992-97.
India's record in social development has been as modest as its achievements in economic field.
As per the 2002 Human Development Report of the United Nations, among 173 countries, India
ranks 124 in the Human Development Index and 123 in terms of per capita gross domestic
product. Two other populous Asian countries, China and Indonesia, rank higher than India on
both the indicators (China 96 on both, and Indonesia 110 on HDI and 111 in GDP) What
particularly pulls India down is its record on education. It has an education score of 0.57
compared to 0.79 of China and 0.80 of Indonesia. The Census of 2001, while recoding a
significant improvement in literacy since the last census, has shown that 35 percent ol
population age 7+ are illiterate. India also performs poorly on Gender Development Index
Among 146 countries, India ranks 105 in GDI while China and Indonesia have a rank of 77 and
91, respectively.
1.1.3
Demographic Features
According the Census of 2001, India’s population was 1,027 million. The annual growth rate ol
population is estimated to be about 1.8 percent. Thus India adds nearly 19 million persons per
year, or roughly the total population of Australia, which has more than twice the land area of
India. During most parts of the last half-century, population grew by more than two percent per
annum, and population size nearly tripled from 361 million in 1951.
1 /
The sex ratio of India’s population has been unfavourable to females since the beginning of the
century, and has declined in every decade except 1971-81 and 1991-2001. Although the latest
census has shown a marginal increase in the sex ratio of total population from 927 females per
1,000 males in 1991 to 931, the sex ratio at age 0-6 has declined in many parts of India. The
rising incidence of female foeticide appears to be mainly responsible for the decline in the
juvenile ex ratio.
India has a young age structure of population. It is estimated that in 2000, 36 percent of the
population was in the age group 0-14 years, 60 percent in the working ages of 15-64. and only I
percent was age 65 years and over. But population projections indicate that over 85 percent of
total growth of the population during the next two decades (i.e., 2000-20) - estimated to be
about 300 million - would be in the working ages, 15-64. By 2020, the population in the age
group 0-14 is expected to constitute 25 to 28 percent of the population, the age group 15-64.
about 66 to 69 percent of the population and age 65 and over about 6 percent of the population.
Thus the expected age structural changes imply that demand for reproductive health services
would multiply rapidly during the next two decades while the demand for child health services
would remain more-or-less stable.
The process of urbanization has been rather slow in India. The percentage of total population
living in urban areas has increased from 20 percent in 1970 to 28 percent in 2001. In 1991, onefifth of India’s population lived in Class I cities and Class II towns that have population of 50, 000
and above. One-fourth of India’s population lived in villages that had fewer than 1,000
residents. Census data indicate that scheduled tribes and scheduled castes, which form tht
most vulnerable section of the population, constitute 8 and 16 percent of the total population,
respectively. The data collected in the second National Family Heath Survey (NFHS-2) suggest
that people of other backward groups constitute about one-third of the population.
1.1.4 Achievements of Family Welfare Programme
An accurate assessment of India's demographic achievements is hampered by data
deficiencies, particularly for the period before the 1970s. The official estimates of fertility ana
mortality levels at the time of independence are believed to be gross underestimates
Nonetheless, even the official estimates suggest significant achievements in this field. Thf
crude birth rate, which was officially put at 42 per 1,000 in 1951-61, has declined to 26 in 2000.
as per the estimates available from the Sample Registration System (SRS). Total Fertility Rate,
which was over 6 births per woman before the 1960s, has declined to 3.2 in 1998. The
percentage of women currently using contraception, which was negligible before the 1960s, has
increased to 48 percent in 1998-99, as per the second National Family Heath Survey (NFHS-2)
With respect to mortality, the crude death rate has declined from 23 per 1,000 in 1951-61 to 9 ii
2000. Infant mortality rate, which was estimated be 146 in 1951-61 (but actual level was
probably close to 200), has declined to 68 in 2000. The life expectancy at birth has increased
from 41 in 1951-61 to 61 in 1993-97. Maternal mortality ratio was probably over 10 per 1.000
live births in the 1950s. It has declined to 4 in the 1990s. In the early 1970s. less than T
percent of the deliveries were occurring in institutions. It has increased to 34 percent in 1998-99
i i
Before the expanded programme of immunization was lunched in 1978, the percentage oi
children immunized against the six vaccine preventable diseases was negligible. As per NFHS2, the percentage of fully immunised children has reached 42 percent at the all-lndia level
However, more recent data suggest some slackening in the progress towards better health
During the 1990s. the SRS data suggest deceleration in the decline of Infant Mortality Rate
In particular, neonatal mortality rate has hardly shown any sign of fall. The level of child
immunization is also not increasing at the rate observed in the 1980s. During the six-year
interval between NFHS-1 and NFHS-2, the proportion of fully immunized children increased
by only one percentage point per annum. At this rate, India could hope to reach the goal ol
universal immunization only after 50 years! The surveys also indicate that the decline in
maternal mortality rate may have also been stalled. The decline in the birth rate is yet to pick
up speed in some northern states.
1.1.5 Burden of Disease
Reliable data on causes of death and morbidity are lacking for India. However, the Global
Burden of Disease (GBD) project of the WHO has made some rough estimates for India
based on small community studies and data collected through verbal autopsy. The project
has assessed the disease burden in terms of Disability-Adjusted Life Year (DALY). One
DALY is equivalent to one lost year of healthy life. Table 1 shows the data on distribution ol
deaths and distribution of DALYs by cause for India in 1998. According to this data,
communicable, maternal, preinatal and nutritional diseases account for 42 percent of deaths,
and 50 percent of DALYs. Non-communicable diseases account for 48 percent of deaths but
only 33 percent of DALYs. In this regard, it is interesting to note that although cardiovascular
diseases account for 30 percent of deaths, they constitute only 10 percent of DALYs. On the
other hand, neuropsychiatrc disorders gain in importance when disability is taken into
account. Injures also gain in importance when disability is taken into account as they
contribute to 17 percent of DALYs as against 10 percent of deaths.
According to GBD estimates, the ten leading causes of death in India are ischaemic heart
disease (15.8%), diarrhoeal diseases (7.6%), perinatal conditions (6.6%). cerebrovasculat
disease (6.0%), tuberculosis (4.5%), acute lower respiratory infections (3.1%), acute upper
respiratory infections (3.1%), road accidents (2.3%) measles (2.0%) and HIV/AIDS (1.9%). The
ten leading causes of morbidity measured in DALYs are acute lower respiratory infections
(9.5%), acute upper respiratory infections (9.2%), perinatal conditions (8.7%), diarrhoeal
diseases (8.2%), ischaemic heart disease (4.3%), falls (4.1%), unipolar major depression
(3.6%), maternal conditions (2.9%), tuberculosis (2.8%) and measles (2.4%).
The most pertinent to this report is mortality and morbidity from maternal and perinatal causes.
As per the GBD estimate, these causes account for 8 percent of deaths and 12 percent ot
DALYs. Also according to this source, HIV/AIDS was responsible for 1.8 million deaths and 4
million lost years of healthy life in 1998.
J
1.1.6 Reproductive Morbidity
Several studies conducted in India during the past decade suggest high prevalence of
reproductive morbidity among women. One early study conducted in a tribal area in central India
showed that while 55 percent of women reported gynaecological problems, clinical
examinations revealed 92 percent had at least one gynaecological disease. Infections of genital
tract contributed to half of this morbidity. In a much larger sample investigated in South India,
about one-third of women reported at least one symptom of reproductive morbidity. In both
studies, women who had undergone tubectomy reported greater reproductive morbidity.
Laboratory assessments made in a few community studies suggest wide variation in prevalence
rates: bacterial vaginosis 14-64 percent; candidiasis 2-34%, tricomoniasis 1-14 percent,
gonorrhoea 1-3 percent; chamydia 1-2 percent, and syphilis 1-10 percent.
NFHS-2 also tried to collect information on some common symptoms of RTIs. In this nation
wide survey, 39 percent of women reported at least one reproductive health problem. 36
percent reported problems with vaginal discharge or urinary tract infection 13 percent reported
painful intercourse and 2 percent reported bleeding after intercourse.
1.1.7 Regional Variations
Although several Indian states have done remarkably well in population stabilization and
provision of reproductive and child health services, what makes the Indian performance look
mediocre in international reckoning is the extremely slow progress made in a few large, northen
states. The Government of India has recently begun to focus attention on eight states where
the programme performance is particularly poor. Tables 2 to 4 present data on several
population and reproductive and child health indicators for 15 major states of India, which make
this regional contrast quite apparent. The performance is particularly poor in five Empowered
Action Group (EAG) states of Bihar, Madhya Pradesh, Orissa, Rajasthan and Uttar Pradesh
falling in a geographically contiguous territory, that includes now three newly formed states.
Chattisgarh, Jharkhand and Uttaranchal. A few examples would suffice to show the
backwardness of this region that accounts for 43 percent of India’s population. The population ol
EAG states grew by 25 percent during 1991-2001 compared with the all-lndia average of 21
percent. Total fertility rate is 4.2, which is a whole one birth higher than the all-lndia average.
Infant mortality rate is 82 as against 68 at the All-lndia level. In EAG states, only 44 percent of
women are having antenatal check up during pregnancy, one-fourth of the deliveries are
attended by health professionals, one-fifth of the children are fully immunized, and one-third ol
married women of reproductive ages are using contraception.
The reason for this striking regional contrast is complex and deep-rooted. On the one hand, high
rates of poverty, illiteracy and low autonomy of women lead to poor knowledge and low demand
for reproductive and child heath services. On the other hand, poor infrastructure and bad
governance compound the problem. Bridging the gap would require raising public awareness,
h
sensitising administrators and encouraging the involvement of private sector in the delivery cl
services.
1.1.8 Public Health Care System
a) Organisational Structure
Under the federal structure of the Indian Union, states are responsible for public health,
hospitals, sanitation etc, while items having wider ramifications at the national level; both state
and the centre are jointly responsible (i.e., they are in the concurrent list). The union ministry ot
health and family welfare is responsible for the implementation of programmes in the areas ot
prevention and control of major communicable diseases, maternal and child health and famil.
planning. Within the ministry, there are separate departments for health, family welfare anc
Indian System of Medicine and Homoeopathy (ISM&H), each headed by a secretary to the
government of India. The reproductive and child health programs come under department ot
family welfare. This division is headed by a joint secretary, under whom there are deputy
commissioners/directors for child health, maternal health, training and information, education
and communication (IEC). There is a separate wing for monitoring and evaluation that looks
after the health management information system and evaluation studies and directly reports the
Secretary, Family Welfare. But an important area of family welfare, namely child nutrition, is not
under the purview of this department, but under the Department of Women and Child
Development in the ministry of Social Welfare. The coordination of two ministries is thus critical
for the successful implementation of child health programmes.
The administrative set up at the state level could vary from state to state, but generally, there
are separate directors for health services, medical education, family welfare and ISM & H. At the
district level, the district family welfare officer looks after the implementation of reproductive and
health programmes through first referral units (FRUs)/community heath centres (CHCs), primary
heath centres (PHCs) and sub-centres (SCs). However, district hospitals and medical colleges
are under the purview of directorates of medical education and ISM & H.
T he 73rd and 74th constitutional amendments act of 1992 have made heath, family welfare aneducation a responsibility of village panchayats. Under the decentralized planning ane.
implementation of programmes envisaged in the NPP 2000, the Panchayati Raj Institutions
(PRIs) are to play a key role in the administration of family welfare programme However, in
many states delegation of administrative and financial powers to PRIs have not taken place yet
for realizing the full potential of micro-level planning and monitoring implementation of the
program.
b) Heath Facilities
The sub-centre, manned by an Auxiliary Nurse Midwife (ANM), is the most peripheral health
institution available to the rural population. As per the norms established under the Basic
Minimum Services programme in 1997, there should be one sub-centre for every 5,00C
11
population in plain areas, and for every 3,000 population in hilly/tribal areas. In 2002, there were
1,37,271 sub-centres, or one sub-centre for 4,579 rural population.
The primary health centre is a first referral unit for six sub-centres. In 2002, there were 22,975
PHCs, one for every 27,364 rural population. PHCs provide outpatient services and have 4-5
inpatient beds. According to the norm they should have one medical officer and 14 paramedical
and other supporting staff. But in many remote areas there are no functional PHCs.
Community Heath Centres are planned as first referral units (FRUs) for four PHCs for ofteniv,
specialized care. According to the norm they should have at least 30 beds, one operation
theatre, X-ray machine, labour room and laboratory facilities. The staff complement consists ol
at least four specialists, a surgeon, a physician, a gynaecologist and paediatrician who would be
supported by 21 paramedical and other staff. Currently there are 2,935 community heath
centres, or one for 2,14,000 population. But majority of CHCs do not function as FRUs as they
either do not have the required number of specialists or the facilities.
The facility survey undertaken as a part of RCH-I has brought out the serious shortfalls in
physical infrastructure, staff and supplies at pubic heath institutions. This survey covered a
sample of 7,959 PHCs, 886 CHCs yet to be upgraded to FRUs, 760 FRUs, and 210 district
hospitals. The survey considered a heath institution as adequately equipped if it had 60 percent
of the critical inputs. According to this criterion, at the All India level, only 36 percent of the
PHCs had adequate physical infrastructure such as building, water and electricity supply,
laboratory and labour room, vehicle etc., 38 percent had adequate staff in position. 31 percent
had adequate supplies of kits, drugs, vaccines and contraceptives, and 56 percent had the
adequate equipments in function, such as weighing machine, vaccine carrier, BP instruments,
autoclave, etc. The position of CHCs, FRUs, and district hospitals were somewhat better, but
they too had severe shortage of supplies. Only 10-15 percent of them had adequate supplies
The staff in position in CHCs (25 %) and FRUs (46%) was also far from adequate. In EAG
states, the position of PHCs was far worse than the all India average. Only 15-20 percent of
them had adequate infrastructure, staff and supplies. It was also observed that only 12 percent
of medical and paramedical staff (only 4 percent in EAG states) had received adequate in
service training. The FRUs/CHC and district hospitals attended only about 10 referred cases of
delivery in a month.
Fl
u
Table 1: Deaths and Disability-Adjusted Life Years (DALYs) by Cause, India,
1998
DALYs
Deaths
Cause
(000)
%
42.2
(000)
1. Communicable, maternal, perinatal & nutritional
3944
A. Infectious and parasitic diseases
2121
987
22.7
10.6
67619
25556
125
612
1.3
6.6
7891
23316
B. Respiratory infections
C. Maternal conditions
D. Perinatal conditions
135263
%
50.?
25.1
9.5
2.9
8.7
E. Nutritional deficiencies
100
1.1
10881
4.0
II Non-communicable conditions
4470
47.9
88657
33.0
A. Malignant Neoplasms
653
5
7.0
0.1
8754
3.3
238
1.1
0.0
1.1
1981
96
22944
0.1
0.7
E. Neuropsychiatric disorders
102
2
104
F. Sense organ disorders
0
G. Cardiovascular diseases
2820
284
0.0
30.2
3701
26932
3.0
5833
10.6
2.2
5618
2036
114
21
0.8
0.0
B. Other Neoplasms
C. Diabetes mellitus
D. Nutritional/endocrine disorders
H. Respiratory diseases
0.0
8.5
1.4
L. Musculoskeletal diseases
3
2.6
1.1
0.0
0.0
1710
0.6
M. Congenital abnormalities
153
1.6
7454
2.8
N. Oral diseases
0
0.0
1247
0.5
III Injuries
9.9
7.7
2.1
45032
39716
5316
16.7
B. Intentional
923
723
200
Total
9337
100.0
268953
100.0
I. Digestive diseases
J. Diseases of the genitourinary system
K. Skin diseases
A. Unintentional
Source: WHO (1999).
240
102
2
14.8
2.0
u
Table 2: Some Population Indicators for Major States from Population Censuses, SRS
and NFHS-2
Major states
Natural
Percentage
Crude
Crude
Growth of
Birth rate
Death rate Growth rate
Population
(2000)
(2000)
(2000)
1991-2001
21.3
26.9
Bihar *
13.9
18.9
27.1
Gujarat
22.5
25.2
Haryana
28.1
26.9
Karnataka
22.0
Kerala
17.3
9.4
Madhya Pradesh *
22.7
30.2
Maharashtra
22.6
Orissa
Punjab
15.9
19.8
21.0
24.3
Rajasthan
28.3
21.6
31.4
Tamil Nadu
11.2
Uttar Pradesh *
West Bengal
All India
Andhra Pradesh
Assam
30.6
8.2
9.6
8.8
13.1
17.4
21.8
17.7
19.4
Total
Expectation Female
Exposure
Median
Cui rent
Fertility
Of life
Literacy
To mass
Acje at first
of
Rate
at birth
rate (7+)
media
marriage
cei I'on
(1998)
1993-97
NFHS-2
NF 65 1
2.4
62.4
3.2
4.3
56.7
3.0
59.6
2001 NFHS-2
51 2
56 0
76.3
15 1
52.6
18 1
35 0
58 6
27 3
14 9
66.2
11 -j
56 3
66.9
78.6
16 -j
88.5
54.8
70.4
20 2
14.7
16.4
44.
44.3
82.0
17.5
46
20.0
6i
36.9
79.7
15 1
40
45.3
61 4
15 0
16.8
59.7
41.7
16 4
3.3
61.9
64.1
14.3
2.4
63.3
57 5
11.5
20.1
1.8
73.3
87 9
3.9
2.7
10.5
7.4
13.8
2.9
55.5
65.5
57.2
50.8
13.5
14.2
2.6
67.7
63 6
8.5
23.0
4.1
60.0
44.3
19.3
7.9
11.4
2.0
64.1
64 6
25.5
17.8
32.2
10.1
7.0
22.1
13.6
4.6
2.4
57.6
62.8
43 8
20.7
21.3
25.8
8.5
9.6
17.3
21.2
3.2
EAG states___________________ 25.0________ 30.8
4.2
61.1
57.9
17.9
7.5
7.5
7.8
6.4
10.1
7.5
■ including newly formed states of Jharkhand, Chattisgarh and Uttaranchal.
Source: Census 2001, SRS and NFHS 2 1998-1999
67.5
51.0
60 2
54.2
43.5
16.8
18 7
15 1
h
Table 3: Some Indictors of Reproductive Health, for Major States from NFHS-2
(1998-99)
Major states
Andhra Pradesh
Assam
Bihar
Delivery care
Antenatal care
Institutional Attended
At least one Two or more Iron and
by health
delivery
folic acid
antenatal
tetanus
professional
tablets/syrup
check-up
toxoid
65.2
92.7
81.2
49.8
81.5
21.4
51.7
55.0
17.6
60.1
23.4
24.1
14.6
36.3
57.8
Reporting
at least one
Percentage
of women
reproductive
with
health problem anaemia
49 8
48 5
50 6
69 7
44 2
63 4
Gujarat
86.4
Haryana
Karnataka
58.1
72.7
79.7
78.0
67.0
46.3
22.4
53.5
42.0
28 6
38 2
46 3
47.0
86.3
98.8
74.9
86.4
78.0
95.2
51.1
42 4
Madhya Pradesh
Maharashtra
61.0
90.4
55.0
74.9
48.9
42.4
44 9
22 7
54 3
84.8
20.1
52.6
59.1
94.0
29.7
59.4
18 8
Kerala
40 0
48 5
Orissa
79.5
67.6
22.6
33.4
27 5
Punjab
Rajasthan
74.0
47.5
98.5
74.3
89.9
52.1
95.4
51.4
79.6
39.3
93.2
32.4
37.5
21.5
62.6
35.8
63 0
41 4
79.3
15.5
83.8
22.4
28 3
43 2
27 8
82.4
71.6
40.1
44.2
38 1
45 3
48 5
56 5
48.7
62.7
66.8
55.4
57.8
36.6
33.6
17.2
42.3
26.1
39.2
40.6
51 8
54 4
Tamil Nadu
Uttar Pradesh
West Bengal
34.6
90.0
65.4
All India
EAG states_______________44.4_____
Source: NFHS 2 1998-1999
93.0
11
Table 4: Some Indictors of Child Health, for Major States
Major states
Child vaccinations (%)
At least
Infant
Child
mortality
mortality
morality
Received
Received
one dose of Diarrhea
rate
rate
rate (age
All
none
vitamin -A
(1-4 years)
50
54.4
53
65.2
45.1
45.2
28.9
25.7
47 2
34.6
48.4
34.3
66.5
43 9
2.2
43.6
26.9
21
24.4
47.9
29.8
68.5
13.9
64.2
55.1
51
2.0
64.7
33.2
49.6
39
9.4
8.7
42.0
35.1
38.5
58.0
54.4
44
56.5
42.3
36.3
28.7
39.
22.5
17.6
16.2
20.3
53.7
50.6
27.9
48.3
36.7
15.8
40.5
56.9
48.8
48.7
H
45
Assam
69.5
72.9
21.4
17.0
33.2
Bihar
44.6
46.5
24.8
15.4
34.7
16.8
10.2
Gujarat
39.6
62.6
24.0
11.0
53.0
6.6
51.9
Haryana
34.9
37.1
56.8
21.2
62.7
9.9
51.5
19.3
60.0
7.7
Kerala
13.8
79.7
54.9
32.0
48.6
34.3
16.3
86.1
2.6
Madhya Pradesh
56.4
22.4
78.4
81.0
57.1
15.0
25.5
15.9
43.7
80.4
37.6
48.2
86.7
15.9
39.2
48.7
Tamil Nadu
49.5
34.8
72.1
17.3
months
55.2
4.5
Rajasthan
ORS
38
58.7
Punjab
age -2
in first 4
36.0
21.0
Orissa
Heigh*
age -2SD
treated by
37.7
65.8
43.7
breastfeeding Weight tor
74.6
43.8
Maharashtra
Chud ma
Exclusive
42.5
Andhra Pradesh
Karnataka
Children with
Neonatal
29.5
19.9
88.8
21.2
43.8
13.6
13.9
43.4
0.3
39.6
37.1
15.4
51.7
West Bengal
53.6
31.9
All India
43.4
67.6
29.3
42.0
14.4
29.7
26.8
55.2
47.0
EAG states____________ 51.3
82.1
40.1
20.1
21.3
17.3
20.1
57.6
53.1
Uttar Pradesh
Source: NFHS-2 (1998-99)
55
i i
Table 5. Percentage of Public Heath Institutions that are Adequately Equipped, Facility
Survey 1999
Category
Primary Heath
Centers
infrastructure
Staff
Supply
Equipments
Referrals *
Training
Number surveyed
All India
EAG states
36
15
38
31
56
19
16
37
12
4
7959
2059
Community Health
Centers
EAG states
All India
District Hospitals
EAG states
First Referral Units
All India
EAG states
All India
46
84
62
24
46
94
<34
10
49
5
57
25
27
26
69
34
30
14
70
30
886
184
760
158
66
25
92
33
85
12
85
19
210
52
28
89
Note: Institutions with 60% of critical inputs have been considered as adequately equipped
’ Referred cases of delivery attended during the three months preceding the survey
' Training of medical and paramedical staff.
7.2 Program Objectives and Approach
i) OVERVIEW OF REPRODUCTIVE AND CHILD HEALTH (RCH) PROGRAM (Phase I
1997-2003)
From October 1997, National Family Welfare (FW) Program and the National Child Survival
and Safe Motherhood (CSSM) Program merged into the Reproductive and Child Health
(RCH) Program. In addition to the family planning and MCH services, the RCH program
includes strategies for prevention and management of reproductive tract and the sexually
transmitted infections (RTIs/STIs).
RCH program was not intended to be just a new package of services; it laid emphasis on
quality of services and satisfaction of the users. It incorporated a shift of management
paradigm from a provider-driven, centralized system to a target-free, decentralized program
aimed at satisfaction of the individuals (client centered approach).
ii) Background
The National Family Planning Program was launched in 1951, and changed to National
Family Welfare Program (NFWP) in 1977.
The main stress during these decades was on achieving the contraceptive targets, with major
emphasis on female sterilization, and monetary incentive to acceptors as well as providers
The target-driven, incentive-based family welfare services were insensitive to the needs and
the sensibilities of the individuals resulting in poor acceptance of the program. The prevailing
services lacked quality and hence had poor credibility among communities. Centralized
planning ignored the need of the individual areas and evoked inadequate participation of the
peripheral health care managers and grass-root workers. The program also did not take into
11
account the gender issues as well as the problems of reproductive tract and sexually
transmitted infections adequately, although they have a considerable effect on the health of
women and children. The main impetus for recasting the family welfare program was the
growing concern that the population control strategies of the country needed reorientation.
International Conference on Population and Development (ICPD) at Cairo in 1994 hastened
the pace of review of our family welfare program and population policy and placed it in the
wider context of the international concerns and consensus.
ICPD recommended initiation of national reproductive health programs in countries. The
principal goal of a reproductive health program was envisaged to reduce the unwanted
fertility safely, and to provide high quality health services, thereby responding to the broad
reproductive needs of individuals, as well as to concerns regarding population stabilization
The conference also underlined that the numerical, method-specific targets and monetary
incentives for providers should be replaced by a broader system of performance goals and
measures focused on a range of reproductive health services, realizing that such an
approach enhances fertility reduction as well as client satisfaction and health status. The
Government of India accepted the ICPD Program of Action and agreed to orient the National
Family Welfare Program towards the RCH approach.
iii) THE REPRODUCTIVE AND CHILD HEALTH (RCH) SERVICES
The Table 6 outlines the elaborate package of services at different levels of health services
envisaged in the RCH program.
Target free approach. Hitherto, the Family Planning Program revolved around achieving
numerical, method-specific targets. The target-orientated policies are detrimental to the
client-concerns because provider’s achievement and not the satisfaction of individuals is the
driving principle in this approach. The obsession with FW targets also severely undermined
the commitment of the health care delivery system to other national programs. Administrative
arm-twisting to meet the targets hurt the morale and initiative of the health care workers and
their supervisory cadres.
The RCH program envisaged target-free implementation of the family welfare activities based
on community needs assessment (CAN). The characteristics of the target free approach
included abolishing the contraceptive targets and withdrawal of motivation certificate and
incentive fee to the motivator. Moreover, family planning performance in the district was not
be used to rank or assess the administration.
The target free approach, however, does not mean 'no work approach' for the grassroot
workers. Since the health workers and the medical officers were now being made more
responsible for their ‘client’, namely, the public in their areas, they were to be judged on the
basis of qualitative and quantitative achievement vis-a-vis the assessed needs.
I J
Family planning methods: Female sterilization accounted for about three-quarters 01 the
modern methods of contraception in India. It was envisaged that the RCH program would lay
a greater emphasis on information choice about contraceptives to the clients. The singular
dependence on sterilizations was to be modified. The couples were to be encouraged to
consider alternative FP methods including oral contraceptives, intrauterine devices,
injectables, condoms, and diaphragms etc.
Safe abortion. The RCH program aimed to extend the MTP services down to the PHC level
from the present district hospital level. Counseling for MTP was to be made available at the
sub-centers.
iv) Child Survival and Safe Motherhood (CSSM)
The Child Survival and Safe Motherhood (CSSM) program was launched in 1992. It
combined the maternal and child health (MCH) interventions. It aimed to prevent maternal
and under-five morbidity and mortality. The CSSM program incorporated a package of
services for the children (child survival component) and the mothers (Safe Motherhood
component).
Better outcome of pregnancy forms the essence of reproductive health. A part of the
definition of reproductive health states that the ‘women should be able to go through
pregnancy and child-birth safely and the outcome of pregnancy be successful in terms of
maternal and infant survival and well being’. Hence, it was considered logical to incorporate
CSSM as a component of the RCH.
This program was being implemented essentially through the existing network of sub-centers
primary health centers (PHCs), and community health centers (CHCs) and district hospitals.
A total of 1748 first referral unit were to be created by upgrading CHCs. By 1997, the child
survival component was expected to be extended to the entire 466 districts, while the safe
motherhood component was to be implemented in 219 districts. However, the expansion of
the CSSM) services was slower than expected.
Thus, the activities already initiated under the CSSM program continued to be strengthened
and expanded under the RCH services
v) Services for reproductive tract and sexually transmitted infections (RTIs/STIs)
The RTIs/STIs are a relatively common problem, documented in 1 to 5 percent among
women attending the antenatal clinics in cities. These infections have a profound effect on
the health of women and children. HIV infection is lethal to the mother and her offspring to
whom she may transmit it. Other infections (syphilis, gonorrhea, chlamydia, herpes etc.) can
cause infertility, pelvic inflammatory disease, and ectopic pregnancy. Many of these
infections are also associated with low birth weight and childhood mortality.
i 1
The services for the detection and treatment of RTIs/STIs were included in the RCH package
as one of the key components.
vi) Management strategies
The management interventions to improve the reach and the quality of RCH services are
discussed below.
Bottom- up- planning: In the RCH approach, the planning for the services was not to be
centralized (top down) which does not reflect the needs of individuals or communities.
Instead, it was to be based on the assessed needs of the communities in each sub-center
area through community needs assessment exercises. The aggregated needs of the villages
will make up the PHC plan. Likewise the planning for the district will be aggregation of the
PHC plans plus the requirements of the first referral units (FRUs) and the district hospitals.
The district plans were to together constitute the State plan.
Improved management information and evaluation system (MIES): It was proposed to
replace monitoring of the program by contraceptive target achievement to a broad spectrum
of indicators covering the full package of RCH services. Few of these include (i) the
proportion of institutional deliveries and deliveries by trained personnel, (ii) the number of
health facilities providing essential obstetric care (iii) the number of pneumonia, polio and
neonatal tetanus cases reported, (iv) the number of planned IEC sessions on diarrheal
diseases and ARI. and number actually held, and (v) the total number of immunization
sessions planned and number of sessions actually held.
IEC and community participation: The RCH program envisaged area-specific IEC
(information, education and communication) campaigns. The contents of the messages were
to depend on the assessed needs and would take into account the prevalent perceptions and
practices in the concerned area.
Other managerial ingredients: It was proposed to enhance the role of the private sector
especially by revitalizing the social marketing program, expanding the use of private medical
practitioners, and partnering implementation of the publicly funded programs.
d
Table6: Reproductive and Child Health Services at Different Levels of The Health
Services System
Prevention and
management of
unwanted
pregnancy
1.
2.
3.
4.
Maternity care
Prenatal
services
1.
2.
3.
4.
Delivery
services
Sub center level
Community level
Health
Intervention
1.
2.
3.
4.
5.
Primary health center
level
Sexuality and gender
information,
education and
counseling.
Community
mobilization and
education for highrisk adolescents
youth, men and
women.
Community-based
contraceptive
distribution.
Social marketing of
contraceptives
through retail outlets.
No. 1 and
Providing oral contraceptive and
2.
condoms.
Providing IUD after screening for
3.
contraindications.
Motivating referral for sterilization.
4.
5. Counseling and referral for
medical termination of pregnancy.
6. Counseling/management/referral
for side effect, methods related
problems, change of method
where indicated.
7. Add other methods to expand
choice, such as injectables,
progestin - only OCs (for lactating
women), barrier methods.
Nos. 1-7 and
8. Performing tubal
ligation
9. Performing
vasectomy.
10. Providing first
trimester medical
termination of
pregnancy
Awareness raising for
risk factors.
Counseling/education
for breast-feeding,
nutrition, family
planning, rest,
exercise, etc.
Detection and referral
of high-risk
pregnancies.
Delivery planning
Nos. 1-4 and
5. Antenatal services at clinics and
through outreach at least 3 visits.
Detection of complication, e.g.,
6.
hypertension, pre-eclampsia,
eclampsia, severe anemia (<8g),
malaria, TB, diabetes, placenta
previa, cephalopelvic
disproportion.
7. Referral for hospital delivery in
above cases
8. Treatment of malaria.
Nos. 1-4 and
9. Treatment ot TB
10. Routine testing for
syphilis
Recognizing danger
signals (rupture of
membranes of more
than 12 hours
duration of the cord,
hemorrhage).
Conducting clean
deliveries with
delivery kits.
Detection of
complications,
referral for hospital
delivery
Routine prophylaxis
for gonococcal eye
infection.
Providing transport
for referral.
Nos. 1-5 and
Partograph.
Supervising home delivery.
Treatment of infection
6.
7.
8.
Nos. 1-8 and
Delivery services
where PHCs are
functional
10. Repair of episiotomy
and perineal tears
9.
First referral
unit/district
hospital level
Nos. 1-10 and
i Providing services
i for medical
I termination of
pregnancy in the
I second trimester
< where indicated
NOS
id
n '
1 11. Routine
testing feu
syphilis
I Postpartum
services
1.
2.
3.
4.
5.
Child survival
1.
2.
3.
4.
5.
6.
Management of
RTI/STIs
1.
2.
Breastfeeding
support.
Family planning
counseling.
Nutrition counseling.
Resuscitation for
asphyxia of the
newborn
Management of
neonatal
hypothermia._______
Health education for
breastfeeding,
nutrition,
immunization etc.
Detection and referral
of high risk cases,
such as low birth
weight, premature
babies, babies with
asphyxia, infections,
severe, dehydration,
acute respiratory
infection (ARI), etc.
Immunization
Vitamin A
supplementation
Treatment of diarrhea
and ARI cases
Treatment of
asphyxia and
management of low
birth weight._______
Sexuality and gender
information,
education and
counseling for highrisk adolescents,
youth, men and
women.
Condom distribution
Nos. 1-5 and
6. Outreach care within 24 hrs of
delivery by ANM
7. Treatment of puerperal sepsis.
8. Manual removal of retained
placenta.
9. Referral for complications
Nos. 1-9 and
10. Management of
referred cases
Nos. 1-10 and
11. Laboratory
diagnosis and
treatment I y
specialists
Nos. 1-6 and
7. Treatment of infection.
8. First aid for injuries etc.
Nos. 1-8 and
9. Management of
referred cases.
Nos 1-9 and
10. Laboratory
diagnosis and
treatment by
specialists
Nos. 1-2 and
3. Pilot testing of the syndromic
approach.
4. Identification and referral for
vaginal discharge, lower
abdominal pain, genital ulcers in
women, and urethral discharge,
genital ulcers, swelling in scrotum
or groin in men.
5. Partner notification/referral.
Nos. 1-5 and
6. Treatment of
RTIs/STIs.
7. Partner notification.
8. Routine serology for
syphilis testing in
antenatal women.
Nos. 1-8 and
9. Laboratory
diagnosis and
treatment of
RTIs/STIs.
I j
1.2.1 Lessons learnt from RCH I
Management and Institutional
1. Weak management capacity especially in planning, supervision, budgeting, fund flow,
2.
3.
4.
5.
6.
implementation of civil works and in the delivery of quality services
Inadequacy of decentralization of processes and modalities from the Center to the
states and from the Center to the Districts in management of finance, procurement and
related issues.
Low levels of ownership of and commitment to RCH at state levels
Weakness of program management at the district levels, including lack of skills,
frequent turnover, lack of specific assignments, inadequate delegation and lack of
integration, especially at the EAG states.
Lack of clear mandates to supervisors and inadequacy of field level supervision from
the state and district level
Governance issues including that of lack of clearly laid down demand and supply
forecasts for human resources along with ad hocism in human resource utilization and
resource gaps in reaching national norms for doctors and ANMs.
Strategic Inputs and Systems
7. Lack of an operational IEC/BCC strategy.
8. Lack of an effective MIES.
9. Poor implementation of the training component.
10. Poor maintenance of infrastructure especially in the post-project periods
Quality and Infrastructure
11. Lack of an effective FRU network and referral back ups
12. Inadequate quality of care in PHCs and FRUs as reflected by a poor client
responsiveness, lack of general cleanliness, lack of basic amenities such as running
water and electricity, management of instruments, lack of waste management and
infection control systems.
Service Coverage
13. Weakness of outreach services, particularly regarding routine care and in retaining
clients for completing the cycle of care.
14. Little involvement in involving communities and local elected bodies in planning,
management and monitoring of program performance
15. Inadequate range of services such as in iron supplementation in women and children.
STI/RTI management, MTP and emergency obstetric care
16. Unsatisfactory coverage in areas of ANC, emergency obstetric care, PNC.
contraceptive prevalence, immunization, Vitamin A, ORS and ARI.
17. Lack of emphasis on neonatal health, adolescent health and breastfeeding promotion
1 i
Coordination
18. Multiplicity of funding agencies leading to high transaction costs, fragmented scheme
and confusion among implementing bodies.
19. Lack of one unified concept/ system and one unified nomenclature.
20. Lack of optimum convergence with ICDS system.
Regional variations-requirement of a differential approach
It needs to be noted that while the overall implementation of the RCH I program left room for
improvement, there have been district/state/regional variations with some states such as
Andhra Pradesh and Tamil Nadu performing reasonably well. It should be noted that although
several states have done remarkably well in population stabilization the national average
looks mediocre in the context of international figures due to extremely slow progress in a few
large northern states. There are deep rooted causes causing such variations:
•
•
High rates of poverty, illiteracy and low autonomy of women lead to poor knowledge
and consequent low demand for RCH services.
Poor infrastructure and low quality of governance compound the problem.
The government has recognized the importance of bringing these states to the national level
achievements. The states of Bihar, Madhya Pradesh, Orissa, Rajastan, Uttar Pradesh,
Chattisgarh, Jharkhand and Uttaranchal have been designated as the Empowered Action
Group States. The following brings about the striking difference:
•
•
•
Total fertility in EAG is 4.2 a whole birth higher than the national average
Infant mortality rate is 82 as against national average of 68.
Only 44% of women are having antenatal check up during pregnancy
The above are only a few parameters exhibiting striking contrast but it leads to a clear lesson
that within the national program these states need to be provided a differential approach and
with a focus different from other states.
d
•
1.2.2 Appraisal of RCH I interventions
Interventions
MATERNAL HEALTH
Antenatal care (including TT,
I FA)
Institutional deliveries
Emergency obstetric care
Safe deliveries at home
Safe deliveries at sub-center
Referral
Post-partum care
Schemes:
24 hour delivery services
Contractual staff
Private SM consultants
Private
anesthetists/obstetricians
Additional ANMs
Referral transport
RCH outreach scheme
RCH camps
CHILD HEALTH
Immunization
Routine
Pulse Polio
Newborn care
Diarrheal disease control
ARI control
Breastfeeding promotion
Complementary feeding
promotion
Vitamin A, IFA
TRAINING
CONVERGENCE
ICDS system
Worked well
in RCH I and
to be
continued
Worked but
needs
strengthening
/
A/
A
a/
y/
A/
V
a/
V
A/
a/
a/
7
Did not work
and should
be
discontinued
iI
7
MIES
■
Behavior change
communication/social mobilization
h
NGOs
Private sector
V
H
District Surveys- Important findings:
1
As compared to 1998-99, by the end of 2002 social awareness for delayed
marriage for girls have gone to the community. Out of about 200 districts surveyed
the percentage of girls marrying below 18 years, have decreased in 65% of the
districts. In 26% of the districts, the decrease is more than 10%.
2.
In 85% of the districts, out of 200 districts for which the results are available, the
contraceptive use has increased suggesting the movement of the population
towards stabilization. In 34% of the districts the increase in contraceptive
acceptance is more than 10% as compared to 1998-99. The contribution of birth
order 3 and above towards the total births during the period 1999 to 2002 has
decreased in 85% of the districts, showing good achievement adopting small family
norms in the country. In 32% of the districts, the decrease in higher order births is
more than 10%.
3.
The safe delivery has increased in 85% of the districts in 2002, as compared to
98/1999. In 58% of the districts, the increase is more than 10% as compared to
1998-99. This indicates more effectiveness of the safe motherhood programme
under which better safe delivery was given by the health professionals in ths
country.
4.
The decline has been observed in the complete immunization status of children as
compared 1998-99. In about 45% of the districts, the Immunization has been
reduced by more than 10%, indicating routine immunization need to be
strengthened.
Comparison - States
7. The district survey was conducted in the year 1998 and 1999 covering 50% of the
districts in each year. In 2002, the survey was repeated covering 293 districts of
which results of about 200 districts are available.
2. A comparison was made tentatively based on the results of these districts and the
observations areas follows:')
The states of Assam, Gujarat, Karnataka, Madhya Pradesh, Maharashtra.
Orissa, Tamilnadu, Uttar Pradesh and West Bengal has shown a decline ol
more than 5% points of girls marrying below 18 years during 2002 as
compared to the earlier period. However, this is stagnant or minor variation
in the states of Andhra Pradesh, Bihar, Haryana, Punjab and Rajasthan.
>')
The contribution of higher order births in all the major states has come
down substantially, showing more progress towards population
stabilization. Notable achievements of 10% points have been made by the
states of Assam, Bihar, Rajasthan and Uttar Pradesh, where the level was
quite high in 1998/99.
i 1
iii)
Contraceptive prevalence has gone up in all the major states, especially in
Uttar pradesh(22 to 33%), Madhya Pradesh (44 to 50%) and Himachal
Pradesh(62 to 70%)
iv)
The unmet need has come down in almost all the major states, especially
in the states of Assam, Bihar, Madhya Pradesh, Rajasthan & Uttar
Pradesh, where it was quite high.
V)
Safe delivery has gone up considerably in Andhra Pradesh(60 to 78%),
Gujarat(56 to 74%), Haryana(33 to 57%), Himachal Pradesh(36 to 66%).
Karnataka(60 to 68%), Madhya Pradesh(28 to 44%), Orrissa(33 to 49%).
Punjab(55 to 86%), Uttar Pradesh(21 to 33%) & West Bengal (46 to 67%).
vi)
The Status of full Immunization however, has shown a decline, except in
the states of Himachal Pradesh, Karnataka, Punjab where it has increased,
while the states of Bihar, Gujarat, Orissa and West Bengal is almost
stagnant as compared to the previous survey.
ii
1.2.3 PROPOSED STRATEGIES UNDER RCH II
Implementing the program as a
National RCH Mission
in pursuance of the
National Population Policy (2000)
and the
Millennium Development Goals
•
Institutional & Systems Strengthening
•
•
•
•
•
•
•
•
•
Restructuring and strengthening the implementation and monitoring mechanisms to
ensure success of the Mission.
Introducing a holistic concept of RCH, with one unified approach/system and one
unified nomenclature and integrating family welfare/family planning with RCH
Establishing ownership and strengthening of management capacities including that for
operation and maintenance at the state level
Streamlining the service delivery structure so as to preclude multiplicity of structures
duplicating efforts in the same area.
Ensuring comprehensive convergence and synergy between RCH and ICDS systems
for RCH interventions.
Revamp the monitoring information and evaluation system to ensure effective program
implementation.
Developing the district organization of the program into a vibrant result-oriented and
well-empowered system.
Developing monitoring, supervision, technical and managerial capacity at the center
and state levels
Ensuring smooth funds flow.
Focused Approach
•
•
•
•
•
•
•
Bring about a comprehensive integration of Family Planning activities with safe
Motherhood and Child Health activities.
Differentiated strategic approach for the EAG states and the other states.
Ensuring a special focus on the poor and marginalized sections of the society who
contribute a disproportionately higher burden of ill health.
Amalgamating similar activities such as polio, routine immunization, outreach
immunization sessions in order to build up one strategic framework for one broad
intervention.
Integrating fragmented schemes as provided for under different projects by different
donors (Donor Convergance)
Standardizing activity and training norms as for example in schemes such as of Dai
training, safe motherhood consultants, and community skilled birth attendants.
Integrating systematic referral networks with the FRUs, Sub divisional. District level
hospitals and tertiary level facilities
11
•
•
•
Strengthening the quality aspects of service delivery such as strengthening client
responsiveness, better maintenance, improved cleanliness, provision of basic facilities
such as running water, electricity, management of instruments and infection control.
Implementing a nation-wide behavior change communication strategy
Integrating an operational research component in the program for generating evidence
Quality of Service and Coverage
•
•
•
•
Enhancing coverage in areas of newborn care, ANC, institutional deliveries,PNC
immunization services, ORS, ARI treatment, emergency obstetric care and fertilib.
regulation
Re-examining the community needs based assessment approach and systematizing
the same at a realistic level such as the district wherein capacities are to be
strengthened to be mature and developed enough to handle such community based
planning.
Strengthening quality assurance, reforms and new initiatives in contraception and MTP
services
Improving the quality of training and implementing the training activities efficienil
through a mix of government, NGO and private institutions.
Intersectoral Collaboration
•
•
•
•
Working wherever feasible, through Panchayati Raj Institutions and people*
representatives.
Enhancing the partnership with the private sector, NGOs and ISM practitioners
Involve NGOs in service delivery through outsourcing of PHCs downwards.
Building a strong base of private-public partnership to enhance service provision.
Empowering Structures and providing Enabling Environment
•
•
•
•
Introducing a community chosen, community resident link worker.
Enabling and empowering the provider teams at community levels, PHCs, CHCs.
FRUs and district levels.
Improving mobility of district program managers, MOs, LHVs and ANMs for fieldwork
and supervision.
Introducing infection prevention and waste management initiatives in facilities.
I j
1.2.5 MATRIX OF ISSUES ARISING FROM RCH I AND PROPOSED FEASIBLE ACTIONS
IN RCH II
Item
Development of FW
systems
9
Issues
System needs to be
more efficient and
effective.
To
concentrate on core
functions
and
prioritized activities
Lack
of
field
supervision
and
provision
of
feedback
to
the
states
Interventions
Desired Outcomes
Clarify priorities and core
Strengthen
commitment
to functions
RCH and enhance
Management
capacity both at
at
national
and
state levels through
Expressions of Interest
training,
through
Letters
of
institutional
Undertaking
from
states
strengthening and
holistic approach to
RCH
and
FW
activities
Mods between the
Central and State
governments
on
performance
achievements and
Institutional
arrangements
Micro management
at
state
levels
rather than that of
the MoH&FW
States may adopt
policies
to
strengthen
the
supervision
machinery through
correct placements,
training
on
supervisory roles,
and
enhancing
effectiveness of the
mechanism;
establishing
supervision
and
from
feedbacks
different
and
to
health
tiers
of
administration
Use of quantitative
u
Health Care Providers
Management
and
Development and the
Supply
of
Human
Resources
performance
for
statistics
program
management which
may be monitored
by
Independent
Agencies
Private
Sector Appraisal
of Policy identified for public
partnership and
dominates especially options of the role, private
in out patient care
scope and potential NGOs.
Public
sector, for partnership with
although
important the private sector
for in patient care, and NGOs.
especially for the
economically weak,
has
very
little
evidence
on
admissions
of
in
patients
as
evidenced iin EAG
states.
sector
Public
important in the area
of preventive Health
Although they serve
as crucial resources
as service providers,
there is the need to
work out a clear
strategy as how to
work
with
local
private practitioners.
develop
a Strategy developed and
Actual supply and To
for
Human
resource costed
placement of the Human
resources
various cadres of policy/ strategy
To
develop
service providers
workforce
Skill mix
attract management
Ability
to
Service providers to options
rural areas
Evaluation Criteria
Need to have draft
training
policy
in
place which should
be ratified, costed
and implemented
Ii
F Infrastructure
maintenance
same
and
of the
Supply of drugs and
equipment
In most EAG states
there is a lack of
essential
infrastructure
especially at the Sub
center
and
PHC
levels.
Another critical issue
is
operation
and
maintenance of the
infrastructure
and
allotment of non plan
funds for the same
from the budgetary
provisions of the
state______________
To be in consonance
with Essential drug
policy
basic
Shortfall
in
equipments
Potential utilization
of infrastructure to
be examined prior
to
actual
constructions
Necessary to look
at linkage factors
such as electricity,
water
supply,
boundary walls and
approach roads.
Strategy for Infrastructure
Development developed
for
logistics
Centralized supply Strategy
in
EAG
states; developed
coordination
both Skills for O&M enhanced
O&M
strategy
at the state and the and
systematized
consignee levels
Actual utilization of
equipments
Skill training in use
of equipments
Operation
and
maintenance
of
equipments
and
furniture
I j
Decentralization
Strong
thrust
on The CNA system
requires
grassroot planning
to
Community
Needs redesigning
facilitate
Assessment
community
Approach
and
Involvement of PRIs, participation
and
NGOs and District / planning
level monitoring at the
village
functionaries
for appropriate levels.
This
may
be
planning,
and supplemented with
management
level
review of preventive district
household/ facility
health services
Lack of capacity at surveys
to
be
regularly conducted
these levels
much to
assess
the
CNA
not
practiced in actual movement:of
utilization
service
planning
impact
synergy and
Lack
of
between
the sub indicators.
center, the PNC, the
district and the state
levels
in
actual
planning
of
the
requirements for the
state in the sense
that plans are to
develop from the
sub center levels.
not
State
level
to
equipped
experience
paradigm
shifts
policy
towards
and
setting
performance
evaluation
Strong
line
management
vs.
in
flexibility
health
managing
facilities
Lack of supervision
and monitoring at
field levels to be
able to provide feed
Agreement
reached
on
core functions and health
established
as
the
community's agenda.
Programs to development
capacity developed
Greater responsiveness of
functionaries at the village
level.
11
Inter
sectoral
Coordination
in
Convergence
with
working
external agencies
Strengthe
ning
Service
Delivery
back to the field
functionaries
level
from the other tiers
few
Quite
a
carry
Departments
out functions, which
have a bearing on
preventive
health
activities but there is
no clear strategy for
integrating work at
the state level.______
Too much of donor
involves
presence
transaction
high
duplication
costs,
fractured
and
responses with a
lack of clarity on
ownership as to how
these interventions
contribute
to
the
policy
overall
objectives
of the
MoH&FW
not
Services
are
responding
adequately to the
needs of the rural
and
urban
poor,
services are of poor
quality
and
are
mostly inaccessible
Uncontrolled pattern
of service delivery in
the private sector
core
Identify
and
departments
also
areas
of
mutual interest.
Create a structure
and
to
lead
coordinate
Integrated
responses
identified, developed and
costed
with
key
departments
Donor funding to
be area specific or
activity
specific,
MOUs
to
be
entered into with
external agencies
on ways of working
within the overall
policy framework
Review
against
governance
structures
Greater efficiency in the
use of external resources
combined with a reduction
in management costs and
duplication
Provide
quality
services which are
accessible
and
client sensitive
Enable contracting
of staff, mobility
support
and
contingency
support to service
providers and clear
mandates
on
supervision
Service
delivery
patterns,
patterns
of
expenditure,
activities
and
competencies are
at different levels
may work against
stated priorities
Policy options to
Concentration on essential
services
improves
utilization by the poor
Role of private sector to be
supportive
of
/
be
complementary to public
health priorities
11
achieve
feasible
staffing
patterns,
service provisions
and referrals
Targeting of services
The
responsiveness
of services
essential
Poor are able to Define
utilize much less of services for the
poor
the services
physical
Most poor oriented Review
and
financial
programs are funded
mostly
by
the performance
such
Central government
against
priorities
on
Undertake
Complaints
responsiveness
insensitive,
inefficient and costly and service quality
public
service reviews from the
perspectives
of
providers
Distrust of private both clients and
sector as motivated service providers
review
Options
by profit
for
Clients have little exercise
between demand
led
choice
expensive
/ interventions
inadequate
private
sector providers and
apathetic
public
sector providers
Resources
are
predominantly
used
to
finance essential services
that address the needs of
the poor
Need based/ performance
based financing.
Strategies to improve the
responsiveness of service
providers are defined and
implemented
Options
for
demand
generated interventions are
identified and piloted
Monitoring
Evaluation
Service quality is improved
A
clearly
through the development
specified
and
implementation
of
service quality
instruments
and
improvement
mechanisms to monitor
strategy
service cjuality
Including
systematic
training
needs
assessment and
supervision
be
I EC
to
oriented
towards
behavior
change
I PC to be a two
way
process
tailored to the
needs of local
clients
Improving
the
monitoring,
evaluationi and
feedback
on
service <quality
as an incentive
for
service
providers
lead Effective system of M&E
Data collected is not Assign
developed,
implemented
used necessarily for organization/
planning,
institutions to work and used
management
and with MoH&FW and Greater public participation
implementation
of the states on HMIS in making the program
and other forms of more accountable to the
services
community
been M&E.
HMIS
has
Facilitate
states
to
identified as a key
area for review and use data especially Carry out annual surveys
application
those collected on to generate information on
health
Decentralization
RHS on the basis important
oriented M&E to be of district indicators parameters in the EAG
at states.
to
arrive
in place
and
public planning
Lack
of
participation
in management
management
and decisions on focus
evaluation
of areas
medium
Develop
services
There has been little
or no success in
developing systems
to
measure
and
improve
service
quality
Little achievement in
improving
the
technical quality of
supervision
and
making
it
more
supportive
Developing
the
communities/ NGOs
and the local elected
bodies'
Capacity to oversee
the
program
performance
Service Quality
and
1J
term strategy for its
development
and
implementation
Policy options for
greater
public
participation
in
M&E at the state
and
the
district
levels addressed in
the medium term
strategy
Carry out annual
to
surveys
generate
on
information
important
health
parameters in the
EAG states.
1.2.8 Linkages with Other programs
a) Inter-Sectoral Coordination
Inter-sectoral Coordination is a key strategy to be initiated during RCH II because this can
lead to cost-effective results and would sustain them over the long run.
The concept of inter-sectoral coordination emanates from the following:
•
•
•
Outcomes jointly determined by policies in multiple sectors
Sectors providing services to the same target groups/locations
Different programs reaching the same target group can also be effectively utilized to
build on them or utilize the services offered by them
Hence, if these sectors can work in close coordination with each other to bring about a
common objective to be achieved then outcomes can be achieved in a shorter span of time
and in a cost-effective manner. The following matrix outlines the linkages and the extent of
impact that it can have:
High
Maternal
Health _
Very High
Disease
Control
High
Newborn
care
High
High
High
High
High
Sector
Child Health
Rural
development
Urban
development
11
Roads______
Women and
Child
Development
Forest
Department
Education
Public-Private
partnerships
High____
Very High
Very High
High
Moderate
Moderate
High
Very High
In Tribal
Areas High
Very High
Very High
In Tribal
Areas High
Very High
Very High
Tribal Areas
In Tribal areas
Very High
Very High
Very Higl
Very Higl
The above is only illustrative and not exhaustive and this can be very clearly brought out only
after consultations with the different departments and analyzing their programs and
objectives..
The Report of The Steering Committee on Family Welfare For the Tenth Five Year Plan has
observed the following:
' Inter-sectoral coordination, especially between the Departments of Health, Department of
ISM&H, Women and Child Development, Human resource Development, Rural development
Urban Development, Labor, railways, Industry and Agriculture is critical for increasing the
coverage of the Family Welfare Program and improving implementation. Some of the areas
where inter sectoral coordination is envisaged in the tenth plan include:
•
Involvement of the extension workers of these departments in propagating IEC
messages pertaining to reproductive and child health care to the population whom
they work with;
•
Efforts to improve the status of the girl child and women, improving female literacy and
employment, raising the age at marriage, generating more income in rural areas,
improving the nutritional status of women and children;
Coordination among village-level functionaries- anganwadi workers, TBAs, Mahila
Swastya sangh, Krishi Vigyan Kendra volunteers and school teachers - to achieve
optimal utilization of available resources
•
b) Private-Public Partnerships
The pattern of service provision can be currently captured as follows:
•
•
•
Primary health services both preventive and promotive is provided by the public health
delivery system
The secondary health care is provided by a mix of public health delivery system and
the private system
The tertiary health care is provided by largely private and to a limited extent by public
health system
The role of the private sector needs to be increased in the primary health care provision
through social insurance and franchising systems especially in the rural areas. The role of the
for profit' and ‘not for profit' sectors also needs to be enhanced.
The private public partnership needs to address:
•
•
•
•
•
•
•
•
The NGOs who could be involved
Private sector providers of health care
Medical facilities run by missionaries
Medical facilities run by public and private sector organizations in the organized sector
Railways which have a chain of service provision institutions
Consumer goods and durable goods manufacturers who have a direct product market
linkage
Pharmaceutical companies
Corporate hospitals
Hence, it can be seen that the inter sectoral-coordination can play an important role in
integrating the service delivery at the grass root level.
The organizational arrangements that are suggested to bring about the coordination are as
follows:
State Level
At the State Level the RCH&FP Society would have the following composition:
Chief Secretary of State- Chair Person
Principal Secretary Family Welfare-Deputy Chair person
Secretaries of the related departments such as WCD, Rural Development, Education,
Panchayati Raj etc., to be Members
Program Director-FP&RCH- Member Secretary
District Level
The District Level FP&RCH society would have the following composition:
District Collector-Chair Person
The Chief District Medical Officer -Deputy Chairperson
District FP officer/ RCH Officer-Member Secretary
Functionaries of the related departments such as the district education officer, district
rural development officer, members of the Zilla Parishad, Local elected representatives
-Members.
c) Linkages with other programs:
It is essential that the linkages between the National AIDS Control Project (NACP II) is
established especially because the NACP is addressing the issues of RTI/STI in a large way
through a network of facilities within the public health delivery systems. Hence, this linkage
can enable the scaling up of the availability of specialist services in this area The following
linkages are envisaged with the NACP II:
•
•
•
•
•
•
•
•
•
Linkage with the RTI/STI programs over the next five years including the Family Health
Awareness Programs. This is expected to be achieved through setting up a small
expert panel to examine the issues relating to ANMs in RTI/STI screening and
management. This committee would also recommend the drugs that can be included
in ANM kit for treating simple RTI.
The committee referred to above would review the training module for STI for the
Medical Officers.
Prevention of Mother to Child Transmission of HIV/AIDS
Counselling services at CHC/FRU levels
Couple counseling would be an important part and ANMs would be equipped with the
appropriate skills.
Blood storage and related training and NACO would support the training for cross
matching of blood etc;
Infection control processes at institutions
School health programs being taken up by NACO and the RCH can focus on the out of
school adolescents.
Provision of BCC kits with AWWs.
Linkage with the Integrated Child Development Scheme can facilitate the interventions in
the area of postpartum care and community based management of newborn care. It can also
bring about the synergy of these two types of services as it addresses the common target
group.
The women and Child Development Department is closely working at the village level through
the Anganwadi system to bring about better nutrition outcomes of women, children and
adolescents in the villages through ICDS. Better nutrition and reduction in anemia can have a
direct impact on the pregnancy related complications, reduce maternal mortality and infant &
child mortality and can bring about better health outcomes.
11
Further the Anganwadi worker stays in the village itself while the ANM covers a population of
5000 spreads over the different villages. Hence, AWW can become the focal point in the
village and provide complementary support to the services of ANM
The focus of the programs is on women and children and these are the target group of the
health systems as well. Since there is a close correlation of the objectives of the WCD and
Health &FW the establishment of linkages with this system is considered Vital.
The Steering Committee on Family Welfare For the Tenth Five-Year Plan has provided the
following areas of convergence.
Convergence of services with the Department of Women and Child Development include
•
•
•
•
•
Involvement of the anganwadi workers in the compilation of births and deaths and the
identification of pregnant women
Involving anganwadi workers in weighing babies as soon as possible after delivery and
referring neonates with weight below 2.2 kilo grams to centers where a pediatrician is
available
Utilizing the services of anganwadi workers in improving the coverage of Vitamin A in
children when they are 18 months, 24 months, 30 months and 36 months and
improving the compliance among pregnant women under iron and folic acid
medication
Identification of undernourished pregnant women and lactating mothers and pre
school children to ensure they get priority in food supplementation programs under the
ICDS and appropriate health care from the ANMs and doctors
Promoting the cultivation of adequate quantities of green leafy vegetables, herbs and
condiments in coordination with the PRIs and agricultural extension workers and
ensuring that these are supplied to anganwadis on a regular basis to improve the
micro-nutrient content of food supplements
The anganwadi worker can assist the ANM in organizing health check ups of women and
children and immunization in the abganwadi. She should act as the depot holder for iron and
folic acid tablets, ORS, Condoms and disposable delivery kits. She should be provided with a
list indicating the nearest facility to which women and children could be referred so that she
can help in organizing emergency referral.
Ii
1.3Financial and Economic Analysis
1.3.1 Financial Analysis: Family Welfare Program
The Family Welfare Program is a central scheme funded by the Central government and
implemented largely by the state governments. The justification for central governments rol
in funding the program can be attributed to the spillover effects of high levels of fertility, which
are not confined to one or two states. In the absence of such transfers, the expenditure would
have been lower than those justified by the total benefits accruing from such investments.
Almost 86% of the budgeted resources are administered by the states.
Table: 7 Share of States in the total social sector expenditure of
Center and States (% 1998-99_______
Share of states (%) 1998Major heads
99
Education, art and culture________________________________ 88.1
89.3
Medical and public health, water and
sanitation_________________________________________
85.9
Family welfare_________________________________________
Housing_______________________________________________ 44.6
93.1
Urban development______________________________
60.4
Labor and employment_______________________________
89.2
Social security and welfare___________________________
21.2
Others*_______________________________________________
82.3
Social and community services (1 to 8)_________________
64.2
Rural development
80.0
Total(9+10)
* Others include scientific services and research, broadcasting,
information and publicity.
Note: the information given in the table relates to actual expenditure
Source: Computed from the data available in Indian Public Finance
Statistics, Ministry of Finance, GOI (1995-2001)
Budgetary expenditure on the program for 2002-03 is Rs.4954 crore; over three times the
expenditure in 1996-97. It is interesting to see over the period; the share of family welfare
expenditure in the total on health and family welfare together has gone up.
Ii
Table: 8 Central Government Expenditure on Health and Family
Welfare
Share in
Years Plan Exp Non Plan
Total Exp
%
change
total
exp
(Rs.cror
Exp
(Rs.crore)
__(%£
(Rs.crore)
e)
319
66.15
1.45
1980-81 229
90
1985-86 690
1990-91 1037
1995-96 2086
1996- 97 2260
1997- 98 2579
1998- 99 3213
1999- 0014106
2000- 01 4384
2001- 02 4742
2002- 03 6048
117
236
456
491
595
780
906
969
992
990
807“
1273
2542
275?
3174
3993
5012
5363
5734
7038
705
203
5.35 ‘
O2~
15.38
25>
202
7.00
OO
22.74
1.53
T.TT
T’43
1.37
1.37
T43
T.68
1 65
1 57
1 72
2001-02: Revised estimate, 2002-03^ Budget estimate
Source: Estimated from Budgets
A further analysis of family welfare expenditure (Table 8) would show a distinct increase in
the share of expenditure on maternal and child health in the total central government
expenditure on health. This is clearly the result of replacing MCH by RCH. As far as the share
of rural family welfare services is concerned its level has almost remained stationery over the
period.
11
Table: 9 Central government expenditure on social sector (plan and non-plan) (as % of
GDP)
0090- 91- 92- 93- 94-95 95- 96- 97- 98- 9997
00
96
98
99
01 (R)
91
92
93
94
Educ., sport, youth welfare 0.30 0.27 0.25 0.28 0.28 0.31 0.29 0.33 0.38 0 34 0.36
etc____________________
Health and family welfare 0.22 0.21 0.23 0.24 0.24 0.22 0.20 0.21 0.23 0.24 0.25
0.15 0.14 0.11 0.13 0.13 0.15 0.22 0.22 0.23 0 22 0.21
Water supply, sanitation,
housing and urban
development____________
Information and
0.08 0.06 0.05 0.05 0.05 0.05 0.04 0.06 0.06 0.06 0.06
broadcasting____________
Labour and employment
0.05 0.05 0.05 0.04 0.04 0.04 0.04 0.04 0.04 0.04 0.04
Welfare of SC,ST and BC 0.06 0.06 0.07 0.07 0.07 0.07 0.16 0.05 0.05 0.05 0.05
0.15 0.14 0.15 0.14 0.19 0.12
Other social services (1to 0.09 0.10 0.11 0.10 0.1
nTotal
__________
Social Services
0.95 0.90 0.86 0.95 0.91 0.98 1.00 1.04 1.12 1.14 1.15
Rural Development______ 0.47 0.35 0.43 0.54 0.57 0.56 0.37 0.37 0.33 0.24 0.19
0.18 0.19 0.21 0.21 0.23
Basic Minimum Services
(BMS)__________________
1.42 1.25 1.29 1.49 1.49 1.54 1.56 1.60 1.67 1.59 1.58
Total
Source: Expenditure Budgets of GOt, Vol.1
1.3.2 Donor Financing
Past budgetary allocations for the family welfare program have provided both physical and
human resource infrastructure for a family welfare approach, which has focused largely on
the delivery of a very narrow range of contraceptive methods. The orientation changed with
the launch of RCH-1. This requires additional inputs, which to be effective needed to be
implemented in an integrated way. This need will remain even after the completion of RCH-1.
thus justifying supplementary donor assistance. In RCH-11, apart from continuing with
funding activities begun in RCH-1 in RCH-II, greater emphasis is being laid on EAG States,
tribal and urban areas. Also the activities that were initiated in RCH-1 will need to be
strengthened and consolidated. In RCH-II, the newborn care component and Emergency
Obstetric Care will receive greater attention. Another focus area of RCH-11 will be to assist in
improving the existing infrastructure and equipment to ensure better quality care.
ii
1.3.3 Economic Analysis Of Reproductive Health In India
Rationale for Public Investment:
Public investment in family welfare services can be justified on the principle of both efficiency
and equity. Family Welfare Services yield both short term and long-term benefits. More
importantly, the program provides positive externalities or benefits to individuals beyond
those receiving the service. For instance, the program envisages improvement in maternal
health and nutrition, which improves the survival chances and well being of children leading
in turn to lower fertility levels. Births so averted may then lead to reduced infrastructure
expenditure and higher savings in net future consumption leading to improvements in the
overall standards of living. Births averted would also eventually result in the savings in
program costs. In the absence of public financing, the effective demand and provision of
these services is likely in many cases to be below the socially optimum level. Equity
arguments in favor of subsidized health services are strong in India, where the recent work
on poverty suggest that over one third of rural population has access to just Rs 6-7 or less a
day. The public provision of services, in addition to their financing, is justified when private
sector does not exist, the public sector is a more efficient provider or consumers exhibit a
clear preference for public services.
Specifying and quantifying the measurable benefits of the Family Welfare Program (FWP) are?
generally difficult due to high degree of positive externalities. There is sufficient information
on the costs of the program but for both intermediate and final benefits one can rely on
some select measurable outcomes from a host of indicators including couple years of
contraceptive protection and births averted, savings in public expenditures resulting from a
smaller population, levels of reduced morbidity and mortality among women and children,
reductions in the unit costs of a given type of service, improvement in women s
empowerment, etc.
1.3.4 Trends in Family Welfare Expenditure:
Before proceeding further we give a brief description of the trends of family welfare
expenditure in India. It would be seen from Table 10 that over the period expenditure on
family welfare has shown a rising trend.
IJ
Table 10 Progress of Family Welfare Expenditure in Ninth Plan & Approved Outlay for
Tenth Plan
The scheme wise outlays for the Ninth and the Tenth Five Year Plans and the anticipated
expenditure during the Ninth Plan are given in Table
(Rs Crores)
IX
Plan
Approved
Outlays
Tenth
Plan
A
INFRASTRUCTURE
MAINTENANCE
6231.90
Ninth
Plan
Sum of
Annual
Outlays
66505
B
INFRASTRUCTURE
DEVELOPMENT
1050.00
1202.35
915.76
2412.00
364.20
C
TRANSPORT
150.00
250.50
250.65
378.00
113.00
D
TRAINING
257.35
301.28
289.29
521.00
99.60
E
RESEARCH
96.00
107.00
96.58
159.50
30.30
F
CONTRACEPTION
1541.50
1578.70
1458.35
1 2727.50
483.50
G
REPRODUCTIVE &
CHILD HEALTH
5150.00
4423.00
3753.49
' 6333.86
1174.20
H
OTHER FAMILY
WELFARE
PROGRAMMES
643.25
450.72
318.68
1900.50
355.90
GRAND TOTAL
15120.00
14968.70
14588.97
27125.00
4930.00
X
Plan
Name of Scheme
Approved
Outlays
Ant.Exp
7506.17
12645.64
Annual
Plan
2002-03
2303X10
___ I
Source: Tenth Plan Document
i I
In the Ninth Plan, the centrally defined method specific targets were abolished, emphasis
shifted to decentralized planning at the district level based on community need assessment
and implementation of program aimed at fulfillment of these needs. A massive pulse polio
campaign was also taken up to eliminate polio from the country. Monitoring and evaluation
was also emphasized as a means of carrying out mid-course corrections Another landmark
was the taking up of the Reproductive and Child Health program to provide integrated good
quality maternal, child health and contraceptive care.
Unfortunately despite all these efforts, mortality and fertility rates remain high, especially in
the EAG states. The high fertility is also the result of the unmet needs for contraception.
Therefore in the 10th plan, the focus is on meeting (I) the unmet needs for contraception (ii) to
reduce fertility through undertaking programs for reduction in IMR/MMR, and (iii) to enable
the families to achieve their reproductive goals. In drawing up the financial plan for the X fiveyear plan, emphasis is laid on utilizing the available funds to make the existing health
facilities fully functional by providing equipment, consumable, diagnostics and drugs.
Financing family Welfare Program: It is one of the largest centrally sponsored scheme under
which funds are provided to supplement the funds available for infrastructure, manpower and
consumables needed to provide MCH and contraceptive care. During the Ninth plan, three
major projects, namely, RCH, PIP and strengthening of routine immunization with substantial
outlays were added. On the whole between 1997/98 and 2001/02, out of the budget amount
of Rs 14968.70 crores Rs 13951.25 crores was spent.
In the X Plan, an outlay of Rs 27125 crore has been approved against an outlay of Rs
14968.7 crores in the IX Plan, showing an increase of almost 100%. In the X Plan the outlay
for RCH is Rs 6333.86. Further almost 47% of the X Plan outlay is for Infrastructure
maintenance. Within this rural sub-centres account for Rs 9663 crores (76%) Similarly
compared to IX Plan the outlay on infrastructure development has almost doubled. The outlay
on RCH in X Plan has also been increased by almost 43%. It may be mentioned that part of
this increase in outlay in the X Plan over the IX Plan will be offset by price increase.
11
Table: 11 State Government Expenditure on Family Welfare (in Rs crore)
States
165.8
32.6
140.2
97.9
35.4
22.8
220.7
39.8
113.6
122.9
44.4
30.3
1999- 2000-01 2001-02
2000
290.4
266.6
228.8
96.7
98.2
51.2
282.2
£85.9
253.3
123
152.3
143.9
_5974
'42.8
55.9
31.7
'29.1
31.9
112.4
69.4
83.7
120.6
61.9
36.8
116.2
153.6
23.2
92.5
79.5
100.7
94.8
83.5
41.6
156.8
191.6
215.9
150.3
27.8
146.9
'104.4
115.3
'106.5
' 75.8
' 39.7
'156.3
177.3
215.6
'161.4
' 19.7
204.2
57.3
172.8
190.9
117.3
64.5
190.9
179.9
263.5
163.7
20
228.7
55.1
137 2
253
115.7
68.9
197.5'
204
3853
143.1
20
1741.2
1862.1
2113.8
2631.5
2882/11
1994-95 1995-96 1996-97 1997-98 1998-99
Andhra Pradesh
125.12
129.1
37.7
Assam_________
38.13
102.46
321
Bihar
Gujarat________
85.07
76.1
30.8
34.39
Haryana
18.9
19.5
Himachal
Pradesh
64.01
91.5
Karnataka______
59
54.01
Kerala
121.68
78
Madhya Pradesh
131.5
135.08
Maharashtra
61.2
81.66
Orissa_________
50.65
38
Punjab________
78
106.8
Rajasthan______
122.4
74.29
Tamil Nadu
270.09
218.1
Uttar Pradesh
71.24
91
West Bengal
NA
Jammu &
12.9
Kashmir_______
1417.68 1654.3
All India
Source: CMIE, Publication
168.3
31.6
111.8
76
33.7
24
80.2
63.9
84.1
126.6
60.3
46
119
103.4
292.4
88
12.8
1558
322.3
94.5
If we look at the expenditure on maternal and child health, we find this expenditure has also
shown a secular rise. This following figure will demonstrate expenditure on the maternal and
child health.
Table: 12 Estimated Expenditure on MCH
Year
%
FW
expenditure
on
MCH
1994-95
10.5
1995-96
13.9
1996-97
22.8
This shows increasing emphasis on safe motherhood and child health (as MCH component
largely relates to expenditure on immunization).
49
11
This is found to be true from primary surveys as well. In order to ascertain the expenditure on
safe motherhood, we carried an exercise for 1994-95 for which we had some disaggregated
data.
Table13 Safe Motherhood 1998-99
States
% receiving
ANC
Child
Mortality
Neonatal Mortality
Safe mother
hood
%birth delivered expenditure
per
in medical
beneficiary'
institutions
India
iNorth
43.4
29.3
65.4
33.6 NA
Delhi
29.5
34.9
22.1
40.3
34.3
49.5
9
21.2
8.3
16.1
15.9
37.6
83J5
58.1
86.8
83.2
74
59J
22.4
47.5
54.9
53.6
56.4
39.2
__61_
34.6^
20J
15.5
50 6
26.111
46.5
48.6
31.9
34.7
25.5
19.9
36.3
79.5
90
14.6
22.6
40.1
34J 4|
33 87
15.41
41.8
44.6
18.6
50.7
18.8
20.1
26.3
37.4
21.4
19.9
36.2
18.4
22.7
28.4
61.6
60.1
80_2_
53.6|
91.8
60.4i
69.9I
31.2;
17.6
34.5
17.3
57.7
IZt
31.5
63 1
76 id
Harayana
HP_______
J&K
[Punjab
Rajasthan
28^9
35.6
37.5
21.5
4_2 8'
116
101 9|
35.32!
46 1
[Central
Imp
r---------------------
UP
East
Bihar
Orissa
WB
North East
Aruna chai Pradesh
Assam
Manipur_________
Meghalaya
Mizoram
(Nagaland
i--------------------------------------------------
iSikkim
|------------------------[Tripura___________
286 <
131.031
225
285
46.4 7
West
Goa_____________
Gujarat__________
Maharashtra______
South
______
APKarnataka
Kerala
31.2
39.6
32
10.5
24
15
_J)9|
86.4j
90.4[
90.8
46_3
43.8
37.1
13.8
34.8
21
19.3
2.6
15.9
92.7
86.3
4^8
51_1
93
79.3
TN
Source : NFHS II, 1998-99, UPS 2000 India Report
* Data refers to 1994-95
gsjf
98.5 j
52.6
172 7
2 7 24
4.28’
24.2 31
25 58
36 95
In order to provide some idea about the expenditure on safe motherhood per beneficiary as
well as data on antenatal and neo-natal mortality data is provided in (Table 13). One picture
that emerges is that states with high existing infrastructure can absorb larger population with,
of course, some additionality on variable expenditures like drugs, etc.
1.3.5 Economic Analysis:
One of the central features of the reproductive heath and family planning services provided
by the government is encouragement of a greater choice of contraceptive methods. In
practice this would imply a shift away from, particularly female, sterilization (termination
methods), which allow for control over the spacing of births. This raises the issue of cost
effectiveness. A study of cost-effectiveness of various forms of contraception in slums and
the surrounding rural areas in India yielded the following benefit cost ratios (where benefits
were measured in terms of birth averted).
Table: 14 Cost Benefit Ratios
Methods
Benefit Cost Ratio
Condoms
2.96
Pills
3.11
IUD
4.39
Sterilization
4.84
Source: PAD, RCH Project India, World Bank, 1997
A study of the family planning program in India carried by Gupta & Talwer (1994)1 showed
very high internal rates of return in the two analyses carried out by them. In the first analysis
relating to the period 1971-2000, the IRR worked out to be 13% and for the period 1991 2020, the IRR was as high as 51%, both of them justifying for intensified family planning
program with higher investments.
In a similar study, Gupta (1997)2 compared the future public expenditure savings from a lower
population to the costs of the past family-planning program. In principle such an approach
allows for comparisons of the returns with those from interventions outside of the health
sector. The analysis followed three steps:
First, a population model provide estimates of population with and without the family planning
program from 1971 to 200 using actual and predicted values of the total fertility rate and life
expectancy at birth by five year periods. To project fertility in the absence of the program.
’ Gupta Y.P; Taiwan (1994)" Cost Benefit Analysis of Family Planning Program in India". Social Change
September-December, 1994, vol 24, nO 3-4, pp 156-165
Gupta, D.B (1997) "Economic Analysis of the RCH Project" World Bank, NJDO )mimeo)
08399
data on contraceptive acceptors was utilized. Without the family planning program it was
estimated that the population by 1990 would have been 63 million higher.
Second, for 1971-2000, the benefits of reduced population in terms of savings to government
through not having to provide for social services and food subsides were calculated using the
per capita expenditures on these at constant prices and the difference between the two sets
of population projections.
Third, the cost of the family planning program between 1970 and 1990 was calculated. Finally
the streams of costs and benefits were discounted and an IRR of 11.3 was derived. This rate
is clearly above the rate normally required to justify public investment.
Clearly there are many limitations of the above method; a major contestable assumption is
that increased number of acceptors relied heavily on family planning program.
1.3.6 Cost per-capita couple year of protection and birth averted
Unit cost of acceptors, couples years of protection and birth averted have been calculated for
India for years from 1991-92 to 1997-98, and for various major states for the two time periods
1994-95 and 1998-99.
Table: 15 Estimated Unit Costs of CYP, birth averted and acceptors (in Rupees)
Year
FW Expenditure
CYP
Birth Averted
Acceptor
s
1991-92
1065.60
147.82
839.52
414.36
1992-93
1055.02
142.67
827.21
390.37
1993-94
1342.86
168.78
1020.72
425.86
1994-95
1486.41
181.22
1060.23
485.025
1995-96
1827.34
216.59
1252.03
619.91
1996-97
1985.09
236.47
1399.92
620.05
1997-98
2186.76
259.67
1480.70
650.78
In 1997-98, the overall cost per-capita couple year of protection was Rs.259.67 compared to
Rs.147.82. If we assume during the period 1991-92 and 1997-98, the cost increased by
nearly 60%, and so did the government consumption inflation increase, the program may
have become somewhat more cost-effective. If we look at the unit cost of birth averted for
different states, we observe very wide variations. The states most out of line appear to be
Bihar, Orissa and Kerala, which show relatively higher unit costs. In the case of Kerala higher
I i
costs probably reflect the larger percentage of acceptors using methods other than
sterilization (e.g. 1998-99 figure), which in other cases, the cause is more probably an
underutilization of the existing widespread infrastructure.
We also estimated the total commodity costs of all the family planning methods and of those
costs, the shares utilized for each method in various states. These estimates show
sterilization constituting the major share followed by condoms. In 1998-99, the importance of
both IUD and pill user has improved.
1.3.7 Further Economic Analysis
We have made some crude estimates of productivity losses due to averting births by
investing in family planning program. The assumptions are questionable and can be modified.
Table 16 gives the loss in earnings due to stopping births. The period is 1997-98.
Table: 16 What is Lost By Averting Births?
147.63
lakhs
Number of births averted due to Family Planning
Program (1997-98)
Estimated annual earnings of unskilled worker
working for
240 days
(a) Male Rs. 12,000
(b)
Rs. 9,000
Female
Productive life expectancy
(a) Male 20 years
(b)
16 years
Female
Male/ Female Ratio
50%:
50%
Average rate of employment
(a) Male
(b)
Female
Of the births averted 85% enter labor market
75%
50%
147.63 x 0.85 = 125.48 lakhs
Ii
112.93 lakhs (or 113 lakhs)
Of 125.48 lakhs, 10% are unable to work because
of various disabilities
Averted births entering labor market
(a) Male 56.5 lakhs
(b)
56.5 lakhs
Female
Earnings lost due to births averted
(a) Male 20 x 0.75(56.5) x 12000=
Rs.101700 crores
(b)
Female
16x 0.5(56.5) x
9000=
Rs. 40680 crores
Total earnings lost due to birth averted
Rs. 146380 crores
Assuming that on average, households consume
90% of
earned income, Net Benefit
Rs. 14638 crores
It will be seen that the economy would be deprived of Rs.14638 crores earnings after
providing for the fact that 90% of the earnings represent consumption expenditure. However
in order to bring up these children upto the age of 15 years when they start earning, the
society incurs certain costs. These costs are worked out under two scenarios. Scenario 1, the
family spends Rs.30000 on the child including costs of ANC, PNC, and delivery and of
bringing up to the age of 15 years. The computations are contained in Table 17.
Table: 17 What is Gained By Averting Births
Cost of bringing up a child till he enters the labor
market*
Scenario 1 : At Rs. 30,000 per child
30000 x 147.63 x 0.925 =
40967 crores
Scenario 2 : At Rs. 50,000 per child
50000 x 147.63 =
Rs. 73815 crores
(including ANC, delivery and PNC costs).
i1
If we take the loss in earnings as the cost to the society and the expenditures incurred on
supporting child's consumption until he reaches the age of 15 years as the gains to the
society, we find the following (Table 18).
Table: 18 What is Eventually Gained
Net Benefits of Family Planning Program
Scenario 1 Scenario 2 -
Rs. (40967-14638) = Rs. 26329
crores
Rs.( 73815-14638)- Rs. 59177
crores
Note: Indeed if maternal deaths which are averted when a birth does not take place, more
women may survive, and may contribute to family income through saving on time and loss in
wages associated with having a child. The difference however may not be very large.
Thus under scenario 1, the gains are Rs.26329 crores. These gams are the outcomes ol
public expenditure on family planning of the order of Rs.2186.76 crore incurred in 1997-98.
The gains are clearly several times the investments. The gains under scenario 2 are much
larger.
Clearly the above exercise is based on rather simplistic assumptions, but whichever
assumptions one might consider in terms of other costs and benefits, the inference will not be
different, suggesting justification for public investments in family planning and reproductive
health services.
1.4 Program Risks and Factors that may affect the Success of the same
Program Risks
(')
(iii)
Reversal of target-free Policy-currently there is still apprehensions about this policy.
One way to reduce this risk is through intensive and extensive sensitization of health
program management including opinion leaders.
Under funding of the program: The GOI may provide necessary assurance on
maintaining its contributions to the FW Program. Given the current fiscal health of the
GOI, the risk is low to moderate.
At the state level, the real risks are associated with capacity, particularly of the weaker
states, to implement various components of RCH-II. These concern their weak
implementation capacity, poor fiscal health, and lack of commitment and poor
monitoring system. A considerable amount of preparatory work and planning will have
to be done in these states. Suitable eligibility criteria, sticking to prescribed
performance indicators and linking release of funds to performance indicators may to
an extent minimize the risks.
Ii
(IV)
(V)
(vi)
Some of the innovative approaches introduced in RCH II program are new, innovative
and not fully tested, particularly to those relating to newborn care and outreach and
community linkage schemes. To minimize risks, pilots and evaluations may be carried
out and these relatively new programs may gradually be introduced.
A major thrust of the program is on population stabilization with emphasis on
institutional strengthening, monitoring and awareness creation through exposure to
media and use of rural health practitioners. The success of RCH II hinges a. great deal
on these interventions. To minimize the risks, no compromise should be made on the
implementation of these interventions, and expertise from both government and
private sectors be drawn.
The RCH II program assumes financial management is in place both at the Center and
states, including the districts and there is regular flow of funds from GOI to states and
on to the districts. It also assumes timely assignment of staff and consultants, and
timely procurement. As most states have established Societies and they are largely
effective the risks are low. As far as processing staff and consultant appointments is
concerned, the risk can be minimized by making it as condition of negotiation. Similarly
risk on account of procurement can be minimized by making it as condition ol
negotiation.
IJ
Section 2
Institutional Arrangements
The program implementation arrangements at the National. State. District and below the
district levels are discussed in this section.
2.1 National Level Implementation Organization
The RCH ll&FP is viewed as Program and not as a project thus clearly establishing the
understanding and the related issues of structure, processes and financial flexibility. The
issues of systems and institutional strengthening have been addressed in the institutional
issues.
At the National Level it would carry out the strategic function of program design (based on
consultation with the states), program planning based on the Program Implementation Plans
(PIPs) from the states, estimation of resources and carry out donor coordination and actual
generation of resources. This is expected to be carried out through a National level facilitation
organization with adequate human resources and other resources as required. This can be
termed as the Reproductive and Child Health and Family Planning Organization functioning
under the overall supervision of the Secretary, Ministry of Health and Family welfare but
having an Additional Secretary designated as the Ex-officio Project Director for RCH
including Family Planning.
This implementation structure is expected to handle the different functions as described
below to handle the requirements of the RCH program. The functional analysis has been
carried out to identify the appropriate structure to manage the program at the National Level.
The strategy to be adopted would be to identify existing functionaries within the system to
handle the functions and also through contractual mechanisms for quickly putting into place
the required structure.
Functional Analysis
National Level Functions and Description
The following description provides the functions to be carried out at the National level
Program Planning
•
•
Develop the program taking into account the underlying governing documents at the
national level such as the 10th Plan Document, National Population Policy, National
Health Policy etc.,
Develop the overall technical strategies for the project for the maternal health and child
health taking into account the present position obtaining at the state levels and the
extent to which these have to move in order to be able to achieve the national goals.
Ii
•
•
•
•
Policy formulation would be a key task that would be addressed.
Resource support would be directly addressed both in terms of financial and other
resources.
Provide assistance to the state in preparing their plans and providing them with a
framework for developing the plans in a participative manner and ensure ownership at
the different levels.
Analysis of the state plans for estimating the resource requirements such as:
Infrastructure
Human resources
Logistics
Drugs, Consumables and equipments
Training
One time requirements and recurrent requirements
•
•
•
•
•
•
•
Consolidate the state plans and add on the requirements at the national level for
effective implementation and arriving at the overall resource estimation for the
program.
Dissemination of the plan and approach to the states and the process adopted.
Carry out annual planning based on the overall program plan in order to arrive at the
annual resource estimates.
Develop the planning cycle and planning calendar in order that the states follow these
schedules to be able to receive un interrupted resources
Disaggregate the plan into its constituent components such as the elements provided
above in the point on estimations.
Intersectoral coordination among the other departments who are carrying out
programs oriented towards the same target sections.
Coordination between the different wings within the ministry of health and family
welfare.
State Level Planning, facilitation and Monitoring
This function is a critical function to ensure success of the program. The functional
description is a generic one and it would require about 5-6 officers to carry out the function
and these can be termed as state facilitators and can be the focal point for the group of
states. The focal point would provide all facilitation to the states. The states would thus be
clear regarding the persons with whom they are interacting. The functions to be carried out by
the facilitation officers are:
•
•
•
Finalization of state plans along with the finalization of Memorandum of Understanding
regarding the various achievement parameters.
Enable and cause timely release of resources as per agreed plan with the states.
Divide the plan into core components (common to all states) and the state specific
components specific to particular states in question
•
•
•
•
•
•
Provide facilitation to the states for their requirements for technical, managerial or
resources (financial and human) related issues by taking the help of specialists at the
National level.
Follow up with the states for the reports to be submitted by them on the progress. The
financial reports and training reports also need to be followed up
Examine the reports for the achievement of the parameters and assess whether the
direction of implementation is according to the desired objectives. Apart from the
quantitative analysis a qualitative analysis of processes also needs to be undertaken
This would take into account the performance monitoring of the states.
The linkage between the financial progress and the physical progress on the different
parameters need to be correlated
If the reports do not show the progress as desired then facilitate with the individual
states to understand the problem and evolve jointly mechanisms to overcome the
same.
Overall be responsible for the facilitation of the states assigned in all aspects of the
program.
Technical Functions
The technical functions include the following:
•
•
•
•
Maternal Care
Child Care
Family Welfare
Behavior Change Communication
The technical functions have been provided with the generic descriptions and the detailed
activities would follow from these.
•
•
•
•
•
•
•
•
Evolve strategic plans for the specific technical function at the national level.
Examine the state level strategic plans in the light of the state plan and examine the
efficacy of such plans to be able to achieve the objectives set out in the state plans.
Also need to establish the correlation with the strategies developed at the national
levels.
Document the successful practices adopted by different states and disseminate it to
the other states.
Review the performance of the strategies and suggest modifications to the states
where necessary to ensure effectiveness.
Examine the cost effectiveness of alternative strategies and enable the states to
choose the cost-effective strategy.
Provide periodic technical inputs as requested by the facilitation officers to the states
Review the performance of the states from the technical standpoint and provide
suggestions for improvements.
Provide technical inputs to training modules to effectively incorporate the technical
strategies in the training.
i i
Finance Function
To procure the resources as per the annual plan outlay.
Examine and disburse financial resources to the states as per the agreed plan and
after being recommended by the state facilitators and the receipt of accounts and
utilization for the period under question.
Impart financial management skills and accounting skills to the states and different
units operating within the program.
To set systems for financial management and accounting to facilitate the states in
maintenance of accounts.
Review from time to time the financial records and systems being followed at the state
levels to ensure compliance and effectiveness.
Provide inputs to the training units to facilitate the up gradation of skills in finance
accounts at the different levels in the state.
To facilitate the technical heads in the state to appreciate the importance of financial
and accounting systems to ensure timely and smooth flow of accounts.
Facilitate the state coordinators to correlate the progress reports with the accounting
and financial statements.
Introduction of budgeting and financial planning system within the national
organization and the states.
Donor negotiations and ensuring convergence of donor funded plans.
As has been done for the health in terms of a National Accounting System initiate
similar processes for family welfare also.
Training
•
•
•
•
•
•
•
•
•
To carry out the training needs assessment at the different states based on the
training needs analysis carried out by the different states. (This presumes that
activities would have been initiated at the state level to identify the specific training
needs for the different categories of personnel.)
To develop the training strategy to be adopted at the national level.
Facilitate the states in developing their training strategies.
Evolve a training plan based on the training strategy.
Facilitate in the development of the training curriculum, training modules, and trainers
guides.
Develop mechanisms to assess the effectiveness of the training through the evaluation
of contents, processes and knowledge.
Develop systems to monitor the effectiveness of the training strategy and its
implementation at the different states.
Facilitate the states in developing a system to assess the effectiveness of training by
assessing the impact of the training in work situations.
Evolve and maintain a database of consultants, trainers and research (both individuals
and institutions) in the different fields.
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•
•
Suggest consultants and trainers as and when requested by the states. Obtain
feedback on the performance of the consultants/trainers from the users and maintain it
on the database.
Facilitate research both primary and operational by different states as required to
strengthen the program and also suggest research areas at the national level in areas
where the design of the program had difficulty due to non-availability of information
based on research based evidences.
Support Functions
The following have been classified as support functions at the national level. These are:
•
•
•
•
Procurement and logistics management
Infrastructure engineering and construction management and maintenance
management.
Surveys (such as facility surveys), Community Needs Assessment Analysis
Monitoring Information and Evaluation systems
Procurement and Logistics
•
•
•
•
•
•
•
•
Assess the overall procurement requirement in the program basically for drugs,
services, consumables and equipments.
Review the current logistics management and infrastructure facilities available at the
states and the requirement of additional facilities and the improvements in the logistics
function.
Examine the structure and systems for logistics management and evolve suitable
logistics management and support systems.
Provide for successful procurement practices at the different states and design the
procurement mechanisms to be adopted for the different states. The variable practices
to be followed for the different states needs to be documented and the requirement of
central procurement needs to be assessed and in built into the implementation of the
plan.
Assess the improvement requirements in the area of logistics in the different states
and facilitate initiation of processes within the different states.
Enable development and implementation of logistics and procurement management
systems by standardizing successful practices followed in some of the states such as
Tamil Nadu and Orissa.
Equipment procurement and specifications can be standardized for different
application as is required. These specifications along with the possible suppliers can
be identified and informed to the states for them to initiate the procurement process.
For states wherein it has been decided to follow the central procurement route these
need to be procured and supplied to the states.
Maintenance of small value equipments, which do not have maintenance warranty or
contract maintenance facilities pose problems at the different facilities level. Hence,
systems to outsource the maintenance function needs to be evolved and possible
IJ
•
agencies available at the different states who have past experience in such functions
can be gathered and disseminated to the states.
Carry out procurement through centralized agencies.
Construction management and maintenance of facilities
•
•
•
•
•
The infrastructure creation at the Sub-center (specifically for the EAG states), and
improvements to the PHC and CHC and creation of warehouses is expected to be
substantial in the program. Hence, standardization of type designs for each type needs
to be developed. The type design developed needs to be aesthetic, and flexible for
adoption of construction through locally available material. Convenience for users and
providers need to be reckoned.
Alternative designs to suit soil geological conditions and terrains of construction
depending on the location preference to suit the user requirements also need to be
taken into account.
Cost factors need to be worked out. These should be developed in ranges using a
menu approach ratheron unit approaches.
Maintenance schedules also need to be drawn up and possible-outsourcing
mechanisms can also be provided to the states.
Construction planning, design and management systems manuals need to be evolved
and training provided to the states.
Surveys and Special Studies
•
•
•
•
•
Identify areas requiring surveys and special studies both at the National level and at
the state levels
Create a data base of institutions and research organizations along with their
capability profiles, past experience, staff strengths, financial strengths, feed back from
users (if any) and areas of specialization.
Draft the Terms of Reference, Scope of Work, time estimations, outputs expected
(including dissemination requirementsO, possible framework for the study/surveys,
capability profiles required/expected and the criteria for short listing evaluation and
selection.
Create a database of resource persons who can provide training to agencies in
carrying out studies/surveys (if required).
For studies, which have been carried out over a number of cycles document the
methodology and disseminate it as and when required.
Monitoring Information and Evaluation Studies
•
•
Draft out indicators for input, processes and output, outcomes and impact required to
monitor the performance of the program.
Identify data sources maintained within the system and the processes to be adopted in
arriving at the indicators. If certain new systems need to be introduced draft out the
requirements and examine the feasibility of introduction of such system and the
capability of the system to generate such data.
62
i I
•
•
•
•
•
•
•
Analyze the system capability and plan for providing capacity building to effectively
introduce the monitoring information system at different levels.
Develop and introduce quality assurance systems and monitor the quality parameters
to be achieved.
Provide capacity building at different levels in the system to utilize the data and
information for effectively monitoring the program.
Identify evaluation stages in the program and in build these into the plan.
Identify agencies to carry out evaluation and contract agencies to carry out evaluation.
Inform the states regarding the requirement of evaluation and take them on board prior
to finalizing the evaluation plan, parameters and methodology for evaluation.
Arrange for dissemination of the evaluation findings to the state and analyze the
consequent changes to the program strategies required through interaction with the
project planning.
The organogram at the National level is provided in Annex 1.
2.2 State level implementation Organization
At the state level the functions to be carried out would be similar to that of the
national level but would restrict itself to the particular state.
The states would formulate the policies as considered appropriate within the framework
laid down by the National policy and the policy framework would govern the state
strategies. The state level implementation structure would carry out the function of
program planning (in consultation with the districts), program plans based on the Program
Implementation Plans (PIPs) of the Districts, estimation of resource requirements for the
state and finalize the state plans with the national level organization, working and
agreeing on the memorandum of understanding with the National Level Organization and
putting in place appropriate and requisite systems to ensure efficient implementation as
also the periodic monitoring and evaluation of the performance. This is also expected to
put in place the planning system at the District Levels based on the data available
regarding the various parameters affecting the RCH status in the state and hence arrive at
appropriate combination and intensiveness of efforts in the required direction. The human
resource planning to meet the requirements for program implementation would also be a
requisite function of the state level implementation body.
The EAG states would have a particular focus on augmenting management capacity, as
this would be a key requirement for successful implementation. Capacity building
requirements by the training function proposed would address it as a strategic issue by
carrying out a training needs assessment and from the performance point of view of
service delivery. Hence outsourcing been considered as an alternative wherever it is
found infeasible to capacity strengthening is found infeasible. The lines of control that are
considered stumbling blocks have been addressed in the design to obviate the hurdles
and ensure smooth flow of decision making and resources. Performance linked incentives
have been built into the system up to the implementation level of districts. The design of
the monitoring system has taken into account the quality aspects of performance as well
11
The functions at the state level would be implemented through a state level facilitation
body with adequate human resources and skill mix as would be required to perform the
functions. This can be termed as the Reproductive and Child Health/FW Society
functioning under the overall supervision of the Principal Secretary, Department of Health
and Family welfare but having a Secretary, Family Welfare designated as the Project
Director for FW/RCH including Family Planning. The Project Director would be possessing
managerial and program management capacity. To provide technical assistance the
Director, Family Welfare from the system would be designated as the Additional Project
Director. This structure would be under the assumption that the states would be managing
the human resources of the Department through a Human Resources management
function thus relieving the technical function from the human resource management
function.
The State level Implementation Organization would draw the technical resources of the
State Family Welfare Bureau. Further the State FW Bureau would provide the secretariat
for the State RCH&FP Society and thus bringing about the linkage between the
implementation organization and the existing state level structures. The FW bureau
collects and collates information for the FW aspects in the state. This function would be
used for planning and monitoring the state level programs. In order to preclude isolation
and avoid creating parallel structures it is necessary to mainstream the functioning of the
implementation organization with the state systems right from the inception. The
integration of the functioning of the FW bureau would provide logical linkages to the
implementation structure and clear role definition to the Bureau by making it the
secretariat for the RCH/FP Society. The commonality of the Member Secretary of the
State level society would be the project director and this person would also serve as the
chairman of the FW Bureau.
This implementation structure is expected to handle the different functions as described
below to handle the requirements of the RCH program. The functional analysis has been
carried out to identify the appropriate structure to manage the program at the State Level
The strategy to be adopted would be to identify existing functionaries within the system to
handle the functions and also through contractual mechanisms for quickly putting into
place the required structure.
The strategic management capacity proposed at the state level is as follows:
•
•
•
Adequate planning system based on the current situation prevailing in the
state as provided by the data on the different RCH parameters and the final
RCH outcomes as desired by the state.
Dedicated management organization with clearly defined functions to be
carried out.
Technical functions to be relieved of the human resource management
functions and hence to focus on the technical aspects
1 j
•
•
To carry out the resource requirement analysis including the human resource
requirement and build in strategies for meeting the requirements at different
levels of the system both in the short run and in the long run.
Introduce performance accountability at the different levels of the system
through systemic and resource-based strategies.
Functional Analysis
Program Planning
•
•
•
•
Develop the program taking into account the underlying governing documents at the
national level such as the 10th Plan Document, National Population Policy, National
Health Policy etc., and the State Policy documents available
Develop the overall technical strategies for the project for the maternal health and child
health taking into account the present position obtaining at the state level and the
extent to which these have to move in order to be able to achieve the national goals.
This needs to spell out the priorities at the district level as analyzed from the different
district level profiles for the different parameters involved.
Provide assistance to the districts in preparing their plans and providing them with a
framework for developing the plans in a participative manner and ensure ownership at
the different levels. The participation needs to be from the grass root level upwards
and involving the communities, PRIs etc.,
Analysis of the district plans for estimating the resource requirements such as .
Infrastructure
Human resources
Logistics
Drugs, Consumables and equipments
Training
One time requirements and recurrent requirements
9
•
•
•
•
•
•
Consolidate the district plans and add on the requirements at the state level for
effective implementation and arriving at the overall resource estimation for the
program in the state.
Dissemination of the plan and approach to the districts and the process
adopted.
Carry out annual planning based on the overall program plan in order to arrive at the
annual resource estimates and the phasing involved.
Develop the planning cycle and planning calendar in order that the districts follow
these schedules to be able to receive un interrupted resources
Disaggregate the plan into its constituent components such as the elements provided
above in the point on estimations.
Intersectoral coordination among the other departments who are carrying out
programs oriented towards the same target sections.
65
11
•
Coordination between the different wings within the department of health and family
welfare
District Level Planning Facilitation and Monitoring
This function is a critical function to ensure success of the program. The functional
description is a generic one and it would require about 5-6 officers to carry out the function
and these can be termed as district facilitators and can be the focal point for the group of
districts. The focal point would provide all facilitation to the districts. The districts would thus
be clear regarding the persons with whom they are interacting. The functions to be carried
out by the facilitation officers are:
•
•
•
•
•
•
•
•
•
Finalization of district plans along with the finalization of Memorandum of
Understanding or agreed performance parameters regarding the various program
components.
Enable and cause timely release of resources as per agreed plan with the districts.
Divide the plan into core components (common to all districts) and the district specific
components specific to particular districts in question.
Provide facilitation to the districts for their requirements for technical, managerial or
resources (financial and human) related issues by taking the help of specialists at the
state level.
Follow up with the districts for the reports to be submitted by them on the progress.
The financial reports and training reports also need to be followed up.
Examine the reports for the achievement of the parameters and assess whether the
direction of implementation is according to the desired objectives. Apart from the
quantitative analysis a qualitative analysis of processes also needs to be undertaken
The linkage between the financial progress and the physical progress on the different
parameters need to be correlated
If the reports do not show the progress as desired then facilitate with the individual
districts to understand the problem and evolve jointly mechanisms to overcome the
same.
Overall be responsible for the facilitation of the districts assigned in all aspects of the
program.
Technical Functions
The technical functions include the following:
•
•
•
•
Maternal Care
Child Care
Family Welfare
Behavior Change Communication
The technical functions have been provided with the generic descriptions and the detailed
activities would follow from these.
66
11
•
•
•
•
•
•
•
Evolve strategic plans for the specific technical function at the state level based on the
national level strategic plans.
Examine the district level strategic plans in the light of the state plan and examine the
efficacy of such plans to be able to achieve the objectives set out in the state plans.
Also need to establish the correlation with the strategies developed at the national
levels.
Document the successful practices adopted by different states/districts and
disseminate it to the districts.
Review the performance of the districts from the technical standpoint and provide
suggestions for improvements.
Examine the cost-effectiveness of alternative strategies and enable the districts to
choose the cost-effective strategy
Provide periodic technical inputs as requested by the district facilitation officers to the
districts
Provide technical inputs to training modules to effectively incorporate the technical
strategies in the training.
Finance Function
To procure the resources as per the annual plan outlay.
Examine and disburse financial resources to the districts as per the agreed plan and
after being recommended by the district facilitators and the receipt of accounts and
utilization for the period under question.
Impart financial management skills and accounting skills to the districts and different
units operating within the program.
To set systems for financial management and accounting to facilitate the districts in
maintenance of accounts.
Review from time to time the financial records and systems being followed at the
district levels to ensure compliance and effectiveness.
Provide inputs to the training units to facilitate the up gradation of skills in
finance/accounts at the different levels in the state.
To facilitate the technical heads in the districts to appreciate the importance of
financial and accounting systems to ensure timely and smooth flow of accounts.
Facilitate the district coordinators to correlate the progress reports with the accounting
and financial statements.
Introduction of budgeting and financial planning system within the state and the
districts.
T raining
•
•
To carry out the training needs assessment at the different districts based on the
training needs analysis carried out by the different districts. (This presumes that
activities would have been initiated at the district level to identify the specific training
needs for the different categories of personnel.)
To develop the training strategy to be adopted at the state level.
67
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•
•
•
•
•
•
•
Evolve a training plan based on the training strategy.
Facilitate in the development of the training curriculum, training modules, and trainers
guides based on the documents provided by the national level organization.
Develop mechanisms to assess the effectiveness of the training through the evaluation
of contents, processes and knowledge.
Develop systems to monitor the effectiveness of the training strategy and its
implementation at the different districts.
Facilitate the districts in developing a system to assess the effectiveness of training by
assessing the impact of the training in work situations.
Evolve and maintain a database of consultants, trainers and research (both individuals
and institutions) in the different fields by supplementing the database maintained by
the national level organization.
Facilitate research both primary and operational by different districts as required to
strengthen the program and also suggest research areas at the state level in areas
where the design of the program had difficulty due to non-availability of information
based on research based evidences.
Procurement and Logistics Management
•
•
•
•
•
•
•
•
Assess the overall procurement requirement in the program basically for drugs,
services, consumables and equipments. The central level procurement would continue
forthose items which are normally procured such as contraceptives, Kit A, Kit B etc.,
Review the current logistics management and infrastructure facilities available at the
districts and the requirement of additional facilities and the improvements in the
logistics function.
Examine the structure and systems for logistics management and evolve suitable
logistics management and support systems.
Negotiate and agree with the national level procurement function regarding the sharing
of the procurements between the national and the state levels.
Assess the improvement requirements in the area of logistics in the different districts
and facilitate initiation of processes within the different districts.
Enable development and implementation of logistics and procurement management
systems by standardizing successful practices.
Examine the possibility of outsourcing maintenance function of different aspects within
the state and initiate processes for putting these in place.
Carry out procurement through state level agencies.
Construction Management
•
•
Examine the type designs provided by the national level agency and choose the
appropriate design to suit the requirement at the state level. This would be mainly
applicable in the EAC states where facility creation would form a key component.
Examine the proposals received from the districts and obtain approvals to the creation
along with required resources.
t j
•
•
•
•
Put in place contracting mechanisms to contract out the construction including
standardization of costs based on standard estimation processes.
Put in place contract supervision and reporting mechanisms.
Put in place quality assurance systems to ensure quality of construction applicable
both for primary construction and improvement activities.
Certification mechanisms for taking over the buildings after they are complete.
The organogram at the state level is provided in Annex 2.
2.3 District Level Implementation Organization
The District Level implementation structure has been discussed here based on the
following three premises being fulfilled. These are important for effective implementation
of the program at the district level and also creating a structure to facilitate the district
level planning. The premises deal with the managerial capacity of the district level
program managers, the functioning of the district Societies and the creation of a program
implementation structure at the district level.
Premise 1
The overall premise in the district level organization is that the person
posted as the head of the district would possess the following:
•
•
•
Adequate training and knowledge of public health functions and its requirements.
Has been provided with training for transforming himself/herself into a public health
system manager rather than just managing a function.
Needs to have adequate tenure of service to lead the district at least for three
years.
Premise 2
The fund flow would be smoothened out In order to achieve this the following is
suggested:
•
•
•
All health related district Societies are merged into one District Health society and
have the District Collector as the Chairman and the District Level Health Manager as
the Member Secretary in the long run and at least have one integrated Family Welfare
society to begin with by integrating the RCH and Family Welfare/Family Planning.
The composition of other members (other than what has been discussed here and
who already are members) could be similar to the existing arrangements.
It has been difficult to convene the executive committee as frequently as required
because of the pre-occupation of the official heads with other areas of work that they
handle. Hence, there needs to be a feasible expenditure and fund sanction committee
carved out of the executive committee, which can meet periodically to sanction
disbursement of funds and take decisions on procurement etc., which can be vetted by
the executive committee. This smaller committee can have the alternative structures
11
•
•
•
•
depending on the availability of District Administrative Practices. In the states where
there are District Development Officers as in the states of Gujarat and Maharashtra
these could head the committee and since the focus of such personnel is on
development can provide time to the health functions and there would be no need for
separate committees for fund sanctions.
However, in other states where such practices do not exist then the existing system of
executive committee being headed by the District Collector needs to continue. It can
be arranged that this committee meets on fixed days every month to carry out
sanctions for purchases and fund releases in order that the inability of the committee
to meet may not hamper the progress of work.
The recruitment of contract staff can be carried out by a committee consisting of a
committee with CMOH as the Chairman and the Members being drawn from Medical
Superintendents from the District hospitals (Male & Female), Representative as
nominated by the District Collector, CHC/PHC Medical Officer, and President of the
District IMA and prior to sending out the appointment letters the same needs to be
approved by the executive committee headed by the district collector.
The financial sanctions for the various funded programs need to be vetted in one
sitting by the executive committee. The processes to facilitate these needs to be put in
place.
The transfer of funds from the State to the Districts needs to be quick and follow the
schedule of disbursement by the national level to the states.
Premise 3
District Family Welfare Bureau would serve as the Project management Unit and perform
the following functions covering all the components of the ROH program:Project planning
Human Resource Planning and Availability
Infrastructure planning and execution
Equipment, drugs, consumables supply
Training provision
Quality assurance at different levels
Monitoring and review.
The alternatives for project management unit are:
•
•
•
Can be carved out from the existing resources after providing training
Can consist of contract personnel
Can be a combination of contract and deputation personnel.
The sustainability of the project management unit can be achieved as follows
•
Due to the achievement of the desirable health outcomes the incidence of cost on
project related activities would decrease.
•
The incidence of the common diseases would also reduce the public health endeavor
in this direction.
• The people having become more aware and the improvement in health seeking
behavior itself would reduce the burden.
The funds released from the above would sustain this structure and this can be turned into a
district health planning and monitoring unit functioning under the District Health Manager.
The District FW Bureau would provide the Secretariat for the District RCH & FP society and
would have a chairman in the District Collector/District Development Officer as the case may
be. The statistics being collected by the FW Bureau would facilitate the planning at the district
level. The CMHO would be the member secretary and the ADMO; FP&RCH would be the
convener. Further the commonality of CMHO being the Member Secretary of both the Society
and the FW Bureau would bring about the necessary linkages. The integration of the
functioning of the FW bureau would provide logical linkages to the implementation structure
and clear role definition to the Bureau by making it the secretariat for the RCH/FP Society
The functional analysis for the District Level has been carried out using the above premises
Functional Analysis
Planning and Monitoring
•
•
•
•
•
•
•
•
Impart the concept of participative planning with the involvement of stakeholders from
grass root level upwards (Community, PRIs, Institutions outside health system, NGOs,
etc.,)
Provide guidelines for planning and develop the system for participative planning.
Develop mechanisms to develop data based planning as obtained from the health
statistics of the district and the different blocks within the districts.
Mechanisms to evolve clear goals, processes, outcomes and indicators
Develop simplified monitoring and reporting formats to periodically measure the levels
of achievements of indicators.
Mechanisms for decentralized monitoring through PHC/CHC.
Evolve feedback mechanisms for improvements.
Disaggregate the District Plans to identify the resource requirements such as:
Infrastructure
Human resources
Logistics
Drugs, Consumables and equipments
Training
One time requirements and recurrent requirements
•
•
Mechanisms to obtain the required resources from the State level.
Participate in finalization of District Plan with the concerned facilitation officer at the
State level.
I i
•
Obtain performance reports from the other levels below the districts and consolidate
and send them to the state level as per agreed schedules.
Finance and Accounting
•
•
•
•
Introduce the concept of budgeting itself as a planning function based on bases to be
developed for costing and budgets calculated from the desired levels of activities to be
carried out.
To liaise with the District Societies to obtain funds required as per the plan.
To provide capacity building and manuals to the units to facilitate maintenance and
timely submission of accounts by the units.
Review from time to time the accounting and financial records maintained by the units
to ensure compliance and effectiveness.
Human Resource management and Training
•
•
•
•
•
•
•
Analyze the existing position of resources at the different units and estimate the
requirement of additional resources.
Evolve strategies within the framework of norms laid down by the state to fill the gaps
in the existing levels.
Estimate the capacity building requirements and the capacity building needs for the
different levels of personnel.
Plan for providing the capacity building to the personnel as required within an
appropriate time frame.
Monitor effectiveness of training.
Maintenance of training profiles receivePd by the different levels of personnel and
ensures appropriate training and posting policies in order that the training is not
rendered futile.
Timely renewal of contracts for contractual staff by appropriate systems being initiated
Vital Statistics and evaluation
•
•
•
•
•
•
Collection of important statistics and also the epidemiological data within the district.
Analyze the information gathered at the different levels of district and serve as early
warning system for adverse trends if any in order that corrective action can be initiated
through focused attention.
Put in place systems for regular gathering of data on important parameters and for
periodic analysis of such data gathered.
Introduce formal feedback systems for incorporating the findings of the analysis into
the planning process.
Put in place systems for evaluation of programs at agreed intervals to judge the
progress. Correlate the findings of the evaluation with the periodic analysis and
provide appropriate feedback for district managers to take corrective action.
The district hospitals would supervise the functioning of the CHC/FRUs
I i
It is assumed that the infrastructure creation/improvements to be carried out at the
different levels would be a State Level Function with appropriate resources for contract
management, supervision and certification. Therefore this function has not been provided for
in the district level structure.
The organogram at the District Level is provided in Annex 3
2.4 Implementation Arrangement at CHC/FRU level.
The CHC, which forms the first link in the provision of referral medical service, would need to
be:
•
•
•
•
Easily accessible to the population from different locations.
Availability of assured services when sought for.
Can provide emergency OBS care.
Supervises the PHC functioning in the block.
Considering the importance of the link it may be a pre-requisite that the following analysis is
carried out:
•
•
•
•
Load analysis of attendance at the CHC/FRU
Pattern of services that have been provided.
Location of CHC with respect to easy accessibility and distances, motorable roads
availability to ensure referral transportation, availability of specialists and timings of
CHC.
Other institutions available in the area such as the sub-divisional hospitals, area
hospitals etc., which are being currently utilized /under utilized.
Based on the analysis carry out an exercise to:
•
•
Rationalize locations of CHC/FRU
Ensure availability of the following complement of staff namely
■
■
■
■
■
•
•
•
Four specialists OBS/GYN, PAE, ANAE and GP
Seven staff nurses
One pharmacist
Two Lab Technicians (PC 1 only)
One radiographer
Availability of transportation funds at the village levels to refer emergency cases
Availability of transport facilities at the village level and systems to use them in case of
emergency.
Availability of anesthetists for emergency services either through contract
arrangements or through training of Medical Officers in this area subject to the legal
and medical requirements.
d
•
Availability of emergency OBS/GYN either on retainer or contract arrangements to
handle emergency and night deliveries.
The functions of the CHC/FRU would be:
•
•
•
•
•
•
Regular patient care as necessary
Emergency referral care for referred patients
Participate I CHC based RCH activities.
Monitor the functioning of PHC and initiate mid course corrections as may be required
Participate in reviews at the district level and take corrective actions as may be
advised.
Supervise the functioning of the PHCs
2.5 Primary Health Centers
This institution is the primary level institutions providing services at an institutional level. This
provides for basic treatment of common diseases, provision of drugs, delivery of simple
cases and referral of complicated maternity cases and other cases to the next referral level
institution. There are basic provision of inpatient especially for observation and providing
drips etc., especially in cases of poisoning and acute diohorrea.
The basic structure provides for the following staff complement:
One Medical Officer
One Staff nurse
One Male Health Assistant
One ANM
One lab technician
One Pharmacist
The functions to be delivered by the PHC are:
•
•
•
•
•
Planning and monitoring of health and family welfare programs
Provide basic curative services
Organize and supervise preventive and promotive health and family welfare related
activities
Develop a viable and functional referral system
Supervise the Sub-center functioning
The issues with respect to the functioning of this institutional structure are:
•
•
•
Location being in remote places renders accessibility difficult.
Doctors do not stay at the location as would be desirable.
Non-availability of transportation facilities for the medical officers to carry out
supervision and participate in promotive health care.
11
•
•
•
Absence of well-defined transfer and posting policy may make the medical officers
locked into remote places for periods longer than normal.
Absence of accountability for performance.
Inability to develop professionally.
Considering these the following reviews and suitable solutions need to be worked out:
•
•
•
•
•
•
•
•
•
Review of the location of PHC and relocate them where found necessary.
Consider the requirement of full time medical professional at PHC and consider the
alternatives of ISM doctors heading the PHC with a certain amount of training,
pharmacists managing the PHC with a certain amount of training and the staff nurses
handling the delivery as required. These alternative arrangements would require
strengthening the referral systems to the next higher-level institution.
This can release a number of medical officers who can be used at the different levels
where there are shortages currently.
This arrangement may involve incentive provision to alternate human resources who
handle additional responsibilities. This can ensure availability of services when
required.
It would entail effective supervision system also being put in place to ensure effective
functioning.
In the long-run NGO capacity can be built to take on these functions in specified areas
Ensure availability of adequate residential accommodation for the staff to stay in the
location.
Provision of incentives to staff nurses for conducting night delivery.
Rewarding the team for good performance (measured through laid down criteria)
through financial and non-financial incentives to promote team approach in service
provision.
2.6 Sub-Center
This is staffed through a Health Worker (Male) and a Health Worker (Female), who carry out
the preventive and promotive aspects of health and family welfare.
The workload on these field level workers (especially the ANMs) is very high The following
needs to be carried out in respect of sub-centers:
•
•
•
•
The location analysis of the sub-centers and the necessary relocation as necessitated
Review coverage not only using population norms but also using other parameters
such as terrain, availability of public transport systems, population density and the
distances to be covered and arrive at reasonable norms required for effective
coverage.
If this requires additional resources then examine the alternative of contractual
employment.
Provide incentives for coverage above a limit and services provided such as home
based delivery.
I i
L j
•
•
Review the position of Male Health Workers and also the availability of workers under
other programs who can be trained to carry out the work of Male Health workers.
Examine alternative options for filling the posts as per norms after taking into account
the manpower that can be trained.
The supervision by Male Health Workers and Lady Health Visitor needs to be strengthened
and made systematic and accountable. This would require provision of mobility related
expenses periodically and also fixing supervision norms and supervision being carried out by
PHC officers and CHC officers.
If the additional requirements of sub-centers result from the rationalization analysis then the
contractual ANMs would be posted to these new facilities.
A suggested Job Description is provided in Annex 4.
2.7 Village Level
Currently there are no formal mechanisms at the village level. Following the planning
commission recommendations it is proposed to strengthen this by having a village level Link
Worker. The role of the village level worker would be a motivator to mobilize the village level
population, registering of pregnancies, motivating the pregnant mothers to have regular ante
natal check as required, take and folic acid tablets, vaccinate themselves as required in the
regimen and identify complicated cases to be referred to higher level institutions. Hence the
role is expected to be complementing the work of ANMs in the field of RCH.
The institutional arrangements need to be examined. The following alternatives are
suggested:
•
•
•
Contract employment to village based female link workers based on performance
based payments.
In stronger village panchayats which are active, payment through the village
panchayats can be examined
The trained Dais/or TBAs/or JSRs can be considered to carry out this function and
payment mode can be based on a performance linked incentive payments rather than
regular contractual payments.
The importance of these arrangements stems from the functions to be carried out by this link
volunteer:
Proposed Functions of the Link Volunteer
- Maternal health
•
Mobilizing women for institutional deliveries and accompanying women to facilities for
deliveries
11
•
•
•
Providing immediate care in obstetric emergencies, arrange and facilitate referral
transport, accompany the women to the facility
Paying post-partum visits and providing necessary care.
Assisting ANM in antenatal check up (history taking, checking for anemia, foeutal
height, edema, Blood Pressure, counseling for birth preparedness and institutional
deliveries and for IFA, nutrition etc.,
- Child Health
•
•
•
•
•
•
•
•
•
Providing home based care to neonates through home visiting
Diagnosing and treating diahhorea/dehyderation and ARI using ORS, co—trimaxazole
etc.,
Facilitating referral of sick children
Assist ANM in immunizing children ensuring 100% coverage
Attending deliveries to provide resuscitation and care to neonates at birth, weighing
babies at birth and identifying low-birth weight infants.
Counselling on breast feeding and care of breast related problems
Facilitating birth and death registration
Diagnosing newborn sickness, treating simple illnesses and referring those requiring
institutional care
Counsel on complementary feeding of children
- Family Planning
• Counselling for contraception and spacing
• Counselling for safe MTPs
- RTI/STI
• Counselling for prevention of RTI/STI
• Referral for RTI/STI
- Adolescent Health
• Assisting in counseling of adolescent health
It may be possible that at a later stage to train and permit the RCH Link Volunteers to
administer vaccines and emergency medication for mothers
(oxytocin, magsulph) and neonates/children (Gentamycin) etc.,
The link volunteers’ choice needs to be based on the following:
•
•
•
Needs to be a village based woman
Educated up to class 8
Ability to communicate clearly and has initiative.
They need to be trained for providing the services, work as team with ANM and AWW and
would be paid a performance-linked incentive.
77
I1
The complementary and convergent roles to be played by the AWW has been outlined in the
planning commission recommendations which look at the roles of AWW as:
• Assist the ANM in organizing health check up
• Act as depot holder for Condoms, contraceptives, IFA, OPS and DDKs
• Arrange for referral transport and maintain sources of such transports
• Maintaining a list of complicated pregnancy cases for organizing referrals
• Assist in compilation of births and deaths
• Weighing babies on birth and periodically to monitor growth
• Administer vitamin A to children and IFA to mothers
• Identification of under nourished women (pregnant & lactating) and children to enable
food and nutrition supplementation
A comparison of the two alternative arrangements are provided in the Table below
Comparison of AWW and RCH-link volunteer
AWW (Upgraded)
Somewhat less
RCH Link volunteer
Somewhat more
Wages (Performance
linked)
Same
Same
Orientation / mind set
Teacher, nutrition worker
Health
Time availability
Questionable (Busy 4-6
hrs) with ICDS work
Assured
Commitment to health
tasks
Not taken for granted
Assured
Providing care at birth
Unlikely
Possible
Attending to patient
needs at night
Questionable
Can be assured
Supervision by health
department
Not certain
Assured
Coordination at distt level
and up
Problematic
Assured
Overall quality of work
Modest
Better
Potential to add new
Limited
Feasible
Training effort & expense
1
_____
78
i 1
Support Staff
2
Infrastructure
Engineer (lnfra)/Architect
Support Staff
1
2
IEC & NGO
Consultants
Support Staff
2
2
4 LMIS personnel plus support staff
outsourced through Procurement &
Logistics Agency
Procurement & Logistics
Safe motherhood, Public Health, Demography and Pediatrics can be considered for
contractual employment if no suitable person is identified from within the system.
Others
O & M costs
One time
Office Consultation/Rental
Furnishing (one time)
Computerisation (one time)
States
Additional Manpower
Deputy Director (HRM)
Other Staff
Joint Director (Urban Health/NGOs)
Other Staff
District Facilitation Officers
1
5
2
2
4
2
1
Procurement & Logistics
4 LMIS personnel plus support staff
outsourced through Procurement &
Logistics Agency
(large states)
(small state)
UTs
District Level
AD (Planning & Monitoring)
Staff
AD (Finance)
Staff
AD (HRM/Training)
Staff
1
2
1
2
1
2
80
I i
AD (Vital States/Rental)
Staff
1
2
CHC/FRU
Contractual Staff/Private Sector/Retainer
• OBS/GYN, ANAE/Lab Technicians/Staff nurses/Safe Motherhood Consultants
• Monitoring & Supervision (Mid-term Revision)
• Referral Transport
• Infrastructure
Primary Health Center
Monitoring & Supervision/ Mid-term Revision
Infrastructure
- Referral Transport
Sub-Center
Fill in all the vacant ANM position on a contractual basis.
Village Level
Link volunteer
2.8.2 Strategic Approach
The design process itself has been strategic and based on the lessons learnt from the past
The process has been to increase ownership at the different levels by making the planning
process a participative and a decentralized one. The development of monitoring mechanisms
based on accepted Process, output and outcome indicators would make the program need
based and realistic. The process of consultation at different stakeholders levels would build r
the need based requirements being addressed. Further, thrust on differential strategies foi
E.AG states and other states to achieve health outcomes itself has been strategically inbuilt
into the program. The unification of a single RCH/FW society at the state and district levels
would smoothen the funds flow and streamline the decision making process by building in
second line structures for quicker decision making.
2.8.3 Accountability
The accountability at different levels has been attempted to be brought out through the
Memorandum of Understanding mechanism. The draft MOUs prepared is provided in Anne1. The MOU builds the elements of institutional mechanisms, planning mechanisms and thf
process indicators and output indicators to be achieved. Further the linking of funding to
performance and capacity to absorb and utilize builds in considerable accountability on the
part of the state and in turn the districts. The systems to measure the indicators through the
*
11
Monitoring Information and Evaluation system have also been envisaged A draft of a genern
MOU is given in Annex 5.
2.8.4 Human Resource management
This has been provided adequate emphasis at the state levels by bringing about the
requirement of a separate Human Resource management Division at the state. Further it has
also looked at the promotion and posting policies, requirements for human resources
planning, training prerequisites, and assurance of tenure of service at the level of key
positions. The development of managerial skills especially for Public Health Managers has
been emphasized. The skill development through capacity building both for technical and
managerial positions has been provided enough importance in the design. Human resource
management and development have been considered as one of the key parameters for
success.
2.8.5 Strengthening of Teaching Institutions
IMPROVING INFRASTRUCTURE OF TEACHING INSTITUTIONS FOR REPRODUCTIVE
AND CHILD HEALTH
Aim
•
To improve the infrastructure of 100 government-run teaching institutions to enable
them to contribute to the RCH II program more effectively.
Objectives
•
Strengthen facilities at teaching institutions for providing optimum obstetric, family
planning, neonatal and child health services.
•
Strengthen capacity of teaching institutions for imparting pre- and in-service education
and training to providers in reproductive and child health.
Scope
•
The purpose of; this initiative is to supplement the resources available to the
government sector teaching institutions to improve Obstetric, family planning, neonatal
and child health services, and to strengthen the training/education capability of the
departments of Obstetric & Gynecology and Pediatrics.
•
Funds will be equally divided between the departments (i) Obstetrics & Gynecology
and (ii) Pediatrics:
Obstetrics & Gynecology: Labor and delivery room(s), operation theatre(s)
(minor/major), maternity wards; teaching room & A-V aids.
i i
Pediatrics: Newborn unit(s), lying-in ward, sick child treatment room(s); teaching
room & A-V aids.
•
The funds (approximately 50 lakhs for each medical college) to be made available
under this scheme would be meant for development, repair, expansion, improvement
and equipping of the existing areas and to provide essential equipment. Since the
requirements of the different institutions are likely to be different, the exact extent of
infrastructure/equipment strengthening will be individualized.
•
Detailed guidelines will be developed to implement this scheme in consultation with
medical professionals.
11
Section 3.
Implementation Plan
The program design is based on the premise of a differential approach as arising from the
lessons learnt. The differential approach is discussed below. In formulating the
implementation plan this strategy has bee applied.
Differential Approach for Implementing RCH II Program
India is a vast country with a wide range of diversity in socio-cultural factors, economic
development, governance and work culture. Different states are at different levels of
reproductive and child health status and their capacities to implement programs are highly
variable. Thus, the one size fit all’ approach in RCH II implementation is unlikely to be
effective. The Tenth Five Year Plan steering committee on Family Welfare recommended
differential strategy for maternal health. It appears that such an approach is also necessary
for child health
IMR in TN, Punjab and WB is around 50, while in Orissa, UP and MP it is above 80 per 1000
live births. Strategic priorities at different levels of health status are different The strategies
required to bring down IMR from 80 to 50 are different from those required to it bring down
from 40 to 30. In the former, the focus would be immunization and diarrhea disease control,
while in the latter, skilled attendance at birth and newborn care would be crucial Generally
speaking, early declines in child mortality are possible with preventive approaches, but
referral and curative care at facilities becomes increasingly important as the child mortality
reaches lower levels.
States with limited implementation capacities need to be offered the choice from within
simpler strategies that can bring about the desired impact. For instance, immunization
program has been implemented intensively for more than two decades. The delivery and
managerial systems for this program have been progressively refined over the years.
However, it is a reality that there are wide variations in the immunization coverage among
different states. Coverage in EAG states and Assam is less than 25%, whereas in TN.
Kerala, HP and Karnataka it has been 60% or higher (NFHS II). Similar variation is noted at
the facility level. Adequate staff at FRUs was reported in less than 20% FRUs in Bihar and
MP, but in more than 60% FRUs in WB, TN, and Haryana (Facility Survey 1999). Ensuring
operationalized FRUs for emergency obstetric care is managerially more demanding than
running a successful immunization program. Furthermore, if a state does not possess the
capacity to ensure a reasonably high proportion of well functioning FRUs located in towns, it
may not be possible for it to operationalize the strategy of 24 hours delivery at PHCs located
in the periphery.
Hence, considering the above arguments it has been considered that a reasonable approach
for states with non-favorable indicators to begin with strengthening of programs such as
immunization and ORS. Further the focus would be to operationalize district and FRU level
i I
care in the first phase and then move towards I operationalization of 24-hour delivery service
at primary health centers.
Based on these considerations a suggested framework of the differential approach to
prioritize strategies in different states is provided:
Outline of differential approach
Prevailing
scenario
•
•
States A
High IMR (>50)
Weak health system
•
•
States fitting
this scenario
Strategies in
RCH II
•
States B
Moderate but high IMR
(<50)
Relatively strong health
system
Institutional deliveries
picking up
Institutional deliveries low
•
EAG, Assam and NE.
•
Non EAG UTs
Main focus on the
community sub-centre and
Anganwari; start
operationalizing of
facilities at district level,
then FRUs in a step-wise
manner
•
Same for the community,
sub center and Anganwari
but equal focus on full
operationlization of
institutions all the way
down to PHCs
Home based newborn care
to supplement facility care,
important, perhaps not
critical
Home-based newborn care
very important and critical
•
RCH link volunteer, a key
necessity
•
TBA training relevant
•
Community IMCI approach
highly relevant
•
TBA training less important,
only for some pockets; TBA
incentive for institutional
deliveries important
•
IMCI approach less critical
11
•
Adolescent health low priority
*
Basic service delivery to be
strengthened
•
•
♦
Building referral network
•
•
Adolescent health important
priority
Hospital waste management
important
Quality improvement
Major strengthening of
referral network
This approach needs to be viewed as a broad roadmap and not as a prescription. The
states need to be involved in prioritizing their strategies, but need to be guided based on the
outlined approach This approach is also not a static framework.
One prerequisite for planning state specific strategies would be to model how different states
need to contribute to the overall achievement of the key goals of IMR and MMR reduction
The national burden of infant deaths is the sum total of infant mortality in all the states/UT
put together, each contributing its individual burden based on the population (and birth rate;
and the infant mortality rate. A hypothetical example is provided to illustrate the point
Assume that the EAG states with a high IMR and large population are contributing two thirds
of the infant mortality burden. Thus, as an illustrative example, it would appear that in order
to bring down the overall national IMR from 66 to 45 by 2007 (a reduction of about 3 '
percent), it may be necessary for EAG states to bring down IMR to 50 (from around 80) b
the year 2007, while non-EAG states may need to reduce their IMR from around 50 to 35 n
the same period.
The estimates need to be made on the basis of factual data as a part of the action plan to'
RCH II in order to achieve the overall goal of IMR and MMR reduction. This exercise would
enable the individual states to prioritize their strategies as per their prevailing scenarios and
move towards achieving state specific milestones in a concerted manner.
The North Eastern states present a different scenario in terms of the following
•
•
Fragile communication networks and lack of connectivity
Constant depletion of natural resources due to natural calamities
J
•
•
•
Have shared borders with other countries making them strategically important
They have difficult and sometimes inaccessible terrain coupled with poorly develop^
transportation network making them difficult to provide health services
Sparsely distributed tribal population in forest and hilly regions.
The above geographical features make them considerably difficult to provide health and RCI l
services and also render the unit cost of providing services extremely high and fall outside
the norms of the rest of the regions. These regions have a large variation when viewed from
the socio-cultural viewpoint. Each tribe has distinct customs and traditions and varying socio
economic activities. This necessitates a separate North East Initiative for sector reforms an :
improvement of service delivery.
Hence, viewed from the different perspectives of demographic performance, the stage of th<
development the different states are in and the socio-cultural variations it would be necessar
to follow a differential approach by adopting locally relevant strategy to achieve the desire,1
results.
3.1 Maternal Health
3.1.1 Maternal health goals and approaches for RCH II
a) The 10th Plan Goals
Reduce maternal mortality ratio to 200 per 100000 live births by the year 2007 and
150 by 2009 from the current level of 407.
b) Enabling goals
•
•
•
•
•
Increase institutional delivery rate to 65% by 2007 from the current level 36%. (NFHS
1998-99)
Increase proportion of deliveries by health professionals (skilled birth attendants) to
80% by 2007 (current level 42% NFHS 2 1998-99)
Increase proportion of pregnant women receiving 3 or more antenatal check ups to
90% from the current level of 44%. (NFHS 2 1998-99)
Increase proportion of pregnant women receiving two or more tetanus toxoid injections
to 100% from the current level of 67% (NFHS II).
c) Approach
•
•
Goals
Expand and strengthen
institutional base for basic and
comprehensive emergency
obstetric care.
Increase institutional deliveries
and skilled attendance at birth.
•
•
Approach
Provide 24 hours delivery
services at 50% PHCs, all CHCs,
FRUs and district hospitals
Operationalize emergency
obstetric care at all FRUs and
district hospitals
I i
•
•
•
•
Increase proportion of pregnant
women receiving 3 or more antenatal
check ups and 2 or more TT injections
And iron and folic acid tablets
•
Develop a system of
compensating grassroot
providers for mobilizing pregnant
mothers for institutional
deliveries.
Involve private and NGO sector
institutions in delivering essential
and emergency obstetric
services, especially for the poor.
Strengthen referral transport of
pregnant women by community
involvement and provision of a
dedicated fund at the village
level
Provide training to at least one
traditional birth attendant in each
village
Universalize antenatal care
coverage including Check up, TT
and intake of iron-folic acid
tablets
1.1.2. Problem of high maternal mortality in India
Every 5 minutes a women dies somewhere in India due to a pregnancy-associated cause
The annual toll of over 100,000 maternal deaths constitutes over 20 percent of the global
burden, which is perhaps the highest for any single country.
Prevailing high maternal morbidity and mortality has been a source of concern. Antenata
and intra-partum care aimed at reducing maternal morbidity and mortality has bee
components of the Family Welfare program since inception. In India, data on state/disim
specific maternal morbidity/mortality data is not available. However, the available data Iron
SRS and survey of causes of death provide sufficient information to formulate a rational
maternal health program. In the nineties the SRS and the National Family Health Survey;
have provided independent data to assess the impact of ongoing programs on the materna
mortality (Table 19).
i
Table: 19 Maternal Mortality ratio
RGI (Sample Registration Scheme)
National Family Health Survey
1992-93
1997
1998
407
424
NA
408
540*
! ’ Differences are not statistically significant
'Source: RGI & NFHS 1 & 2
Data from SRS indicate that the major causes of maternal mortality continue to be unsafe
abortions, ante and post-partum hemorrhage, anemia, obstructed labor, hyper-tensive
disorders and post-partum sepsis (Table 29). There has been no major change in the cause
of maternal mortality over years. Increasing access to safe abortion services can prevent
deaths due to abortion. Death due to anemia, obstructed labor, hypertensive disorders and
sepsis are preventable with provision of adequate antenatal care, referral and timely
treatment of complications of pregnancy, promoting institutional delivery and postnatal care
Emergency obstetric services will help saving lives of women with hemorrhage during
pregnancy, complications during deliveries conducted at homes. The Ninth Plan envisaged
universal screening of all pregnant women, identification of women with health problems,
problems during pregnancy and provision of quality care for obstetric emergencies This,
however, has not been achieved. The planning commission calls for assigning the highest
priority to operationalizing essential and emergency obstetric care
Table: 20 Causes of maternal death (%)
Hemorrhage
Anemia
Sepsis
Obstructed labor
Abortion
Toxemia
Others
30
19
16
10
8
8
8
Source: Survey of causes of death 1998
3.1.3 Maternal Health Interventions in RCH I
Under the Reproductive and child health care efforts were made to improve the coverage
content and quality of essential and emergency obstetric care in order to achieve a
substantial reduction in maternal morbidity and mortality. A number of special schemes were
introduced to expand and strengthen these services.
a) Essential Obstetric Care
Essential obstetric care intends to provide the basic maternity services to all pregnant womc'i
through:
• Early registration of pregnancy (within 12-16 weeks).
ii
•
•
•
Provision of minimum three antenatal check up by the ANM or medical officers to
monitor the progress of the pregnancy and to detect any risk / complications so thai
appropriate care, including referral, could be given on time.
Promotion of institutional deliveries and provision of safe deliveries at home.
Provision of post-natal care to monitor the postnatal recovery of the women and to
detect complications.
This component of the RCH Program is relevant to all States, but more so to the states
where most of the deliveries are still conducted at home in unclean environment causing
high maternal morbidity and mortality. These states include: Assam, Bihar, Jharkhand,
Rajasthan, Orissa, Uttar Pradesh, Uttaranchal, Chattisgarh and Madhya Pradesh,
Haryana and the North Eastern States
b) Emergency obstetric care
Complication associated with pregnancies is often not predictable. Therefore, emergency
obstetric care is an important intervention to prevent maternal morbidity and mortality Jnd<.-r
the RCH Program, efforts were made to strengthen the emergency obstetric care services
and make a total of 1748 FRUs operational.
c) Scheme for improving Obstetric care services in RCH I
Additional ANMs. In order to improve delivery services, all category C districts of Uttar
Pradesh, Uttaranchal, Jharkhand, Bihar, Madhya Pradesh, Chattisgarh, Orissa, Haryana.
Assam, Nagaland and Rajasthan and the North Eastern States are being supported for
providing additional ANMs in 30% of sub-center of these districts. In addition, Delhi has beer
provided with assistance for appointing 140 ANMs for extending services to slum areas
Public Health /Staff Nurses: For improving the institutional deliveries, under the program
Public Health/ Staff Nurses are also provided to 25% PHCs in C category districts and 50'
PHCs in B category district in all States / Uts.
Laboratory Technicians. To build the capacity of the First Referral Units for looking after the
needs of emergency Obstetric care and RTIs/STIs, the districts are being assisted to engage
two laboratory technicians on contractual basis for doing routine blood, urine and RTI tests.
Private Anesthetists. The sub-district hospitals, CHCs and FRUs are entitled to hire
services of Private Anesthetists for conducting emergency operations for which they are to nt
paid Rs. 1000 per case.
1i
Safe Motherhood consultants: To alleviate the shortage of trained manpower in
PHCs/CHCs and sub-district hospitals, the States/UTs are being assisted for engaging the
doctors trained in MTP techniques (Safe Motherhood Consultants) to visit these institutions
one a week or at least once a fortnight on a fixed day for performing MTPs and providing
other services like ante-natal check up and treatment of pregnancies with complications.
These doctors are being paid at the rate of Rs. 800/- per day visit.
24 hours delivery services at PHCs /CHCs: To promote institutional deliveries, provision
has been made under the current RCH Program to give additional honorarium to the staft to
encourage round the clock delivery services at PHCs and CHCs. This is to ensure that al
least one medical officer, nurse and cleaner are available beyond normal working hours. The
scheme has been implemented well in parts of Tamil Nadu and Andhra Pradesh.
Referral Transport. Under the RCH program provision has been made to assist women
from indigent families in 25% of the sub-centers of all States/UTs in transporting to referral
unit. A lump sum corpus fund has been provided to panchayats through the district family
welfare offices. The utilization of the scheme has been poor.
Dai training. A scheme for training of Dais was initiated during last year. The scheme is
being implemented in 142 districts in 17 states of the country. The districts have been
selected on the basis of the safe delivery rates being less than 30%.
RCH camps. In order to provide the RCH services to people living in remote areas where
the existing services at PHC level are under utilized, a scheme for holding camps has been
initiated during this year. The scheme is being implemented in the 17 states. Initially 102
districts have been selected in these States. A recent evaluation has shown that RCH camps
are often poorly planned, coordinated and organized, and that they dislocate the normal
working of the health system.
d) Medical Termination of Pregnancy
Abortion is a significant medical and social problem worldwide. It is estimated that half the
abortions taking place in the country every year are performed outside authorized health
services and/or by unauthorized often-unskilled providers. Whether spontaneous or induced
abortion has been a matter of concern over many decades now, particularly because of
sepsis and other complications, associated with it.
L i
The Medical Termination of Pregnancy Act was passed by the Indian Parliament in 1971 and
came into force from April 1, 1972. The aim of this Act was to reduce maternal mortality and
morbidity due to abortion. The MTP Act, 1971 lays down the conditions under which a
pregnancy can be terminated and the place where such terminations can be performed. A
recent amendment to the MTP Act, 1971 includes decentralization of power for approval
places as MTP Centers from the States to the district level with the aim of enlarging the
network of MTP services. The amendment also provides for specific punitive measures for
performing termination of pregnancy by unqualified persons and in places not approved b\
Government.
Complications of abortions continue to be a major contributor to maternal death. This >s ai
indication of the unmet need for safe abortions. The National Population Policy 2000
includes provision of safe abortions as one of the operational strategies.
Under the RCH program, actions were initiated to expand and improve the MTP facilities and
their utilization and to make safe abortion services accessible to all women in the country
particularly in the rural areas. Assistance has been provided for skill based training to doctors
in MTP techniques and supply of MTP equipment. The guidelines for MTP up to eight weeks
using Manual Vacuum Aspiration technique have been developed to assist the medical
officers to provide safe abortion services at the PHC level and above.
e) Reproductive Tract Infections (RTI)/ Sexually Transmitted Infections (STI)):
Reproductive tract and sexually transmitted infections (RTI/STI) were not recognized as a
public health problem until recently. Research conducted in India to document the magnituc
of reproductive morbidity, has made these infections more visible and brought them into the
reproductive health agenda. The spread of HIV infection and the role RTI/STI play in the
transmission of HIV have also drawn attention to the problem.
To create awareness and generate demand for treatment of these infections, the National
AIDS Control Organization, in close collaboration with the Department of Family Welfare,
have been organizing the Family Health Awareness Campaign almost every six months.
During the campaign, detection, management and referral for RTI/STI cases is being
undertaken.
To strengthen the services for RTI/STI, assistance from the government is being provided h
the form of training, drug kits, disposable equipment and provision for engaging two
laboratory technicians per district on contractual basis in the First Referral Units
11
3.1.4 Progress made in RCH I
Antenatal care
Data from the Rapid Household survey (1998-99) and NFHS II (1998-999) indicate that at the
national level, only two thirds of pregnant women receive an antenatal check up (RHS 65.3‘)z<
NFHS II 66.0%). Only 30 percent women had the first ANC visit in the first trimester 31.8%
women as per RHS and 44% as per the NFHS II received ‘Full’ ANC. In Andhra Pradesh,
Tamil Nadu and Kerala antenatal coverage was good in almost all the districts. UP. Bihar
and, surprisingly Punjab, had reported a very low coverage figures in most districts.
Rapid Household Survey data also indicate that in 265 districts, less than 40% of the women
had three antenatal visits during pregnancy and in only 95 districts, more than 75% had three
antenatal visits. In UP and Bihar, the content and quality of AN care was reported poorer as
compared to Haryana or Tamil Nadu.
Anemia is a major cause of maternal mortality in India. The Ninth Plan envisaged universal
screening for anemia in pregnant women and appropriate iron-folate supplementation. The
program is yet to be operationlised fully. Data from Rapid Household Survey indicate that
iron folic acid consumption is still very low; in 267 districts less than 30% women had taken
IFA tablets.
11
Table: 21 Key indicators of maternal health program
SI
No
I.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
II
1
2
3
4
5
6
7
8
State/UT
Any ANC
Safe Delivery
Full ANC
Districts with less
than 40% Full
ANC Visits
(RHS, 98-99)
Total
No. of
district
Distt
cover
ed
RHS
NFHS
31.6
NFHSII
3 or
more
checku
P
43.8
40.4
42.3 1
267
504
92.7
63.4
80.1
60
65.2
0
23
60.1
36.3
86.4
58.1
86.3
98.8
61.0
24.8
10.1
42.7
23.9
60.1
86.1
20.2
30.8
17.8
60.2
37.4
71.4
98.3
28.1
31.1
18.8
56.3
32.8
60
97.4
27.5
21.4
23.4
53.5
42.0
59.1
94.0
29.7
18
30
3
7
0
0
31
23
30
19
17
20
14
38
90.4
54.8
65.4
61.4
59.4
0
30
79.5
74.0
47.5
98.5
34.6
32.5
24.5
16.6
75.3
11.2
47.3
57.0
22.9
91.4
14.9
32.9
55.0
32.5
82.5
21.9
33.4
62.6
35.8
83.8
22.4
23
5
30
0
55
30
17
30
23
58
90.0
33.4
57.0
45.6
44.2
10
19
61.6
19.8
40.5
28.2
31.9
12
13
NA
83.5
99.0
86.8
27.1
73.1
80.3
52.7
NA
68.2
95.7
60.9
22.4
73.8
95.1
36.4
NA
65.9
90.8
40.2
5
0
0
0
7
1
2
12
NA
83.2
80.2
18.9
23.8
30.9
NA
66.0
54.4
19.9
46.8
50.0
NA
42.4
53.9
10
5
4
13
13
8
RHS
NFHSII
RHS
3
checkup
TT+IFA
65.3
INDIA
MAJOR STATES
Andhra
~T 94.2
Pradesh
56
Assam
26.4
Bihar
79.1
Gujarat
77.7
Haryana
88.9
Karnataka
84.5
Kerala
53.9
Madhya
Pradesh
Maharashtr
87.8
a
72.9
Orissa
87.2
Punjab
62
Rajasthan
98.4
Tamil Nadu
48.0
Uttar
Pradesh
84.1
West
Bengal
SMALLER STATES
44.4
Arunachal
Pradesh
Chattisgarh
52.2
' Delhi
89.5
98.3
Goa ____
87.1
Himachal
Pradesh
42.8
Jharkhand
58.0
J & K
77.0
Manipur
65.4
ii
9
10
11
12
13
14
III
1
2
3
4
5
6
20.6
35.7
31.3
30.9
53.6
55.0
Meghalaya
67.5
62.9
43.7
75.8
91.8
80.3
Mizoram
32.8
25.1
23.1
15.6
60.4
45.7
Nagaland
35.1
36.8
42.6
31.9
69.9
63.1
Sikkim
NA
48.4
NA
34.8
NA
69.1
Tripura
NA
NA
22^3
NA
17.5
40.6
Uttaranchal
UNIObTTERRITORIES
NA
67.2
NA
84.4
NA
95.9
A&N Islands
NA
71.6
NA
62.9
NA
79.6
Chandigarh^
NA
27.9
NA
62.0
NA
D&N Havel i
90.6
NA
70.7
NA
71.1
NA
95.1
Daman &
Diu
NA
74.1
NA
91.4
NA
99.4
Lakshadwe
ep
93.5 j NA
NA
83.8
NA
Pondicherry
99.8
Source: RHS and NFHS 2 Data. RHS-Rapid Household Survey 1998-99
6
1
5
3
1
3
7
3
6
4
3
10
0
0
0
0
2
1
1
2
0
1
0
4
Deliveries
Skilled birth attendance rate in the country is around 40% (RHS 40.2%, NFHS II 43.8%).
Most deliveries attended by the skilled birth attendants occur at institutions in India
Institutional delivery rates were 34% (RHS) and 36% (NFHS II) in 1998-99.
In RCH I, it was envisaged that efforts will be made to promote institutional deliveries both 11
urban and rural areas. Simultaneously, in districts where majority of the deliveries were taking
place at homes, efforts were made to train the TBAs through intensive Dai Training Prograi
The available data from the NFHS-I and II and the Rapid Household Survey suggest son.
improvement in the institutional deliveries, especially in states like Tamil Nadu and Andhra
Pradesh. There are, however, a large number of districts in many states where the situation
with regard to safe deliveries is far from satisfactory.
In Kerala over 90% of deliveries occur in institutions. In states like UP or Rajasthan, majority
of deliveries take place at homes conducted by untrained persons. Data from NFHS II
showed that even though there has been a steep increase in the institutional deliveries in
Tamil Nadu and Andhra, there has not been a commensurate decline in the neonatal
mortality indicating that there is a need to improve quality of intrapartum, post-partum and
neonatal care for even those who are coming for institutional deliveries. In states where
majority of deliveries still occur at homes, efforts were made to train Traditional Birth
Attendants through the Dai Training Program and to increase availability and access to
disposable delivery kits.
I i
Emergency obstetric care
The RCH I program aimed at operationalizing 1748 FRUs for emergency obstetric care
Flowever, the progress has been far from satisfactory (Table 31). In particular, the major
deficiencies are in the availability of specialists and blood bank access.
Table: 22 Status of FRUs (FRUs surveyed 760)
Feature
Infrastructure
Tap water
Electricity
Generator
Phone
Delivery facility
Aseptic LR
OT
Gynae OPD
Linkages with district blood bank
Staff
Obstetrician
Pediatrician
Anesthetist
Gen M.O.
One physician trained in
EmOC/NBC
Utilization
Utilized as referral
Fulfilled
50%
96%
71%
80%
89%
36%
70%
63%
17%
48%
37%
22%
89%
17%/22%
34%
Source: Facility Survey 1999
Post-partum care
Post-partum care of mothers is a very deficient area at present. Only 16.5% women receiv< ■■
post-partum check up within 2 months of delivery (NFHS II). Of them, less than one third
were seen within the first post-partum week, a period associated with high complication raie
Medical Termination of Pregnancy
It is estimated that in 1998 about 8 of maternal deaths are due to unsafe abortion. Available
service data on MTPs indicate that following an initial rise, the number of MTPs have
remained around 0.5-0.7 million in the last decade. The estimated number of illegally
induced abortions in the country is in the range of 4-6 million. There has not been any
I j
substantial decline in estimated number of illegal abortions, reported morbidity due to illega
abortion or share of illegal abortions as the cause of maternal mortality. Management of
unwanted pregnancy through \arly and safe MTP services as envisaged under the Medical
Termination of Pregnancy Act isyan important component of the ongoing RCH Program
In spite of these efforts there has n\t been any increase in terms of coverage, number of
MTPs reported and reduction in number of women suffering adverse health consequences .)■
illegal induced abortions.
RTIs/STIs
Prevention, early detection and effective management of common lower reproductive i-.(i
infection have been included as a component of the essential care through existing primal
health care infrastructure.
The Department of Family Welfare has provided necessary drugs for treatment and also
inputs to fill the gaps in laboratory support in PHCs/CHCs. However, the skill upgradation
training of health care personnel has lagged behind in most states Department of Family
Welfare has coordinated their efforts with the NACO so that NACO provides the input for
diagnosis and management of RTI/STD at and above district level. The importance of
prevention, early detection and effective treatment of RTI/STI is well recognized by the public
health experts, practitioners and public themselves. Reliable, easy-to-perform tests for
accurate diagnosis of RTI/STI are available. Most of the infections still respond to commonly
used antibiotics and chemotherapeutic agents. However, it is important to recognize that
there are problems in the current programs for management of RTI and the coverage in very
low. It is imperative to build as the RCH I initiatives and improve RTI/STI related services n
RCH II.
3.1.5 RCH II strategies for maternal health
3.1.5.1. RCH II objectives and strategies for safe motherhood
Objectives
•
•
•
•
•
Promote institutional deliveries and skilled attendance at birth.
Widen the institutional base of basic and comprehensive emergency obstetric care
services.
Strengthen referral pathways and improve access to emergency obstetric care
Universalize antenatal coverage for pregnant women.
Enhance coverage of post-partum contact.
Strategies
1. Facility strengthening (This is topmost priority)
•
Upgrade_and operationalize PHCs, CHCs and FRUs for 24-hour delivery service an<'
FRUs and district hospitals for 24-hour comprehensive emergency obstetric care.
i I
•
Involve private sector obstetricians and anesthetists in providing care at government
facilities on contract or for a fee.
•
Provjde short-term skills-oriented training in anesthesiology and cesarean deliveries k
physicians.
•
lnvolve_general surgeons for cesarean deliveries at FRUs and district hospitals.
•
Shift specialists (obstetricians, anaesthetists and pediatricians) from
PHCs/dispensaries to FRUs and district hospitals for optimum utilizxation of then
expertise.
•
Provide blood storage facility at all FRUs and blood bank at all district hospitals
2. Institutional deliveries (This is main focus area)
•
Mobilize families for institutional deliveries in government/private facilities. Provide
monetary incentive to TBAs, AWWs, link volunteers, ANMs etc for accompanying
pregnant women for deliveries at institutions; use referral transport funds
•
Launch a sustained social mobilization effort for institutional deliveries with the help of
panchayati raj institutions, opinion leaders, NGOs, self help groups and other
stakeholders; reward those villages that achieve high rates of institutional deliveries
Train TBAs/Link volunteers/ANMs/AWWs to mobilize pregnant women for institutii'
deliveries. It is suggested that an incentive is paid to the link worker/TBA based or
performance.
•
Educate communities in danger signs of pregnancy, labor and post-partum period
•
Promote referral transport for routine deliveries and emergency obstetric care. Make
referral transport fund available with AWW/link volunteer / ANM. Map facilities; | da11
transport options; develop community support systems.
•
Provide delivery and emergency obstetric services free to BPL families at recognized
private facilities.
3. Sub-centre & Home deliveries (Wherever institutional deliveries are not feasible)
•
Promote deliveries by ANMs/nurses at sub centers and at homes
•
Promote deliveries by Community Skilled Birth Attendants, a new category of healtl
professionals (being piloted).
•
Ensure_that home deliveries are safe and clean. Train traditional birth attendants
educate families, promote birth preparedness, and universalize clean delivery kit
I i
4. ANC
•
Ensure 3 or more antenatal check ups to pregnant women. TT two doses and IF A for
all; reach out to each pregnant woman especially the poor, the tribal and the SC
specially focus on the adolescent and first pregnancies, ensure first check up in first
trimester; involve TBAs, link volunteers and AWWs in organizing ANC sessions: hole!
fixed day ANC sessions by ANMs in villages, and MOs/LHVs at facilities; promote
concepts of institutional delivery, birth preparedness, skilled attendance and
breastfeeding. Train TBAs/ Link volunteers/ANMs/AWWs to mobilize women for ANfJ
5. Post-partum care
•
Ensure pgsEpartum contact on days 1 and 7, and then at 6 weeks, link with visits for
neonates.
6. Monitoring/ records /audit
• Monitor state/regional level MMR
•
Monitor coverage, unmet need of basic and comprehensive emergency obstetric car monitor caeserean rate and case fatality rate at facilities
Introduce mother - child linked card along with details of birth registration
•
Conduct audit and review of care provided in case of maternal deaths whether in the
community, in transit or in the hospitals; strengthen system of reporting of maternal
deaths
3.1.5.2 RCH II Objectives and strategies for Safe MTP
Objectives
• Expand the network of facilities providing quality MTP services in the government and
private sectors.
• Train more health professionals for conducting safe MTP
• Provide access to MTP counseling through ANMs, AWWs, link workers, and facility
staff.
Strategies
• Obtain registration of PHCs, CHCs, FRUs and district hospitals for MTP services.
•
Encourage private and NGO sectors to establish quality MTP services
•
Enhance access to confidential counseling for safe MTP; train ANMs, AWWs and link
volunteers.
•
Train adequate number of physicians in MTP skills, especially the manual vacuum
aspiration (MVA) technique, in government/NGO and private sectors.
I i
3.1.5.3 RCH II objectives and strategies for RTI / STIs
Objectives
•
•
Promote recognition and referral of women (and partners) with suspected RTI & S11
Strengthen services for diagnosis and treatment of RTI/STI at PHCs, CHCs, FRUs and
district hospitals.
Strategies
• Train ANMs, link volunteers and AWWs to identify and refer suspected cases c
RTI/STI."
• Operationalize services for diagnosis and treatment of RTI/STI at PHCs, CHCs. • ■
and district hospitals.
• Promote behavior change communication for prevention and early care seeking for
RTI/STI. ’
•
Train technicians in laboratory diagnosis of RTIs and STIs.
3.1.5.4 Schemes on safe motherhood
The schemes on safe motherhood to be implemented in RCH II are shown in the panel ■
detailed description and action plan for each will be prepared in consultation with sratprogram managers and experts. (RCH I lessons and experiences will be kept in view whir
refining existing schemes.
S.No.
1
Scheme_
Contractual staff
2.
Safe Motherhood
Consultant
scheme
Comment
This scheme has been found useful although implementation
in different states has been highly variable
Apart from
ANMs, nurses, anesthetists and obstetricians as in RCH i ii
could also be extended to include pediatricians, general dutv
doctors, paramedic staff, helpers/cleaners and laboratory
staff etc., wherever needed. The remuneration should be
competitive enough to attract guality personnel. The scheme
should encompass all levels from community/SC to clismct
hospitals.
SM consultants to do the following:
1. ANC and post-partum check up, assess
women in labor and advise referral if
reguired
2. Perform MTP
3. Insert IUDs
4. Treat STI/RTI
5. Counsel for contraceptive use.
Implementation of this scheme should be streamlineci
strengthened. NGO’s and professional bodies should be
involved to identify the consultants. Honorarium / pei diem
may be enhanced, if necessary. Provide mobility. Ensui .
that the visit of the consultant is well advertised to attract tic.
\ 1
n
3
RCH
Outreach
scheme
4.
24 hours Delivery
Services
5.
Operationalising
FRUs
6.
Referral transport
for mothers and
children
7.
Community
Skilled
Attendant
Birth
clients.________ _________
RCH outreach services should not be seen as a substitute
for routine services. This initiative is meant to serve
populations that are not readily accessible due to distant or
inaccessible locations Take measures to improve mobility
With resident doctors and nurses.
This scheme introduced in RCH I has made a promisincj
progress in some states and the valuable experience gaine
can be built upon to scale it up other states. In RCH II, th.:
scheme may be extended to 50% PHCs and all the CHCs
The PHCs to be selected should be those that are more
readily accessible by the catchment population and have a
relatively better infrastructure and staffing. At these facilities
services such as assisted vaginal deliveries, manual remove
of retained placenta, administration of antibiotics, oxytoci-.
drugs anti convulsants. These PHCs will also have newborn
care corners and areas for care of sick children Ambulance
facilities would be available for transporting women with
complications to facilities with comprehensive emergency
obstetric care. Criteria for operationalization of such PHCs
will be developed, monitored and sustained.
Emergency obstetric care (EMOC) and services for sick
neonates and children will be operationlised at all the
designated FRUs. Additional 612 CHCs (50% of the nonFRU CHCs) will also be upgraded as FRUs in RCH II. OTs
labor rooms, newborn care corners and blood storage
facilities will be established / strengthened. Criteria for
operationalization will be developed, monitored and
sustained. Quality assurance system will be introduced
These facilities would provide Caeserean deliveries and
access to blood transfusion.
TFe referral transport fund should be used all mothers going
for institutional deliveries or obstetric emergencies at
government or private facilities. If should also be used for
taking sick neonates and children to government or private
facilities.
The fund should be available with each link
volunteer, AWW and ANM, and readily disbursable in cash
round-the-clock. The information on the availability of the
fund should be widely disseminated. Village health
committees or other self help groups should be encouraged
to map facilities around their settlement where the required
services are available and to keep transport arrangements in
readiness._____ _______
C-SBAs are being trained in a pilot program to provide
availability of skilled birth attendants in the community The
pilot will be carefully evaluated and if found useful, the
K f-M 0
0839U
IJ
8.
(C-SBA)
TBA involvement
scheme will be scaled up in RCH II.
It is proposed to continue to train TBAs in RCH II. India is in
transition from home-based deliveries to institutional
deliveries, and from unskilled birth attendance to skilled birth
attendance. Nation’s commitment to move towards skilled
attendance and institutional deliveries is clearly enunciated
in NPP goals and the RCH II objectives. However, there are
many states where deliveries by TBAs would continue to
take place in the next decade or so.
It is true that TBA’s contribution to reducing maternal
mortality is modest, if any. But they have a very useful role in
promoting newborn health and survival. They are accepted
by the families and are involved in care of the infant in the
crucial first few days of the neonatal period They can be
educated to provide simple resuscitation, clean delivery can
and warmth; promote exclusive breast-feeding, and identify
sick neonates who need referral. Experience from tht
community studies indicates that TBAs are also critical for
providing access to the neonates by other care-providers.
RCH-II also envisages another critical role for the TBAs
They will be involved to counsel families for deliveries at
health facilities. TBAs who bring pregnant women foi
institutional deliveries may be suitably compensated i ..i, i
100/- per case).
There is an important and changing role for TBAs as a
community resource. With appropriate education, they can
contribute substantially to newborn survival, a role that
needs to be recognized and supported in RCH - II.
3.1.5.5 Research in maternal health
•
Develop models of operationalization of obstetric care combined with newborn and
sick child care at PHC, FRU, and district levels.
•
Develop models of sustainable referral system for safe deliveries and emergency
obstetric care.
•
Develop tools for maternal death audit and reporting.
•
Refine and test syndromic approach algorithms for the management of RTI/STI.
•
Estimate burden of RTI/STI and bacterial vaginosis.
I i
•
Study feasibility and safety of administration of emergency drugs like Oxytocin
Magsulph by ANMs/Link Volunteers (by injection or unijet)
•
Study the utility of microbicides in treating RTIs/STIs
•
Ascertaining changing pattern of causes of maternal death in community/at facilities.
[NB: As a note of caution it would be necessary to carry out an exercise to ascertain whether
there exists adequate institutional capacity to meet the target increase of institutional
deliveries to 65% through a combination of public, private and NGO institutions. This needs
to be carried out to examine the feasibility of achieving this goal]
The program summary for Maternal Health, Safe MTP and RTIs/STIs components at
different levels of Health System is provided at Annex 4a.
3.2 NEWBORN AND CHILD HEALTH
3.2.1. NEWBORN AND CHILD HEALTH GOALS AND APPROACHES
3.2.1.1
FOR RCH-II
The 10th Plan goals
•
Reduce infant mortality rate (IMR) to 45 per 1000 live births by the year 2007 and 35
by 2009 [Current level 66 (SRS 2001)].
•
Reduce neonatal mortality rate (NMR) to 26 per 1000 live births by 2007 and 20 b\
2009 [Current level 45 (SRS 1998)].
3.2.1.2
Enabling goals
•
Reduce post-neonatal mortality rate to 19 per 1000 live births by 2007 and 15 by 2009
from the present level of 28 (SRS 1998).
•
Ensure 100% coverage of immunization for all children with the six vaccine
preventable diseases.
•
Eradicate poliomyelitis by 2005.
•
Eliminate neonatal tetanus by 2005.
•
Reduce deaths due to measles by half by 2007.
•
Reduce deaths due to diarrhea by half by 2007.
•
Reduce deaths due to ARI by one third by 2007
.11
3.2.1.3
Broad approaches to newborn and child health
Goals
Reduce neonatal
mortality
Approaches
Strengthen maternal health interventions. Universalize essential
obstetric care, promote skilled attendance at birth, enhance
institutional deliveries, improve access to emergency obstetric care,
and provide post-natal care
Implement a package of home-based newborn care delivered by
anganwadi workers, TBAs and link workers.
Strengthen care of inborn and outborn sick neonates at
facilities, strengthen referral pathway
Reduce post-neonatal
and child mortality
Provide 100% immunization coverage for six vaccine preventable
diseases; achieve countrywide coverage of community -based care
of children with diarrhea and acute respiratory infections (ARI),
through AWWs, ANMs, link workers and private providers
Facilitate referral of and provide quality care to sick children at
facilities.
Launch a sustained movement to promote exclusive
breastfeeding and appropriate complementary feeding practices
among infants and children.
Strengthen implementation of Vitamin A and anemia
prophylaxis initiatives.
i i
3.2.2.1 Immunization Program
Routine Immunization
The Universal Immunization Program (UIP) was taken up in 1986 as a National Technology
Mission and became operational in all districts in the country during 1989-90. UIP become a
part of the Child Survival and Safe Motherhood (CSSM) Program in 1992 and the
Reproductive and Child Health (RCH) Program in 1997. Under the immunization Program
infants are immunized against tuberculosis, diphtheria, pertussis, poliomyelitis, measles and
tetanus. Universal immunization against 6-vaccine preventable disease (VPD) by 2000 waone of the goals set in the National Health Policy (1983). This goal has however not been
achieved till date.
NFHS-II and Rapid Household Survey
(RHS), conducted during 1998-99, show ful
immunization coverage of only 54.2% and 42.0%, respectively. Over 80% coverage was
documented in only Tamil Nadu, Kerala, Himachal Pradesh, Goa, Delhi. Lakshadweep and
Pondicherry (Table 23).
Coverage levels in states like Bihar UP and Rajasthan were very low 11.0% and 17.3%,
respectively, NFHS II). The drop out rates between the first second and third doses of or.-i
polio vaccine and DPT have been high in most of the states. Among all the individual
vaccines, the immunization rates for measles antigen remain the lowest across the states li
has been suggested that one of the major reasons for not achieving 100% routine
immunization is the focus on campaign mode programs.
Children in rural areas have almost three times risk of no immunization (17%) than their
urban counterparts (6%). Children in families with low standard of living index have only
30.4% full coverage rate compared to 64.7% coverage among children of high index families
Thus, the rural poor children require urgent attention in the program Further, it is seen that
as the distance of houses increases from the site of immunization session the coverage
drops in both the rural as well as urban areas.
The Department of Family Welfare has taken up a scheme for strengthening of routine
immunization. In addition, a pilot project on Hepatitis B immunization and injections safety
has been initiated in 32 districts and slums of 15 cities in 2002.
Public medical sector remains the prime provider of childhood immunization (82.0%), the
private sector (12.5%) and NGOs / others (5.6%) play only a minor role (NFHS II).
I i
State/UT
SI.No
Full Immunization
RHS
I.
1
2
3
4
5
6
7
1 8
9
10
11
12
13
14
15
' INDIA
MAJOR STATES
Andhra
Pradesh
Assam
Bihar
Gujarat
Haryana
Karnataka
Kerala
___
Madhya
Pradesh___
Maharashtra
Orissa
Punjab_________
i Rajasthan
Tamil Nadu
Uttar Pradesh
West Bengal
No Immunization
Districts with Full
Immunization
No.
Total Distt.
Covered
504
151
RHS
54.2
NFHSII
42.0
18.7
NFHSII
14.4
74.7
58.7
2.4
4.5
0
23
46.7
20.1
58.2
66.0
71.6
83.8
47.3
17.0
11.0
53.0
62.7
60.0
79.7
22.4
11.6
53.1
10.2
10.4
5.7
1.8
13.3
33.2
16.8
6.6
9.9
7.7
2.2
13.9
9
30
2
0
2
0
16
23
30
19
17
20
14
38
79.5
57.4
72.6
36.9
91.5
44.5
51.3
78.4
43.7
72.1
17.3
88.8
21.2
43.8
1.9
10.0
9.7
33.6
0.4
27.3
14.0
2.0
9.4
8.7
22.5
0.3
29.5
13.6
0
2
0
19
0
26
6
30
30
17
30
23
58
19
I
II SMALLER STATES
SI.No.
State/UT
Full
Immunization
NFHSRHS
II
No Immunization
NFHS
-II
No.
10
13
1
0
0
1
7
1
2
12
NA
9
2
4
5
1
5
0
1
13
13
8
7
3
6
4
3
NA
0
10
Districts with Full
Immunization
RHS
Total
Distt
Covered
30.4
20.5
22.9
59.1
84.8
88.3
80.5
NA
7.8
2.4
0.0
2.4
NA
6
7
8
9
10
11
12
13
Arunachal
Pradesh__
Chattisgarh
Delhi
Goa
Himachal
Pradesh
Jharkhand
J & K
Manipur
Meghalaya
Mizoram
Nagaland
Sikkim
Tripura
28.7
NA
NA
34.1
1.0
20.5
18.0
5.7
8.8
4.2
16.9
14
Uttaranchal
62.8
NA
19.4
1
2
3
4
5
30.8
52.8
50.6
32.7
66.7
26.2
65.4
45.4
69.8
82.6
83.4
NA
56.7
42.3
14.3
59.6
14.1
47.4
5.1
0.0
2.8
10.4
17.2
42.3
10.4
32.7
17.6
ii
III UNION TERRITORIES
SI.No.
1
i 2
3
4
5
6
Table23:
State/UT
A&N Islands
Chandigarh
D&N Haveli
Daman & Diu
Lakshadweep
Pondicherry
Full
Immunization
No
Immunization
RHS
NFHSII
RHS
NFHSII
77.4
61.6
77.3
72.0
94.8
95.3
NA
NA
NA
NA
NA
NA
1.8
1.8
2.7
4.2
0.3
0.1
NA
NA
NA
NA
NA
NA
Districts with
Full
Immunization
No.
Total
Distt.
Covered
0
2
1
0
1
0
2
0
1
0
4
0
Immunization coverage (RHS 1998-99, NFHS II 1998-99)
RHS = Rapid Household Survey
NFHS = National Family Health Survey
Pulse Polio Immunization (PPI)
India initiated the pulse polio program in 1995-96. Under this program all children under five
years are to be administered two doses of OPV in the months of December and January
every year until polio is eliminated. Pulse Polio Immunization in India has been a massive
program covering over 12 crores children every year. Coverage of the pulse polio
immunization has been reported to be over 90% in all States. However, it has been a matter
of concern that over the last 5 years, coverage under routine immunization has not improved,
in fact in some states there has been a substantial decline. There are segments of
population who escape both routine immunization and the pulse polio immunization. As a
result of all these, the decline in number of polio cases, though substantial, was not sufficient
to enable the country to achieve zero polio incidences by 2000 as envisaged National Pc.di
Surveillance Program (NPSP) was started in 1997 with DANIDA and USAID assistance and
is working under the management of WHO. Management of NPSP will ultimately transferred
to GOI. The program has helped in the detection of cases, case investigations, and
laboratory diagnosis and mop-up immunization.
Confirmed polio cases reported in the last five years is shown in Table24 Uttar Pradesh and
Bihar account for most of the reported cases. Mop-up immunization is being undertaken
following detection of any wild poliovirus including areas with clusters of polio compatible
cases and in areas of
I i
Continued poliovirus transmission. Special efforts are being made to achieve high
routine and campaign coverage in under-served communities, remind families about
need for routine immunization during the PPI campaigns.
Table 24: Year wise Polio Cases
Number of Polio cases
Year
1998
1999
2000
2001
2002
No of confirmed
poliocases
1931
1126
265
268
1599
Source: Department of FW
The medical goal of polio eradication is to prevent paralytic illness due to polioviruses by
elimination of wild poliovirus the virus so that the countries of the world need not continue to
immunize all children perpetually. If for the next three years there are no more cases of this
disease the country will be declared polio-free. As and when this is achieved the country will
have to take steps to ensure that the disease does not return. The oral polio vaccine
contains the live attenuated virus. Recent experiences in Egypt, Dominican Republic and
Haiti have shown that the vaccine derived viruses can become neurovirulent and
transmissible. Such mutant viruses have caused outbreaks of polio when immunization
coverage drops. It may, therefore, not be possible to discontinue polio immunization.
Several of the countries, which have eliminated polio, have shifted to injectable killed polio
vaccine after elimination of the disease. India along with other developing countries of South
Asia may have to consider all these options and prepare appropriate strategies in time
RCH II objectives and strategies to strengthen immunization program
Objectives
1. Provide 100% coverage with six vaccines (BCG, 3 doses of DPT & OPV and measles
to all children.
2. Eradicate poliomyelitis by 2005.
3. Eliminate neonatal tetanus by 2005
4. Reduce measles deaths by half by 2005
Strategies
• Reach out to every child. Use anganwadi register to identify each child, organize
regular immunization session in each village/urban settlement on a fixed day at subcentre/anganwadi/health post/community action site: involve TBAs, anganwadi
workers, link workers, local NGOs and self help groups to mobilize beneficiaries, make
special efforts to reach out to children of the poorest families, and those residing awa\
from the venue of immunization session.
•
Strengthen delivery system. Consider approaches to deliver vaccine to the ANM at
session sites (saving her time in picking up supplies), refurbish cold chain and
sterilization eguipment wherever needed, provide back up power at vaccine storage
sites, provide improved vaccine carriers, introduce smaller dose vaccine vials (e.g 5
dose vial for BCG) (to curb reluctance in opening a large dose vial to avoid wastage j
Launch a massive national IEC and social mobilization effort
•
Streamline monitoring and evaluation system to provide village level data.
•
I mpl e me nt new strategies in a phased manner.
o Introduce auto-disabling syringes to improve injection safety.
o Expand coverage of Hepatitis B vaccine
o Introduce combination DPT plus hepatitis B vaccine
B. Strategies to strengthen the pulse polio program
Pulse Polio Immunization is under constant monitoring, supervision and strengthening by the
Department with the assistance of WHO.
Research
•
•
•
•
Assess burden of other vaccine preventable diseases (H. influenza, Rubella,
Rotavirus, Penumococcus, Typhoid etc.)
Develop a reliable system of surveillance of vaccine preventable disease
Develop models of care of neonates at PHC and FRU facilities.
Develop approaches to linking community based newborn care with institutional care
and in providing safer referral transport
3.2.2.2 Newborn health
Background
The first four weeks of life are termed as the neonatal period. Neonatal mortality constitutes
two thirds of infant mortality (Table 25). Neonatal mortality has declined significantly in India
since the seventies largely due to maternal tetanus toxoid immunization leading to neat
elimination of neonatal tetanus. Between 1972 and 1992, NMR declined by almost 30P
(Table 25). However, the NMR in recent years has become static hovering around 45 pc
1000 live births. This is a major cause of concern, as improving neonatal survival holds tlv
key to reducing infant and child mortality.
i i
Table: 25 Neonatal mortality rate per 1000 live births.
Year
Rate
Proportion of
infant mortality
rate
1972
1982
1992
72
67
50
51%
64%
63%
1993
1994
1995
1996
1997
1998
47
48
48
47
46
45
63%
65%
65%
65%
65%
63%
At 1.2 million neonatal deaths per annum, India contributes 30% of the global burden
highest for any country. India is a vast country, a sub-continent, and NMR in different states
varies considerably. NMR is lowest in Kerala (just 8), while the highest rates are seen in
Orissa and Madhya Pradesh (over 60). Within the neonatal period, the first week is even
more crucial. Three fourths of all newborn deaths occur during the first week of life (early
neonatal period).
The major causes of neonatal mortality are sepsis (bacterial infections) (52%), birth asphyxia
(20%) and prematurity (15%) and others (13%). Newborn deaths in the first week of life ar
predominantly caused by the birth asphyxia and prematurity, whereas those after the first
week are mostly due to bacterial infections.
Irrespective of the primary causes of deaths, over two thirds of neonatal deaths occur among
infants who are born low birth weight (weighing less that 2500g at birth). In India, over one
third of all neonates are low birth weight (LBW), this rate is among the highest in the world
Only 36% of 26 million annual births in India occur in institutions, the rest three-fourths take
place at homes (NFHS II). The proportion of home births in rural areas is 75% and for tht
poor families 80%. There is a clear relationship between the proportion of non-institutional
deliveries and neonatal mortality rate in different states. Higher the non-institutional honvdelivery rate, higher the neonatal mortality rate. Thus, the challenge of newborn health is
really in the home setting.
I i
There is a wide variation in regard to the proportion of institutional deliveries in different
states. In Kerala, the state with the lowest NMR, institutional delivery rate is a high 93%. In
Tamil Nadu the rate is 79%, while in Rajasthan, Bihar and UP, the institutional delivery rates
are under 25% (NFHS II).
Newborn care has for long been equated with hospital-based, high cost affair requiring
incubators and other expensive equipment. This is not so. The principles of newborn care art
simple and eminently achievable through primary care (Table). Studies show that grassroots
providers can deliver most of these components in a highly cost-effective manner at homes
and at simple facilities. In an elegant community based study conducted in Gadchiroli
District in Maharasthra by an NGO, SEARCH, it was demonstrated that by promoting
preventive and therapeutic interventions (including home treatment of sepsis with oral
cotrimoxazole and intramuscular gentamicin), It was possible to reduce Neonatal Mortality
rate by 62% and infant Mortality rate by 45% over 3 years (Annex 34). The challenge in RCh
II is to translate this knowledge into action across the country.
Basic components of newborn care
• Antenatal care; maternal tetanus toxoid immunization, iron folic acid
• Skilled attendance at births
• Care at birth including basic resuscitation
• Thermal protection
• Prevention of infection
• Exclusive breast milk feeding
• Extra care of low birth weight babies
• Early detection of illness, early care seeking, care of sick babies at homes and at
facilities
• Care during transport
Maternal health has a profound bearing on the health and survival of the fetus and the
newborn. Maternal under nutrition, young age, infections, anemia, pre-eclampsia, and
hypertension are associated with low birth weight. Complications of labor and delivery not
only cause maternal morbidity, but also lead to fetal distress/demise, birth asphyxia and
neonatal mortality.
Essential newborn care (ENC) became a part of the Child Survival strategy in the Chile'
Survival and Safe Motherhood program and continued into the RCH program. The focus ha:
been strengthening of facilities, provision of equipment and training of physicians. In RCH I.
operationalization of newborn care was accomplished in 60 districts by 2001-02. Additional
20 districts are being covered in 2003. In 142 districts of 17 states with safe delivery rates ol
less than 30%, a TBA training program was initiated in 2001.
Newborn health interventions in RCH I were primarily facility -focused. There is an urgent
need to orient the program to the care of the newborn infants at homes where most neonates
take birth, fall sick and die.
I i
RCH II objective and approaches for reducing newborn deaths
Objective
•
Achieve neonatal mortality rate of 26 per 1000 live births by 2007 and 20 by 2009
Strategies
•
Introduce a package of home-based newborn care. Aim at improving family practices with
the involvement of the mother, TBA , mother in law, and other members of the household
Ensure home visiting of neonates by AWWs / link volunteers supported by ANMs (two
visits by AWW/ link volunteer for all neonates on days 1 and 7; additional 5 visits on days
2,3,14,21 and 28 for LBW neonates). Provide care at birth for deliveries at home; achieve
100% weighing of neonates within 24 hours. Ensure warmth, asepsis, exclusive breast
feeding; provide extra care to low birth weight babies including Kangaroo mother care anc
assisted feeding; promote early care seeking, treat common illnesses; administer
oral/intramuscular antibiotics for sepsis, if feasible. Facilitate prompt and safe referral for
conditions that cannot be managed at home. (A total of 400 districts will be covered by the
based newborn care package by the year 2009).
•
Improve care seeking and referral of sick neonates who cannot be managed at home.
Educate families, facilitate transport, and make referral funds available with AWWs &
ANMs.
Ensure that home deliveries are safe and clean. Train traditional birth attendants, educate
families, promote birth preparedness, and universalize clean delivery kit.
•
Mobilize families for institutional deliveries in government/private facilities. Launch a
sustained social mobilization effort with the help of panchayati raj institutions, opinion
leaders, NGOs, self help groups and other stakeholders; compensate TBA, AWW. link
volunteer, ANM etc. for bringing pregnant women for delivery at institutions.
•
Operationalize facilities for newborn care. Strengthen newborn care infrastructure and
facilities at PHCs, CHCs, FRUs and district hospitals, establish new born care corners,
provide training in newborn care to nurses and doctors in government and private sector,
ensure a sustained quality assurance system.
•
Upgrade neonatal services and education infrastructure/expertise in medical and nursing
teaching institutions, and ANM training schools, introduce competency-based newborn
health curricula.
•
Ensure 100% birth registration. Provide suitable incentive to TBAs/others for facilitating
this process.
11
Differential approach on prioritizing newborn health strategies
Among newborn health interventions, there are some that are relatively easy to implement
than others. Drying and wrapping the neonates at birth can be implemented more readily
than resuscitation with bag and mask, and kangaroo mother care is more doable than
incubator-based care; cotrimoxazole or amoxicillin treatment is easier than treating with
gentamicin injections. Promotion of clean delivery kits and exclusive breast-feeding would
take priority over creating newborn units in resource-constrained circumstances If a health
system cannot achieve sufficiently high levels of maternal TT coverage and reduce neonatal
tetanus drastically, it is unlikely that it can operationlize PHCs effectively for newborn care.
Capacity of the health system is thus an important determinant of the effectiveness of th*;
program.
In view of the do ability of the newborn health interventions and the health system capacity, it
is proposed that a scenario-based approach may be taken in prioritizing newborn health
strategies. States with high neonatal mortality rate (NMR), of say over 50 per 1000 births, are
likely to have most deliveries at homes, often by TBAs and would have a high post -neonatal
mortality due to poor coverage of the simple child survival interventions. These states must
first educate TBAs for provided rational care at birth, eliminate tetanus neonatorum, an<:
promote clean deliveries, exclusive breastfeeding and birth spacing. In states with NMR c i
25-50 per 1000 live births, the emphasis should be on home-based newborn care with th
help of TBAs, AWWs and link workers. As the NMR declines, institutional care of newbor
infants will become increasingly critical for achieving further improvement in newborn
survival. In states where NMR is under 25 per 1000 live births, institutional care supported bv
home-based care will be the answer.
Thus, newborn health action in EAG states like UP or Rajasthan with predominantly home
deliveries may be in the community settings, while the major thrust of newborn health
strategies in a state like Tamil Nadu, where institutional delivery rates have picked up, would
be strengthening facilities for newborn care. The above-stratified approach based on two
factors, namely, the newborn health status and the health system scenarios may be applied
in different states in consultation with experts and program managers in RCH II.
Research
•
Develop models of primary care newborn service delivery in rural and periurban settings
•
Assess role of micronutrient supplementation in reducing morbidity and mortality among
LBW neonates.
Other
•
Introduce quality control measures to ensure manufacture and marketing of neonatal
equipment of high standards and quality; implement measures to improve after-sales
service of neonatal care equipment at facilities located in diverse settings
I i
3.2.2.3 Diarrrheal Disease
Background
Diarrhea is one of the leading causes of death among children. NFHS II showed that as
many as 19% children under the age of three suffered from diarrhea in the preceding two
weeks. Most of these deaths are due to dehydration caused due to frequent passage of
stools and are preventable by timely and adequate replacement of fluids. Persistent diarrhea
contributes to malnutrition, which further enhances the risk of morbidity and mortality.
Dysentery is an acute from of diarrheal disease due to invasive bacteria that leads not only lc
dehydration, but also multi-system manifestations, which can prove fetal. Dysentery occurs
in 14% children who suffer diarrhea (NFHS II). The Oral Rehydration Therapy (ORT)
program was started in 1986-87. The main objective of the program is to prevent death due
to dehydration caused by diarrheal diseases among children under 5 years of age due to
dehydration. Health education aimed at rapid recognition and appropriate management of
diarrhea has been a major component of the CSSM program. Use of home available fluids
and ORS has resulted in a substantial decline in the mortality associated with diarrhoea from
estimated 10-15 lakh children every year prior to 1985 to 6-7 lakhs death in 1996. In order to
further improve access to ORS packets are provided at sub-center as part of the drug kit-A
under the RCH program. In addition, social marketing and supply of ORS through the public
distribution system are being taken up in some states. Data from NFHS II & RHS regarding
ORS coverage is shown in Table 26. The usage of ORS was very low among children wh<
had diarrhea (RHS 11.2%, NFHS II 26.8%), even though 62% of mothers had knowledge? of
ORS (NFHS II).
Table:26 ORS usage (RHS 1998-99)
SI.N
o.
I.
1
2
3
4
5
6
7
8
9
10
11
12
13
ORS use
State/UT
INDIA
MAJOR STATES
Andhra Pradesh
Assam_________
Bihar
Gujarat
Haryana
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Orissa______
Punjab
___
Rajasthan
__
Tamil Nadu
RHS
NFHS
@
$
11.2
26.8
25.2
17.1
8.6
13.8
4.8
15.0
24.3
7.9
10.4
24.8
2.4
4.7
16.6
39.6
37.1
15.4
28.9
25.7
34.3
47.9
29.8
33.2
35.1
42.3
20.3
27.9
I i
14
15
II
1
Uttar Pradesh___
West Bengal
| SMALLER STATES
Arunachal
Pradesh
Chattisgarh
Delhi
Goa
_ __
Himachal Pradesh
Jharkhand
2
3
4
5
6
7
8
9
10
11
12
13
14
J&K 2
Z
Manipur
____
Meghalaya
Mizoram
__
Nagaland_______
Sikkim
i Tripura
___
Uttaranchal
III
1
2
23.5
15.8
40.5
13.7
40.2
NA
NA
13.8
17.2
NA
12.0
13.6
10.4
23.5
30.9
40.3
14.1
NA
NA
39.1
55.6
45.6
NA
47.5
50.7
22.4
44.7
29.7
27.0
NA
NA
4.9
UNION TERRITORIES
NA
A&NIslands
29.8
35.7
NA
Chandigarh
NA
’7.9
D&N Haveli
NA
Daman & Diu
17.3
NA
3.1
Lakshadweep
NA
18.9
Pondicherry
_____________ _ _______________________
I 3
4
5
6
@ Percentage of mothers whose children got ORS packets as treatment of diarrhea
$ Percentage of children who suffered diarrhea and got ORS packets as treatment.
RHS = Rapid Household Survey
NFHS = National Family Health Survey
Source: NFHS 1998-99
RCH II objectives and approach to reduce diarrheal deaths
Objectives
• Reduce deaths of children due to diarrhea by half by 2007
• Enhance ORS usage in diarrheal disease to 60%.
• Introduce the more effective low osmolality ORS
Strategies
•
Generate increased demand for treatment of diarrhea and promote healthy home
practices. Educate families and communities in the use of home fluids, continuing
breast feeding and solid feeds in diarrhea, for early introduction of ORS to prevent
dehydration, and to seek early care; launch nation-wide behavior change effort.
11
•
Make ORS readily/freely available. Make ORS packets available with all primary care
providers (AWWs, ANMs, male workers, link workers, teachers etc.) and at all
anganwadis, sub centers and facilities (PHCs, FRUs, CHCs, Hospital); use alternative
approaches for making ORS readily available (public distribution system, social
marketing).
•
Widen the net of providers who can treat diarrhea. Train AWWs, male workers, ink
workers and village practitioners apart from doctors, ANMs LHVs and nurses to
diarrhea with ORS, and to advise early referral of children who cannot be managed in
the community. Train private practitioners of modern and ISM systems in rational
treatment of diarrhea.
•
Facilitate transport of cases of diarrhea requiring referral. Undertake facility mapping,
use referral transport funds, build community support mechanisms.
•
Strengthen facilities (PHCs, CHCs, FRU, district hospitals for treatment of referred
cases ofdiarrhea. Ensure prompt emergency care and admission; ensure supply of
intravenous fluids, ORS, antibiotics, vitamin A etc.
•
Introduce the more effective low osmolality ORS.
•
Contribute to intersectoral action to improve clean drinking water supply and
sanitation.
Operational research
•
Undertake surveillance of dysentery-causing bacteria and their antimicrobial
sensitivity.
3.2.2.4 Acute Respiratory Infections (ARI)
Background
Acute respiratory infections in children can involve the upper respiratory tract (nose, throat;
the lower respiratory tract (bronchi, lung). The lower respiratory tract infectious (broadly
termed as preumonias’) is a major cause of deaths of infants and children in India accounting
for about 30% under-five deaths. The disease is extremely common. In NFHS II, 19%
children under the age of 3 years experienced cough accompanied by fast breathing
(indicating lower respiratory tract infection) during two weeks preceding the survey. Timely
treatment based on well-researched algorithms can save most children with ARI. Majority of
cases of ARI have non-severe disease, and can be managed in the community with oral cotrimoxazole. Severe ARI cases require urgent referral to a facility for injectable antibiotic
therapy and supportive care.
IJ
The ARI control program was initiated as a pilot project in 14 districts in the country in 1990.
Ten more districts were added in 1991. Since 1992, the ARI control strategy become part of
CSSM program, which continued into the RCH, I program in 1997. Co-trimoxazole tablets
are being provided at sub-centres and above. ANMs are being trained to treat children with
ARI. The Rapid Household Survey (1998-99) showed that utilization of government facilities
for children with ARI was very low (13%). On the contrary, NFHS II reported that the
proportion of children with ARI taken to facility or provider was a high 64%. There is no
reliable data on the progress of ARI control program in RCH I. Since the training of
ANMs in ARI treatment skills (as a part of integrated skills training) is only around 30% till
date; one would assume that coverage of ARI control program is likely to be far from
satisfactory.
RCH II Objectives and strategies to reduce ARI deaths
Objectives
Reduce deaths of children due to ARI by one third by 2007
Strategies
• Educate families in early care seeking for ARI. Launch a well-sustained countrywide
behavior change communication campaign.
•
Widen the net of providers who can treat ARI. Train the following grass roots
providers in treating ARI: ANMs, AWWs, male workers, link workers and village
practitioners; grant permission to these cadres to prescribe co-trimoxazole wherever
required; train government doctors and private practioners (modern / ISM) in rational
treatment of ARI.
•
Promote referral of cases of severe pneumonia. Undertake facility mapping, use
referral transport funds, build community support mechanisms.
•
Strengthen facilities (PHCs, CHCs, FRU and district hospitals) for treating children with
severe ARI Ensure prompt emergency care and admission; ensure supply of
antibiotics, other drugs and oxygen.
Operational research
•
Provide surveillance and antimicrobial sensitivity of ARI causing bacteria
3.2.2.5 Breastfeeding and complementary feeding
Background
Exclusive breastfeeding is a well-recognized infant and child survival intervention. Breast fed
infants have better nutritional status and lower rates of morbidity and mortality. Breast milk
not only provides essential nutrients for the first six months of life, but also protects the child
against infections.
I j
WHO recommends exclusive breast-feeding for the first 6 months of life. Successful
breastfeeding requires initiation of breastfeeding soon after birth and avoidance of prelacteals, supplementary water or top milk. The Baby Friendly Hospital Initiative of UNICEF
and the Government, launched since 1992, aims at promoting successful breastfeeding in th(
facilities where deliveries take place. Promotion of breastfeeding in the community is not
being adequately addressed. According to NFHS II, the proportion of exclusively breast fed
infants at 4 months of age was only 37% and that at 6 months was around 19%. The delay n i
initiation of breastfeeding is almost a rule. Only 16% mothers initiate breastfeeding within the
desired one-hour after birth, and only 37% do so by the end of the first day. As many as 63°/<
women do not feed the first milk (colostrum).
From 6 months of age, the introduction of complementary food is necessary to meet the
nutritional needs of infants. However, in a majority of children starting of complementary food
is delayed and, if introduced, is often insufficient in nutrients. Only 46% infants receive solid
food at 9 months of age (NFHS II).
The nutritional status of children in India is a cause of a serious concern. According to NFHS
II, 47.0% children under 3 years of age were below -2 SD by weight for age (malnourished •
and 45.5% were below SD by height for age (stunted). Over one third infants are born low
birth weights (<2.5 Kg). Poor nutritional status is a potent risk factor of neonatal, infant and
child mortality.
Promotion of exclusive breastfeeding and introduction of appropriate complementary feeding
will go a long way in improving the nutritional status of our children
RCH II Objectives and strategies to promote breastfeeding and complementary feeding
Objectives
• Achieve exclusive breastfeeding rates of >75% at 4 months and >50% at 6 months by
2007
• Achieve complementary feeding rate of >75% at 9 months of age by 2007
Strategies
•
Implement a nation-wide behavior change effort: involve all grassroots workers TBA<
AWWs, ANMs, village practitioners, male workers, link volunteers etc.; involve
panchayats, self help groups, agents of change, opinion leaders, NGOs: employ mass
media; use all health-related contacts to promote improved feeding; give specific and
uniform message (viz. 1 exclusive breast feeding for 6 months’)
•
Augment AWW’s contacts with mothers. Home visiting by AWWs in the antenatal,
neonatal and infancy periods.
•
Strengthen breastfeeding promotion efforts at facilities. Promote ten steps of
successful breastfeeding at all facilities, including PHOs, CHCs, FRUs and district
hospitals.
•
Improve lactation skills of providers. Train TBAs, AWWs, ANMs, LHVs, male workers,
link workers, as well as physicians (government, private; general, specialist; modern
ISM) and nurses in lactation and feeding counseling techniques.
•
Implement the IMS (Infant Milk Substitutes, Feeding Bottles and Infant Food
regulation, supply and distribution) Act more effectively.
•
Promote appropriate and adequate complementary feeding. Strengthen AWW s role,
use all health related contacts to counsel regarding solid foods: emphasize portion
size and calorie density; promote culturally acceptable, low cost, balanced, locally
available infant foods (prepare local lists for counseling).
3.2.2. 6 Vitamin A, Iron and Folic acid Supplementation program
Objectives
• Achieve sustainable elimination of vitamin A deficiently by 2010.
• Reduce by one-third the prevalence of anemia including iron deficiencies by 2010.
Strategies
Working closely with the ICDS functionaries:
•
•
Ensure regular Vitamin A, Iron -Folic and supplementation of all children through the
Anganwadis.
Provide syrup formulation of iron and folic-acid
(An action plan to strengthen this component should be developed through close interaction
with DWCD).
3.2.2.7 Integrated Management of Childhood Illness (IMCI)
IMCI is an approach to a comprehensive and structured management of diarrhea, ARi
malaria, young infant illness and feeding problems developed by WHO/UNICEF. The generic
IMCI guidelines and training modules have recently been adapted for the country. The Indian
version, termed as Integrated Management of Neonatal and Childhood Illness (IMNCI), is
specially oriented to newborn care to order to address the high priority given to neonatal
health in the country. A module for the basic health workers (ANMs, AWWs) has also been
developed which, incorporates home visiting of the neonates. A pilot introduction of IMNCI
has been initiated in the Border District Cluster Services (BDCS) of the UNICEF in 6 districts.
The health system and community components of IMNCI need to be developed urgently s.
ensure that providers’ training is utilized optimally to save lives. There is also a need lor pilei
experiences in settings other than the BDCS system for gaining more insights for sustainable
implementation of the strategy. IMNCI can be introduced in RCH II in a phased manner onethe pilot experiences are available.
The program summary for Newborn and Child Health components at different levels of
Health System is provided at Annex 4a.
3.3 Adolescent Health
3.3.1. Introduction
Adolescents (age 10-19) constitute over 23% of the population in India, numbering 23 crores
Adolescence is a phase of rapid physical growth, psychosocial development and sexual
transformation. Adolescents are not a homogenous entity but, depending upon the region
culture, socio-political and economic background, have diverse educational, career, social
behavioral, developmental and health needs. A large number of adolescents lack formal or
informal education. School dropout rate amongst boys is 54.4% and girls 60 %. Many ot
them work in unsupervised and unsafe conditions.
Data from NFHS-2 indicate that median age at marriage of girls in India is 16 years. Early
marriage has profound consequences on demographic dynamics. The age specific fertility
rate age 15-19 is 107 per 1000). Habits and behaviors picked up during adolescence have;
life-long impact. Risk taking habits, substance abuse, food fads, rebellious attitude, cynicism
often have roots in adolescence experiences. Sexual relations in adolescents occur before
they acquire skills in self-protection. Several studies indicate that sexual activity in Indian
adolescents starts at a relatively early age. Only 59% of adolescents know about condoms
and 49% know about oral contraception. Contraception use amongst married adolescents of
age 15-19 years is only 7%. Young people between the ages of 10-25 years make up 50%
of all new HIV infections.
Many adolescents suffer from malnutrition and anemia. About 59% boys and 37% girls au
stunted (NNB 2000). Anemia among adolescents is very common (56% Baroda study) Mam
may not have received tetanus immunization. Adolescent age is the “last- opportunity to
correct the growth lag and prepare Studies show that pregnancy in the early teens before 16
years is associated with an adverse effect on maternal nutrition, birth weight and survival of
the offspring. The extra nutritional requirements of pregnancy coming close after the
adolescent growth spurt contribute to the poor nutritional status of girls who conceive as
teenagers enhancing the risk of fetal growth restriction and low birth weight. Anemia during
adolescence can only get worse during an ensuing pregnancy, again contributing to fetal
growth restriction and predisposition to maternal morbidity and mortality. Thus, ill health
during adolescence has profound implications for maternal, perinatal, neonatal and infant
mortality.
A large number of adolescents in India are out of school, get married early, work in
vulnerable situations, are sexually active, unemployed, and are exposed to peer pressure for
initiating tobacco or alcohol use. These factors have serious social, economic and public
health implications. Adolescent pregnancy, excess risk of maternal and infant mortality,
1 j
sexually transmitted infections and reproductive tract infections in adolescence, rapidly rising
incidence of HIV in the 15-24 year age group, high rates of addiction for tobacco and
substances are some of the health challenges. The National Population Policy 2000 called for
developing an adolescent health package for adolescents.
The key domains of an adolescent health package are documented the following panel
Panel: Key domains of adolescent health and thej^espective health implications
Health implications
Domains
1. Growth and Development
• Smooth transition to adulthood
• Body and mind changes of
adolescence
• Understanding body and mind
changes of adolescence
• Preventing psychological stresses
and complexes
• Menstrual/sexual hygiene
• Graining self esteem and self
confidence
2. Nutrition
• Prevention of anemia
• Macro- and micronutrient needs
• Attaining optimum growth potential
3. Reproductive & Sexual Health
• Healthy sexual attitudes
• Nominative sexuality
• Postponing early sexual debut
• Contraception
• Avoiding early unwanted pregnancy
• Pregnancy
• Preventing unsafe abortion
• RTIs/STIs
• Preventing and treating RTIs/STIs
• HIV
• Preventing HIV infection
4. Marriage and parenthood
• Marriage
• Pregnancy and child birth
• Parenthood (child care)
•
•
•
•
•
•
•
5. Life skill education
• Self help, negotiation and decision
making skills
• Coping with stress
• Avoiding tobacco, alcohol, and
substance abuse
•
•
•
•
Marriage at appropriate age
Marital harmony
Pregnancy at appropriate age
Antenatal care including checks,
tetanus immunization and IFA
Skilled attendance at delivery
Post-partum care
Child health and development
More responsible attitudes, better
social adjustment
Preventing addictions
Better fitness
Preventing adult diseases
11
•
•
Physical activity
Healthy diet
•
Better coping behavior
Adolescents avoid visiting public health facilities. Therefore, on the one hand, we need to
reach out to them in their communities, and, on the other, orient the health system to the felt
and unmet needs of the adolescents. The widely prevalent anemia and malnutrition,
substantial number of adolescent pregnancies; and the looming threat of HIV/HIDS on one
side, and the requirements due to unfinished adolescent development and growth on the
other, have to be kept in view while devising effective interventions for adolescents. Services
for adolescents cannot be provided on the basis of ‘one size fits all'. The health needs of a
10-years-old boy who is at the threshold of puberty are very different from an 18-years-old girl
who has just got married. In addition, adolescents, for a variety of reasons, present
themselves to the health workers with complaints that may have little to do with their real,
underlying concerns or problems. Many such concerns are related to growth, development,
bodily concerns; or stress due to studies, career or relationships. The health services in their
present form are designed for curative purposes and the adolescent’s needs for information,
counseling and specified services (contraceptive, IFA, etc)) are not built in. The adolescents
perceive many barriers and road blocks in seeking care and counseling from the health
system. These factors make it imperative for the health system to be adolescent friendly.
Innovative experiences in the NGO settings have demonstrated how comprehensive
adolescent health needs can be effectively addressed through interdisciplinary teams.
It is important to note that the scope of adolescent development is very broad. The
health component should be viewed as just one critical component of a holistic
national effort to nurture the youth of India. The Ministry of Youth Affairs and Spots is
the nodal Ministry for Adolescents. In addition, Departments of Education, Women
and Child Development, Rural Development and the state governments have important
roles to play in this endeavor.
The RCH program will aim at addressing the prime health needs of the adolescents with a
focus on interventions that can be delivered through the health system, both government and
the private, in synergy with other health initiatives, in particular, the National AIDS Control
Organization.
3.3.2. Overall goal and objective
Goal
To achieve optimum health and development of the adolescent segment of the population, in
a phased manner.
11
Objective for RCH II
Introduce a comprehensive Adolescent Health Initiative (AHI) in selected districts.
3.3.3. Adolescent Health Initiative (AHI)
3.3.3.1 The AHI framework
The AHI will consist of two components:
1 Adolescent friendly health services
2. Adolescent health counseling services
3.3.3.2 Coverage
The AHI package will be implemented in 75 (about 12% districts) districts in the country in the
RCH II program during 2003-08. These districts will be those where IMR has declined to less
than 60 per 1000 live births. The districts will predominantly be in the non-EAG states where
more urgent maternal health and child survival priorities have already been tackled to a
significant extent. The tentative phasing of the program will be as follows:
Preparatory phase:
2003-04
•
•
•
•
Preparation of action plan
Development of behavior change
communication strategy
Development and pilot testing of
training and counseling modules
Capacity development
Implementation
phase:
2004-05
5 districts
2005-06
10 districts
2006-07
20 districts
20007-08
40 districts
3.3.3.3 Operationalizing Adolescent Health Initiative in a district
The AHI at the district level will be implemented by the District RCH/FW Society through a
District Partnership for Adolescent Health (DPAH) consisting of representatives of: Health
department, Education department, Welfare department, ICDS, NGOs PRIs, National
Service Volunteers, Nehru Yuva Kendra Sangathan, National Reconstruction Corps
volunteers, other youth organizations, local chapters of Indian Academy of Pediatrics &
FOGSI and other stakeholder groups. The DPAH may constitute tehsil/block level
partnerships for imparting the initiative.
11
3.3.4 Adolescent Health Initiative / Component I: Adolescent friendly health services
in selected districts
Under the AHI, adolescent friendly health services will be provided at PHCs, CHCs, FRUs
and district hospitals in the selected districts. Adolescent Health Clinics will be conducted al
least once every week at these facilities to provide following services:
Clinical services
- General examination
Nutrition advice
Detection and treatment of anemia
- Easy and confidential access to medical termination of pregnancy
- Antenatal care and advice regarding child birth
RTIs/STIs detection and treatment
HIV detection and counseling
- Treatment of psychosomatic problems
De-addiction
- Other health concerns
•
Counseling services
- As per the behavior change domains referred to above
The format of the Adolescent Health Clinics will be as shown in the following pane.
Facility
Adolescent Health Clinic:
Frequency and Providers
PHC
At least once a week; run by
MO, LHV
Partners for
running the
Clinics
NGOs, members
of FOGSI / IAP
CHC, FRU,
District
Hospital
At least once a week, run by
MO/ Obstetrician/ Pediatrician
(or
by
designated
private
practitioner/s who could be
given suitable honorarium)
3.3.5 Adolescent Health Initiative / Component II: Adolescent Health Counseling
Services
i1
a) Contents of communication package for target adolescents
Contents of the communication package stratified into age groups 10-14 years and 15-19
year are shown in the following Table:
Table: Contents of the communication package for the two sub-groups of
adolescents
Age
10-14 years
Age
15-19 years
Reinforce contents for age 10
14 years, plus:
• Legal rights
•
•
•
•
Understanding and coping up with
changes during puberty: physical,
emotional, sexual
Anatomy/physiology of
reproductive system, menstrual
system, conception, pregnancy
and child birth
Menstrual/sexual hygiene
Gender issues, roles and rights
Balanced food
Iron/folic acid supplementation
•
Healthy sexual attitudes
•
•
•
Self help skills
Healthy and positive habits
Dangers of
tobacco/alcohol/substance abuse
Healthy diet
Exercise
Reinforce contents for 10-14
years, plus:
• Contraception
• Abstinence
• Problems of adolescent
pregnancy
• Risks of RTIs/STIs
• Preventing HIV infection
• Safe abortion
• Appropriate age for child
birth, birth spacing
• Care during pregnancy,
birth preparedness, skilled
attendance at birth, post
partum care
• Newborn and child care
(including breast feeding,
immunization,
complementary feeding,
early stimulation, sickness)
Enforce content for 10-14
years, plus:
• Negotiating skills
• Stress handling skills
Domain
1. Growth and
Development
•
•
2. Nutrition
3. Reproductive
and Sexual
Health
4. Marriage and
Parenthood
5. Life Skill
Education
•
•
Reinforce contents for 10-14
years
Ii
Outline for Adolescent Health Counseling services in a districts shown in the following panel
Target group
Strategy
Channel/provider*
Group
counseling
sessions
AWW, NGO’s
SHGs block
extension officer,
male health worker,
self help groups,
National Service
Volunteers,
National
Reconstruction
Corp volunteers
(Identify
coordinator)
Tools /training
required
Operational
target
Training
module/s for
all categories
of counselors
IEC/IPC
materials
At least one
session
each for
boys and
girls every
1-2 months
in each
village
IEC/IPC
materials
First contact
within one
month of
marriage,
then once
every 6
months
RURAL
ADOLESCENTS
1.1 Unmarried
Out of school
1.2 Married
Individual
/couple
counseling
sessions
2.URBAN
ADOLESCENTS
2.1 Unmarried
Out of school
Group
counseling
session
Help line
ANM, AWW, block
extension officer,
NGOs, male health
worker, link worker
(Coordinator
ANM/AWW)
NGO’s,volunteer
physicians (IAP,
FOGSI, members),
local bodies
members, self help
groups, National
Service Volunteers,
National
Reconstruction
Corp volunteers
(Identify
coordinator)
NGOs, AWWs,
•
•
IEC/IPC
materials
♦ At least one
session each
for boys and
girls every 1-2
months
2.2 Married
Individual,
couple
counseling
and group
counseling
sessions
Help line
volunteer
physicians (IAP,
FOGSI, members),
IPP-* workers, local
bodies members,
self help groups,
National Service
Volunteers,
National
Reconstruction
Corp volunteers,
link/outreach
workers
(Identify
coordinator)
IEC/IPC
materials
At least one
contact
within one
month of
marriage,
then once
every 6
months
kNB: Training modules on counseling for all categories of providers and counselors
will need to be developed.
The RCH functionaries will focus primarily on out of school married/unmarried adolescent,
districts with adolescent health programs, social marketing of sanitary napkins should be
promoted.
Evaluation / operational research
Adolescent health is a new component of RCH program. In order to convert this initiative
into a sustainable activity, it will be important to carefully monitor and evaluate its
implementation. The lessons learnt should be ploughed back into the ongoing and future
phases of the program. It is also important that operational research studies are built into
the program to develop new strategies, as adolescent health emerges as an increasingly
important priority for India in coming years.
3.4 Population Stabilization and Social Marketing
3.4.1. Policy Evolution
In 1951, India became the first country in the world to launch a family planning programme to
check population growth. Since then, the population programme in India has undergone variety
of forms. The passive, clinic-based approach of the 1950s, gave way to a more proactive,
extension approach in the early 1960s. The late 1960s saw the emergence of a "time-bound'
"target-oriented" approach with a massive effort to promote the use of IUDs and condoms. Thr
was followed by even more forceful "camp approach" to promote male sterilization in the 1970s
The excesses of these campaigns lead to a severe backlash from which it took years for thr
-
i I
programme to recover. The 1980s saw the rebuilding of the programme with an emphasis on
female sterilization, and maternal and child health. In the 1990s the ICPD, Cairo prompted
paradigm shift in the Indian programme, with the advocacy of a client-centred, quality-oriented
reproductive health approach. The method-specific targets were lifted, and the programme
professed addressing the unmet needs of clients. The National Population Policy of 2000 while
legitimising the new approach also set 2010 as the target date to achieve replacement-leve!
fertility.
3.4.2. Achievements
Although India's success in fertility reduction is not comparable to that of some other Atcountries, its achievements are by no means modest. The total fertility rate (TFR), which used
be over 6 births per woman at the beginning of 1960s, has declined to 3.2 in 1998. as per the
data from the Sample Registration System. Thus essentially, India has crossed two-thirds of thway towards its goal of replacement-level fertility of 2.1. Several states in the south, with
populations as large as some other Asian countries, have either already reached replacement
fertility or about to reach it in a few years (Table 27). The percentage of married women using
contraception has increased from a level just over 10 percent in the early 1970s to 44 percent n
1998-99, as per the data from the second National Family Health Survey (NFHS-2). For the firstime in recent decades, the 2001 census has registered a fall in the growth rate of populatio
below two percent, indicating that the decline in the birth rate has begun to overtake the deci
in the death rate.
3.4.3. Regional Contrasts
However, striking regional differences make the Indian progress seem less spectacular. The
five Empowered Action Group states of Bihar, Madhya Pradesh, Orissa, Rajasthan and Utta
Pradesh (together with the three new states formed in this region, Jharkhand. Chattisgarh anUttaranchal) had a combined TFR of 4.2 around 2000. For this region as whole it would take,
another 26 years to reach replacement fertility under the current rate of decline (Table 28'
Thus, without acceleration of fertility decline in EAG states, India cannot hope to achieve
replacement fertility by 2010. Assuming the prevalence of below-replacement fertility in som
southern states, at best, India could hope to achieve a TFR of 2.6 by this date.
What are the hopes for a faster reduction in fertility in the EAG states? Table 29 shows the
position of EAG states with respect to some important determinants of fertility around 2000
average changes in the determinants during the last 10 years, and the number of years it ma .
lake the region as whole to reach the levels required to attain a TER of 2.1. The current levels ol
the indicators in some southern states that have achieved, or close to achieve the mark have
been taken as the required levels to reach replacement-level fertility. As Table 6 shows, under
the current trends, it would take the EAG states at least 25 years for the use of contraception,
female age at marriage, unmet need for contraception, ideal family size and regular exposure to
mass media to reach their respective levels required to attain replacement-level fertility. Onb.
trends in infant mortality and female literacy suggest that they would be reaching the require .'
levels earlier. But an important caveat with respect to their trends must be noted. Although the
average decline in IMR during the last 10-years has been quite rapid, there has been substant ;■
u
deceleration in the decline in recent years, and further decline could be more difficult than oui
linear projection suggests. With respect to female literacy, the 2001 census has recorded a
substantial increase probably because of adult literacy campaigns. It is doubtful whether an
increase in literacy by such means would have the same effect on fertility as through formal
channels. Thus the prospects for India achieving replacement fertility by 2010 seem bleak.
3.4.4. Unmet Need for Contraception
The NPP document and the recent report of the steering committee on family welfare for the
tenth five year plan lays great stress on meeting the unmet need for contraception as an
instrument to achieve population stabilization. The presence of high level of unmet need foi
contraception in EAG states is not a myth, as it is supported by both NFHS-1 and NFHS-2 data
(Figure 1). The district RCH surveys have also confirmed this fact. But it could be a mistake t
assume that inadequate access to services should be the dominant, or even a major,
explanatory factor for its presence. As a carefully conducted in depth investigation in thcPhilippines had shown, unmet need for contraception could arise from several reasons, such as
weak motivation, low female autonomy, perceived health risks, and moral objection to the use ol
contraception. The elimination of these factors, and thus the unmet need, could be as difficult as
generating fresh demand for contraception. The estimated number of couples with unmet need
for contraception is provided in Table. It needs to be noted that since the eligible coupk
population would have gone up by about 10% during the period 1998-2003, and the unmet
need may have gone down by 10% during the same period the number of Eligible couples wit!
unmet need for 1998 can be taken to be roughly the same for 2003.
3.4.5. The Role of Mass Media
An instrument that has become increasingly important these days is the use of mass media in
promotion of small family norm and providing information on reproductive and child health
services. The rapidly increasing exposure to electronic media has made this an important
channel of behavioural change communication. The analyses of NFHS data have shown that
the exposure to mass media, and family planning messages through these sources have strong
independent effects on the current use of contraception, and future intention to use among non
users. It is used to be contended that interpersonal communication is a more effective agent ol
behavioural change than the mass media. But recent research shows that messages though
media stimulate discussion between husband and wife, among friends and neighbours and with
health workers.
Thus mass media and inter-personal channels should be seen as
complementary rather than substitutes in the process of developmental communication.
3.4.6. Diffusion Through Satisfied Users
It has become increasingly clear that fertility decline in India is the result of horizontal and
vertical diffusion of a new reproductive idea and information about various methods ol
contraception. Strong spatial patterns in fertility decline, and systematic changes in fertility
differentials by socio-economic status, support the innovation-diffusion hypothesis. The satisfied
adopters of the method play a key role in this ideational change. By recruiting such couples for
working in liaison with grassroots health workers, it may be possible to increase the rate?
diffusion.
3.4.7. Expanding the Basket of Contraceptive Choice
Female sterilization has been the mainstay of Indian family planning programme. The users ol
reversible methods form less than 15 percent of the users of all methods. A high level of infanl
and child mortality, and strong preference for sons in EAG states, deter women from accepting
a terminal method of contraception early. The data from the NFHS show that about half of the
unmet need for contraception is for spacing. The Hindu-Muslim difference in fertility and use <
contraception has become major political issue in India. Partly the difference stems from th
religious objections for the use of sterilization among Muslims. Under these circumstances
there is an urgent need to expand the basket of reversible methods of contraception offeree
under the programme. Research indicates that addition of a method to the basket of choices
has an independent effect on the overall use. Injectibles and implants, which are not currently
offered under the programme, must be introduced as early as possible by taking necessary safe
guards. Female condoms would also be a welcome addition to the programme
3.4.8. Increasing Male involvement
Male methods account for only 6 percent of current contraceptive use. Vasectomy, which usee
to be a popular method, went out of favour after the excesses committed in the 1970s
Vasectomy is safer and easier to perform in primary health centres than tubectomy. In recent
years, the introduction of no scalpel vasectomy (NSV) has shown some signs of success in
some states. Vigorous efforts should be made to promote this method, and train more doctors in
performing this task. As males are the main decision makers in Indian households. IEC
activities also need to focus on men for imparting knowledge on reproductive heath of both men
and women and about the advantages of small family.
3.4.9. Social Marketing
In spite of longstanding social marketing programme for condoms and oral pills, the use of these
methods has not picked up. The growing epidemic of HIV/AIDS provides an opportunity to
promote the use of condoms. Experience of neighbouring countries suggests substantial
potential for greater use of pills by younger couples, if supported by counselling and IEC
activities. The social marketing programme has suffered from (i) strong urban bias in the
distribution network; (ii) low incentive to commercial participants; (iii) limited product range and
(iv) simultaneous presence of wasteful, free distribution system. Schemes are proposed under
RCH II for the strengthening of social marketing of contraceptives, especially in rural areas.
3.4.10. Involvement of Private Sector
There is an urgent need to increase the involvement of private sector in the delivery of familv
planning services, especially in areas where the pubic sector is weak This includes inner-( I
slum areas and large parts of EAG states. It is estimated that private medical practitioner'
1 i
provide more than two-thirds of all health care in India. In rural areas, they are more respected
and accessible than government grassroots heath workers. As experience of Janani in Bihai
has shown, rural heath practitioners could be recruited for social marketing of non-clmica.
methods and for referring clinical methods to public/private health institutions.
3.4.11. Schemes for Implementation
With the above considerations in mind, the following schemes have been suggested loi
implementation in RCH-II:
3.4.11.1. Social Marketing of Contraceptives through Rural Health Practitioners (RHPs)
Objective and Rationale
Surveys have disclosed large unmet need for contraceptives, particularly in EAG states.
Apparently government delivery system is not reaching the needy. As per the NFHS data, less
than 10 percent of rural women report that they are visited by the ANMs during a year. This
implies that ANMs are able to visit less than 100 households in the whole year. On the other
hand, there is a large pool of formally or informally qualified Rural Health Practitioners (RHPs,
who meet the day-to-day health care needs of rural folks. It is proposed to use them in the
delivery of non-clinical methods of contraception and referring the clinical cases to the PHCs or
FRUs, for a nominal fee. The successful experimentation of this approach by Janani in Bihar
gives hope that this scheme could work if implemented with care and imagination.
Operational Strategy:
RHPs will provide condoms and oral pills (also perhaps injectibles if introduced in the
programme) for a nominal charge, after ascertaining the needs of the clients, possible options
open to them, explaining the advantages and disadvantages of each method, and what should
be done in case of side effects. The experience of Janani suggests that it is a good idea to sell
an improved version of these contraceptives under new brand names, so as to differentiate from
those provided earlier. The pricing of contraceptives and the subsidy to be given to the RHPs
should be worked out after a detailed costing exercise. The current programme of free
distribution of these contraceptives may be discontinued as it has not increased the use
appreciably, and lead to huge wastage.
Male health worker/ANMs would supply the contraceptives to RHPs and maintain an account ol
contraceptives supplied and the receipts from the sale. Wherever the government machinery is
weak, the distribution network could be entrusted to NGOs. RHPs would maintain a register of
clients who have obtained contraceptives, which would be available for inspection.
The RHPs would also refer clinical cases of Vasectomy, Tubectomy, and IUDs etc. for the
PHC/FRUs. They would be paid a nominal fee (to be decided) for referring the cases. The
records will be maintained at the PHC/FRU and grassroots workers of PHC would disburse the
money accruing to the RHPs during their monthly visits.
Ii
Programme Risks
Instead of distributing the contraceptives to clients, the RHPs may sell them to the pharmacies
and other retailers. To check such malpractices, the brand sold through RHPs should have
distinct colour and should not be sold through any other commercial outlets. Also. RHPs shoulc
be asked to maintain records of their clients, and health workers should inspect the records and
make discrete inquiries. PHC officials should inspect claims of unusually large disbursement oi
contraceptives. Steps would have to be taken to ensure that RHPs do get paid for referring the
clinical cases.
Administrative Requirement
The village level worker must visit the RHP on a fixed day in a month, disburse contraceptives
and collect sale receipts, check the registers maintained by the RHP and visit some
beneficiaries randomly. Also pay the referral fees for clinical methods.
PHC medical officer should keep a vigil on claims of unusually large disbursement o!
contraceptives, and ensure that referral fees for RHPs are paid regularly.
Requirement of Procurement
Procurement and supply of new brands of condom and pills, having distinct colours an
packaging.
Wall charts, pamphlets and other information and publicity materials to be given to RHPs
Requirement of Training
RHPs should be trained at least for two days on various methods of contraception,
contraindications, management of side effects, and record keeping. Community and political
leaders of the area should be asked to address the trainees on the first day of the training
programme, to underscore the importance of their involvement in the programme.
Requirement of MIES
At PHC:
Village/Sub centre wise list of RHPs involved in the scheme and number of clinical cases
referred and payment of fee for referral cases.
Collection and maintenance of referral forms from RHPs.
Monthly distribution of condoms and oral pills under the scheme, and monetary receipts from
the sale.
L i
At Sub centre:
Village wise list of RHRs, monthly distribution of condoms and oral pills, receipts from their sale
voucher for disbursement of referral fees. The list of participating RHRs should be revised each
year based on their performance.
At RHP Clinic:
Register for maintaining the name and address of clients.
Forms for referring clinical cases.
Requirement of Referral
As above.
3.4.11.2. Community Mobilization through Satisfied Acceptor Couples
Objective & Rationale^
Research has shown that contraceptive use increases in closely-knit communities through
diffusion of information and the idea of small family norm. Inter-personal communication play1.,
a key role in the ideational change. Thus satisfied users can serve as active agent in this
process. The Janmangal program in Rajasthan is based on this idea. Janani also uses
"Women Health Partners" for IEC. As the family planning program has been there for half a
century, there are already some users of contraception in every community. The scheme
intends to use them to rapid transmission of small family norm.
Operational Strategy:
ANMs would identify a ‘satisfied’ acceptor couple (SAC) of each method from caste and
communities among whom the acceptance of the method is low. They would be requested tc
spread information about the method, and motivate others in their community. They would work
in coordination with the Link Workers (LWs), RHRs and the ANM. For their services, a fixed
honorarium would be provided (to be decided). It would not however, be on the basis of cases
they bring, as that is likely to be counter productive in the long run. The performance of these
SACs would be reviewed each year by the ANM to decide whether they would be retained foi
this work next year.
Programme Risks
ANMs could make false claims of SACs her area, and pocket the money herself.
i j
Administrative Requirements
ANMs should make a list of SACs in each village, for each method (an acceptor of that method;
every year. It is imperative that they are selected from castes and communities among whom
acceptance of the method is low. ANMs should maintain a list of cases the SACs have
motivated in each year, and make payment for her services.
Procurement Requirement:
None.
Training Requirement:
SACs should given training for about 3 days on all aspects of contraceptive methods and then
role in the programme.
MIES Requirement
A form for ANMs to maintain a list of SACs in each village and the number of cases they
motivate.
Referral Requirement
None.
3.4.11.3. Increasing the Exposure to Mass Media and Improving Communication
among Service Providers
Objective & Rationale
Research shows that exposure to mass media has a strong independent effect on the use oi
family planning methods. Mass media has a wide reach, and would help to raise curiosity and
create grounds for interpersonal communication to occur. However, surveys show that in EAG
states, regular exposure to mass media has not yet reached desirable levels to have a wider
impact. It is therefore proposed to raise exposure to mass media in EAG states by providing
DVD/CD player and Television set to PHCs, FRUs and Mahila Mandals. As a part of this
scheme, imaginatively produced DVD/CDs on reproductive and child health, including
information on various methods of contraception would be distributed.
Facility surveys show that less than 20 percent of the PHCs have telephone connections. For
efficient referral services and monitoring of the programmes, telephone connections are
essential. It is therefore proposed to provide telephone connections to every PHCs, FRUs and
CHCs.
Ii
Operational Strategy
PHCs and FRUs receiving at least 10 outpatients/maternity cases in a day in EAG states woulc
be identified for the supply of DVD/CD Players and TV sets. For moving the TV set between
OPD and inpatient ward, a trolley would also be provided. During fixed hours in a day, DVD/CDs
on RCH and family planning should be played for viewing by the outpatients/women coming for
delivery.
DVD/CD players and TVs would also be supplied to Mahila Mandals on the condition that they
would arrange DVD/CD viewing sessions (along with TV shows) at fixed hours in a day. ANMs
during their field visits would check whether these are effectively used.
The production of DVD/CDs would be out-sourced. Telephone connections would be supplied
to all PHC/FRU/CHCs. There would be a fixed budget line to cover monthly telephone bills and
maintenance, as in other government offices.
Programme Risks
The equipments may be misused, or may not be maintained well. Vigilance would be essential
at all levels.
Administrative Requirements
Hike in the budget of health institutions to cover maintenance and repair
Procurement Requirement
Procurement and supply of TV, DVD/CD player, TV trolley and telephones to designated health
institutions and Mahila Mandals. Providing telephone connections.
Procurement and supply of DVD/CDs on reproductive and child health.
Training Requirement
Nil.
MIES Requirement
PHC/FRU action plan forms should indicate whether the facilities provided are working or not
ANM/LWs should report whether Mahila Mandals are holding Video-viewing sessions regularly.
Referral Requirement
None.
I i
3.4.11.4. Arranging Group Meetings of Newly Wedded Couples and Pregnant and Nursing
Mothers
Objectives & Rationale
In India, about 10 marriages occur for every 1,000 population. Many women marry at young
age. It is therefore extremely necessary to impart knowledge on the responsibilities ol
parenthood to newly weds as early as possible. Similarly, group meetings of pregnant and
nursing mothers can be arranged to provide them information about maternal and child heath
care and contraception. It is not sufficient to just ask the ANMs to make home visits for IEC. as it
is difficult to monitor such activities. Surveys show that heath workers visit less than 10 percent
of eligible women during the whole year. To give a formal platform for such communication
strategies, ANMs with the help of SACs, and LWs would be asked to arrange group meetings of
newly weds in a village every year. Such formal meetings will also give the required visibility tc
the programme.
Operational Strategy
In villages with population more than one 1,000 the ANMs with the help of LWs and SAs will
organise group meetings of newly weds, and pregnant and nursing mothers at least twice in a
year. In villages with less than 1,000 populations, such meetings may be held once in a year. In
these meetings, ANMs will impart information and knowledge on prenatal, natal and post natal
care of women, new-born care, child immunization, virtues of small family size, interval between
births, methods of contraception and abortion, STI/RTI and HIV/AIDS, with the aid of illustrative
pamphlets and booklets. The active cooperation of Panchayat members would seek to arrange
these meetings.
Programme Risks
Attendance in such meetings could be thin. Therefore sensitising, and seeking active
cooperation of Panchayat and other community leaders would be essential.
Administrative Requirements
Sensitisation of local leaders, monitoring the activity, provision of a small contingency grant to
ANM for covering the meeting expenses.
Procurement Requirement
Illustrative pamphlets and booklets for the ANM to be used as communication aids.
IJ
Training Requirement
Nil.
MIES Requirement
Sub centre/ PHC/FRU action plans should show how many such meetings were held and how
many attended the meetings.
Referral Requirement
None.
3.4.11.5 Increasing the visibility of the Population Stabilization programme
Objectives & Rationale
The inverted red triangle, the eye-catching logo of the Indian family planning programme of
yesteryears has slowly fading from the public memory. There is an urgent need to bring back
the visibility to the population stabilization programme. The paradigm shift in the programme?
calls for a new but simple logo.
Operational Strategy
An award would be announced for developing a simple but effective logo. A private agency
would be hired at the national level to publicise the logo and the programme.
Possible Risks
Poor monitoring of the activities outsourced.
Administrative Requirements
Monitoring the activities of the private agency at state, district levels
Procurement Requirement
Nil
Training Requirement
Nil.
MIES Requirement
Data on the publicity activities at the district level
u
Referral Requirement
None
3.4.12. Contraceptive Requirements
The demand for contraceptives in the country would rise rapidly if the above schemes wer
implemented with earnest. It is therefore necessary to plan carefully the contraceptive
requirements under RCH-II. As per the goals of the 10th plan, permanent method use should
be 50 percent, and reversible method use should be 15 percent in 2007, compared to 35V
percent and 8 percent respectively, as per NFHS-2 and RHS conducted in 1998-99. The pla;
document has also set contraceptive goals for all the states (see Table 30). To achieve these,
targets, the required increase in the annual acceptance rates of various methods ol
contraceptive methods has been worked out. To do this, it was found necessary to correct the
official estimates of acceptance rates for the base period (1997-2002). NFHS-2 and RHS have
shown that the percentage of sterilized women is 20 percent higher than that suggested by the
official estimates of couples currently protected, whereas IUD and pill users are one-fourth and
condom users are two-thirds of the corresponding official figures
Therefore, a corrected figure for 'equivalent sterilizations was arrived at by raising the
sterilizations by 20 percent but dividing the number of IUD insertions by 12, pill users by 36 and
condom users by 27. The corrected annual equivalent sterilization rates at the state level Ic
1997-2002 showed strong correlation with the survey-based estimates of modern method us<
(r=0.83), and suggested that for the modern method use to reach 65 percent at the national
level in 2007, the annual equivalent sterilization rates should be raised by 60 percent from the
average annual achievement during 1997-2002. As the population in the reproductive ages is
also projected to increase by 19 percent in the meanwhile, the annual number of in equivalent
sterilizations should nearly be doubled (an increase of 90 percent). Computations also showed
that, to achieve the anticipated change in the method mix, the number of sterilizations should be
increased annually by 8.6 percent, and acceptance of reversible methods should be raised
annually by 11.0 percent. The required rates of increase are considerably higher than what wen,
achieved during the last decade. During 1990-2002, sterilization acceptance had increased by
annual rate of 3.1 percent (with an adjustment for the shortfall following adoption of the target
free approach) and reversible method use; measure in terms of equivalent sterilization had
increased, by 4.6 percent per annum (IUD 4.5 percent, OP 10.0 percent, CC 2.9 percent).
Table 31 shows for all India, the projected number of new adopters of tubectomy, vasectomy
(NSV), IUD, pill, condoms and injectibles/implants from the first to fifth year of the programme
The calculations assume that NSVs would rise to 10 percent of all sterilizations by the fifth year
of the programme. It is also assumed that injectibles/implants will be introduced during the
second year of the programme, which would arrest the growth in the number of IUD and pill
users. We also recommend the introduction of female condoms, which is expected to reduce
the procurement requirements for male condoms.
ii
For comparison, Table 32 shows the expected number of new adopters of various methods oi
family planning computed under the assumption that new adopters would increase at the rates
observed during 1990-2002. Under this 'business-as usual' scenario, the number of annual
sterilizations to be done in the country would grow to 5.5 million by the year 2007-08. But tc
achieve the tenth plan goals, the number of sterilizations that have to be done would grow to 8/
million per year. The number of condom users would be required to rise to 35 million compared
to 20 million under the business-as-usual scenario. Figure 2 shows the trajectory of increase in
contraceptive use under the two scenarios.
Table 33 shows for major states, the annual rate of increase required in the number of new
users of sterilizations and spacing methods in order to reach the goals of the tenth plan. To give
an idea about the actual magnitude of the task, the table also shows the number of sterilizations
to be done and new users of spacing methods (measured in equivalent sterilizations) in the year
2007-8 in each state. Computations assume that wastage and use-effectiveness of different
methods do not vary substantially by state. As per the table, in order to reach the tenth plan
goals. Assam, Bihar, Jharkhand, Haryana, Uttar Pradesh and West Bengal would have to make
particularly strong effort in increasing the annual acceptance of sterilizations and spacing
methods.
11
Table 28. Total Fertility Rate around 2000 and the Expected Number of Year
Take to Reach Replacement-Level Fertility, Major Indian
States
TFR
2000
2.5
Andhra Pradesh
3.2
Assam
4.3
Bihar *
3.0
Gujarat
3.3
Haryana
2.4
Himachal Pradesh
2.4
Karnataka
1.9
Kerala
★
3.9
Madhya Pradesh
2.7
Maharashtra
2.9
Orissa *
2.6
Punjab
4.1
Rajasthan *
2.0
Tamil Nadu
Uttar Pradesh *
4.6
2.4
West Bengal
3.3
All India
Year
4.2
Mean for EAG
* EAG states.
** State-weighted average.
@ As per the SRS data.
Mean
Expected
Years
fall
during
last 10 required forTFR
2010
years© TFR=2.1
4
1.8
0.81I
2.6
18
0.61
3.2
20
1.08
22
2.6
0.41
2.4
14
0.86
2
1.8
1.35
1.8
3
1.03
1.8
0
0.17
20
3.0
0.86
7
1.9
0.79
2.0
0.89
9
1.8
0.82
6
3.7
45
0.45
1.8
0.49
0
34
3.9
0.75
1.8
1.02
3
2.5
0.74
16
0.82
(18)**
26
(2.6) **
3.4
It
Would
I i
Table 29: Levels of Some Important Determinants of Fertility in BAG States
And the Numbers of Years it May Take for Them to Reach
the Level Required for Replacement-Level Fertility
Indicators
Level
around
2000
34
Percent using contraception
15
Median age at marriage
Unmet need for contraception
21
3
Ideal family size
45
Female literacy rate, age 7+
85
Infant mortality rate
Low
Empowerment of women
41
Exposure to mass media
5
Home visit by ANM (%)
Change Required Required
during lastlevel for no. of
10-years TFR = 2.1 years
31
65
10
60
18
0.5
32
5
5
33
2
0.3
23
80
15
28
?
12
?
40
High
75
20
16
9
28
?
Li
Table 30. Tenth plan method-specific contraceptive targets and require annual rate of
increase in permanent and reversible method users during RCH II programme period foi
major states
States
Tenth plan goal for Required annual growth
2007
rate (%)
Permanen
Modern
Modem Permanent
t
reversibl
reversible
methods
methods
e
methods
methods
Expected users in 2007
8
Permanent
Modern
methods
reversible
methods *
Andhra Pradesh
65.0
10.0
2.3
9.0896,661
151,747
Assam
35.0
16.9
29.0
34.1 141,962
74,595
Bihar
30.0
10.0
13.5
26.9338,216
122,695
Chattisgarh
45.0
10.0
9.8
4.5215,947
73,571
Gujarat
60.0
21.2
9.4
8.1491,270
192,602
Haryana
56.3
26.0
10.4
11.7195,155
100,116
Jharkhand
30.0
10.0
13.5
26.9128,289
46,540
Karnataka
60.0
12.7
3.4
10.0511,199
118,423
Kerala
60.0
10.7
9.0
14.9277,790
54,914
Madhya Pradesh
Maharashtra
55.0
66.0
17.0
14.8
9.8
7.3
4.5569,315
14.3
1,023,749
193,960
250,546
Orissa
55.0
12.9
15.2
8.7314,389
81,040
Punjab
55.0
30.0
7.8
7.5199,248
119,953
Rajasthan
45.0
15.5
8.1
4.7424,693
161,207
Tamil Nadu
60.0
12.0
6.5
10.0576,528
125,534
Uttar Pradesh
35.0
21.0
13.3
7.8896,551
590,025
West Bengal
50.0
19.4
11.3
23.4657,810
276,772
u
Smaller States/UTs
Arunachal
Pradesh
30.0
20.8
13.8
31.95,087
Delhi
40.0
30.0
13.9
19.9101,593
Goa
Himachal
Pradesh
45.0
12.4
9.2
20.59,090
65.0
19.6
10.4
12.968,656
22,825
Jammu& Kashmir
40.0
18.5
21.5
36.7 59,322
30,101
Manipur
30.0
15.8
22.6
22.89,159
5,282
Meghalaya
30.0
10.8
24.2
32.29,404
3,633
Mizoram
56.8
15.5
12.4
24.96,978
2,054
Nagaland
30.0
14.1
22.5
42.36,334
3,208
Sikkim
31.3
28.5
11.8
29.32,469
2,386
Tripura
30.0
36.4
10.9
27.816,110
A&N Islands
50.0
15.0
6.0
18.03,060
1,009
Chandigarh
40.0
35.0
10.1
24.06,401
6,244
D&N Haveli
35.0
10.0
9.1
36.61,254
384
Daman & Diu
50.0
10.0
11.9
10.31,190
265
Lakshadweep
30.0
10.0
28.4
12.2278
103
Pondicherry
65.0
10.0
0.6
8.611,551
1,978
Uttaranchsd
India
40.0
50.0
18.2
15.0
13.3
8.6
7^857,227
11.0
8,233,933
3,802
85,285
2,759
20,996
37,661
2,964,216
* Equivalent sterilizations computed according to the formula:
1 Sterilization = 12 IUD insertions, 36 pill users and 27 condom users.
14
i1
Table 31. Annual adaptors of various methods of contraception needed to attain
the tenth plan goals, All India
Method
Sterilization
Tubectomy
NSV
IUD
Require
Average
d
achievemen
2007-8
2004-5
2005-6
2006-7
2003-4
t
Growth
1997-2002 rate (%)
8.6 5,830,390 6,355,871 6,928,711 7,553,181 8,233,933
4,500,547
6,140,669
Pill
7,469,212
Condom
Female
Condom
17,611,661
5,655,478 6,101,636 6,512,989 6,948,927 7,410,540
174,912 254,235 415,723 604,254 823,393
11.0 8,544,108 8,544,108 8,544,108 8,544,108 8,544,108
10,392,63 10,392,63 10,392,63 10,392,63
11.010,392,637
7
7
7
26,809,85 29,319,49 32,050,15 35,019,27
11.024,504,809
0
9
7
547,140 1,221,646 2,045.755 3,045.154
Injectibles/
Implants *
A Assumed to be equivalent to two IUDs and six pill
users.
698,841 1,479,021 2,350,009 3,322,373
Table 32. Expected annual adaptors of various methods of contraception under
the “business-as-usual scenario,” All India
Method
Sterilization
Tubectomy
Vasectomy
Actual
Growth
achievemen
2003-4
t
rate (%)
19902001-2002 2002
3.1 4,875,710
4,726,882
4,778,196
97,514
2004-5
2005-6
2006-7
2007-8
5,029,2245,187,572 5,350,905 5,519,381
4,928,6405,083,821 5,243,887 5,408,994
100,584 103,751 107,018 110,388
Ii
IUD
6,202,399
Pill
8,619,508
Condom
17,476,568
4.5 6,487,882 6,786,505 7,098,874 7,425,620 7,767,405
10,527,89 11,635,11 12,858,79 14,211,16
6
10.0 9,526,030
1
9
55
17,990,80 18,520,18 19,065,13 19,626,11 20.203,60
9
10
4
4
2.9
14 5
11
Figure 1. Unmet need for contraception (in percent) in Major States, NFHS-1 and NFHS-2
35
CM
(/)
30 -
I
z 25 LL
■O
<D
C
O
E
UP
BH
20 -
%PA^r
15 KL
10 -
MTN
HP
AP
Z)
WfcK
HR
5
5
15
10
20
25
30
35
Unmet need, NFHS-1
Figure 2: Actual and projected trends in annual acceptance of sterilization and reversible
methods (in equivalent sterilizations) under the ‘business-as-usual’ scenario and for
meeting the tenth plan goals, All India, 1990-2008.
9000000
8000000
7000000
J
i
!
6000000
- St rilization-BAi I
5000000
Spacing-BAU
Sterilization- lOthPiar1
Spacing lOlhPlan
4000000
3000000
2000000
•
1000000
»•
«-
■»
»..................... -*■............................ •
.................... *
.«. ®. ... W..... *. *'
'
0
1990- 1991- 1992- 1993- 1994- 1995- 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 2004- 2005- 2006- 2007
91
92
93
94
95
96
97
98
99
00
01
02
03
04
05
06
07
08
Year
d
Table33
Major states
Andhra Pradesh
Estimated number of couples with unmet needjor contraception ''' ■
Unmet need for contraception
Eligible couples
NFHS-2, 1998-97
31 March. 1998
Spacing
Limiting
Total
5.2
2.5
7.7
Num!"
Spa
COOs)
7 17n
137876
Assam
7
10
17
38885
Bihar *
12.6
11.9
24.5
171605
Gujarat
4.8
3.7
8.5
81862
Haryana
2.9
4.7
7.6
32555
Karnataka
8.3
3.2
11.5
85723
Kerala
6.9
4.9
11.7
51590
16.2
136767
is i;
lz I.
Madhya Pradesh *
8.9
7.3
Maharashtra
8.1
4.9
13
153387
Orissa
8.7
6.8
15.5
58690
Punjab
2.8
4.5
7.3
36740
Rajasthan
8.7
8.9
17.6
92146
■|
Tamil Nadu
6.6
6.4
13
105506
Uttar Pradesh *
11.8
13.4
25.1
274389
West Bengal
6.3
5.5
11.8
129748
I /' !
All India
8.3
7.5
15.8
1658687
137 o i
10.9
11
21.9
733597
EAG states
J 2 •. /
’ Including newly formed states of Jharkhand, Chattisgarh and Uttaranchal.
Since the population (EC) would have gone up by about 10% during 1998-2003, while unmet
need may have come down by 10% during the same period, the above estimated number of
ECs with unmet need for 1998 could be taken to be roughly the same for 2003
14 7
IJ
3.5 Urban Health
3.5.1 Introduction
Nearly 30% of India's population lives in the urban areas. Urban population is aware and has
ready access to health care. The data from many surveys have clearly established that health
indices of the urban population are better than those of the rural population. However, urban
migration has resulted in rapid growth of urban slums. The slum population is posed with
greater health hazards due to the following:
•
•
•
•
Overcrowding
Poor sanitation
Lack of access to safe drinking water
Environmental pollution
Some research studies have indicated that the health indices of urban slum dwellers are
lower than that of their rural counterparts.
It has been realized that the available health care infrastructure is inadequate to meet the
health care requirements of the growing urban population. In order to mitigate these the
urban local bodies, state and the central governments have attempted to develop the urban
health care facilities. Majority of the hospitals and beds, doctors, beds and para-professionab
are in urban areas. These urban health facilities especially the tertiary care institutions catei
to both urban and rural population. Unlike the rural health services there have been no efforts
to provide planned and organized primary, secondary and tertiary care services in
geographically delineated urban areas. This has resulted in many areas not having primary
health care services. The paradoxical situation of equipment and expertise available in the
secondary hospitals co-exist.
During the ninth plan it was envisaged that a well-structured network of urban primary health
care institutions providing re-organizing the existing institutions would develop health and
RCH services. The Report of The steering Committee on Family Welfare for the Tenth Five
year Plan has observed “ though there are several success stories, hardly any progress has
been achieved in the overall task of restructuring the urban primary health care linked to
secondary and tertiary care and appropriate retraining and redeployment of the personnel.'
Therefore, it has been considered essential to develop a strategic approach for handling
urban health requirements. This has caused priority to be provided to Urban Health as one of
the thrust areas in The Tenth Five Year Plan, National Population Policy 2000 and National
Health Policy 2002.The same is reflected in the RCH II design as well
11
3.5.2 Goals and Objectives
Goal as derived from National health Policy 2002
To improve the health status of the urban poor community by provision of quality integrate*.:
Primary Health Care Services.
Objective
•
•
•
To provide integrated and sustainable system for primary health care services delivery
in the urban areas of the country to cater to the requirements of urban slum population
and other vulnerable groups.
To provide technical assistance and enhance the capacity of urban local bodies to
plan and implement such service delivery.
To bring about an overall improvement in the urban health scenario through both the
primary and strengthened referral system.
3.5.3 Considerations to be taken into account
•
•
•
•
•
The situations vary from city to city (urban area) and hence it may not be possible to
develop a uniform model of service delivery. The variables that influence this
consideration are the level of service availability, agencies managing the services, the
types of services being provided and the extent of involvement of states and the
differing levels of financial support.
Outsourcing service delivery in urban areas through NGOs/private provider groups
need to be considered
The urban cities need to be prioritized based on a set of well-developed criteria
The ownership and involvement of the state government would also be essential for
the sustainability and better utilization of the resources spent on facility creation and
capacity building of the human resources.
States need to be provided clearly developed guidelines and methodology for
conducting baseline survey in order that it can provide a structured database for
prioritization of cities in the future and also be able to enable development of indicators
for measurement of achievement.
3.5.4 Coverage
•
•
•
All the states need to be covered by the program but priority needs to be accorded to
the EAG states and the Northeastern states.
Differential coverage criteria need to be evolved for bigger and smaller states. In
bigger states priority needs to be accorded to cities with population of less than 10
lakhs with a pattern of growing slums and migrant population. In smaller states it is
suggested that cities with a population of greater than a lakh and showing indications
of growing slums and migrant population need to be accorded priority
Support would be provided for strengthening existing facilities, hiring of facilities where
facilities are not available (because construction is not envisaged), provision of support
11
•
for minimum equipments, and prepare them for providing basic primary services in
family planning and RCH and to extend minor curative services at the primary level.
Strengthen system of referral from primary levels to the secondary and tertiary levels
The coverage is to be achieved through:
•
•
•
•
•
Strengthening the existing urban health infrastructure by renovation/upgradation ol
existing facilities
Provision by establishing new facilities in uncovered urban slum areas
To support the development of a referral system for institutional deliveries, emergency
obstetric care and terminal method of family planning
Involvement of the NGOs/Private Sector in the provision of Primary Health Care
Services and also as part of the referral system
Integration of the existing health infrastructure with the proposed urban health program
3.5.5 Prerequisites
•
•
•
•
Identification and prioritization of cities in the respective states by using criteria such
as population, health indices and service availability
Urban slums in each city (slum dwellers and other vulnerable groups) i to be identified
and prioritized by the concerned urban local body through appropriate mapping
methodologies and in consultation with the respective state governments
Detailed vulnerability assessment using community based approaches needs to be
undertaken by the urban local body.
Mapping of existing health services classified as public sector, private sector. NGO in
order to develop a coordinated strategy and avoid duplication
3.5.6 Strategy
•
•
•
•
•
•
Focus to be on service delivery rather than addition of infrastructure. It is expected that
facilities would be carved out of the existing available infrastructure or be taken on
rent.
The identification of requirements and choice of facilities to be supported for
strengthening through minor maintenance activities and provisioning of minimum
equipments required for delivery of service package identified.
Integrating existing government facilities in the area by up
gradation/relocation/reorganization and by making the nomenclature uniform to
facilitate recognition
Bring about both horizontal and vertical linkages
Out sourcing the complete service delivery function at the primary level to not for profit
private sector wherever found feasible.
Establishing a management structure at the city/urban local body level and by
constituting committees at the individual disaggregated levels by involving the different
stakeholders and empowering the management structure with the requisite
administrative, financial and decision-making powers.
Ii
•
•
•
•
•
•
•
•
Sustainability options through cost recovery and by cross subsidy arrangements
especially to address the needs of the below poverty line population. Identify
innovative local resource generation options.
Clear performance accountability through the framework of MOU under RCH II.
Identify methods of sustainability and provide commitment for sustainability after
assistance ceases.
Health services component under different programs being implemented by different
ministries needs to be pooled together in order to enhance resource availability and to
ensure coordinated management to derive maximum cost-effectiveness.
Management and Human Resource arrangements, costing and fund flow
mechanisms). Develop the guidelines for the systems and approaches to develop
each of them through manuals prepared by constituting expert panels for each of
them.
Initiate and bring about an inter-sectoral coordination for cost-effective management of
the program.
Development of a framework of indicators based performance assessment and
systems for periodic monitoring and supportive supervision.
Develop guideline and framework for contracting and outsourcing service delivery
through public-private partnerships
Set up a technical support unit (TSU) within the Urban Health Division to carry out the
development of the manuals and frameworks. The TSU needs to be adequately
equipped for carrying out these activities. It needs to be posted with personnel (2 in
number with expertise in urban health and urban affairs)
3.5.7 Program Description
As a part of the program, the support will be provided for implementation of urban
health projects in the identified cities as per the following:
Coverage:
The program would be implemented in a phased manner in all the states with priority
being accorded to EAG and Northeastern states. The latest 2001 census reveal that
there are 423 towns/cities having a population of more than 1 lac. Of these 423 cities,
28 cities are having population of more than 10 lacs. Keeping in view the type of urban
health infrastructure already available in these cities and the ongoing
facilities/programs already under implementation in big cities by various agencies viz.
State Government, Municipal Corporation, Private Nursing Homes/Hospitals, NGOs.
etc. the proposed urban health program will focus on cities having population between
1-10 lacs (numbering 395 as per the 2001 census). Depending upon the availability of
funds the support to big cities having a population of more than 10 lacs will be
restricted to bringing improvement in the quality of services. . Other components to be
need based and considered on case-by-case basis. List of the cities having population
greater than 1 lac is enclosed in Annex 35.
Prerequisites:
•
•
•
•
Efforts should be made to re-deploy the existing staff from the existing facilities,
wherever possible
The new staff will need to be appointed through contractual mechanisms
Existing service delivery system will be reorganized and restructured to serve a
defined geographical area for a defined population. The new facilities to be established
to serve the remaining area or target population
ANM needs to be given an identified area for outreach services
II Tier
Referral Hospital (City /District Hospital/Maternity Home/Private & NGO Nursing
Homes/Hospitals
The support envisages strengthening of existing centers with public-private partnership,
recognition of private nursing homes/hospitals to provide the pre-determined services &
mobile support for floating/migrating population/temporary slums/construction workers.
3.5.8 Type of Services
The I Tier Health Center will provide only the outdoor services. The complicated referral
cases and indoor services will be available only at the II Tier namely Referral Institutions. The
details of the service provision at these two levels is as under:
I Tier Health Center:
•
•
•
•
•
•
•
Antenatal care, postnatal care, Referral for institutional deliveries
Immunization
Services under national programs like DOTS, NMCP Etc.
Family planning including IUD, NSV & referral for terminal
methods
Lab services
Treatment of minor ailments including RTI/STI
Depot holder services for contraceptive and ORS ,
Promoters/Education and help ANMs for outreach services
through social community/link volunteers.
Support activities like -
•
•
Demand generation through targeted IEC
Training
IJ
II Tier Referral Center:
•
•
•
•
Institutional delivery
Emergency obstetric care
Terminal methods of family planning
2nd Tier curative services for RTI/STI
3.5.9 Support/inputs to be funded under the program
The financial support and interventions will depend upon the specific proposals received from
the State Governments to meet the outlined objective of providing integrated Primary Health
Care & FW Services in urban areas. However, the main activities/interventions to be
considered for financial support to become an integral part of such proposals are summarized
as under:
I Tier Healthi Center:
• Renovation/upgradation of existing facilities
• Renting of accommodation for establishing new Urban Health Centers. This facility
will include provision of space for services, office, minor OTs. Lab and storeroom
for equipments etc. besides patient waiting area.
• No new construction will be supported under the program
• Equipments & furniture for services to be provide from the urban health center (to
be ascertained through a facility survey for the existing facility and as per the
standard list for the new facilities to be established)
• Support for additional manpower on contractual basis only after redeployment of
the existing staff.
• Needs based drugs & supplies (excluding supplies being made under other
programs/schemes)
• Mobility support (hired vehicle for referral services)
• A support for services to be provided by NGOs will be considered on similar pattern
as per specific agreement reached.
II Tier Referral Center:
• Renovation/upgradation of existing referral facilities
• Support for need based additional add on lab/indoor facilities.
• Equipments & furniture for services to be provide from the referral centers (to be
ascertained through a facility survey for the existing referral facilities)
• Support for local contractual arrangements for specialist/part time Specialist
medical officer.
• Need based drugs & supplies (excluding supplies being made under other
programs/schemes)
• A support for services to be provided by NGOs will be considered on similar pattern
as per specific agreement reached.
11
3.5.10 Public Private Partnership
Successful implementation of the project will require a vibrant partnership between thu
DoFW, GOI, State Government and the Urban Local Bodies. While the DoFW will provide
technical assistance, the State government will provide leadership to the project facilitating
ground implementation by the Urban Local Bodies. The private sector can be fruitfully
engaged for service delivery to fill in gaps. The donor agencies can provide technical
assistance to the program by sharing experience across the globe in urban health
development and facilitate program design. The main specific interventions envisaged for
support under the program are as under:
•
•
•
NGOs and private nursing homes/hospitals may be involved in the program including
service delivery through a framework of partnership.
Accreditation methods can be followed for private and NGO operated facilities. All
facilities within the framework should follow uniform reporting system and referral
system.
Outsourcing/franchising of discrete services (such as diagnostics) to NGOs/Private
Sectors
3.5.11 Work plan
Under the program, the States are required to prioritize the cities by doing facility mapping
and baseline survey of indicators in identified cities. Based upon this, the proposals for the
respective cities would be sent to come to Government of India for consideration of financial
support. While doing so, the States must ensure that the urban health programs supported by
any other donor agency/NGOs are also taken into account to ensure that there is no
duplication of efforts in the same area and the projects outside the purview of this program
are also consistent with the overall objective and strategies of this program and convergence
of the services. The work plan showing the main activities to be undertaken at the national &
State level is given below:
National level
• Preparation of guidelines & Terms of Reference for the program
• Request for proposal from the concerned States.
• Evaluation of the proposal for financial support.
• Physical and Financial Monitoring of the program.
State level
•
Prioritization of the cities to be covered under the program.
11
•
•
•
•
Need assessment including mapping of all existing health services run by public
sector and private sector including non-profit organizations to prevent
duplication.
Existing government facilities in the project area to be integrated by up
gradation/ relocation/ reorganization/ closure.
Identification of the agencies for formulation of the proposal
Submission of the proposal to the Government of India.
After the approval of the proposal the main activities to be undertaken by the States are as
under:
•
•
•
•
•
•
•
•
•
•
Setting up of Technical Support Unit in State Directorates.
Capacity building and reorientation of key officials of state and urban local bodies.
Constitution of a state level empowered committee and monitoring committees to
approve plan of action and monitor implementation respectively.
Project Management Units will be set up in ULB, including management consultant
depending on city population and mechanism of service delivery
Undertake I EC and procurement activities.
Contracting out of services to private sector.
Identification of link-volunteers, CBOs/ grassroots organizations.
Training will be conducted under RCH as for rural areas.
Focused capacity building of community volunteers on Behavioral Change
Communication methods.
Provision of doctors at the centers through the department of local administration by
reallocating the medical personnel in this department or through secondment from the
urban local bodies as is found feasible.
3.5.12 Funding Pattern
•
•
•
Funds flow will be from GOI to State Government/State level society for further
transfer of funds to the implementing agency.
Funding support would be provided for a maximum period of 5 years starting from the
beginning of RCH-II.
The ongoing urban health projects under implementation in the identified cities will be
integrated and will become an integral part of overall urban health program.
3.5.13 Cost
As regards the costing of a Health Center, the indicative costs of inputs based upon the IPPVIII experience are as follows:
Personnel Cost_________
Monthly
Annual
No. Of post Recurrent/
I. Category of Personnel
Sanctioned
Capital
Expenditure
Exp.
(Each health center)
Recurre
12600/1,51,2001) Lady Medical Officer*
pm
00
nt/
u
2) LHV/PHN
1
3) ANM’s
3
4) Link workers
10
5) Security Guard @ Rs:
5000/- PM
6) Clerk
II. Annual maintenance of
^equipments, Furniture etc.,
Each health centre
III Electrical, Water, Building
Charges etc^______________
IV. Building Maintenance
charges (Repair & Painting)
V. Drugs
VI. Training*
VII. IEC materials
VIII Hiring of Vehicles
GRAND TOTAL
Equipments
Furniture
Grand Total
1
Recurre
nt/
Recurre
nt/_____
Recurre
nt/
Recurre
nt/
Recurre
nt/__
Recurre
nt/
Recurre
nt/
Recurre
nt/
Recurre
nt/
Recurre
nt/_____
Recurre
nt/
Recurre
nt
Recurre
nt/
Equipments & Furniture
Non
recurrent
Non
recurrent
6,500/pm
5,500/pm
500/pm
4,000/pm
5,000/pm
78,00000
1,98,00000
60,00000
48,00000
60,00000
10,00000
50,00000
1,00,00000
30,00000
1,00,00000
10,00000
1,75,00000
10,70,200
-00
10,00,00000
1,00,00000
21,70,20000
' To be provided by the states and will not be funded by the program.
The cost for renovation & upgradation of the existing facility into a Health Center will in the
range of Rs.2-3 lakhs. The rent for a new facility will cost around Rs. 1,00,000/- to
Rs.2,00,000/- per annum. As regards the costing of services to be provided at the referral
center and through public-private partnership, the costing would depend upon the specific
interventions to be supported and the agreement reached with the private institutions
I
Based upon the above costing, it is imperative that in the subsequent years of the project
implementation, the recurring liability will be a major portion of the cost to be met out of the
budget provision to be kept in that particular year.
11
It needs to be pointed out in the above the costs for The Medical Officers, training and the
maintenance costs will not be funded and these have to be met by the funding of the state
governments through the provisions made by them. The costs have been indicated here but
have not been taken into account while estimating the program costs.
3.5.14 Sustainability
The support under the program will be limited to the project implementation period of RCH-II
Program. It therefore, becomes imperative that all the project proposals should have
detailed plan of action for sustaining the program after the GOI funding comes to an end Thidetailed plan of action should address the issue of cost recovery, cost sharing and user fee.
3.5.15 Monitoring & Evaluation
The program will be closely monitored at National; State & City level and also need to be
evaluated from time to time. For this purpose a Committee will be constituted at the state
level with GOI and donor agencies for review. The monitoring will not be restricted to physical
and financial achievements but will also include the following:
•
•
•
•
Comparison of the Baseline and end line, process & impact indicators will allow projeci
results and achievements to be measured.
Regular monitoring on the basis of service data.
Performance monitoring to be consistent with CNA.
Concurrent evaluations by independent agencies.
3.6 Tribal Health
3.6.1 Introduction
Tribal population in India is considered socio-economically backward and disadvantaged. The
tribal communities can be classified as one homogenous group. They belong to different
ethno-lingual groups, profess diverse faith and are at varied/different levels of developmenteconomically, educationally and culturally. There are more than 400 tribal groups in the
country of whom 75 are primitive tribes (PTGs) characterized by declining /static/low growth
rates, pre-agricultural level of technology and extremely low levels of literacy
There are six predominantly tribal states/Union territories where more than 50 percent
population is tribal and another nine states where majority of scheduled tribe population lives.
As has been already stated there are 75 PTG, which have been identified on the basis of low
rate of growth, low levels of technology and low levels of literacy.
The major contributors for the poor health status and disease burden of the tribal people are:
I j
•
•
•
•
•
Poverty and consequent under nutrition in both macro and micronutrients
Poor environmental sanitation, poor hygiene and lack of safe drinking water
Lack of access to health services and health care facilities resulting in increased
severity and/or duration of illness
Social barriers preventing access and utilization of available health care facilities
Vulnerability to specific diseases such as malaria, TB, Yaws, Sickle cell anemia.
Thalassemia G-6PD deficiency etc.,
3.6.2 Magnitude of the problem in the Tribal Areas
Poor health, nutrition, reproductive and child health status of the tribal people along with poor
availability, accessibility and utilization of health services are the main problems in the tribal
area.
•
•
•
•
•
•
•
•
•
•
Decadal growth rate of ST population is reported to be higher than that of the
total population
Sex ratio of the tribal population has been better (provide 2001 census figures)
Percentage of girls marrying below 18 years in many tribal districts is as high as
60
Statewise MMR for the tribal population is not available due to inadequate
sample size in various demographic surveys.
NFHS 2 data shows that 43.1 % of tribal pregnant women did not receive any
antenatal check up, 38.7% did not receive any tetanus toxoid injections and
only 48.6% were given iron and folic acid tablets. 81.1% tribal pregnant women
delivered at home. 44.4% of all deliveries were attended by TBA and 32% by
other untrained persons. Only 14% had any postnatal check ups within 2
months after birth.
Unmet need for family planning is 15.4%
High RTI, STI/HIV (33.4% of ever married women had any abnormal vaginal
discharge, 20.4% had symptoms of any Urinary Tract infection and 42% of
currently married women had any reproductive health problem).
High prevalence of falciparum malaria, TB, sickle cell disease, G-6PD
deficiency also adds to the problem.
Infant mortality is higher in the tribes as compared to the non-tribes. 79.8% of
tribal children were anemic. Only 26% of children receive all vaccines. 55% of
children belonging to the tribes were under weight. (NFHS II)
The above clearly suggests that the tribal people especially women and
children require special attention for improving the health status and
reproductive and child health status.
Some of the problems of accessibility and poor utilization of health services unique to tribal
areas are because of:
11
Difficult terrain and sparsely distributed tribal population in forest and hilly regions
Locational disadvantage of sub-centers, PHCs and CHCs
Non-availability of service providers due to vacant posts and lack of residential
facilities
Lack of suitable transport facilities for quick referral of emergency cases
Lack of appropriate HRD policies to encourage/motivate the service providers to work
in tribal areas
Inadequate mobilization of NGOs
Lack of integration with other health programs and other development sectors
IEC activities are not tuned to the tribal vocabulary, beliefs and practices
Services not being client friendly in terms of timing, and cultural barriers inhibiting
utilization
Non involvement of local traditional faith healers
Weak monitoring and supervision system
3.6.3 Objectives of Tribal Health
The overall objective of the strategy for RCH in tribal areas is to contribute to the
achievement of the socio-demographic goals set out in NPP 2000 to be achieved by 2010
and thereafter.
The specific objectives are:
•
•
•
•
•
•
Assess the unmet needs of RCH services in different tribal areas and in
different tribes
Provide integrated and quality RCH services
Improve service coverage, accessibility, acceptability and its utilization.
Promote community participation and inter-sectoral coordination
Provide opportunity for employment of tribal people
Promote and encourage tribal systems of medicine
In addition tribal health would address other general health issues such as malaria, TB,
Yaws, Sickle cell anemia, Thalassema G-6 PD deficiency etc.,
3.6.4 Approaches and strategies to be used
Basic health and RCH services need to be integrated in the overall development of tribal
areas. Tribal communities have strengths like strong community bond, positive value towards
health and a strong faith in the traditional healing systems. Close partnership should be
developed with NGOs, who are very active in the tribal areas and are doing good work. They
should be involved in the planning, management and delivery of health care services.
11
The approach to handle the tribal health problems has to be multi-pronged and area specific
and need based. This is especially important, as the tribal population of India is not
homogenous. Tribal groups are at different stages of development socially and economically
The seven states in the North East will require a very different strategy since the education
level is high in these areas and economically they are better than other tribal groups in the
country. Similarly in the in the ERG states the health of the tribal population is lower than that
of the general population.
Many of the poorly performing districts chosen by the Department of family Welfare also
cover the tribal areas/population with special schemes. However, there is a need to have
special focus on tribal areas/population, as their health/RCH status is not the same as
general population.
In order to increase utilization of health services by the tribal population some of the
innovative approaches that need to be addressed are:
•
•
•
•
•
•
Involving the community in the planning process as well as in the management and
implementation of various programs.
Using community based workers both men and women from the community as social
mobilizers, educators and provider of non-clinical Services
Involvement of local elected bodies including tribal boards
Involvement of NGOs
Promotion of tribal system of medicine, and tribal healers to be part of the health team
Initiate community midwife training.
The Tribal Health Strategy is attached at Annex 33.
3.6.4.1 Promote Community Participation
•
•
•
Training and working with Panchayati Raj Institutions: work with local political elected
bodies and bring health on the local political agenda. They need to be actively involved
in the planning and management of health care delivery system. Community based
organization should be motivated to take active part in the management of local
services.
Training Community Based Providers: To enhance the access and demand for health
among tribal population, community based volunteers from local community can play
an important role in extending outreach services at the door steps of tribal population
Because of terrain and sparsely populated areas, in the tribal villages it would be an
advantage to have a team of men and women, preferably a married couple, working
as CBD workers. This has been successfully implemented by SARTHI in 150 tribal
villages of Gujarat and SEWA-Rural in Bharuch district of Gujarat. By having a male
worker the reproductive health needs of men can be addressed. The CBD workers can
also act as depot holders for contraceptives and other health related products like IFA
tablets. ORS, DDK and sanitary pads etc.,
If community wants village health/delivery huts/ethno-medicine center to be set up in
their village to carry out routine heath activities, group meetings, IEC, conducting
1 i
•
deliveries etc., it should be done with full community involvement. Community could
either provide land for its construction or input in terms of time for its construction.
CBD workers/TBA and the local traditional tribal medicine practitioner will man these
low cost village huts.
A large network of Anganwadi workers is available in the tribal areas under ICDS
scheme, who should be involved in creating awareness and demand for services for
women and children. They must be provided in service training, supported and
encouraged to participate in the program.
3.6.4.2 Public Private partnership:
•
•
•
•
NGOs mapping should be carried out in the tribal areas and credible NGOs specially
with clinical services back up should be encouraged to take the total responsibility of
managing the RCH and health services in the sub-center/PHC/CHC where public
health system is deficient/inadequate
NGOs and corporate sectors should be encouraged to take up CBD projects covering
minimum of a population in the block and be assigned coordinating function for the
mobile health services, referral transport, awareness creation and social mobilization
Training and working with ISMPs and tribal system of medicine practitioners. They
should be provided orientation training to provide counseling services on health/RCH
services. They can provide contraceptives such as condoms and pills and refer clients
to public health facilities for lUDs/sterilization, immunization, ANC and other services
Develop good referral linkages with facilities providing secondary and tertiary level of
health care
3.6.4.5 Communication Strategy
Prioritize behavior change initiatives based on sound communication research. In order to
increase demand for RCH services, BCC strategy appropriate to tribal population should be
developed. Communication strategy needs to be based on the values, beliefs and practices
of the tribal population, with regional differences. Focus would be placed on inter personal
communication, use of tribal dialect in audio-visual presentation, involving local tribal
artists/cultural groups in IEC material planning and development.
3.6.4.6 Support to infrastructure and service delivery
•
•
Facility for emergency obstetric care at block levels, PHC levels and at sub-center to
be strengthened and the skills of public sector providers upgraded wherever available
Besides various technical training, special emphasis should be given to training on
counseling, appreciative inquiry approach to quality improvement, supportive
supervision, and infection prevention
Mobile clinic to provide curative and preventive care once a month at sub-center level
A doctor (allopathic and /or ISM&H), ANM and HW (M) will form the team. AWWs,
Sahayika, PRI, NGO and traditional tribal medicine practitioners will provide local
assistance. This clinic should follow the fixed day clinics in the area.
•
•
Revamp, equip and strengthen the existing health service facilities according to the
local health/RCH needs.
Establish mini sub-centers in limited hilly, farflung and difficult to approach areas only,
to be manned by village mid-wives/ANMs. The population norm for such mini sub
centers should be flexible and would be within the range of 700-2000. Department of
Women and Child Development has followed a similar approach for ICDS scheme in
far-flung tribal areas by establishing mini anganwadi centers for a population of 300
3.6.4.7 Human Resource development
•
•
•
•
•
•
Identify, tram and equip local tribal traditional birth attendants. In many areas
especially in difficult to reach areas TBA is the first RCH care provider for the tribal
people. They need to be trained and equipped and supported.
To promote births by skill providers, initiate on a pilot basis Community Maternity
training. Local married women to be recruited, Trained and helped to set up their
services needs to be explored.
Develop suitable human resources development policy for tribal areas that may
include relaxation of ANM qualification for ANM training at the entry level but a longer
duration of training at the ANM training schools. This proposal is subject to the
approval of the Nursing Council of India or on the approval of an expert committee
Selection for the training at District/Block level chosen from among the local tribal girls
and recruitment for employment also to be made at the distnct/block/panchayat level
Opening of new ANM School in tribal areas or conducting special batches of training of
ANMs exclusively for tribal girls at the existing ANM schools
Selection/nomination for MBBS course and recruitment of doctors and specialists
should be done at zonal/district level
Short duration training in anesthesia for MOs and such trained personnel to be posted
at FRUs. Department of FW is taking up this with the MCI
3.6.9 Program Management
•
•
Program management is important to ensure both effectiveness and efficiency of the
program. This has been a weak link so far in health sector. Support and training needs
to be ensured for public health staff in planning, supervision, monitoring and evaluation
including logistics management
Existing MIS mechanism should be reviewed to generate disaggregated data for the
tribal population/area. A proper reporting format needs to be developed and used to
reflect the activities of the village level workers.
3.6.10 Integration with other departments
•
Inter-sectoral linkages of various agencies involved in the tribal development need to
be encouraged. Efforts should be made to integrate with other departments like
forests, education, rural development for the delivery of services, especially where
public health care facilities are inadequate. Projects with integration of the other
departments need to be encouraged.
i i
3.6.11 North Eastern States
The North Eastern States comprises the eight states of Assam, Arunachal Pradesh,
Manipur, Meghalaya, Mizoram, Nagaland, Tirupura and Sikkim. These states have ahigh
concentration of tribal population but present a different set of characteristics both
demographically and geographically necessitating a separate North East initiative. The
geographic peculiarities are:
•
•
•
•
•
•
These states are cut off from the rest of India
Fragile communication networks and lack of connectivity
Constant depletion of natural resources due to natural calamities
Have shared borders with other countries making them strategically important
They have difficult and sometimes inaccessible terrain coupled with poorly developed
transportation network making them difficult to provide health services
Sparsely distributed tribal population in forest and hilly regions.
The above geographical features make them considerably difficult to provide health and RCH
services and also render the unit cost of providing services extremely high and fall outside
the norms of the rest of the regions. These regions have a large variation when viewed from
the socio-cultural viewpoint. The NE region has almost all types of physical formation,
including alluvial plains, tablelands, low hills, high mountains, narrow valleys, and flat ranges
Consequently, two distinct kinds of agricultural; practices are popular- settled plough
cultivation in the plains, valleys, and gentle slopes and jhum (slash and burn) agriculture
elsewhere. Within each state, a substantial variation is found in terms of socio-cultural setting
and the level of economic development. Each tribe has distinct customs and traditions and
varying socio-economic activities. This necessitates a separate North East Initiative for sector
reforms and improvement of service delivery.
These states exhibit a varying demographic profile and the following Table provides the
variations on some key indicators:
State
TFR
IMR
<5
Mortality
89.5
98.1
Safe
Deliveries
53.2
39.6
Assam__
2.31
69.5
Arunachal 2.52
63.1
Pradesh
65.2
89
122
Megalaya 4.57
54.7
83.6
37
Mizoram
2.89
78.7
56.1
Manipur
3.04
37.6
41.3
42.1
63.8
Nagaland 3.77
92.8
"1.87
44.2
51.3
Tripura
35.7
71
43.9
Sikkim
2.75
Source: NFHS 2 1998-99
From the above the following can be observed:
•
Institutional
deliveries
31.2
17.3
57.6
34.5
‘12.1
45.2
32
CPR
43J3
35.4
20.2
57.7
38.7
30.3
55.5
53.8
Nagaland, Manipur, Meghalaya and Mizoram is higher than All India average
II
•
The level of unmet needs are typically in the range of 35-55% except for Tripura and
Mizoram
Infrastructure and Human Resources Position
The following table provides the position of infrastructure and human resources:
State
Assam
SC
Short
fall
SC
without
building
PHC
Shortfall
PHC
without
building
CHC
Short
fall
CHC
without
building
ANM
Gapa
Add!
ANMs
posted
Gaps in
MPW
5109
Arunachal
pradesh
420"
2928
610
116
100
81
364
65
~20
manipur Meghalaya Mizoram Nagaland Sikkim Tripura
420
413
51
204
28
69
85
36
40
16
13
6
5
16
147
539
40
70
44
58
46
8
10
9
9
5
-I.22
11
13
4
2
2
19
186
60
93
54
104
30
214
39
64
35
15
49
58
38
6
58
76
4789
199
302
23
37
(ML
Gaps in
LHV
346
80
25
T
27
Though the shortage is not severe in terms of infrastructure and human resources except in
the case of Assam there needs to be a considerable emphasis in terms of developing these
in the NE and hence would require a separate initiative.
The health status of women and children also vary highly among these eight states and
hence even among the states a differential approach would be required. The service
provision and service utilization varies among the states and within states among the Urban
and Rural areas. The seeking of services from the private sector is common among
households with a relatively high standard of living as compared to the households in the
lower income strata. The service provision from the different workers of the program is low m
most states and this can be attributed to the low accessibility, difficult terrains and non
availability of transport network.
In order to increase reach and accessibility for essential and emergency care the strategies
outlined for the other tribal areas would hold good for the North Eastern states except that
these need to take into account the socio-economic-cultural variations.
The provision of infrastructure has been provided for under the Infrastructure to better utilize
the 10% allocation of budget for NE in the tenth plan outlay.
3.7
INFRASTRUCTURE
3.7.1 The existing infrastructure at the selected functional PHCs, FRUs/CHCs across the
country from 221 districts were surveyed in 1st phase in 1999 for their present status &
effectiveness and the findings have been summarized in the facility survey report
prepared in 2001 by MOH & FW. These findings have now been reviewed & discussed
in the light of ‘ensuring total safe motherhood & new born care' and it is strongly felt
that the infrastructure needs up-gradation by strengthening some of the existing
facilities and also by introducing new facilities to make these health centers meet the
need of the hour.
3.7.2 The findings of the facility survey (1999) about the key facilities in place, conducted in
760 FRUs & 866 CHCs (total no. of FRUs / CHCs - 3,077) and 7,959 of 22,928
PHCs have been summarized in the table 1 given below. Details of the existing health
centers, nationwide are given in table 2, enclosed as Annexure - 9. No facility survey
details are available regarding the existing facilities in the Sub Centres and then
effectiveness.
SI.
No.
FACILITY
Availability
In FRU
17" Own buildings
98 %
OT
~
2.
93 %
3.
Labour room
36 %
Over head water storage tank & pump
82 %
Blood
bank
/
BSF
/
Linkage
with
D
BB
17 %
5.
Diesel Generator
71 %
| 6.
80 %
7.
Telephone
2 %
Computers
___________________
873 %
vehicle
[
t_Functional
_________________________
Table 1 - Summary of findings of the facility survey 1999.
Availability
In CHC
96 %
86 %
28 %
71 %
Availability
In PHC
92 %
28 %
92%
52 %
62 %
20 %
2 %
61 %
29 %
62 % of the PHCs surveyed are having water supply facility only but not having
storage tanks & pumps, etc.
11
Note: Many EAG states have informed that no Facility Survey has been done in
their states after 1997. Data available from the Facility Survey done in 1997 is
being used in this document.
3.7.3 Extension of Existing Facilities
After deliberations, it is proposed that all of these essential facilities are to be
introduced in a phased manner in the remaining centers, in RCH - II. prioritizing the
EAG states.
3.7.3.1
New Construction
It is proposed that 8,092 new Sub-Centres are to be constructed in the EAG states
and North-East states in a phased manner during RCH - II. Details are given in the?
table 3 enclosed as Annexure -7. No new construction of buildings for new FRUs.
CHCs and PHCs even in the EAG states is proposed in RCH - II.
The proposed new Sub Centre shall be of approx. 73.5 sqm area including the ANM
residential quarter. The construction should be a RCC framed structure and shall
have ordinary internal and external finishes. The typical lay-out plan for the proposed
sub centre including ANM quarter is enclosed as Annexure - 6
The estimated unit cost as in Mar’ 2003, for constructing Sub centres including normal
internal & external finishes, electrical conduits & wiring, plumbing & sanitary works,
etc based on the CPWD plinth area rates ( 1992 ) works out to be Rs. 5.13 lakhs
(excluding the cost of land) @ Rs. 7,000 per sqm of construction. However it may be
noted that the unit cost of construction, especially in NE states may vary depending up
on the location, availability of construction material, method of construction, etc
Further, the rates do not include the natural escalation, which needs to be added for
the lapsed period @ 5 % per year at the time of construction Details of unit rate per
sqm., derived from CPWD plinth area rate ( 1992 ) basis is enclosed as Annexure
12. The total financial implications of this proposal are given in table 4 enclosed as
Annexure - 15.
3.7.3.2
Operation Theatres
Operation Theatres are essentially required for managing high risk deliveries and foi
emergency obstetric care and at present OTs are available in only 90 % of the
CHCs/FRUs (refer table 1). It is proposed that at least one OT should be provided in
the balance 10 % of the 1,423 FRUs/CHCs ( 180 in NE states and 1,243 in EAG
states, i.e. 143 nos.
The proposed OT shall be of approximately 27 sqm area with ordinary finishes and
shall have additional area of approx. 57 sqm for patient preparation, doctor changing
(Male & Female), Post operative area, Scrub area, store, disposal area, etc. Further it
is proposed to provide air-conditioning for this OT as it is required for - controlling the
1i
concentration of harmful bacteria, preventing infiltration of less clean air in to the OT
creating an air flow pattern that carries the contaminated air away from the OT Air
conditioning further helps in maintaining a comfortable environment for the patient am:
operating team. Installing a 10 TR package type AC system along with Microvee
filtration, booster fan, etc can do this air-conditioning.
The typical lay out plan for the proposed Operation Theatre and service area is
enclosed as Annexure - 8. The OT and service area as per the layout enclosed can
easily be integrated with the existing hospital set-up with out much difficulty The
centre specific OT layout can be finalised at the time of construction, in consultation
with the center in-charge. Once these Operation Theatres are commissioned, they
should be regularly monitored with respect to air flow/air circulation, to prevent
infection.
The estimated unit cost for setting up of above explained OT & service area, based on
the CPWD plinth area rates (1992) works out to be Rs. 6 lakhs (excluding cost of land
) @ Rs. 7,350/- per sqm for OT area & Rs. 7,000/- for non-OT service area. Details ol
unit rate per sqm., derived from CPWD plinth area basis ( 1992 ) are enclosed as
Annexure - 12 & 13. Similarly the estimated unit cost of providing AC as explained
above is about Rs. 4 lakhs. These rates do not include the natural escalation, which
needs to be added @ 5 % per year at the time of construction. However it may be
noted that the unit cost of construction, especially in NE states may vary depending up
on the location, availability of construction material, method of construction, etc. The
total financial implication for setting up OTs is explained in the table 4 enclosed as
Annexure -15.
However it may be noted that the remaining 165 FRU/CHCs nation wide too shall be
provided with OT facility to achieve the goals set in the ROH - II program. The total
financial implication for setting up OTs is explained in the Table 6 enclosed as
Annexure -17.
3.7.3.3
Labour room
Labour rooms are required for ensuring safe motherhood and also for providing
round the clock delivery services. At present labour rooms are existing at 36% ol
FRUs, 28 % of CHCs and 28 % of PHCs only. In ROH - II it is proposed to have
labour rooms set up in all the balance FRU/CHCs (968 nos) & 50 % of PHCs (4,524
nos) in EAG states and NE states.
The proposed Labour room for FRU/CHC shall have an approx, area of 55.7 sqm
with space for Septic delivery room, Aseptic delivery room, Toilet, disposal, etc. The
typical layout plan for the proposed Labour Room for FRU/CHC is enclosed as
Annexure - 10. Similarly labour room for PHC, shall be of approx 29 sqm with similar
facilities. Once these labour rooms are commissioned, they should be regularly
monitored for infection control.
I j
The estimated unit cost for setting up a labour room for a FRU/CHC and PHC as
explained above, based on the CPWD plinth area rates (1992) works out to be Rs. 4
lakhs & 2.1 lakhs respectively (excluding cost of land) @ Rs.7,000 per sqm. Details of
unit rate per sqm derived from CPWD plinth area basis are enclosed as Annexure
12. The rates do not include the natural escalation, which needs to be added @ 5 0
per year at the time of construction. The total financial implication for setting up labour
rooms as proposed above is given in the Table 4 enclosed as Annexure - 15.
However it may be noted that the remaining 1,125 FRU/CHCs and 3,731 PHCs (only
50 % of PHCs where 24 hours delivery facility is proposed) nation wide too shall be
provided with labour room facility to achieve the goals set in the RCH - II program.
The total financial implication for setting up these labour rooms is explained in the
Table 6 enclosed as Annexure -17.
3.7.3.4 Over head water storage tanks
For smooth functioning of OTs, Labour rooms and other mother & child care services
at the centres, it is very important to ensure uninterrupted water supply. Round the
clock water supply can be ensured by installing overhead/terrace water storage tanks
(may be of readily available HOPE tanks) of sufficient capacity, at least to cater for
day storage, pumps for filling these tanks from the source, Under ground storage tank
of same capacity (wherever required) and distribution piping network (may be ol
Galvanized Iron pipes or PVC pipes). The typical schematic diagram of this proposed
facility is enclosed as Annexure -11.
At present this uninterrupted water supply facility is available in 82 % of FRUs and 71
% of CHCs only. In RCH -II it is proposed to have this facility in the balance 708
FRU/CHCs nationwide. Further it is recommended that the water should be tested
periodically for it’s purity & safe usage and proper treatment should be given if found
necessary.
The estimated unit cost for having this facility in FRU/CHC works out to be Rs. 2 lakhs
(refer Annexure - 14). The total financial implication for having this facility is given in
the Table 4 enclosed as Annexure - 15.
3.7.3.5
Linkage with district Blood banks/Blood Storage Facility
Having own blood storage facilitiy and/or a linkage with the existing district blood bank
is essential for the health centers for ensuring safe, proper and sufficient blood supply
to meet the demand round the clock. At present only 17 % of the FRUs and 9 % of the
CHCs are having this linkage facility with the district blood banks. About 1,700 FRUs
have been provided with Blood storage facility also.
In RCH - II it is proposed to extend this facility to all the balance FRUs & CHCs in
Further necessary steps are to be taken to link these
EAG states (1,238 nos).
I i
FRUs/CHCs with respective district blood banks, the facility which can serve as
standby.
Supplying Blood Bank Refrigerator can create Blood storage facility with temperature
range of 4 C, capable of storing minimum 60 bags of unwrapped 450 ml blood along
with Line Voltage Corrector/Stabilizer. An area of approx. 1.5 m x 1 mts is required for
installing this refrigerator, which require 0.5 kva power from a 15 amp. Socket. Apart
from the refrigerator, other components like centrifuge, VDRL shaker, etc is required
for proper storage of blood bags. The estimated unit cost for supplying this refrigerator
works out to be Rs. 0.80 lakhs (Blood bank refrigerator - 0.65 lakhs, Centrifuge - 0.05
lakhs, VDRL shaker - 0.04 lakhs, other minor accessories - 0.06 lakhs). The rates
considered are as of Feb; 2003 and proper escalation shall be considered at the time
of installation. The total financial implication for having this facility is given in the table
4 enclosed as Annexure - 15.
However it may be noted that the remaining 1,439 FRU/CHCs nation wide too shall be
provided with blood storage facility achieve the goals set in the RCH - II program. The
total financial implication for setting up blood bank refrigerator is explained in the table
6 enclosed as Annexure -17.
Further it is proposed in RCH - II to install walk in deep freezer/cold room for storage
of vaccine, drugs, etc in all the existing district hospitals in a phased manner
prioritizing the EAG states. This should be included in the MoU to be signed with
states.
3.7.3.6
Diesel Generator
Diesel generators are required for ensuring emergency power supply in case the
normal supply fails. At present 71 % of FRUs and 52 % of CHCs are having DG sets.
For ensuring round the clock mother & child care, & for conducting 24 hours deliveries,
in RCH - II it is proposed to have DG sets in all the balance FRU/CHCs (555 nos) and
50 % of the PHCs (6,283 nos) in EAG and NE states.
It is proposed to install a 10 Kva DG set for FRU/CHC to take care of emergency
equipment and lighting load. Similarly a 5 Kva DG set is proposed for PHCs The
estimated unit cost of providing a 10 Kva DG set for FRU/CHC along with necessary
cabling, works out to be Rs. 2 lakhs and similarly a 5 Kva DG set for PHC, works out
to be Rs. 1 lakhs @ Rs. 20,000.00 per Kva. The rates considered are as of Feb; 2003
and proper escalation shall be considered at the time of installing the DG sets. The
total financial implication for setting up DG facility is given in the table 4 enclosed as
Annexure - 15.
However it may be noted that the balance 645 FRU/CHCs nation wide too shall be
provided with generator facility to achieve the goals set in the RCH - II program. The.
total financial implication for installing DG sets is explained in the table 6 enclosed as
Annexure -17.
i J
3.7.3.7
Telephone connections
It is felt that Telephone connections for health centers are very much essential
because of their great help to the patients besides improving connectivity among
service providers and administrators.
At present 80 % of FRUs, 62 % of CHCs and 20 % of PHCs are having telephone
connections. In RCH - II, it is proposed to extend this facility in all the balance
FRU/CHCs in EAG & NE states @ 2 connections per center.
The estimated unit cost of having 2 connections for FRU/CHC works out to be
Rs.6,000.00 per center and Rs. 3,000.00 for PHC. The total financial implication for
getting telephone connections as explained is given in the table 4 enclosed as
Annexure - 15.
However it may be noted that the balance 480 FRU/CHCs and 18,343 PHCs
nationwide too shall be provided with these telephone connections, to achieve the
goals set in the RCH - II program. The total financial implication for installing DG sets
is explained in the table 6 enclosed as Annexure -17.
3.7.3.8
Computerization
It is needless to mention that computerization of the existing health centers is the most
sought-after facility because of it’s numerous applications ranging from assessment &
maintenance of supply needs, consumption records, stock balances, maintaining
records of distribution of contraceptives, sale receipts, clinical cares referred by RHPs.
running effective Management Information System, etc.
At present only 2 % of the FRUs and CHCs are provided with computer facility
(practically negligible) and in RCH - II, it is proposed to computerize all the 1,243
FRUs/CHCs, in the EAG states by providing a computer & peripherals along with
necessary software.
The estimated unit cost of providing computer facility works out to be Rs. 0.70 lakhs.
The total financial implication for computerization as explained above is given in the
table 4 enclosed as Annexure - 15.
However it may be noted that the remaining 1,834 FRU/CHCs nation wide too shall be
provided with computers to achieve the goals set in the RCH - II program. The total
financial implication for providing these computers is in the table 6 enclosed as
Annexure -17.
IJ
3.7.3.9
Vehicle/Ambulance
Vehicles are very much essential to ensure transport readiness for both mother &
child, to shift emergency cases from house to center, center to center, etc and also for
the mobility of service providers.
At present 73 % of the FRUs, 69 % of CHCs and 21 % of PHCs are having this vehicle
facility. In view of the increasing demand, it is proposed in RCH - II to extend this
facility by outsourcing to private vehicles on hourly/daily basis as the case may be in
all the balance FRU/CHCs in EAG states only.
The estimated unit cost for outsourcing vehicles in 5 years period for a FRU/CHC
works out to be Rs. 3 lakhs (assuming 10 requirements a month @ Rs. 500/- per
requirement ). The total financial implication for extending this facility as explained
above is given in the table 4 enclosed as Annexure - 15.
3.7.4 New Facilities Proposed in RCH - II
Further it is proposed that the following new facilities are also to be introduced
nationwide in RCH - II, in a phased manner in the already existing
FRUs/CHCs/PHCs/Sub Centres as the case may be prioritizing the EAG states
3.7.4.1
New Born Care Corner
The studies conducted to evaluate the facilities in place, particularly for new born care
& child health during RCH - I reveal that these facilities are unimpressive and also
having poor coverage. It has been observed that ‘new born baby care' - total care foi
newly born child is completely not available. Even the care given to children suffering
from Diarrhea, ARI, etc is found to be poor at Sub Centre level.
Similarly at PHC/CHC level, the existing facilities for proper care of in-born neonates,
out patient care and pre-referral treatment of sick neonates and children below 5 years
of age, etc are of poor state and also having poor coverage. It is the case with FRUs
where the existing facilities for care of in-born and referred neonates are insufficient
Apart from the above, it is found that the awareness and infrastructure available for
Feeding, Immunization, Vitamin A Prophylaxis, etc are also having less significance &
poor coverage.
In view of the above, keeping the importance of new born care & child health in
population stabilization, it is proposed in RCH - II to develop specific New Born Care
Corners in all the 1,243 FRU/CHCs and 50 % of 10,775 PHCs in the EAG states.
This New Born Care Corner (NBCC) shall preferably be an enclosed area of approx.
30 sqm for a FRU/CHC and 15 sqm for PHC, with partition walls/curtains, facility for
water & power supply etc. This area should be developed within the existing hospital
ii
set up by making certain alterations/modifications in the existing rooms/areas Tht
area should be so selected that it causes minimum damage/disturbance to the existing
set up. The estimated unit cost for developing a NBCC (for Civil & related works only
at a FRU/CHC works out to be Rs. 0.4 lakh and for PHC, Rs. 0.20 lakhs. The total
financial implication for creating this new facility as explained above is given in the
table 5 enclosed as Annexure - 16.
However it may be noted that the remaining 1,834 FRU/CHCs and 50 % of the
balance PHCs nation wide (6,077 nos) too shall be provided with New Born Care
Corners to achieve the goals set in the RCH - II program. The total financial
implication for setting up OTs is explained in the table 6 enclosed as Annexure -17
3.7.4.2
Hospital Generated Waste Management / Infection Control
Various studies conducted so far have reveled that bio-medical waste generated from
different units of hospital/health centre can cause serious health hazards which could
also extend beyond the campus of the hospital/health centre to both personnel
providing support services to the hospital and medical establishment and even to
common people exposed to improperly handled bio-medical waste.
Operation theatres, Laboratories, OPD, Labour rooms, Treatment rooms, wards, etc
are the common areas from where infectious bio-medical waste is generated.
Keeping in view the urgent need for effective & safe waste management & infection
control, it is proposed in RCH - II to introduce Hospital Waste Management System in
the existing health centers nationwide.
This waste management system shall broadly comprise waste identification, collection
in colours coded collection bags and collecting bins/containers, transportation by
convenient means like trolleys, etc and disposing off as per the existing facilities like
land filling, etc. Apart from the above, needle destroyers, Autoclaves for sterilization of
surgical instruments may also be provided at FRU/CHCs.
To start with, it is proposed to introduce this system in all the 631 FRU/CHCs and
3,786 PHCs in Non-EAG states nationwide excluding the NE and SHSDP states.
The estimated unit cost of introducing this system is about Rs. 5 lakhs (collection bins
& trolleys - 1 lakh, Autoclave - 3 lakhs, Needle destroyer - 0.50 lakhs, Preparation of
Land fill - 0.50 lakhs) for FRU/CHC. Similarly, estimated unit cost of introducing this
system is about Rs. 1.5 lakhs (collection bins & trolleys - 0.5 lakh, Needle destroyer
0.50 lakhs, Preparation of Land fill - 0.50 lakhs) for PHC. The total financial
implication for introducing this new facility as explained above is given in the table 6
enclosed as Annexure - 17.
i1
3.7.4.3
TV, VCD I CD Player
In RCH - II it is proposed that TV, VCD/CD players shall be supplied to various health
centers for mass communication. Further it is proposed that CDs would be produced
on reproductive & child health care and messages be transmitted through supplied
electronic media at these centres.
To start with this new facility it is proposed that all the existing 1,423 FRU/CHCs in the
EAG & NE states shall be provided with TV & VCD players in RCH - II.
The estimated unit cost of supplying this TV & VCD/CD player works out to be Rs.
0.25 lakhs and the total financial implication for introducing this new facility as
explained above is given in the table 5 enclosed as Annexure - 16.
3.7.5 After analyzing the status and degree of maintenance of existing
facilities at various FRUs, CHCs PHCs and SCs, nationwide, the following actions are
further proposed to be considered for implementation in RCH - II.
3.7.5.1
Maintenance of Existing Facilities
It is felt that some of the FRU/CHCs, PHCs and Sub Centres need proper repairs &
maintenance for making them more suitable for providing quality services.
The estimated unit cost for these repair & maintenance work (which includes repair of
plaster, flooring, doors & windows wherever required, painting, replacing minor fittings
& fixtures, etc) for a period of 5 years works out to be Rs. 10 lakhs for FRU/CHC, 5
lakhs for a PHC and 0.5 lakhs for sub center.
It is proposed to include this Repair & Maintenance of the existing centers, in the MOU
to be signed with the states.
3.7.5.2
Up-gradation and Renovation of staff quarters
In RCH - II, it is proposed to renovate & up-grade the existing staff quarters
(especially nurses residence & doctors residence at the centers where 24 hour
delivery facility is made available) nationwide with a total estimated cost of Rs. 2.500
lakhs in a phased manner prioritizing the EAG states. Further it is proposed to include
this up-gradation & renovation of the existing staff quarters, in the MoU to be signed
with the states.
Ii
3.8
NGO Involvement
3.8.1 NGO Involvement
INTRODUCTION
The National Population Policy (NPP) 2000 emphasizes the commitment of the Government
of India (Gol) to voluntary and informed choice in family planning and reproductive health
care services. The NPP 2000 provides strategies for addressing the reproductive and child
health needs of the people and achieve net replacement levels (TFR) by 2010. The purpose
is to increase access and coverage of a comprehensive package of reproductive and child
health services, including family planning. To achieve this purpose, the Government, the
corporate sector and the voluntary and non-government sector are expected to work together
in partnership.
The NPP 2000 lists partnership with NGOs as one of the strategic themes. The Action Plan
mentions the objectives of the collaboration. The work of NGOs is essentially supplementary
and complementary in nature to that of the Government. NGOs have a comparative
advantage of flexibility in procedures, and rapport with the local population. The Gol therefore:
proposes to involve NGOs in using strategies for expanding access to health services.
The Department of Family Welfare (DoFW), Gol, envisages collaboration with NGOs through
state governments. The Mother NGO (MNGO) Scheme and the Service NGO Scheme are
expected to facilitate this process. Both the schemes focus on partnerships between the
government and NGOs for improving ROH service delivery. Indicative service delivery
guidelines for the different ROH components are outlined.
The Department of Family Welfare in the Ninth Five Year Plan (1997-2002) introduced the
Mother NGO scheme under the Reproductive and Child Health Program. Under this scheme,
the DoFW identified and sanctioned grants to selected NGOs called Mother NGOs (MNGOs)
in allocated district/s. These MNGOs, in turn, issued grants to smaller NGOs, called Field
NGOs (FNGOs), in the allocated district/s. The grants were to be used for promoting the
goals/objective as outlined in the Reproductive and Child Health Program of Gol.
The underlying philosophy of the scheme has been one of nurturing and capacity building
Broadly the objectives of the program are:
•
•
•
Addressing the gaps in information or RCH services in the project area.
Building strong institutional capacity at the state, district/ field level.
Advocacy, awareness generation.
In keeping with the philosophy of capacity building, four NGOs had been identified as
Regional Resource Centers (RRC) to provide technical support to the MNGOs.
The lessons learned over the past three years have indicated that modifications need to be
Ii
made in scheme. These are in terms of decentralization, simplification of fund disbursal
process, rationalization of jurisdiction, and interface with local government bodies.
Additionally, it was found that involving the NGOs in service delivery and addressing gender
issues cross cutting the RCH service areas would be required to make the program moreeffective.
Scheme Components
In addition to capacity building and nurturing small NGOs, the scheme focuses on addressing
the unmet RCH needs. This is possible by involving NGOs in delivery of RCH services, in
areas, which are under served or un-served by the government infrastructure. Accordingly.
NGOs are expected to move from exclusive awareness to actual delivery of RCH services.
Un-served and under served areas are those socio- economic backward areas, which do
not have access to health care services from the existing government health infrastructure,
especially urban slums, tribal, hill and desert areas including SC/ ST habitations.
In specific terms theses are areas: where the post of MO, ANM &LHV have been vacant foi
more than 1 year; the PHC is not equipped with minimal infrastructure; performance on
critical RCH indicators is poor.
Additionally, interventions are expected to address gender issues. Proposed interventions
must seek to enhance male involvement and partnership in improving the reproductive health
status of women and children. The interventions must also include adolescent population
Community needs to be adequately mobilized to generate demand for RCH services.
Greater emphasis on service delivery means that the service providers are able to
measure outcomes concretely. Hence, the role of MNGO becomes one of an active
facilitator and manager of the project and not only a fund distributor.
A decentralized approach is adopted in the management and implementation of the MNGO
Scheme. This means that the State RCH society is implementing the scheme. The MNGOs
are members of the District RCH Society.
The role of Government of India is one of policy guidance, funding and technical support.
In order to optimize results, the NGO is expected to complement and supplement the
government health infrastructure and not substitute it. The NGOs efforts are more effective
by developing linkages with local governments, related government departments, and
establishing networks with technical and resource institutions.
Rationalization of jurisdiction is done with a view to enable the NGOs to provide in-depth
service in the project areas and optimize resources. The project duration of three years is
extendable to five years, which facilitates long term planning and stable implementation.
a
Role of MNGOs and FNGOs
FNGOs under the MNGO Scheme are involved in service delivery, in addition to advocacy
and awareness generation. The key service delivery areas under the MNGO Scheme are:
- Maternal and Child Health
Family Planning
- Adolescent Reproductive Health
- Prevention and Management of RTI
•
Some MNGOs have expertise in various aspects of development but limited expertise
in the health sector. In order to provide hands on experience in implementing RCH
service delivery interventions to MNGOs, the scheme provides funds to MNGOs for
implementation of demonstrative service delivery projects in the allotted areas. The
scope and scale of the project is comparable to that of the FNGO project.
•
To facilitate implementation of service delivery projects by FNGOs, the MNGOs must
have a dedicated team of staff including Project Director with project management
experience (preferably with regard to health/RCH), and qualified trainer
•
The MNGO cannot simultaneously apply as a Service NGO(SNGO) since these are
two distinct functions.
The Role of the MNGO include the following functions:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Identification of un- served & under served areas
Release of advertisement, identification and selection of FNGOs
Motivate NGOs, CBOs, SHGs & other local level bodies in case of non-availability of
suitable FNGOs.
Development of base line data through CNA and end line project data
Impart project orientation to FNGOs
Development of proposal with output and process indicators for approval.
Provision of IEC materials to FNGO
Capacity building of FNGOs
Technical support to FNGO for induction and in-service training of project staff
• Ensure that qualified staff is appointed by FNGO according to the job requirement and
support their search for the same through development of TOR. information on
resources.
Wherever possible, inclusion of groups such as DWACRA, Mahila Smakhya, NYK, SWA
Shakti in the FNGO orientation and frequent interaction.
Liaison, net work and coordinate with state and district health services and Panchayati
Raj Institutions, linkages with other NGOs and technical institutions
Monitor performance of FNGOs and progress of the project through supportive
supervision
Exchange and share learning and experiences with other MNGOs in the state and region.
Work closely with RRCs and State NGO Coordinator.
Ii
•
•
•
Document best practices
Submit quarterly financial and project progress reports to State RCH Society and District
RCH Society.
Submit statement of expenditure & utilization certificates as per MOU
The Role of FNGOs include the following functions:
•
•
•
•
•
•
•
•
•
•
Conduct Community Needs Assessment
Develop proposal based on baseline data
Provision of RCH services as proposed.
Interaction for convergence with ICDS, rural development and anganwadi initiatives.
RCH orientation to PRI members, DWCRA groups, members of Mahila Samakhya, NYK,
SWA Shakti , Mahila Swasthya groups
Share information on the type of services that can be availed from the government health
infrastructure
Create conducive working environment for the ANM
Facilitate the monthly RCH camps conducted by the PHC through mobilization of
community
Timely submission of quarterly progress reports, utilization certificates etc as per
agreement to the MNGO
Documentation and maintenance of records and registers
Institutional Framework
GOI
Government of India provides support through policy guidelines and release of funds to
State RCH Society.
Regional Resource Centers (RRCs):
Technical support for MNGO capacity enhancement, documentation of best practices,
induction and in-service training, liaison with the state government, updating data base on
RCH issues and development of MIS is provided by Regional Resource Centers and other
technical institutions as found necessary. This is expected to complement the technical
support decisions made by the state RCH society.
Apex Resource Cell (ARC): Located within the NGO division, the ARC will coordinate the
activities of all the RRCs, manage budgets, and facilitate RRC coordination and interaction
with state governments.
Regional Director (RD)
1. Receive all applications from MNGO applicants and conduct Pre Scrutiny/desk review
of all applications, based on checklist.
I i
2. Provide the collated information on the NGO applications to the state RCH society and
convene the meeting of the State NGO Committee till the State NGO coordinator is
identified and placed.
3. Participate in the review of applications as a member of the state RCH society.
4. Undertake field visits if required and submit tour reports to State Secretary (FW) & AC
(NGO) GOI.
State RCH/FW Society
The State RCH/FW Society constitutes a technical NGO Committee, called the State NGO
Committee and ensures the placement of State NGO Coordinator. From selection of MNGOs,
fund disbursement, capacity building, training, monitoring to evaluation, is the responsibility 01
the State RCH society.
State NGO Committee
The State NGO coordinator convenes the meeting of the State NGO committee, chaired by
the Secretary (FW) or his nominee. Till the time the state NGO coordinator is identified and
gets placed, the Regional Director convenes the NGO committee meetings. The presence of
GOI representative, RD and State NGO Coordinator is mandatory. The RRC and Director
(FW) are also members of the Committee.
For review of NGO applications:
• On receiving the pre-scrutiny/desk review reports from the RD s office, the State NGO
Committee convenes a meeting for review of NGO applications and prepares agenda
• Invite Secretary (FW) and other members of the committee to attend the meeting.
• Prepare minutes and decision taken. Communicate the same to GOI and respective
NGOs
The primary responsibilities of the State NGO Committee are:
•
•
•
•
Selection of MNGOs.
Release of grant -in -aid as per agreement.
Monitoring of MNGOs.
Organize meetings to review the MNGO performance from time to time and ensure timely
release of funds.
•
•
•
Commission MNGO Evaluation through external evaluating agency.
Send utilization certificates to GOI.
Act as arbitrator in case of dispute.
State NGO Coordinator
•
The full time NGO coordinator is responsible for management of the DoFW supported
NGO schemes, including the MNGO Scheme.
I 1
•
The roles and responsibilities of the NGO coordinator are one of liaising, coordinating and
supporting the MNGOs.
District RCH Society
The District RCH Society constitutes a technical committee called District NGO Committee
for selection and approval of FNGOs and MNGO projects.
Functions:
-
Select and approve FNGO projects.
Approve and sanction the MNGO project proposal based on FNGO projects.
Facilitate the signing of MOU between the MNGO and the District RCH Society
Send the signed MOU to State RCH Society for release of funds and inform
Gol.
Undertake review meeting to assess performance of FNGOs & MNGO.
Inter-Departmental Linkages:
NGOs under the MNGO scheme are expected to network with PRIs, women's groups
including self-help groups, youth networks, teachers, parents and other members in the
community.
SERVICE NGO SCHEME
Introduction
NGOs with an established institutional base and delivery infrastructure are encouraged to
complement the public health system in achieving the goals of the RCH program. Any NGO
that is engaged in directly providing integrated services in an area co-terminus to that of a
CHC/block PHC with 1,00,000 population (approximately 100 villages or more) is called a
Service NGO. Service NGOs are expected to provide a range of clinical services directly to
the community. For example, services for safe deliveries, neo-natal care, treatment of
diarrhea and ARI, abortion and IUD services, RTI/STI etc. These services must reach out to
male and female population in all age groups. In order to provide these services effectively,
the applicant NGO must have appropriate staff, infrastructure such as clinic/hospital,
ambulance etc.
This NGO Scheme, called the Service NGO Scheme, is expected to promote the
achievement of the RCH objectives in the areas, which are un-served, or under served by the
public health services and infrastructure and complement the MNGO Scheme. SNGOs differ
from MNGOs in terms of their scope and coverage of work. SNGOs can provide a range of
clinical and non-clinical services, directly to the community while the MNGOs provide through
the FNGOs. While FNGOs can take up a particular service delivery area, SNGOs are
expected to provide an integrated RCH services. The SNGO may be provided with a non
recurring one-time grant for infrastructure improvements as required whereas FNGOs are nol
eligible for this.
The SNGOs provide the following comprehensive range of clinical and non-climcal services in
the following RCH areas:
The SNGOs implement large-scale projects in the key RCH service areas covered under the
MNGO Scheme viz. Family Planning, (such as setting up of IUD clinics), Adolescent
Reproductive Health, Maternal and Child Health, and RTI. Additionally, SNGOs can take n
other areas such as MTP services, and Dai Training. SNGO proposals for service
delivery in emerging RCH areas such as Gender based Violence, and Male Participation will
be encouraged. Gender and community mobilization processes are expected to be cross
cutting in all aspects of service delivery. Community needs to be adequately mobilized tc
generate demand for RCH services.
The institutional framework remains the same for the FNGO scheme as has been already
spelt out for the MNGO/SNGO schemes.
The GOI has framed guidelines for involvement of NGOs in the various schemes to facilitate
the state governments. These guidelines set out the processes and details out involvement
3.9 Behavior Change Communication Strategies (BCC)
3.9.1 Objective in RCH I
The objective of this component in the RCH I project was to improve health and care-seeking
behavior among target populations and increasing community participation and responsibility
for reproductive and child health; The thrust of Behavioral change strategies was to improve
interpersonal communication (IPC) skills of frontline workers in order to motivate clients, and
social mobilization at the field level to ensure community support for RCH.
3.9.2 Experience in Implementation
The first task was to develop a RCH Communications Strategy that would be applicable
nationwide to bring about change in health and care-seeking behavior among targel
populations. This was a time-consuming process and evolved through a series of meetings
and consultations.
The key Strategy Directions identified were interpersonal communication (IPC), advocacy
interventions to promote behavior change, decentralization of some responsibilities, capacity
building at all levels, and increased engagement with NGOS and private sector professional
agencies for social mobilization for RCH. The distinct and different roles of the Center. States
and Districts were also articulated in the National Communication Strategy for RCH and a
matrix prioritizing the RCH Behavior Change issues in the area of meeting unmet need foi
contraception, improving maternal health, and raising chances of child survival was also part
of this Strategy.
As a parallel measure, a major BCC program for social mobilization for RCH in the districts
through the Zila Saksharta Samities (ZSS) was initiated by MOHFW. Till date, 227 districts
(ZSS) have been given funds ranging between Rs 3 -5 lakhs per district and totaling Rs 8.96
crores. The experience with ZSS has been uneven and not satisfactory and the scheme was
discontinued. The need for a decentralized social mobilization effort for RCH. however,
remains a priority.
Capacity building among BCC personnel at all levels has been a significant initiative as well
Two training programs in BCC planning and management have been conducted at NID
Ahmedabad for MOHFW and State-level BCC officers. NIHFW has developed curricula for
district and block-level BCC personnel and training programs have been conducted through a
number of institutions identified by NIHFW. Apart from that, Interpersonal Communication
Skills (IPC) has been introduced as a component in the foundation-training program of all
categories of healthcare service delivery staff under the RCH program. However, staff
vacancies and lack of appreciation of BCC at the State Family Welfare Department often
nullified the training effort. A thorough evaluation of the NIHFW-coordinated BCC training
effort is being planned as one of the studies to assess the RCH project. Capacity building of
healthcare personnel in BCC, particularly in IPC, and understanding the behavior change
approach should form a key component of RCH II.
Consistent with the effort at developing the RCH Communication Strategy, initiatives were
taken by MOHFW to induct private sector professionals in mass media materials production
Feature films, radio serials, Interactive Panel Discussions, TV Spots and Hoardings were
some of the activities under RCH that have been tried so far. Also, mass media buying
through a private agency was initiated after following due procedure of the World Bank. Some
of the experience has not been satisfactory but overall the engagement with private
professional agencies has improved the focus and quality productions and utilization of mass
media.
The National RCH Communication Strategy emphasized the need for decentralization of
some responsibilities for Communication to the States. This need is also borne out by the
poor performance of the ZSS scheme owing to lack of supervision and ownership by the
States. In view of these reasons a scheme was envisaged as part of the restructuring of the
RCH Project during the mid-term review in November 2000 where funds were allocated to
low-performing States to execute BCC activities over the remaining period of the RCH
Project. The scheme presumed that the Communication activities will be based on a specific
strategy and the States following the priorities highlighted in the National RCH
Communication Strategy would develop action plan. Financial support was provided for a
range of Communications (BCC) activities based on the priorities defined by the States.
Broadly, these activities could be grouped under the following heads:
a) Mass media - radio and TV dissemination (with limited production activities) through
AIR/Doordarshan;
11
b) Outdoor publicity, mainly hoardings, bus panels and other urban outdoor medi<
vehicles;
c) Rural publicity through wall writings, posters, exhibitions, banners and displays in fair1
and festivals, and folk media performances; and
d) Interactive group processes like orientation camps, community events and grou;
meetings. This approach has been taken further under the special scheme for EAG
States.
The experience so far has not been satisfactory with the States lacking adequatunderstanding and/or interest as well as the professional support to plan and execute the
scheme. In RHC II States will have to take this up urgently and MOHFW will have to provide
the necessary support for it.
3.9.3 Approach for RCH II - Behavioral Change Strategy Component
Based on the experience of implementation of BCC in RCH, the validity of the National
Communication Strategy for RCH is re-affirmed. Some additional issues that have emerged
since the strategy was formulated like the Supreme Court ruling on publicizing the PNDT Act
and the findings of Census 2001 on adverse sex ratio in different states will require inclusion
in the matrix of priorities. Similarly, the new additional priorities of RCH II like Adolescent
Health, Urban Primary Health Infrastructure and RCH Services in Tribal Areas will have to be
taken note of in the planning process. The emphasis on the holistic approach to maternal
care and newborn care also needs to be provided adequate emphasis. The new initiatives to
provide facilities and services require a strategic behavior change approach and a clear
understanding of the difference between Behavior Change communications and Behavior
Change Strategy needs to be comprehended. The success of achieving the desired
outcomes on Maternal Mortality Rates and Infant mortality Rates and overall well being of the
mother and child would require emphasis on the processes and facilities to be widely
communicated, understood and practiced by the target groups. Hence, context of Behavior
Change Communications in RCH II would be closely linked with the desired behavior change
to be brought about and the appropriate strategies for the same.
Behavior Change Communication itself needs to be understood in the right context. More
often than not Behavior Change Communications is associated with awareness or
Information Education and Communication. BCC is a dynamic process, which involves an
exchange or sharing of ideas, information, attitudes, beliefs, myths and misconceptions and
practices.
BCC uses multiple channels to transmit and reinforce messages that addresses well defined
target groups to change the current behavior to the desired behavior by providing the people
the skills and tools required to bring about better maternal and child health and creates a
supportive environment that helps people to adopt and maintain the desired behavior foi
Ii
better health outcomes. Hence, BCC is a process that promotes positive change in the
individual and the environment.
Effective communication is based on:
•
•
•
•
•
•
A thorough understanding of the behavior of the people responsible for poor health
outcomes, the knowledge, practices, beliefs, myths and misconceptions, value
systems, cultural and religious practices, educational levels.
A clear idea regarding the changes that needs to be brought about and the process
that can best bring about such changes
An understanding of the messages that needs to be provided to bring about the?
changes
The mediums and media mix that can effectively bring about the change process
An analysis of who can be the key influencers and involving such influencers in the,
communication strategy
Development of materials, which can be used to enhance the effectiveness of the
communication and also serve the purpose of reinforcement
BCC provides empowerment and skills to the individuals to make changes, creates a
supportive environment in which the individuals can make and sustain the changes and uses
multiple channels/interventions to reach the individual.
The founding principles of BCC are that it needs to be responsive to the needs of the target
group (population segments for which it is meant for), clearly provides the linkage with
services available uses a coordinated multi-pronged approach
Behavior Change Communication requires regular monitoring and tracking of the
communication process. Audiences are placed on a continuum of behavior change
becoming aware, improving understanding through repeated exposure, openness to trial oi
new behavior, experience of the product/services, reinforcement of positive association with
new behavior, sustaining new behavior and propagating new behavior through word-ofmouth. It is necessary to conduct periodic studies to know the effectiveness of the
communication effort and the changes in attitude and behavior brought about through that
Capacity with the BCC Division of MOHFW will have to be developed to guide this process
prepare briefs and assign tracking and monitoring studies - and inform the service delivery
accordingly. Behavior Surveillance surveys as a means of measuring effectiveness of
communication strategy (as is being carried out in the field of HIV/AIDS) can be employed in
RCH too.
While the experience with private agencies for mass media buying has been satisfactory, it
now needs to be extended to include private channels and other new media. In this regard,
support of private agencies may be required not only for media buying plan but developing a
more comprehensive strategy (particularly for urban areas and new issues) and include
preparation of new materials (creative strategy) and a media strategy (mass media buying)
and an evaluation plan. Also, use of new media opportunities through the Internet requires
i J
professional assistance as this is growing to become an important channel for opinion
building and advocacy for changing societal norms regarding RCH issues.
The States will need to identify their local needs and priorities for Behavior Change
Communication and develop capacity to implement their strategy through various agencies.
The Center would need to assist them in the process, especially the EAG states.
The following matrix is an attempt to identify key issues at the Center. States
and District and suggests a strategy and implementation plan. This is a basic
approach to the BCC Component in RCH II. Details will be worked out in due
course.
The steps in developing the BCC strategy in each state needs to be carried out as follows:
•
•
•
•
•
•
•
Assess the current status of knowledge, attitudes, practices, beliefs and myths and
misconceptions among the population regarding the issues involved in maternal
health, newborn care, nutrition, child care, newborn diseases and how to manage
them, important practices to be adopted during antenatal and postnatal periods, breast
feeding, supplementary feeding, immunization of children, growth monitoring of
children, family planning concepts such as spacing and methods available, safe
abortions and terminal sterilization etc.,
Assess the cultural and other socio-economic factors influencing the current behavior
Messages and mediums that can communicate the change messages effectively in a
culturally and contextually sensitive manner
Assess the desired changes in behavior to be brought about and how best to carry
them out
Analyze the service support that would be required to support the process of behavior
change.
Develop a comprehensive behavior change strategy and develop the messages and
materials required for the implementing the strategy
Monitor and track effectiveness of the strategy through periodic behavior surveillance
surveys and reorient, adapt/adopt the strategies in order that fatigue does not set in.
It is gathered that the Communication Needs assessment for developing the BCC strategy is
being carried out in the EAG states. The RCH II preparatory stage would examine the
process and results of such developments and if required integrate the RCH II
communication strategies with these strategies. Therefore in the current design the strategy
development has not been carried out in detail.
11
3.9.4 RCH II: BCC Component Issues
Center
(MOHFW)
States (esp.
Implementation
Mode
Reposition the
program through
mass media and
other new media
like Internet
Issues
Strategy
Promote unified
(holistic) concept of
RCH - position the
program in a new
manner.
Advocacy at all
levels and
Sensitization and
Orientation of all
health staff
Increase exposure
to mass media
Introduction of
message provision
through TV, VCD
etc., by providing
hardware and
software at all levels
Develop software
to be shown at
different levels
providing
messages on
Maternal, Child
health and
contraception.
Supply hard ware
and soft ware in
adequate
numbers.
Continue to
promote new areas
like PNDT Act,
NSV, Adolescent
Health, NPP goals
and demographic
trends (like adverse
sex-ratio) etc
Advocacy and
support to States
with generic
materials in the new
areas
Use mass media
through
professional
agencies and
extend to private
channels
(research based)
EAG States require
support in BCC
Provide technical
and financial
support to EAG
States
Prioritize RCH
Prepare State-
Assist EAG States
to develop State
specific BCC
Strategy and
identify
professional
agencies and
devise BCC
strategy and
research-based
action plan
Use a planned
i1
issues based on
Census 2001,
NFHS II and RCH
Household Survey
data and in
consonance with
NPP and RCH
objectives
EAG)
Districts
3.10
specific BCC
Strategy with the
assistance of
professional
agencies
Training of all
health staff on the
Behavior Change
approach (wherein
bringing a change
in client’s health
seeking behavior is
the responsibility of
all health service
providers)
Develop a BCC
training plan for all
categories of health
care service
providers
Decentralize
planning and
execution of BCC
to the districts
Use appropriate
NGOs and other
agencies for
supporting the
decentralized effort
in the districts
Decentralization of
BCC effort required
in order to be in
tune with the
program and
service availability
(local conditions)
Use local traditions
and folk media and
community leaders
(culturally credible
and acceptable) for
social mobilization
and BCC for
program support
communication
multiple media
approach to
maximize impact
of BCC effort for
social mobilization
and program
support
communication
Identify
appropriate
agencies for
conducting the
training,
particularly in IPC
and coordinated
use of local media
and group
meetings
Develop a scheme
(similar to the ZSS
scheme) for
engaging
professional
agencies and/or
NGOs
Identify NGOs and
other agencies for
social mobilization
effort.
Also foster inter
sectoral linkages
Training
1.
Introduction
National Institute of Health and Family Welfare was appointed by the Government of India in
December 1997 as the National Nodal Agency to coordinate various training activities under
the RCH program all over the country.
The Institute pursued its responsibilities ol
18^
I i
coordinating and monitoring the training activities with the help of 18 Collaborating Training
Institutions (CTIs) in various parts of the country.
2.
Training activities in RCH I
Training program
Different types of training activities being conducted under the RCH program include the
following:
Integrated skills development training (ISI) for health personnel. This training
covers generic RCH skills and is targeted to different categories of service providers
including MO (PHC), ANM, LHV, HW (M)), HA (M)) and staff nurses.
ii.
Specialized skills training (SST). To enhance the clinical skills and thereby increase
the coverage and quality of services, specific skill oriented training under the RCH
program. (Namely laparoscopic sterilization, minilap sterilization, medical termination
of pregnancy, no scalpel vasectomy (NSV) for medical officers and IUD Insertion for
ANM and LHV) was started in the year 1999-2000.
iii.
Specialized management training.
Considering the complexity involved in the
RCH program and in order to enhance the skills of the program managers the State as
well as at district level, specialized management training programs were included in
the training package under RCH program. This training was conducted by a number
of reputed training institutions for the State and district level officers.
IV.
Specialized communication training. In order to improve the communication skills
among the IEC officials at the district and the block level, specialized communications
training was initiated through designated communication training institutions in the
country.
Activities related to development of training materials
Training modules for MO, LHV, ANM, staff nurses, male workers and male health assistants
were developed at NIFHFW with the help of experts.
Achievement in various types of training
Details regarding the number of batches conducted as well as the number of persons trained
under each of the above training activities reported up to 2001-2002 are given in the
consolidated table below: -
Type of Training
Master trainers' training
Training of trainers
Cumulative
No. Trained
Batches
“6
131
174
4003
1i
Awareness generation
training._________________
Integrated skills
development training __
Specialized clinical skill
training_________________
Specialized management
training
______________
Specialized communication
14154
400741
2019
32878
803
6344
42
852
126
_____ —1840
[Annual report of MOHFW 2001-2002]
The overall achievements of the program vis-a-vis the training load are summarized below
Cadre
Training load
(Number of
potential trainees)
Achievement
%
MO
ANM
LHV
HW (M)
HS ((M)
Staff Nurses
41,280
141,163
28,844
81,805
17,269
36,934
26%
48%
41%
30%
29%
12%
1ST
SST
13%
20,042
MTP
45%
4,986
Laparoscopic
sterilization
10%
110,405
IUD
17%
16,626
Mini lap
sterilization__________
It is obvious that there is a massive backlog of training of providers in RCH I
3. Lessons learnt
• No ownership at the state and district levels
• Lack of coordination between NIHFW and the states
• Delay in preparation of training modules
• Poor quality of trainers at the district level
• Poor capacity and infrastructure of training at district level
• Poor monitoring and evaluation of the training workshops
• Inefficient fund flow to the district levels
• Lack of involvement of district level clinicians
• Lack of participation of medical/nursing colleges
• No follow up action to check retention and utilization of skills.
4. RCH strategies fortraining
Categories of trainers
I ]
Categories of providers to be trained are shown in Tables
Categories of health professionals who need to be trained
Categories
1 1 • Community level
Anganwadi Workers
RCH Link Volunteers/workers
Community Skilled Birth Attendant
Traditional Birth Attendants
Private medical practitioners/village
practitioners
Satisfied acceptor couples (SACs)
2. Subentry-PHC
Auxiliary Nursing Midwives
| Lady Health Visitors
! Male Workers
Training modules
New
New
New
>
To be reviewed
New
New
L Existing module to be reviewed and
Supervisors
Medical Officers
Staff Nurses (or ANMs who will attend
24 hours deliveries at PHCs)
Paramedics / helpers_________________
i 3. FRU/CHC/District hospital
Medical Officers
Specialists (Obstetrician, anesthetists,
pediatricians)
Staff nurses
Paramedic/helpers
I Laboratory technicians (Blood storage)
improved, if necessary
4. Functionaries of Indian Systems of
Medicine
New
I 5. Practitioners in private/NGO/informal
sector
New
New
Existing module to be reviewed and
improved, if necessary
New
New
Specializ
ed skills
training
(SST)
program
s for
RCH II
iJ
Training program____________
Training Module
A. For Medical Officers
1. Anesthesiology training
2. Caesarean section training
3. Minilap and laporatomy ligation
4. MTP manual vacuum aspiration [(MVA)] for
5. Non-scalpal vasectomy (NSV)
6. Blood storage and transfusion
First pilot underway
To be developed
Existing module to be reviewed and improved
Existing module to be reviewed and improved
Existing module to be reviewed and improved
To be developed
B. For ANMs
1. IUD
2. Midwifery Skills
Existing module to be reviewed and improved
Existing module to be reviewed and improved
C. For Programme Managers
1. Public health management for district RCH
(and ICDS) managers.
2. Orientation training to Health and FW &
ICDS supervisors; CDPOs etc.
3. Orientation of administrative / accounts staff
Existing module to be reviewed and improved
To be developed
To be developed
Training institutions and resources
Table shows the various institutions /resources in training that can be utilized for
implementing the gigantic training agenda of RCH II program.
Training institutions /resources that can be involved in RCH II training
1. National level: NIPCCD, NIHFW, AllMS, PGIMER, NIPCCD, medical and nursing
colleges, ESI hospitals, public sector health systems (SAIL, Railways etc.), National
Institute of Public Health & Hygiene, IGNOU and others.
2. State level: State institutes of health and family welfare, medical colleges, district training
centers, nursing schools/colleges, ANM training schools.
3. Others: NGOs, professional bodies (NNF, IAP, FOGSI), and private training
organizations.
Guiding principles for the revamped training program under RCH II
In service
• Training should be skills-based and focused on imparting critical communication,
counseling and clinical competencies.
191
11
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Training programs should attract trainers of high ability and motivation; they should be
adequately compensated and recognized fortheir contribution.
Quality of training should be ensured down the line through adherence to clear guidelines
presence of state/regional observers at district level workshops and by establishing a
feedback system.
Utilization and retention of newly acquired skills should be evaluated systematically and
linked to improving the ongoing training activities.
Training program should be decentralized to the state/regional levels.
NGO and private sector training institutions/resources should be utilized in addition to the
government system.
Training modules should be of high quality in content and methodology, and encompass
the desired contents as per the RCH II requirements; existing modules should be
reviewed and new modules developed by experts ensuring that training is participatory
and hands-on with emphasis on practical/clinical sessions.
Smooth and efficient systems of coordination between the MOHFW, training institutions
and state governments need to be developed; the roles and responsibilities of different
functionaries should be clearly defined.
As the overall responsibility for ensuring the implementation of the training program is with
the department of Family Welfare, there is an urgent need strengthen the capacity in the
training division.
Progress on training program, both in terms of quality and quantity, should be one of the
key benchmarks of the RCH II implementation.
Training infrastructure in the state/district levels should be evaluated and strengthened
adequately.
The staff (MOs/nurses/others) at the hospitals assisting in clinical skills training should be
suitably compensated.
Trainers’ training should ensure that trainers not only master the contents, but also
acquire skills as teachers/trainers/facilitators and motivators.
Ways should be explored to acquire services of serving/retired/practicing teachers and
academics who could be involved in the training program.
The training opportunity should also be used systematically to motivate and enthuse the
trainees for achieving the objectives and goals of this National Program.
States, institutions, officials, trainers, professionals and others who excel in implementing
the training program should be recognized through awards/citations
Pre-service Education
•
Pre-service education is the foundation of learning for all providers. In-service and
refresher trainings are built on the core knowledge, skills and attitudes acquired in the
regular pre-service educational programs. This applies to all cadres of health
professionals, from AWWs/ANMs to the specialists.
•
The educational requirements of the national programs must be covered in the curricula of
all categories of health professionals (including doctors, nurses, ANMs, LHVs, ISM
professionals etc.). It is however often seen that the competencies required to perform in
192
1J
the real life setting in the health system are not covered at all or are covered inadequately
in the usual educational courses. Even when formally included in the course, programrelated syllabus may be taught poorly and often not reflected adequately in the
examinations, as teachers do not attach importance to these contents. These anomalies
need to be rectified urgently in order to ensure that the products of health professional
institutions are competent to contribute to the national program.
•
It is therefore recommended that the pre-service curricula of all health professionals
(doctors, nurses, ANMs, WWs, LHVs, ISM professionals, other) be revised/strengthened
to include the RCH II interventions, approaches and skills. This is an essential long-term
endeavor for which the professional councils academia and professionals, should join
hands with the government for a time-bound initiative.
4. Steps for developing an action plan for RCH II training
•
Training in RCH II program will have to be a major improvement over the RCH I training
program. This would require formulation of a detailed action plan. A thorough evaluation
of the ongoing (RCH I) training program (on the lines of the mid-term review) is a critical
requirement. This evaluation should include the feedback of the trainees.
Simultaneously, a review of the existing modules is required for determining the need for
modification of the contents. A review of training methodology is also required. Training
programs for additional categories of providers (AWW, technicians, ISM professionals,
link workers, satisfied acceptor couples etc.) are also to be developed. Furthermore, a
new organizational structure needs to be created for efficient implementation of the
nation-wide training. Accordingly, the following steps towards developing an Action Plan
for Training in RCH II are proposed (Panel):
Time line
By June 2003
Task___
7. Generate the following position papers through
consultants:
• Evaluation of the ongoing RCH I trajning program:
lessons learnt and recommendations for
improvement
• Capacity needs and availability for RCH II training in
government, NGO and private sectors to mount a
national training effort for the required volume and
cadres of providers
• Review of pre-service education program for RCH
competencies for all cadres of health professionals
(including ANMs, AWWs, nurses, LHVs, doctors,
specialist etc.)
8. Review existing training modules with the help of
experts
Appoint
experts to develop training modules/curricula
9.
that are not available presently
11
By August 2003
Develop a detailed Action Plan for training in RCH II
By November 2003
Finalize the improved/new training modules for all
categories of trainees
3.11 Program Phasing
The program phasing has been carried out on the following basis:
• Year 2003 would be used, as a preparatory phase for planning and would involve no
additional cost.
• The model for designating a facility as completely operational from the RCH and FP
service delivery point of view would be developed.
• The training modules would be reviewed from the adequacy to meet the additional
strategies of RCH &FP II.
• Establishment of linkages for bringing about the inter-sectoral collaboration.
• Develop a complete planning for training including identification of regional training
centers for scaling up training and develop the trainers and plan for involvement of
various public sector organizations.
3.12 Program Triggers
These can be defined as those set of activities on which the effective functioning of other
related activities depend. Considered in this perspective it is critical that some initiatives are
put in place before others can follow and take off.
The following are considered as performance triggers from the RCH II point of view:
a) Training: The backlog of training inherited from RCH I is extremely high and the newer
areas, which have been anticipated in RCHII makes the task even more important. Therefore
it is essential that the training be taken as a priority area. It is essential that the following be
carried out:
•
•
•
•
Draw up a clear training strategy to quickly and effectively cover the backlog and
additional load.
Draw up well-defined training calendar with dedicated resource persons to carry out
the training
States to agree through an MOU to send the personnel for training and also follow a
posting policy after training to utilize the trained personnel in the relevant areas.
States through the MOU to develop a HRM policy and system.
(1
b) Reduction in Maternal mortality
The maternal mortality is high due to non-recognition of complications in time and referring
these cases to the appropriate facilities. Further, this also arises due non-coverage of the
pregnant women with a minimum of three antenatal check ups and administering the
requisite number of TTs. In order to bring about these, awareness and health seeking
behavior needs to be improved. The reduction in maternal mortality can bring about better
health outcomes by indirectly impacting upon the Infant Mortality and child Mortality.
This outcome trigger is planned through a combination of process catalysts and
communication catalysts.
c) Reduce Neonatal Mortality
The high neonatal mortality has been attributed to the unsafe delivery conditions, delivery not
being attended by a skilled birth attendant, and not following the processes required for
newborn care. This status could be attributed to the causes of non-awareness of the
processes required or non-availability of facilities for safe delivery and newborn care facilities
The reduction of neonatal mortality can indirectly influence the population growth. This trigger
is also to be operationalized through a combination of process and communication catalysts
to achieve the outcome trigger.
d) Reduce unmet needs for contraception
The National Population Policy 2000 has clearly outlined that meeting the contraception
needs to the complete extent as one of the socio-demographic goals. This arises from the
realization that if there is easy availability and accessibility then usage of contraceptives can
prevent unwanted births and thereby influencing the population growth and the health
outcomes of the woman.
This trigger is planned to be operationalized through expanding the basket of contraceptive
choice, increased social marketing reach and by advocacy and communication through
Satisfied Acceptor Couples.
e) Infrastructure and equipments: It may be a problem if the trained personnel do not have
the appropriate infrastructure and equipments to provide the services they have been trained
for. Hence the plans to equip the facilities with appropriate infrastructure and equipments
needs to closely follow the plan of training. If this linkage is not established then it may lead to
a situation of non-utilization of available infrastructure in the absence of trained personnel.
f) Differential state Priorities: It may be possible to carry out certain activities such as
operationalizing FRUs in already well performing states. However, if this is uniformly followed
in all states it may result in a situation of infrastructure created being unutilized/underutilized.
Hence, the focus needs to be on bringing the EAG states to a critical mass for take off by
following alternative strategies. This may lead to providing focus on community based
Ii
initiatives in EAG states while it may be different for other states. The state planning needs to
address this.
g) Behavior Change Communication Strategy: A well- developed and Need-based BCC
strategy is essential to bring about the change in behavior especially in the health seeking
behavior and in creating awareness regarding the various aspects of ROH and Family
Planning/welfare. The decision on appropriate media mix taking into account the media
exposure levels of the audience would be critical. The documentation of the desired behavior
change expected to be brought about at different stages also would be essential in terms of
messages and materials development.
In short a multi-sectoral approach with broad basing the involvement of players would be a
key performance trigger. Strategic approach to scale up rapidly learning from well-designed
pilots would be another key trigger.
196
I i
Section 4
PROCUREMENT & LOGISTICS
Currently the quantities indicated are calculated based on the existing procedure of RCH-I
Programme. It is only a start up. The important consideration is that RCH-II service utilization
is expected to be far better than RCH-I because of major revamping of the program with the
aim of meeting the program goals over relatively short period of time. It is envisaged that the
drugs availability would increase manifold in RCH-II as envisaged in the program concept
note. Precise estimates could not be made at this stage. A more precise estimate of drug
quantity would require a careful assessment based on first hand feedback from the
concerned levels (from SC’s to Districts). It is suggested that the processes of precise
estimation of drug utilization, community expectation and projected increase during the
program may be carried out.
The Total Estimated Procurement Cost in RCH-II is indicated in Annexure20
DRUG & EQUIPMENT KITS:
The following Drug & Equipment Kits would be supplied under the RCH Programme (PHASE
II) at the various levels:_________________________________
Only FRU Level
CHC/FRU Level
PHC Level
Sub Center
Level/Urban slums
RTI/STI KIT
CHC/FRU KIT
drugWTT
PHC KIT
DRUG KIT B
Mid Wifery Kit for
ANMS________
Sub Center
Equipment Kit
Normal
Delivery set
Essential New
Born Care Kit
MTP Set
IUD Insertion
Kit
Kit for Instrumental
Delivery
MTP Set
Set for Artificial Rupture
of Membranes_____
IUD Insertion Kit
Anesthetic Set
RTI/STI Laboratory
diagnosis
Essential New Born
Care Kit
SCS Set (Caesarean
set)________________
General Set (Set for
Laparotmy Emergency
Hysterectomy)
Cervical Suture set
Minilap Abdominal
Ligation set_______
Essential New Born
Care Kit
The items in each kit are listed in Annexure 21 to 30 ’
197
iI
Drug Kit A & Kit B shall be supplied @ 2 kits per annum to Sub centers & urban slums. The
PHC Kit would be supplied @ 1kit/Annum to 100% PHC’s in EAG & Notheastern states and
20% PHC’s in other states. The CHC/FRU Kit would be supplied @ 2kit/Annum to 100%
CHC/FRU’s in EAG & Notheastern states and 20% CHC/FRU’s in other states. RTI/STI kits
would be supplied @ 2kits/Annum to 100% FRU’s in EAG & Notheastern states and 20%
FRU’s in other states.
The Equipment kits would be supplied as detailed above to all those centers, which are not
covered under RCH-Phase I.
Note: The Drug & Equipment Kits indicated in Annexure 21 to 30 are of RCH -Phase I
supplies. Consultations were held with the experts on the review of Drug & Equipment Kits.
The kits would be revised on receipt of clear recommendations/policy statement including
quantification from MOH&FW.
PROCUREMENT:
The above-mentioned Drug & Equipment kits consist of a limited number of items and are
provided in the form of standard kits to a large number of scattered rural consignees. It is
proposed that the procurement of the bulk of such drugs and equipment may be done
centrally by appointing a National procurement & Logistics Management Agency (PLMA).
The drugs may be procured individually by PLMA and engage a kitting agency to form the
respective kit of individual drugs. These kits would be distributed by the kitting agency to the
districts across the country.
MISCELLANEOUS ITEMS:
It is proposed that the miscellaneous items as detailed in Annexure 26 may be procured by
Financial Envelop states like Tamil Nadu, Andhra Pradesh, Karnataka, Kerala, Maharastra &
Punjab by appointing a State procurement support agency (SPSA). These items will be
distributed to the districts. For other states it may be procured centrally through PLMA.
IMMUNIZATION:
The Equipments & Vaccines under Immunization may be supplied as indicated in Annexure
28 & 30. It is proposed that these may be procured and supplied centrally by inhouse/appointing a National procurement & Logistics Management Agency (PLMA)/other
agencies.
Ii
ISM Drugs:
The ISM drugs are indicated in Annexure 27.
The Ayurvedic sub centre kit shall be supplied @ 1 kit/Annum per sub centre & urban slum
health post across the country.
The Ayurvedic Dispensary & hospital Kit shall be supplied @ 1 kit/Annum per Ayurvedic
Dispensary and @ 2 kit/Annum per Ayurvedic hospital across the country .
The Unani kit shall be supplied @4 kit per unani dispensary and @8kits per unani hospitals
across the country.
It is proposed that these may be procured and supplied centrally by appointing a National
procurement & Logistics Management Agency (PLMA)
PASS BOOK SYSTEM:
It is suggested that the Pass Books would be introduced to all levels of consignees i e state
head quarters, district, CHC/FRU, PHC, SC and ANM’s. These pass books contains the list
of all RCH supplies. Each level has to enter the stocks received, distributed and balance of
the current year. At the end of February of the respective year every consignee would enter
his or her estimate requirement of the supplies of the next year. Through the suggested
bottom-up approach for planning the information from the field units would be collated at the
state level to arrive at the requirement of the state.
EQUIPMENT MAINTENANCE:
Equipments like anesthesia machines, deep freezers, Laparoscopes etc requires AMC
beyond warranty period. It is suggested that while procuring these similar equipment in RCHII the following be the essential criteria:
1. The supplier should have an established network of service centers at the nearby
stations of the supplies with good inventory of spares and requisite experience,
2. should provide two years warranty.
3. Should indicate the cost of AMC for 3 years beyond the warranty period, which is to be
considered at the purchase for comparison.
4. AMC contract will be finalized at the center for 3 years beyond the warranty period and
funds will be released to the State/districts every year to execute the contract with the
suppliers.
For other Equipmen
199
11
Training program_________ ___
Training Module
A. For Medical Officers
1. Anesthesiology training
2. Caesarean section training
3. Minilap and laporatomy ligation
4. MTP manual vacuum aspiration [(MVA)] for
5. Non-scalpal vasectomy (NSV)
6. Blood storage and transfusion
First pilot underway
To be developed
Existing module to be reviewed and improved
Existing module to be reviewed and improved
Existing module to be reviewed and improved
To be developed
B. For ANMs
1. IUD
2. Midwifery Skills
Existing module to be reviewed and improved
Existing module to be reviewed and improved
C. For Programme Managers
1. Public health management for district RCH
(and ICDS) managers.
2. Orientation training to Health and FW &
ICDS supervisors; CDPOs etc.
3. Orientation of administrative / accounts staff
Existing module to be reviewed and improved
To be developed
To be developed
Training institutions and resources
Table shows the various institutions /resources in training that can be utilized for
implementing the gigantic training agenda of RCH II program.
Training institutions /resources that can be involved in RCH II training
1. National level: NIPCCD, NIHFW, AllMS, PGIMER, NIPCCD, medical and nursing
colleges, ESI hospitals, public sector health systems (SAIL, Railways etc.), National
Institute of Public Health & Hygiene, IGNOU and others.
2. State level: State institutes of health and family welfare, medical colleges, district training
centers, nursing schools/colleges, ANM training schools.
3. Others: NGOs, professional bodies (NNF, IAP, FOGSI), and private training
organizations.
Guiding principles for the revamped training program under RCH II
In service
• Training should be skills-based and focused on imparting critical communication,
counseling and clinical competencies.
192
I i
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Training programs should attract trainers of high ability and motivation; they should be
adequately compensated and recognized fortheir contribution.
Quality of training should be ensured down the line through adherence to clear guidelines,
presence of state/regional observers at district level workshops and by establishing a
feedback system.
Utilization and retention of newly acquired skills should be evaluated systematically and
linked to improving the ongoing training activities.
Training program should be decentralized to the state/regional levels.
NGO and private sector training institutions/resources should be utilized in addition to the
government system.
Training modules should be of high quality in content and methodology, and encompass
the desired contents as per the RCH II requirements; existing modules should be
reviewed and new modules developed by experts ensuring that training is participatory
and hands-on with emphasis on practical/clinical sessions.
Smooth and efficient systems of coordination between the MOHFW, training institutions
and state governments need to be developed; the roles and responsibilities of different
functionaries should be clearly defined.
As the overall responsibility for ensuring the implementation of the training program is with
the department of Family Welfare, there is an urgent need strengthen the capacity in the
training division.
Progress on training program, both in terms of quality and quantity, should be one of the
key benchmarks of the RCH II implementation.
Training infrastructure in the state/district levels should be evaluated and strengthened
adequately.
The staff (MOs/nurses/others) at the hospitals assisting in clinical skills training should be
suitably compensated.
Trainers’ training should ensure that trainers not only master the contents, but also
acquire skills as teachers/trainers/facilitators and motivators.
Ways should be explored to acquire services of serving/retired/practicing teachers and
academics who could be involved in the training program.
The training opportunity should also be used systematically to motivate and enthuse the
trainees for achieving the objectives and goals of this National Program.
States, institutions, officials, trainers, professionals and others who excel in implementing
the training program should be recognized through awards/citations.
Pre-service Education
/
•
Pre-service education is the foundation of learning for all providers. In-service and
refresher trainings are built on the core knowledge, skills and attitudes acquired in the
regular pre-service educational programs. This applies to all cadres of health
professionals, from AWWs/ANMs to the specialists.
•
The educational requirements of the national programs must be covered in the curricula of
all categories of health professionals (including doctors, nurses, ANMs, LHVs, ISM
professionals etc.). It is however often seen that the competencies required to perform in
iI
the real life setting in the health system are not covered at all or are covered inadequately
in the usual educational courses. Even when formally included in the course, programrelated syllabus may be taught poorly and often not reflected adequately in the
examinations, as teachers do not attach importance to these contents. These anomalies
need to be rectified urgently in order to ensure that the products of health professional
institutions are competent to contribute to the national program.
•
It is therefore recommended that the pre-service curricula of all health professionals
(doctors, nurses, ANMs, WWs, LHVs, ISM professionals, other) be revised/strengthened
to include the RCH II interventions, approaches and skills. This is an essential long-term
endeavor for which the professional councils academia and professionals, should join
hands with the government for a time-bound initiative.
4. Steps for developing an action plan for RCH II training
•
Training in RCH II program will have to be a major improvement over the RCH I training
program. This would require formulation of a detailed action plan. A thorough evaluation
of the ongoing (RCH I) training program (on the lines of the mid-term review) is a critical
requirement. This evaluation should include the feedback of the trainees
Simultaneously, a review of the existing modules is required for determining the need for
modification of the contents. A review of training methodology is also required. Training
programs for additional categories of providers (AWW, technicians, ISM professionals,
link workers, satisfied acceptor couples etc.) are also to be developed. Furthermore, a
new organizational structure needs to be created for efficient implementation of the
nation-wide training. Accordingly, the following steps towards developing an Action Plan
for Training in RCH II are proposed (Panel):
Time line
By June 2003
Task
7. Generate the following position papers through
consultants:
• Evaluation of the ongoing RCH I training program:
lessons learnt and recommendations for
improvement
• Capacity needs and availability for RCH II training in
government, NGO and private sectors to mount a
national training effort for the required volume and
cadres of providers
• Review of pre-service education program for RCH
competencies for all cadres of health professionals
(including ANMs, AWWs, nurses, LHVs, doctors,
specialist etc.)
8. Review existing training modules with the help of
experts
9. Appoint experts to develop training modules/curricula
that are not available presently
19
Ii
By August 2003
Develop a detailed Action Plan for training in RCH II
By November 2003
Finalize the improved/new training modules for all
categories of trainees
3.11 Program Phasing
The program phasing has been carried out on the following basis:
• Year 2003 would be used, as a preparatory phase for planning and would involve no
additional cost.
• The model for designating a facility as completely operational from the RCH and FP
service delivery point of view would be developed.
• The training modules would be reviewed from the adequacy to meet the additional
strategies of RCH &FP II.
• Establishment of linkages for bringing about the inter-sectoral collaboration.
• Develop a complete planning for training including identification of regional training
centers for scaling up training and develop the trainers and plan for involvement of
various public sector organizations.
3.12 Program Triggers
These can be defined as those set of activities on which the effective functioning of other
related activities depend. Considered in this perspective it is critical that some initiatives are
put in place before others can follow and take off.
The following are considered as performance triggers from the RCH II point of view
a) Training: The backlog of training inherited from RCH I is extremely high and the newer
areas, which have been anticipated in RCHII makes the task even more important. Therefore
it is essential that the training be taken as a priority area. It is essential that the following be
carried out:
•
•
•
•
Draw up a clear training strategy to quickly and effectively cover the backlog and
additional load.
Draw up well-defined training calendar with dedicated resource persons to carry out
the training
States to agree through an MOU to send the personnel for training and also follow a
posting policy after training to utilize the trained personnel in the relevant areas.
States through the MOU to develop a HRM policy and system.
194
11
b) Reduction in Maternal mortality
The maternal mortality is high due to non-recognition of complications in time and referring
these cases to the appropriate facilities. Further, this also arises due non-coverage of the
pregnant women with a minimum of three antenatal check ups and administering the
requisite number of TTs. In order to bring about these, awareness and health seeking
behavior needs to be improved. The reduction in maternal mortality can bring about better
health outcomes by indirectly impacting upon the Infant Mortality and child Mortality.
This outcome trigger is planned through a combination of process catalysts and
communication catalysts.
c) Reduce Neonatal Mortality
The high neonatal mortality has been attributed to the unsafe delivery conditions, delivery not
being attended by a skilled birth attendant, and not following the processes required for
newborn care. This status could be attributed to the causes of non-awareness of the
processes required or non-availability of facilities for safe delivery and newborn care facilities
The reduction of neonatal mortality can indirectly influence the population growth. This trigger
is also to be operationalized through a combination of process and communication catalysts
to achieve the outcome trigger.
d) Reduce unmet needs for contraception
The National Population Policy 2000 has clearly outlined that meeting the contraception
needs to the complete extent as one of the socio-demographic goals. This arises from the
realization that if there is easy availability and accessibility then usage of contraceptives can
prevent unwanted births and thereby influencing the population growth and the health
outcomes of the woman.
This trigger is planned to be operationalized through expanding the basket of contraceptive
choice, increased social marketing reach and by advocacy and communication through
Satisfied Acceptor Couples.
e) Infrastructure and equipments: It may be a problem if the trained personnel do not have
the appropriate infrastructure and equipments to provide the services they have been trained
for. Hence the plans to equip the facilities with appropriate infrastructure and equipments
needs to closely follow the plan of training. If this linkage is not established then it may lead to
a situation of non-utilization of available infrastructure in the absence of trained personnel.
f) Differential state Priorities: It may be possible to carry out certain activities such as
operationalizing FRUs in already well performing states. However, if this is uniformly followed
in all states it may result in a situation of infrastructure created being unutilized/underutilized.
Hence, the focus needs to be on bringing the EAG states to a critical mass for take off by
following alternative strategies. This may lead to providing focus on community based
initiatives in EAG states while it may be different for other states. The state planning needs to
address this.
g) Behavior Change Communication Strategy: A well- developed and Need-based BCC
strategy is essential to bring about the change in behavior especially in the health seeking
behavior and in creating awareness regarding the various aspects of RCH and Family
Planning/welfare. The decision on appropriate media mix taking into account the media
exposure levels of the audience would be critical. The documentation of the desired behavior
change expected to be brought about at different stages also would be essential in terms of
messages and materials development.
In short a multi-sectoral approach with broad basing the involvement of players would be a
key performance trigger. Strategic approach to scale up rapidly learning from well-designed
pilots would be another key trigger.
i i
Section 4
PROCUREMENT & LOGISTICS
Currently the quantities indicated are calculated based on the existing procedure of RCH-I
Programme. It is only a start up. The important consideration is that RCH-II service utilization
is expected to be far better than RCH-I because of major revamping of the program with the
aim of meeting the program goals over relatively short period of time. It is envisaged that the
drugs availability would increase manifold in RCH-II as envisaged in the program concept
note. Precise estimates could not be made at this stage. A more precise estimate of drug
quantity would require a careful assessment based on first hand feedback from the
concerned levels (from SC’s to Districts). It is suggested that the processes of precise
estimation of drug utilization, community expectation and projected increase during the
program may be carried out.
The Total Estimated Procurement Cost in RCH-II is indicated in Annexure20
DRUG & EQUIPMENT KITS:
The following Drug & Equipment Kits would be supplied under the RCH Programme (PHASE11) at the yariousjeyels]_______________________________
_
Only
FRU
Level
CHC/FRU Level
Sub Center
PHC Level
Level/Urban slums
RTI/STI KIT
DRUG KlTA
CHC/FRU KIT
PHC KIT
DRUG KIT B
Mid Wifery Kit for
ANMS________
Sub Center
Equipment Kit
Normal
Delivery set
Essential New
Born Care Kit
MTPSet '
IUD Insertion
Kit
Kit for Instrumental
Delivery
MTPSeF
Set for Artificial Rupture
of Membranes
IUD Insertion Kit
SCS Set (Caesarean
set)__________ __
General Set (Set for
Laparotmy Emergency
Hysterectomy)_______
Cervical Suture set
Minilap Abdominal
Ligation set________
Essential New Born
Care Kit
Anesthetic Set
RTI/STI Laboratory
diagnosis
Essential New Born
Care Kit
]
!
The items in each kit are listed in Annexure 21 to 30
197
Ii
Drug Kit A & Kit B shall be supplied @ 2 kits per annum to Sub centers & urban slums. The
PHC Kit would be supplied @ 1kit/Annum to 100% PHC’s in EAG & Notheastern states and
20% PHC’s in other states. The CHC/FRU Kit would be supplied @ 2kit/Annum to 100%
CHC/FRU’s in EAG & Notheastern states and 20% CHC/FRU’s in other states. RTI/STI kits
would be supplied @ 2kits/Annum to 100% FRU’s in EAG & Notheastern states and 20%
FRU's in other states.
The Equipment kits would be supplied as detailed above to all those centers, which are not
covered under RCH-Phase I.
Note: The Drug & Equipment Kits indicated in Annexure 21 to 30 are of RCH -Phase I
supplies. Consultations were held with the experts on the review of Drug & Equipment Kits
The kits would be revised on receipt of clear recommendations/policy statement including
quantification from MOH&FW.
PROCUREMENT:
The above-mentioned Drug & Equipment kits consist of a limited number of items and are
provided in the form of standard kits to a large number of scattered rural consignees. It is
proposed that the procurement of the bulk of such drugs and equipment may be done
centrally by appointing a National procurement & Logistics Management Agency (PLMA)
The drugs may be procured individually by PLMA and engage a kitting agency to form the
respective kit of individual drugs. These kits would be distributed by the kitting agency to the
districts across the country.
MISCELLANEOUS ITEMS:
It is proposed that the miscellaneous items as detailed in Annexure 26 may be procured by
Financial Envelop states like Tamil Nadu, Andhra Pradesh, Karnataka, Kerala, Maharastra &
Punjab by appointing a State procurement support agency (SPSA). These items will be
distributed to the districts. For other states it may be procured centrally through PLMA.
IMMUNIZATION:
The Equipments & Vaccines under Immunization may be supplied as indicated in Annexure
28 & 30. It is proposed that these may be procured and supplied centrally by inhouse/appointing a National procurement & Logistics Management Agency (PLMA)/other
agencies.
11
ISM Drugs:
The ISM drugs are indicated in Annexure 27.
The Ayurvedic sub centre kit shall be supplied @ 1 kit/Annum per sub centre & urban slum
health post across the country.
The Ayurvedic Dispensary & hospital Kit shall be supplied @ 1 kit/Annum per Ayurvedic
Dispensary and @ 2 kit/Annum per Ayurvedic hospital across the country .
The Unani kit shall be supplied @4 kit per unani dispensary and ©Skits per unani hospitals
across the country.
It is proposed that these may be procured and supplied centrally by appointing a National
procurement & Logistics Management Agency (PLMA)
PASS BOOK SYSTEM:
It is suggested that the Pass Books would be introduced to all levels of consignees i.e state
head quarters, district, CHC/FRU, PHC, SC and ANM’s. These pass books contains the list
of all RCH supplies. Each level has to enter the stocks received, distributed and balance of
the current year. At the end of February of the respective year every consignee would enter
his or her estimate requirement of the supplies of the next year. Through the suggested
bottom-up approach for planning the information from the field units would be collated at the
state level to arrive at the requirement of the state.
EQUIPMENT MAINTENANCE:
Equipments like anesthesia machines, deep freezers, Laparoscopes etc requires AMC
beyond warranty period. It is suggested that while procuring these similar equipment in RCHII the following be the essential criteria:
1. The supplier should have an established network of service centers at the nearby
stations of the supplies with good inventory of spares and requisite experience,
2. should provide two years warranty.
3. Should indicate the cost of AMC for 3 years beyond the warranty period, which is to be
considered at the purchase for comparison.
4. AMC contract will be finalized at the center for 3 years beyond the warranty period and
funds will be released to the State/districts every year to execute the contract with the
suppliers.
For other Equipment maintenance would be outsourced/or carried out in-house
Appropriate funds would be released to the districts for the requisite period.
d
All the consignees at the time of supplies should ensure that the suppliers name and
address, nearest service center, phone number, warranty and AMC are entered in their
respective passbooks.
DECENTRALISATION IN A PHASED MANNER:
It is proposed that the Financial Envelop States like Tamilnadu, Andhra Pradesh, Karnataka,
Punjab & Maharashtra would procure miscellaneous items as detailed in Annexure 26 by
appointing state procurement support agency. Based on their performance others items shall
be increased in a phased manner during the subsequent years. The IPP VIII & IX states
which have equipped warehouses, the storage and distribution system with computerization
would be outsourced to an agency which has requisite experience in storage, distribution &
logistics system.
TRAINING:
Training would be provided to fill the passbooks and their reporting to the next level
200
ii
Section 5
Financial Management
5.1 Financial Management
Introduction
Financial management system is considered
management for several reasons. These are
(i)
(ii)
(Hi)
(iv)
(v)
as an effective tool to assist project
Ensure efficient use of resource.
Achieve better project management by providing timely information on financia
aspects of key performance
Promote accountability at various levels and enhance transparency
Establish satisfactory internal checks and controls, and
Meet the financial reporting requirements of the Government and World Bank including
the societies and their District units.
5.1.1 Arrangements for Financial Management:
The RCH-II program would be implemented by the MOHFW, states and Union Territories
(UTs) and through registered Societies. MOHFW would maintain an identifiable account of
program expenditure that would reflect its own expenditures and those received through
States and Societies, by program components. The account would show amounts received
by each agency and expenditures against the same. For States/ UTs and Societies, the
project director in charge RCH II at state, district, city and society level would maintain an
identifiable account of project expenditures, clearly differentiating the World Bank funds from
all other sources and showing all inward and expenditure transactions. In cases where the
flow of funds to the program is through state finance department channel, the state would
need to provide a separate budgetary grant for the program. In case where flow of funds is
through a registered societies will maintain separate accounts to reflect program expenditure,
ensuring that Bank funds are clearly differentiated from all source. In each situation a
separate head of accounts classification specific to the program will be provided.
Uniform formals or reporting expenditures to meet the specific needs of various
agencies have been designed, and would be used by the field officers at the district level to
submit reports to Program Directors in charge of RCH Program at the State level and they
would in turn consolidate the accounts for their respective states, indicating both the monthly
expenditures, and cumulative expenditure for the years up to the end of that particular month.
Accounts of GOI, states and UTs would be maintained in conformity with the accounting
standards of the Comptroller and Auditor General of India, societies registered as Societies
would maintain their accounts in conformity the requirements of the Registration of Societies
Act.
11
5.2 Budgeting and Flow of Funds
The credit agreement for RCH II program would be between the World Bank and the
Government of India (Ministry of India- Department of Economic Affairs). The funds, through
the budgetary process would be given to the DFW/MOHFW, in turn would provide the funding
directly to societies and directly to State governments where societies do not exist. Annual
budgets would be based on the feedback from various program divisions These divisions
would then be informed. The program divisions will be responsible for the release of funds to
State/societies. The Director (Donor Coordination) in the Ministry would,, as in RCH-I
continue to monitor both the release of funds (on basis of the copy of release received from
respective program division) and the expenditures at state) center levels based on the SOEs
received from the State/Central. The Subsequent funding will be based on performance of
key indicators and the projected requirement of the Societies.
5.3 Disbursements
The disbursements for replenishments of the Special Account for the fund will be based on
the traditional system of disbursement i.e. on the basis of SOEs/full documentation.
5.4 Accounting and Transaction Information Flow
Book of accounts for the project at societies and its district level units would be maintained
using double entry book - keeping principles. Standard books of accounts (cash and bank books, journal, ledgers etc.) would be maintained at the state DFW and MOHFW using an
integrated computerized accounting system. However, state DFW and MOHFW being
government organizations, would need to follow government accounting system. Based on
the experience of RCH-I, it is planned to develop a chart of accounts to enable data to be
captured and classified by budget heads, project expenditure components and
disbursements categories, expenditures, appropriate documentation, levels of authorization,
bifurcation of duties, periodic reconciliation, physical verification.
MOHFW, state DFWs & societies will generate and maintain the transaction vouchers for
their various receipts and expenditures made at MOHFW, state DFWs & societies levels
respectively. However record- keeping and accounting and their supporting for the district
level and beyond, will be maintained at the level, where expenditure is incurred, societies /
state DFW will release money to the districts initially as per annual plan and subsequently
based on performance of key indicators and projected fund requirements of the district
societies units and then the districts on quarterly intervals will send the expenditure statement
to the societies /state DFW. All the expenditure, documents will be kept at the District level.
Consolidation of project accounts would be done at the MOHFW level, by consolidation of
accounts MOHFW/ societies & state DFWs, using the computerized accounting system.
202-
I i
5.5 Internal checks and control
Internal checks and control mechanisms would include the following:
A. The establishment of appropriate budgeting systems and regular monitoring of actual
financial performance
B. Development and adoption of simple, clear and transparent financial and accounting
policies which would govern financial management and accounting for the project. These
policies and procedures would include identification of expenditure, which can be charged
to program, and the categories under which the expenditure would be charged: the
policies and procedures for transfer of funds and accounting of expenditure.
C. At the transaction level, policies, procedures and systems will be being developed for
ensuring standard internal checks and controls such as checking of expenditures.
D. A chart of accounts will be developed to enable data to be captured and classified by
budget heads, Project components, expenditure categories (summary & Detailed) and
disbursement categories. This would match closely with the classification of expenditures
and source of funds indicated in the program document (Project Implementation Plan and
Project cost tables).
Based on the experience of RCH-I, quarterly meetings of state level finance officers will be
held to review the expenditures undertaken and the audit status. Also at these meetings all
financial issues will be discussed and decision taken. Also to ensure avoid any under or over
disbursement by the MOHFW, yearly exercise on reconciliation of SOEs with the states. Also
to take care of any variations in the expenditures and releases as per the records of the
DOHFW and with those of the states the DOHFW will keep the states informed about these
releases and expenditures as per its records, and will deal with these variations through
discussions.
5.6 Staff Recruitment and Placement
The most important requirement for effective project financial management system is the
deployment of the appropriate staff at the DFW. A post of Financial Controller will be created
through redeployment of existing posts. He will directly report to Director (Donor Co
ordination). Two accounts officers, one of them in charge of budgeting, expenditure and
auditing, will assist the financial controller
A Director (DC) supported by financial controller would head the finance and accounting
department at DFW/MOHFW. Both DFW and Societies will have an adequate number /
accounts staff to carry on various routing activities under the direction of key professional
staff indicated above. The structure would follow the financial management organization
structure provided under the institutional arrangements. The structures at the State level and
20
11
at the district levels will also have the organizational; arrangements as provided under the
institutional arrangements.
To promote efficiency and maintain a lean organization, all routine activities relating to
generation of books of accounts, compilation, preparation of financial reports etc. Would be
handled through the computerized financial management system to the maximum extent
possible.
All the staff in the financial management will be computer literate and trained. It will be
desirable to depute the above staff from the ministry/other department. Till such a time that
deputation is done, consultants would be contracted to carry out the work and responsibilities
enshrined above.
5.7 Staff Training
Another key factor for the successful implementation of computerized financial management
system in the project will be continuos intensive on the job training provided to the operating
personnel at DFW and SOCIETIES, and district levels. The consultant will draw out a detailed
program of training on the “PFMS”.
5.8 Audit Arrangements
The purpose of the audit would be to provide an independent confirmation to program
management DFW/MOHFW and to the WB on the accuracy of financial statements and the
working of internal checks and controls. The accounts of DFW / MOHFW being a Govt, of
India organization, will be audited by the Comptroller and Auditor General of India (C&AG).
Annual program financial statement consolidating expenditures reported by the states will
prepared by the MOHFW and submitted for audit. Within 6 months of close of the fiscal year
(March 31) MOHFW will submit to the Bank consolidated financial statement along with the
audit report. The auditors would carry out such tests, checks and controls as deemed
necessary by them.
Chartered Accountancy firms will audit the accounts of SOCIETIES. A consolidated annual
project financial statement will be submitted by MOHFW. Within 6 months of the close of its
fiscal year (March 31) supported by audited reports of MOHFW and all the Societies. In case
of Tamil Nadu and Karnatake where registered Societies have not been formed, the audits
will be carried out by state AG office.
The duly appointed chartered accountants will carry out the audits on regular intervals. Major
work in the audit process would be carried out at the levels of SOCIETIES. The auditors
would carry out such tests, checks and controls as deemed necessary by them. This may
also include visits to the districts, PHC, CHC to verify the bank accounts; teams from FMU
(DFW/MOHFW) may also carry out special audit of SOCIETIES/District units at regular
levels. The terms of reference and the qualifications of the chartered accountants will be
developed in consultation with the World Bank.
I i
It is proposed to hold annual audit workshops of the appointed firms of the chartered
accountants, with the active participation of the office of the of C&AG and DEA to harmonize
and suggest ways to further strengthen the internal checks and control in DFW, SOCIETIES
and district units.
A significant feature of audit is the voucher based rather than SOE based audit, which
is being, currently followed and would continue to be followed. Based on the RCH-I
experience, formats for audit financial statements, audit reports and SOE’s
reconciliation have been standardized. This measure has considerably improved
compliance.
5.9 Sustainability
(a) While the FISCAL BURDEN on completion of RCH-II appears manageable, it will however
need increased financial commitment by GOI. It appears on rough calculations that the
incremental recurring costs in the year following the completion may be around Rs.250
crore plus. This is about 25-30% of revenue expenditure of Central government on
Reproductive and Child Health but around 50% of the total expenditure on family welfare
services. It would be tiny percentage of country’s GDP. It appears that the Central
government would be able to provide for increased recurrent expenditures on the
completion of the project.
(b) Several measures would be needed to sustain the enhanced quality of the program.
Illustratively they are:
Improved pre-service training of staff-health workers and doctors to generate
0)
Improved quality care and greater awareness may generate pressure from
O')
communities to sustain the supply of drugs, equipment and better quality care
(c) Although family welfare program is fully funded by the Union government, states have a
key role as the responsibilities for expanding a bearing on their health budget. The states,
considering their poor financial health, should attempt to recover part of the recurring
costs.
(d) The states need to attempt to fund the salary and certain recurring costs through a
matching agreement in the initial two years and later through a higher state budgetary
allocation over a period of time can scale up the components funded and over a period ot
five years fully take on the funding of salaries and recurring cost of the program
components
(e) Introduce the concept of user charges from all to at least meet the maintenance cost ol
the facilities created and be in a position to create a fund for replacements when due
Once the cost recovery through user charges picks up a differential pricing mechanism for
the type of services sought can be introduced to build in the concept of cross
subsidization.
I i
5.10 Program Risks
Program Risks
(vii)
(viii)
(ix)
(x)
(xi)
(xii)
Reversal of target-free Policy-currently there is still apprehensions about this policy.
One way to reduce this risk is through intensive and extensive sensitization of health
program management including opinion leaders.
Under funding of the program: The GOI may provide necessary assurance on
maintaining its contributions to the FW Program. Given the current fiscal health of the
GOI, the risk is low to moderate.
At the state level, the real risks are associated with capacity, particularly of the weaker
states, to implement various components of RCH-II. These concern their weak
implementation capacity, poor fiscal health, and lack of commitment and poor
monitoring system. A considerable amount of preparatory work and planning will have
to be done in these states. Suitable eligibility criteria, sticking to prescribed
performance indicators and linking release of funds to performance indicators may to
an extent minimize the risks.
Some of the innovative approaches introduced in ROH II program are new, innovative
and not fully tested, particularly to those relating to newborn care and outreach and
community linkage schemes. To minimize risks, pilots and evaluations may be carried
out and these relatively new programs may gradually be introduced.
A major thrust of the program is on population stabilization with emphasis on
institutional strengthening, monitoring and awareness creation through exposure to
media and use of rural health practitioners. The success of ROH II hinges a. great deal
on these interventions. To minimize the risks, no compromise should be made on the
implementation of these interventions, and expertise from both government and
private sectors be drawn.
The RCH II program assumes financial management is in place both at the Center and
states, including the districts and there is regular flow of funds from GOI to states and
on to the districts. It also assumes timely assignment of staff and consultants, and
timely procurement. As most states have established Societies and they are largely
effective the risks are low. As far as processing staff and consultant appointments is
concerned, the risk can be minimized by making it as condition of negotiation. Similarly
risk on account of procurement can be minimized, by making it as condition of
negotiation.
Section 6
Monitoring and Evaluation
6.1 Introduction
A review of India's past performance would show that the country usually falters not in
planning but in the implementation of schemes launched with great fanfare. One of the main
reasons for this failure is the lack of attention paid to build an effective monitoring system and
the incapacity of program managers in using the information generated by the system for
taking corrective actions. An effective monitoring system should collect data not only on the
overall impact of the program, but also on various process indicators that could be of help in
finding what is wrong when the program is not yielding desired results. The main problem
with the current health management information system is that while the workers at the
grassroots level are required to maintain a large number of registers, they are hardly used as
a management tool. The apathy of program mangers in using the information collected
through the system has led to situation where grassroots workers either not maintaining the
registers properly or in complaining that too much of their time is spent in record keeping.
While there is undoubtedly a need to simplify the system of record keeping at the grassroots
level, there is equally urgent need to educate the program managers on the importance of the
data collected through the system and how to use them as a management tool.
6.2 Review of RCH-I Experience
A revised monitoring system and decentralized planning approach through community needs
assessment was proposed under RCH-I. However these systems are, at best, partially in
place. Under the program, districts have only recently been provided with computers and
software for processing and maintenance of records. A manual on community need
assessment approach (CNAA) was prepared but it took some time for program managers to
understand and appreciate the new system and in training the grassroots workers in
preparation of action plans. The CNAA manual itself was not adequately clear in some
important aspects. For example, it suggested consulting the panchayat leaders in the
preparation of action plans, but also provided some formulas for computing the expected
level of achievement from the previous year's performance. It did not suggests ways to
resolve controversies and discrepancies that might arise during the process of consultation,
and what weight ought to be given to opinions of village leaders who may not be wellacquainted with program objectives. As the consultative process could be time consuming,
there were practical problems in submitting the action plans in time.
Another serious problem in the implementation of CNAA is that majority of women are not
visited by the heath workers in a year. Household surveys indicate that heath workers visit less
than 10 percent of women during the whole year. In such a situation it is difficult to plan on the
basis of needs of the community. It is also observed that the registers maintained by the health
workers have no provision for recoding the unmet needs of families and intention to use
services.
Under RCH-I, evaluation of programme’s impact was to be done through district level surveys of
households and facilities, concurrent evaluation of functioning of health institutions and
J
satisfaction of users through a nodal agency at the national level, and inspection by supervisory
staff at all levels. A household survey in all the districts have been conducted in 1998-99. and
another one is currently on. The 1998-99 RCH survey has provided little additional information
at the national and state level than what was available from the National Family Heath Survey
done around the same time. Although RCH survey was to provide estimates at the district level,
they have been difficult to interpret due to smallness of the sample at this level and large
variability in the quality of data collected. However a facility survey conducted as a part of this
programme in 1999 has thrown up some invaluable information on state of health infrastructure
hither to not available from other sources. Another such survey is currently in progress.
The concurrent evaluation done through regional evaluation teams has also provided some
useful information on functioning heath facilities, CNAA and maintenance of registers. But there
is need to standardize the reports prepared by these teams and strengthen the data processing
capabilities of regional directorates handling this work. There is no direct evidence on how well
the supervision and inspection has been functioning. Concurrent evaluation surveys ought to be
collecting data on these aspects too.
Indirect evidence suggests that supervision and
coordination at PHC and district levels are weak in many states. The monitoring work has been
hampered by lack of telephone facility at PHCs.
6.3 Suggestions for RCH-II
Following suggestions are made to strengthen the monitoring and evaluation system under
RCH-II:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Extend telephone facility to all PHCs with supporting maintenance grant
Undertake computerization of PHC and sub-centre records in a phased manner
Simplify and reduce the number of records maintained by the ANM
Train the programme mangers in the use of MIES.
Make concurrent evaluation studies to collect data on inspection visits of supervisory staff
Provide computers and data processing software to regional directorates conducting
concurrent evaluation studies
Standardize the tabulation and reporting format for concurrent evaluation studies
Make provision to record the outcome of pregnancy and postnatal visits by health
workers in the proposed ANC card.
Make provision in the EC register to collect data on unmet need and intention to use
family planning methods
Revise the CNAA manual and make the procedures more practical to apply in the field.
Ask health workers to first prepare a provisional village action plan based on past
performance and finalize it after discussion with panchayat leaders (President of the
panchayat could be asked to certify it).
Complete unfinished agenda of training in CNAA.
Conduct one midterm household survey that would provide data at state level (could be
dropped if NFHS-3 is also being contemplated).
Conduct one midterm facility survey.
Conduct one end line district household survey and a facility survey
If required, increase the number of concurrent evaluation studies.
2 08
Ii
•
Include the key indicators listed below for data collection under MIES
6.4 Key Development Indicators for Measuring Progress
The data for following impact indicators are to be collected primarily through censuses,
registration systems and household surveys:
1. Maternal mortality ratio
2. Infant mortality rate
3. Neo-natal mortality rate
4. Under-5 mortality rate
5. Expectation of life at birth
6. Crude birth rate
7. Total fertility rate
8. Percent of births of order 3 and over
9. Population growth rate
10. Percentage pregnant women receiving full ANC
11. Percentage of Institutional deliveries and births attended by trained birth attendants
12. Percentage of children fully immunized
13. Percentage women using various methods of contraception
14. Percentage of women marrying underage 18 years
15. Percentage of births with birth interval less than 18 months
16. Percentage of unwanted births and women reporting unmet need for contraception.
6.5 Key Progress Indicators
The data on the following input and output indicators are to be mainly generated from the health
management information system. However, a few that need special surveys or concurrent
evaluation studies for collection of data are shown with asterisk mark.
Maternal Health
1. Number of pregnant women registered during the first trimester of pregnancy in a
calendar month.
2. Number of women having 3rd ANC in a month.
3. Number of CHCs, FRUs and DHs having 24-hour delivery services.
4. Number of CHCs, FRUs and DHs achieving a predetermined criteria oi
operationalization
5. Number of normal, emergency and night-time deliveries in a month in CHCs, FRUs and
DHs
6. Number of institutional deliveries referred by Dais/ AWW/ANM/Link Workers in a month.
7. Number of referred cases of Emergency Obstetric Care (EOC) and childcare attended by
private/NGO institutions in a month.
8. Number of BPL families using private/NGO institutions for emergency mother and child
health care in a month.
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Ii
9. Number of deliveries occurring before the full term in a month.
10. Number of caesarean, breach and foetus mal-position deliveries in a month.
11. Number of institutional maternal death audits conducted in a month.
12. Causes of death as per maternal death audits.
13. Number of AWW/LW/ANM/other workers provided receiving funds for referral transport
for mother and childcare.
14. Number of villages with identified referral transportation for mother and children.
15. Public awareness of the scheme for referral transport for EOC.
16. Number of DDKs distributed to Dais in a month.
17. Number of home deliveries attended by health professionals, TBAs and others
18. Number of maternal deaths in home deliveries by cause
19. Number of post-natal visits made by health workers in a month.
20. Proportion of deliveries at any facility starting from home to any institutions including in
transit
21. Proportion of births attended by Physician/Nurse or midwife/ ANM/TBA trained/TBA
untrained/Family Members/Others
22. Proportion of pregnant women who received 2 ANCs and 2 TTs and 100 I FA
23. Number of pregnant woman brought for deliveries to facilities by ANM/ TBA/AWW
24. Number of BPL Women provided care at designated private facilities
25. Number of pregnant women provided Mother-Child link card
Child Health and Immunization
1. Number of children receiving immunization for BCG, DPT measles in a month.
2. Number children completing the whole immunization course in the month.
3. Number of VVM checks done in a month and number that failed the test.
4. Awareness of child immunization profile by women and where to obtain the services
5. Number of infants dying with 1 week, 1-4 weeks and 1-11 months and 1-5 years after
birth during a calendar month and causes of death.
6. Number of sick neonates referred to PHC/CHC/FRU/DHs.
7. Awareness of essential newborn care by ANMs/LWs/AWWs/Dais.
8. Awareness of essential newborn care by pregnant women.
9. Number of CHC/FRU/DHs with newborn care corner.
10. Number of CHC/FRU/DHs having paediatricians.
11. Number of institutions with staff trained in providing newborn care.
12. Number of institutional deliveries with low birth weight or birth abnormalities in a month.
13. Number of births born at home weighed within 24 hours and number of low birth weight
infants, or born with abnormalities, during a month.
14. * Awareness of diarrhoeal management and ORS packets among women.
15. No. of diarrhoeal cases referred to PHC/CHC/FRU/DHs
17. Awareness of Symptoms of ARI by women.
18. Number of cases of ARI referred to PHC/CHC/FRU/DHs.
19. Proportion of children 12-23 months of age who received BCG 1 dose, Polio 3 doses,
DPT 3 doses, Measles 1 dose, and all the above.
20. Proportion of infants who received visits in the first 4 weeks of life classifies as 1 visit, 2
visits, three visits and 4 visits
11
21. Number of neonates who were referred to any facility
22. Proportion of neonates who were visited by AWW/ANM
23. Proportion of episodes of diarrhoea among under 5 children in which OPS was
administered
24. Proportion of AWW who can explain oral re-hydration therapy to a mother
25. Proportion of episodes of ARI in under 5 with cough and rapid breathing was taken to
ANM/AWW/Physician
26. Proportion of infants who received exclusive breast feeding for 4 months/ 6 months
27. Proportion of children who received solid feed at 9 months of age
28. Proportion of under 2 children who received 3 doses of vitamin A
RTI/STI
1.
2.
3.
4.
5.
6.
7*
Number of CHC/FRU/DHs with facilities for treating RTI/STI
Number of institutions with lab technicians to screen for RTI/STI.
Number of doctors trained in treating RTI/STI.
Number of patents treated for RTI/STI by type of institution and infection.
Number of pregnant women screened through VDRL test.
Number IUD acceptors diagnosed for RTI/STI.
Public awareness of RTI/STI, HIV/AIDS.
Safe Abortions
1. Number of PHC/CHC/FRU/DHs having facility for MTP.
2. Number of MTPs conducted in a month by these institutions.
3. * Public awareness about safe abortion services.
4. Number of maternal deaths due to abortions.
5. Number of sterilizations and IUD insertions after MTP.
6. Distribution of women availing MTP by number of female children.
Population Stabilization
1. Number of Rural Heath Practitioners (RHPs) recruited and trained for social marketing of
contraceptives
2. Number of satisfied acceptor couples (SACs) identified and trained for community
mobilization by method used by SACs
3. Number of PHC/CHC/FRU/DHs and Mahila Swasthya Sangh (MSS) provided with TVs.
CD players and educational CDs
4. Monthly acceptors of various methods of family planning
5. Number of condoms, pills distributed in a month by RHPs
6. Number of non-clinical family planning cases referred by RHPs
7. Number of group meetings of newly weds, pregnant women and nursing mothers held in
a month.
8. Honoraria given to SACs for community mobilization
9. Number of hoardings, posters and other publicity materials put up by the contractors ol
publicity campaign
u
10.* Percentage of women reporting viewing of family welfare videos in MSS or health
institutions
11 .* Percentage of women receiving follow-up visits after accepting family planning methods
12. * Percentage of family planning acceptors reporting side effects of method use
13. * Percentage of newly weds, pregnant women and nursing mothers reporting attendance
in group
meetings conducted by health workers
14. Women intending to use contraception in less than 12 months by preferred method
(annual data).
Key Financial Indicators
Consultants and staff assigned by the start of year 1 of program
Specified utilization rate achieved
Percent of approved funds disbursed
Deviation form the allocations as reflected in budget lines
Deviation from cash flow projections
Funds when released, accessed and actually used
Percent of idle funds
Submission of Quarterly SOEs
Computerized financial system in place at Center, States, Districts
Financial unit at center, states and districts in place
212
11
Section 7
Year 1
Infrastructure Strengthening
Civil works (Ref Annex on infrastructure)
- Rental for ANM's housing @ Rs 6000 pa at 15000 Sub-centers
(Year 1 with 10,000 SC)
Renovation/Repairs(esp. of staff quarters in EAG states)
Sub-Total
Equipment Kits(Ref Annex )
Equipment Kit_______________
Immunization Equipment_____
Sub-Total
Drugs & Vaccines (Ref Annex )_____
iDrugs
Vaccines
------------------------------------------------------PIP Operational cum Surveillance costs
Sub-Total
Year 2
17810
33675
600
900
2000
4000I
20410
38575
5979
1609
5979
1609
7588
7588
J 7779
46140
_0
63919
17779
60435
21500
375
375
99714
Adolescent Health
Adolescent Health @ Rs 5 lakh per annum per district for 75 districts
Contractual Staff
- RCH link volunteers performance based payments @ Rs 12,000 pa
for I lakh villages in EAG states based on performance of different
activities such as mobilization for ANC, Immunisation, New Born Care
etc.
eopl
2400
213
Yea
I 1
- Honorarium to TBAs for bringing mothers to facilities for deliveries
in 1.5 lakh @ Rs 1000 pa based on performance of mobilizing
mothers to delivery facilities.
1500
1500
- Rural Health Practitioners for mobilizing people for clinical
contraception for 90,000 RHPs in EAG states @ Rs 3000 pa (Yearl
20,000 RHPs, Year2 50,000 RHPs Year 3/4/5 90,000 RHPs
600
1500
- Honorarium to satisfied Acceptor couples @ Rs 3000 pa for 50,000
villages in EAG states (Yearl 20,000 Year2 30,000 Year3/4/5 50,000)
600j
900
- Honorarium for supervising village level health functionaries and for
BCC and social mobilization for 15,000 PHCs Yearl 3000 Year2
8000 Year3 12,000 Year4/5 15,000
_________
M.O @ Rs 12,000 pa____________________
_____ LHVs @ Rs 9000 pa__________________
630
1680
- ANMs/Staff Nurses @ Rs 6 lakh pa per district for 300 districts in
EAG states
1800
1800
- Gynaecologist/Anaesthetics @ Rs 10 lakh pa for 300 districts
Sub-Total
3000
8730
3000
12780\
■ NGOs @ Rs 1.5 lakh per block for advocacy and Inter Personal
communication, IRC material etc in 4000 blocks to cover completely
the EAG states, and selective other states (Yearl 2000, Year2 3000,
IYears3/4/5 4000
3000
4500
- Sensitization workshops for PRIs/Other women groups
(2workshops pa at a cost of Rs 3000 per workshop for 30 peoples) I
lakh workshop (20000, 35000, 35000, 10000)
600
1050
- 3 newsletters per annum @ Rs 25 per newsletter for 6 lakh copies
of each (including postal charge and production costs in 16
languages)
450
450
- Training of Grass root functionaries to act as behavior change
[Managers 50000 workshops @ Rs 75000 per workshop (each will
[have a batch of 30 persons) (10000, 20000, 20000..... )
750
1500
Behavioral Change & Communication
21
- Outsourcing to Private mass Media agencies for BCC and mass
media response for population statistics data____________
Evaluation of Effectiveness of BCC strategy_____________
Sub-Total
Institutional Strengthening
Center_________________
States (35 states)
Districts_________________
Logistics Management Agency
Sub-Total
10000
50
14850
500
5810
6220
10000
50
7 755^
400
651 O'
6020
100
100
12630
13030\
1500
3000
1600
1600
3100
4600
6450
7530
3500
3500
Material, Record Keeping etc @ Rs 1 lakh per annum for 600 districts
600
600
Research^yaluatjon
Operational Research (Program Relevant)
200
1000
Strengthening Medical College for RCH Rs 50 lakh one time grant for
100 medical colleges
1000
3000
1200
143352
4000
209842
Referral Transport
- Rs 3000 per village per annum for 1-5 lakh villages in EAG states
(50% villages) (Yearl 50000 villages, Year2 1 lakh villages, Year3/4/5
all 1.5 lakh villages
- Ambulance costs for 200 trips pa @ Rs 200 per trip for 4000 PHCs
with 24hrs delivery_____________________________________
Sub-Total
Training
T raining
_
NGO/Pvt Sector Involvement
NGO & Private Sector Involvement
MIES
GRAND TOTAL
2 i
Note: 1. Tribal & Urban Component is in addition to the above (as per the 10th Plan estimates for Urban health is FT.
2. Rupees 880 crores forming 10% of the total cost for allocation to North East is included in the total cost.
ASSUMPTIONS
1. Institutional Strengthening: It is planned to be a National component, and the rationale
is to strengthen the different levels of Institutions at the National, State, district, CHC,
PHC, Sub-center and village levels, by providing any additional support needed for their
efficient working. . Accordingly staffing and other requirements have been worked out,
including those relating to mobility.
In working out the costs of institutional strengthening, the existing infrastructure,
personnel and training requirements which have been detailed out in the section on
Implementation Arrangements for the PIP at the Centre, State, district, FRU/CHC, PHC
and sub-centre levels are taken into account. In the first two years, some additional
provision is made for certain wherewithal, and in the 3rd year, some funds are provided at
the center and the state levels for work relating to mid-term evaluation
Contractual Staff: An innovation proposed in RCH II is the provision of the RCH link
volunteer at the village level in the EAG states. This program also proposes to assign a
critical role to the TBAs especially in motivating families for ANC and institutional
deliveries. It is proposed that these TBAs be provided with some incentives for this
purpose. The other innovations relate to using satisfied acceptor couples and rural health
practitioners as agents for population stabilization. For them as well some token incentive
has been provided. The scope of obtaining specialist services on contract has also been
included.
2. Infrastructure Strengthening: The focus is on EAG states with emphasis on improving
the quality of infrastructure. The scope of new construction is limited to mostly the EAG
and North East States.
3. Equipment Kit: This has been included under procurement.
4. Drug and Vaccines: This has been included under procurement. We have made some
provision for meeting operational costs for the PIP for two years in a situation that funds
do not become available from elsewhere.
5. Behavioral Change & Communication: This is an important component and forms a key
element of the RCH II strategy. We plan to use the NGOs and the private sector as
agents for advocacy and interpersonal communication. We also plan to involve grass root
functionaries and use them as managers for behavior change. Suitable training is also
envisaged under the training component. In addition we plan to bring best practice and
other experiences to the village level. Besides, media is a highly developed science, and
the private sector has the necessary expertise. We plan to outsource it to the private
sector. NGO/ private involvement sector is also sought for developing a high level of
visibility of the RCH and FP agenda.
6. Training: Includes training for different professional staff and opinion leaders and other
stakeholders. Training of Trainers, review of existing modules and or development of
modules would be the other activities.
216
11
7. Adolescent Health: It is a new component, and it is planned to take it up in schools in 75
selected districts on a pilot basis. Counseling modules will be developed. A lump sum of
Rs.5 lakhs per district is provided.
8. Strengthening Financial Management: One of the major problems is the utilization of
funds for several reasons. It is therefore planned to strengthen the financial management
system. This component is taken care of under Institutional Strengthening.
9. Operational Research: Steps for on line corrections are essential, and some operational
research relevant to RCH II including mid-term evaluation is planned. In addition, there
would be SIP funds from the EC.
10. NGO & Private Sector Involvement: NGO/Private sector as conceptualized is to provide
both advocacy and service delivery roles. Hence, costing has been made accordingly.
11. Logistics Management: This component is taken care of in institutional strengthening.
FINANCIAL PLAN
The estimated total cost of RCH II program excluding tribal (Rs. 11500 lacs) and urban (Rs
70000 lacs) components is Rs. 883546 lakhs ( USD 1767 million). The donors including IDA
would cover about 74% of costs net of taxes. The GOI would raise the remaining 26% of the
total costs and all taxes. The component wise breakdown of the RCH II costs is provided in
the following table:
Component wise RCH II costing
USD (in million)
Rupees(Lakhs)
S.N Component
@ 1USD =Rs 50
o.
77130
T~ Institutional Strengthening
113400
2
Infrastructure
development___________
26510
Human Resource
3
Development___________
70000
Urban Health___________
4
11500
Tribal Health___________
5
581706
RCH
Services
(Safe
6
motherhood/Newborn
care/Child/adolescent/RTI
-STI)__________________
84800
Behavioural Change &
7
Communication ________
965046
Total
154
227
53
140
23
1163
170
1930
Note:
1.
2.
The cost of vaccines for Routine Immunization would be met from Domestic
budgetary resources.
10% of the total estimated costs of RCH II excluding the Urban and Tribal
components will be spent on the north-eastern states.
I1
Section 8
Donor Convergence
The necessity to coordinate the donor funding and bring about a convergence emanates from
the following principles:
•
•
Too much of donor presence involves high transaction costs, duplication and fractured
responses with a lack of clarity of ownership
The donor funding and activities need to be managed within the overall framework of
the government policies and design criteria adopted for the RCH And FP program
through better coordination and convergence.
It has been felt necessary, as evidenced from the learning and experiences of other multi
donor funded projects, that a well-designed process needs to be adopted to bring about this
convergence. The Gol in the design of RCH II and FP has adopted the following process
•
•
•
•
•
•
An overall consultation with the donors on the concept and design of RCHII and FP
In order to elicit the responses from the donors GOI designed two sets of formats
namely: I) To identify the broad areas of involvement and the geographic preferences
and ii) A detailed activity based response to identify the technical areas of involvement
within the preferred geographic area.
These formats were circulated to the donor agencies and the responses sought
The donors were expected to provide the quantum of funding and the period of the
funding to examine the overlaps in the period
Most of the donors were met individually and detailed discussions were held to
understand their involvement and priorities and the extent to which the donor priorities
matched the design priorities.
The donor responses have been compiled to obtain a comprehensive idea regarding
the areas of operation, funding and period.
The compiled donor responses has been provided in Annex
The donors such as DFID and EC have indicated a broader involvement while the responses
of most other donors indicate specific geographic coverage with a focus on limited number of
activities. The focus in the case of area-based donors has been in the area of capacity
building, supplies, and in quality enhancement in specific technical areas. The funding period
of the donors and the RCH II and FP period does not directly coincide but indications have
been provided by the donors that if the program period falls outside the current funding cycle
of the individual donors then indicative commitments have been made.
218
I i
Name of
DONOR
Areas of implementation
RCH I
World Bank
Donor Activity and Funding Matrix
Geographical Area of implementation
RCH II
All components of
All
components of RCH II
RCH I
RCH I
Throughout the
country
I Throughout H
country
emphasizing
EAG states
Throughout th'
country exo i i
where bilato. j
aid is availa >
States to be
identified
Immunization
Strengthening
Polio
Eradication
All components of
RCH II
In selected states
European
Commission
SIP covers all
the seven areas
of interventions.
SIP covers all the
seven areas of
interventions
Canadian
High
Commission
BDCS
(Through
UNICEF)
> BDCS
Currently 24 States are
included in SIP named
as under.
Andhra Pr., Assam,
Gujarat, Haryana,
Himachal Pr., Kerala,
Maharastra, Orissa,
Rajasthan, Uttar Pr.,
Arunachal Pr, Manipur,
Meghalaya, Mizoram,
Nagaland, Sikkim,
Tripura, Bihar,
Chhattisgarh,
Uttaranchal, Jharkhand,
West Bengal and J&K.
WCS D’l STR ICTS.
(CIDA)
Bilateral
GAVI
Hepatitis B
DFID
> Safe Motherhood
(Technical assistant to
the design. Appraisal
process)
Hepatitis B same as in
RCH I
RCH II
One or more of the
following States
Uttaranchal ,
Chhattisgarh and
Madhya Pradesh.
( no ties to specific
districts )
15 cities and in 32
districts
To be
determined
according to
State need an< i
priorities.
Across the
country.
IJ
WHO
JICA
across the country
Implementation of
IMNCI
Operationalizatio Strengthening
n of Essential
Essential new born
new Born Care;
care.
Strategic finalization,
Adolescent
strengthening, review
Health
Establishment of and expanding the
network of AFHS of
AFHS Centers
Developing
urban, slums and rural
Adolescent
areas.
Continued support for
Health strategy.
ongoing initiatives
including
Safe
documentation.
Motherhood
Piloting of IMNCI;
Operationalisation of
Tribal RCH
/Health
ENC.
Child Health
Piloting of IMNCI
Reproductive
and Child health
in Madhya
Pradesh
Same in RCH I.
(National)
Urban, slums and rural
areas.
•
•
. Dai Kits (MH)
Elisa Readers/
Automatic
washers
(HIV/AIDS)
Madhya
Pradesh
( Sagar, Dam
Tikamgarh.
Chhatarpor
Panna)
districts).
Developmeni
entirely on Rl
in the state >
MP.
220
IJ
USAID
Institutional
strengthening
Infrastructure
strengthening
Training and
behavioral
change
strategy
Urban
RCH/
Health
Child survival
Same as in RCHI and inclusion of
States.
Uttar Pradesh Maharashtra
Rajasthan , Bihar, Madhya
Pradesh, Chhattisgarh
Jharkhand, Delhi Uttaranchal
Tamil Nadu, Gujarat,
To be identified
Same as in RCH
I.
Orissa, Rajasthan, Gujarat,
Maharashtra, Madhya Pradesh
and Kerala.
Same States a:
in RCH I and
some addition:
| district and in
Kerala ( only
State Level)
Same as in RCH
I
49 districts in the states of
Assam, West Bengal, Orissa,
AP, Karnataka, Tamil Nadu,
Kerala, Maharashtra, Gujarat,
UP,MP, Rajastan, Bihar,
Jharkand, Punjab, HP, J&K
49 districts in thstates of Assam
West Bengal.
Orissa, AP.
Karnataka. Tamil
Nadu, Kerala
Maharashtra.
I Gujarat, UP.Ml
&
UNFPA
UNICEF
adolescence
RCH/
Tribal
Health
All the
interventions
Strengthening
of monitoring
and evaluation
system
Training and
Behavioral
Change
22 2
Strategy
Child Survival
(including
immunization)
and
adolescence
Safe
Motherhood
Rajastan, Bih ir
Jharkand, Puni i
HP, J&K
2 22
i1
ANNEXURES
5
Name of Annexure
National Organogram___________________
State Organogram_______ _____
_____
District Organogram___________________
Job Description of ANM
Program Summary of Maternal & Child Health components
Memorandum of Understanding
6
7
8
9
10
Typical Layout plan of Sub Center
Details of facilities required in EAG & NE states
Typical Layout plan of Operation theatre
National wide details of Health Facilities
Typical Layout plan of Labor room
ri'
Schemafic diagram of overhead water storage tank
Cost estimation of Non OT Area____________
Cost Estimation of OT Area
Cost estimation of uninterrupted water supply system
Financial implications of expanding the existing facilities in EAG & NE
states____________________________________
Financial implications of introducing new facilities in EAG & NE states
Financial implications of expanding the existing facilities/creatmg New
facilities in Non EAG states
Program Phasing ____________________
Phiasing of Infrastructure facilities_________
Cost estimation of Drugs, Vaccines & Equipments
Number
1 “
2
3
4~
4a
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
Cost estimation of Kit A & B
Cost estimation of PHC Kit
Cost estimation of CHC/FRU Kit
Cost estimation of CHC/FRU Kit Contd..
Cost estimation of RTI/STI
Cost estimation of Miscellaneous items______
Cost estimation of ISM Drugs____________
Cost estimation of Vaccines
Cost estimation of Equipment Kits
Cost estimation of Immunization Equipment
NGO Guidelines_______________________
TOR of Logistics Management Agency
Tribal Health Strategy
Newborn health care model (SEARCH)
Cities with population over one lakh
11
LIST OF TABLES
S.No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
Page
Description of Table______________________
12Deaths and disability Adjusted Life years (DALYS) by course,
India 1998___________________________________
13
Some population Indicators for Major states from population
Censes, SRS and NFHS-2
14
Some indicators of Reproductive Health for Major states from
NFHS 2(1998-99)___________________________
Some indicators of Child Health for Major states from NFHS
2(1998-99)_________________________________
Percentage of Public Health Institutes that are adequately
equipped, facility survey 1999_________________
Reproductive and Child Health Services at different levels of the 20
Health services System
_____
42
Share of states in the total social sector expenditure of the
center and states 1998-99_________________
43
Central Government expenditure on Health and Family welfare
44
Central Government expenditure on social sector (Plan & non
plan)
_______________________________
46
Progress of Family Welfare Expenditure in IX plan & approved
outlay for X plan____________________________
48
State Government Expenditure on Family Welfare
49
Estimated expenditure on MCH
_________
' 50
Safe Motherhood 1998-99
_____________
Cost Benefit Ratios_______________________
T51_
52
Estimated unit costs of CYP, birth averted and acceptors
’ 53
What is Lost by averting Births
_
' 54’
What is gained by averting births____________
' 55
What is eventually gained__________________
I 88
Maternal Mortality Ratio___________________
' 89
Causes of Maternal death
' 94
Key indicators of Maternal Health programme
Status of FRUs/FRUs surveyed 760)
96
Immunization coverage (RHYS 1998-99, NFHS II 1998-99)
M07
]
108
Year wise polio cases_____________________
' 110
Neonatal Mortality rate for 1000 live births
’
114
ORS Usage
____________________
125
Contents of the communication package
1
140
Total fertility rate around 2000 and the expected number of
years for replacement fertility level____________
141
Levels of some important determinants of fertility in EAG states
to reach replacement fertility level__________
10nT plan method-specific contraceptive targets
142
144
Annual adaptors of various methods of contraception
144
Expected annual adaptors of various methods of contraception
Estimated number of couples with unmet need for contraception 146
2
u
ACRONYMS
ANM
ARI
BCC
BPL
CBO
CDR
CDD
CHC
CMHO ”
CPR
CSSM
CT I
DALY
DDK
DGS&D'
Emoc
EsOCFNGO
FRU
GNP
GDP
GOI ’
I CDS _
IEC
I MR ~
MCH
MDG
MNGO~
MOHFW
MSS ’
MTP
NGO
NFHS
NHP
NPP
NSV
NYK "
OCP_
OT
PHC
PMO
RCH "
RTI
SAC
SC
Auxiliary Nurse MidWife_________
Acute Respiratory Infections_______
Behavior Change Communication
Below Poverty Line
Community Based Organization
Crude Death Rate_________________
Control of diarrhoel Diseases______
Comm unity Health Centre
Chief Medical & Health Officer_____
Contraceptive Prevalence Rate
Child Survival and Safe Motherhood
Collaborating Training Institutions
Disability Adjusted Life Years______
Disposable Dai Kits______________
Directorate-General of Supplies and Disposal
Emergency Obstetric Care___________
Essential Obstetric care
Field NGO__________________________
First Referral Unit
Gross National Product___________
Gross Domestic product
Government of India
Integrated Child Development Services
Information, Education and communication
Infant Mortality Rate______________
Maternal and Child Health
Millennium Development Goals______
Mother NGO
Ministry of Health & Family welfare
Mahila Swasthya Sangha
Medical Termination of pregnancy
Non Government Organization
National Family & Health Survey
National Health Policy 2002
National Population Policy 2000
No Scalpel Vascetomy______________
Nehru Yuvak Kendra
Oral Contraceptive Pills
Operation Theatre
Primary Health Centre
Principal Medical officer
Reproductive and Child Health
Reproductive tract infection
Satisfied Acceptor Couple_______
Sub Centre
u
SCOVA
SHG
SIHFW
SNGO
SOE
STD
SMO
TFR
UIP
LHV
MO
LT_______
SM Consultant
ZSS“
State committee on voluntary Agency
Self Help Groups__________________
State Institute of health and Family welfare
Service NGO____________________
Statement of Expenditure
Sexually Transmitted diseases_____
Social Marketing Organization_______
Total Fertility Rate_________________
Universal Immunization program
Lady Health visitor_________________
Medical officer__________________
Laboratory Technician____________
Safe Motherhood Consultant______
Zilla Sakshrata Samitis
u
UNFPA
June 2003
C OMMENTS ON RCH II AND FAMILY PLANN1N(.: PIP
1 he draft PIP (Programme Implementation Plan), provides comprehensixc
information on the proposed institutional structures, processes and contents of R( 112
I he special focus on EAG and North Eastern states is to be appreciated, as is the
emphasis on reaching out to the urban poor and tribals. The focus on new born care is
a xvelcome feature in light of the importance of reducing high neonatal mortal il\.
Perspectives:
1 he PIP for RCH 2 and FP takes a strong supply-side perspective to improve reach
and quality of services. Community and gender perspectives for enhancing relex ancc.
quality, access and utilization need to be strengthened in a major wa\. I bis is
especially important since RCH2 is not a project but rather the core of the national
programme. If a balanced, community oriented approach is now neccssan in
reproductixe health services in India, it will be difficult to introduce if ii docs not find
reflection in RCH2.
1 he gender perspective is similarly missing. At a very minimum, future training will
need to build capacities for designing and delivering services w ith an understanding
of the social and structural constraints that affect health status and health service
access for women and men. The document is silent on initiatives to strengthen the role
and responsibilities of men in reproductive health an essential aspect if R( 11 goals
are to be achieved in an equitable manner. The critical issue of sex selection docs not
gel addressed in the programme.
Most importantly, the programme is silent on the role of PRls. implying that the force
for change lies within bureaucracies. The programme carries a strong cfFiciencx
perspective: this is necessary in itself, but perhaps not sufficient, given the changes
that are occurring in governance, and in society at large.
I inally, a uni-sectoral perspective, as currently reflected in the document, would not
be in keeping with the spirit of the national population policy. For example ,
opportunities for working with community and self help groups arc left unexploiwl
The RH Package:
I he proposed programme addresses many of the essential elements of Rl I. such as
maternal health, child health, and RTI/STD. It is surprisingly silent on family
planning. Though family planning finds special mention in the title of the proposal,
this particular element of RH is not woven into the document. (It max also be better to
name the document RCH including FP, rather than RCH and FP. as the latter implies
that I P is not an intrinsic part of RCH). Within family planning also, the proposal
would benefit from an elaboration on essential steps for increasing the basket of
choices for example, the use of the 380A as a long term contraceptix c. the use of
emergency contraception, etc.
u
UNFPA/Comments on RCH2/June 03
Adolescent interventions receive short shift. The focus needs to go beyond
preparation of adolescents for parenting roles, to address life skills in a broader wax
and to include sexual health concerns This national document also needs to make a
beginning in addressing other aspects ofRCH for example infertility. \ iolencc as a
health issue, reproductive cancers - even if only on an experimental basis.
I’rogramme Outreach:
Programme outreach has been insufficiently explored, particularly with regard to
family planning. Wide coverage through CBD programmes is long o\crduc, and
resources for this cannot come from other than programmes such as 1<( 112. Similarh
with social marketing: use of rural service providers is one small aspect of social
marketing. To make socially marketed products widely available would require a
major investment. Thus, RCH2 needs to position CBD and Social Marketing in
strategic ways lo ensure wide coverage nationally.
('apacity a nd I inplenientation Modalities:
Sustained and systematic interventions for capacity building, particular!v al the
district level, need to be reflected in the document. The project is ambitious, and i
review of the achievements and gaps of the first phase points to the rcquiremeni loi
strengthening planning and management skills at the sub-district, dislricl and state
level. Investments for this would be most critical.
In addition to strengthening programme management skills, there is need to design
programme monitoring systems in a fashion that breaks from the contraceptive
delivery mode. This would require recognition that the Community Needs
Assessment approach may have failed to take off in several stales. 1<( 11 2 needs lo
reflect on a new vision for the ('NA, possibly in a new civtcu\ to truly rcllcci
community perspectives. Similarly, it needs to be acknowledged that the target
approach is now making its way back into the programme. An alternative system foi
monitoring the programme is an urgent requirement.
formulation of this PIP is largely been influenced by the performance and pace ol
RCH. RC1I2 needs to take in to account programme delivery constraints in a more
central way. Suggested programme strategies, i.e. BCC, training, outreach services.
MIS and logistics system appear not to take sufficient account of the ground situation
for delivery of the programme, especially in EAG states. For example, there aic a
large number of vacancies for male workers, IEC staff, block level workers, training
faculty and other service delivery staff at peripheral levels. Similarly, training
infrastructure created in the states and districts is far from functional. 1<( 112 cannot be
a success unless it proposes ways of addressing these fundamental gaps
The pages that follow reflect on areas that could be strengthened in the PIP. Annex 1
highlights key issues on the proposed strategies and service package. Annex 2
provides feedback on the programme management modalities and Annex 3 reflects on
information gaps in the document.
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UNFPA/Comments on RCH2/June 03
\iiiH\uri I
(OMMENTS ON PROPOSED STRATEGIES AND SI R\ l( I S
Quality Assurance
Quality Assurance ought not to be restricted to contraception alone Quality
Assurance needs to be mainstreamed in all service components, with an
overarching Quality Assurance programme at district level. This is crucial loi
bringing a quality orientation in the programme. This will also mean rc\ isiling the
list of indicators from a quality lens, as measurement is a first step in
institutionalization Quality Assurance.
BCG:
A nation-wide BCC strategy is suggested. Given the wide variations in
reproductive health status and socio-cultural factors impacting reproductive health
behaviour, decentralization of communication strategies upto the sub dislrii t
levels will be more effective. Given the weak I EC infrastructure in the district,
monitoring of 1EC may be compromised and messages might be ambiguous
BCC strategies also need to dwell on communication activities for reducing
gender inequalities in health care. A subtle shift from IPC towards mass
communication is noticeable, although there is no analysis for juslilying this
move.
Public -Private Partnerships:
The strategies for public-private partnership need to spell out how such
partnerships will be win-win situations for both partners. Some examples mav be
given to show how these partnerships could evolve al the local level.
Linkages:
The linkage between RCH2 and NAC'O’s HIV/AIDS programme needs io be
clearly established. This is all the more important as programme interventions
include prevention and management of RTIs/STIs, infection prevention and
hospital waste disposal, VCT for adolescents, and condom programming at the
village level.
Similarly, many slates are now implementing Health Systems projccb. In the
context ol l-.OC and family planning too, services linkages needs to be established
SERVICES
M ater 111a I 11 ealth:
In order to reduce MMR in line with NPP 2000, the enabling goals as spelled oui
in the PIP could be more evidence based. There seems to be little role for
improx ed TT coverage in reducing maternal mortality as post parluin tetanus is
not a major cause of maternal death. ANC coverage in outreach settings max also
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UNFPA/Comments on RCH2/June 03
•
•
•
•
•
•
•
•
•
have limited impact. A balanced strategy needs to be reflected, incorporating
appropriate ANC and outreach, clinic based emergency use. and transportation.
The suggested programme does not make a distinction in the facilities which can
provide a continuum of services for normal delivery, basic !•()( and ( IOC jarc
The option of strengthening all CHCs to provide Basic I 'Mot serv ices could be
considered. The scope of obstetric care to be provided by village link work rs
needs to be spelled out. RCH link volunteers are supposed to attend to womenA
obstetric care needs even at odd hours. Many of these young women may not be
allowed to move out of the house by their family members due to security threats.
There may be too much emphasis on the conventional components of AN( in
outreaching settings. As the linkage between ANC and reducing MMK is weak, it
may be useful to refer to the new WHO evidence on what works in the package ol
ANC services in a clinic settings.
It will be difficult to monitor impact on the basis of MMR as it w ill not be
amenable to monitoring at the regional level. This will need intensive efforts lor
impro\ ing quality of birth and death registration and also ensuring adcquac . of
data.
In place of monitoring unmet need for HOC, it would be useful to monitor met
need.
In the past also, involvement of the private sector was envisaged. (ii\cn the laci
that the major concentration of private sector providers is at the level of district
HQs, especially in BAG states, innovative strategies need to be defined to make
this happen.
Il is
Strategies give con Hiding messages with respect to place of deli \c
proposed that ANMs be given incentives to conduct home deliver) < )n the olhei
hand. \ullage workers are supposed to accompany them for institutional deli\ er\
and gel incentives. The programme strategy needs to be very clear I here is
some research evidence for India indicating that to bring substantial reductions in
MMR. there is no need to have 100 percent deliveries in institutions. II all
complicated deliveries are managed in institutions fully equipped Io treat
complications, there will be substantial gains in MMR reduction. Also, proposed
incentives are additional to the provisions under the Rastriya Janam Suraksha
Scheme, where a TBA has to be given an incentive of Rs.25 foi each institutional
delivery.
There is very little justification for including management of R I Is, S I ls in the
maternal health component. Such inclusion gives the impression that R I ls S I Is
are linked to maternity only, and that the programme does not offei such scr\ ices
for non-pregnant women.
The operational strategies for training of private doctors in M l P needs to be
reflected in the document. There is no indication whether government training
institutions will be allowed to train private doctors. The possibility of engaging
private medical colleges in training of private doctors in M I P could be explored
as many such colleges are now recognized by the MCI for conduct of post
graduation courses.
Safe Motherhood consultants are proposed to be engaged at the PI l( level. I he
role of the SM consultant is rather unclear. As obstetric emergencies arc
unpredictable, it might not be possible for SM consultants to manage obstetric
complications especially if they have to commute from a city. PPI 1 cases need to
be managed immediately.
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UNFPA/Comments on RCH2/June 03
Family Planning:
The PIP is surprisingly silent on family planning. Though family planning finds
special mention in the title of the proposal, this particular element of KI I is nol woven
into the document. A three pronged approach is recommended: strong reliance on
( BI) and social marketing, coupled with improved quality and availabililx through
the public system. Proper counseling and voluntary acceptances, frc< I'rom the
pressures of direct or indirect targets, needs to be strongly emphasized
Within family planning also, the proposal would benefit from an elaboration on
essential steps for increasing the basket of choices. A perusal of the inlroductorv
analysis provides a strong argument for accelerating programme efforts to reach
anticipated growth in sterilizations and spacing methods. Unmet need theory is well
established and there is empirical evidence that a substantial chunk of this unmet need
can be satisfied with quality contraceptive services that are also accessible. Additional
inputs will be needed so that all CHCs and FRUs are able to provide regular
sterilization (male and female, especially minilap) year round instead of the current
camp approach for 3-6 months in a year in most EAG states. Given the poor qualilv ol
sterilization services in FP camps, additional inputs will be needed. I here should be
some basis of revising the pattern and quantum of existing assistance foi drugs and
other expendable supplies per case of sterilization, as inputs cost hav c gone up
considerably. It would be useful to explore possibilities of linkages w ith private
providers for offering contraceptive services to BPL families on a mutuall\ agreed
cost. A beginning can be made by defining a package of contraceptives at different
service delivery levels and ensuring availability through R( 112 inputs.
■
•
•
1 here arc several CBD initiatives in the states i.e. Janmangal. JSR and othci >
1 he suggested scheme of engaging network of Rural Health Practitioners w ill
constitute an additional source of non-clinical contraceptive supplies. Given the
existing scenario about the different types and hue of such practitioners, including
traditional practitioners, practitioners of ISMs and quacks, potential confusion
needs to be anticipated and addressed. Given the mutual distrust between public
health systems and these practitioners, such intervention may not find favour \v ith
district health authorities, who are also legally bound to initiate actions
fhesc
RHPs w ill be paid for making referrals for clinical methods. This w ill amount io
supporting incentives for promoting particular methods only. Payment of nominal
fee (incentives) for RHPs may unnecessarily promote unfair compclition to rcfci
cases for clinical methods as this will help them to make more monev. Il appear^
that this social marketing programme will be run by the department and there will
be no free distribution. This could jeopardize contraceptive sccuritv of the pool
There w ill be huge transactional costs for administration of this programme, as
many functionaries will have to be involved at different levels for collection and
onward transmission of money.
There is no reference to the quality of contraceptive serv ices offered through the
public health system in the country. Many studies have commented on non
adherence to guidelines in family planning camps. IUD insertions do lake place al
the residence of the clients in rural areas. Similarly IUD retention rales arc very
low due lo very little emphasis on screening.
It is proposed that satisfied acceptor couples will communicate to the local
community highlighting virtues of contraceptive method accepted by them. From
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UNFPA/Comments on RCH2/June 03
all accounts, this will mean promotion of only those methods in a \ illagc. for
w hich there are satisfied clients. Given poor acceptance of spacing methods,
ultimately permanent methods might get promoted. It is also not clear if these
SACs be given any communication aids. There would need to be a monitoring
mechanism in place to oversee contents of messages being transacted. 1 here is
every likelihood to fatigue setting in too soon amongst SACs. especiallv in the
villages of 500-1000 population. They are supposed to be paid, but u is unclcai if
SACs will be paid only after acceptance of method by the person "111010 ated" b_\
■
them.
I Ise of DVD etc for waiting clients at the facilities is suggested. (iiven the ()P1'
figures of 10-20 patients (over a period of 6 hours) at PI ICs. there w ill be hardlv
any waiting clients in OPDs. Women in labour will not enjoy D\ l). There is also
related issue of development of software in local dialect on a periodic basis \lso
it is not clear as how ensuring a telephone line will increase exposure to ma>s
media.
Several studies have shown that most important reason for not accepting certain
contraceptives is linked to rampant myths and misconceptions. I PC with potential
clients can help in dispelling these myths and misconceptions. Unfortunately there .s
very little emphasis on IPC although in RCH1, improving IPC skills was seen a> a
major strategy.
New Born and Child Health:
Analysis is needed as to why interventions suggested in CSSM did not achieve
desired results over the years.
•
Administration of IM injection of antibiotics by ANMs will require changes m
current policy. Also there is risk of indiscriminate administration ol antibiotics lor
other patients, once they are recognized for giving antibiotic injections.
•
The programme goal relates to reducing IMR in line with NPP and Xth 1A P
document. There is no reference to reduction in under five or child mortality rate.
Given the causes of infant death, attribution to Vaccine Preventable Disease
(VPD) is not significant.
•
It is generally recognized that care for sick new horns requires intensive nursing
care. (iiven the meagre availability of nursing staff at CHC s IK! s and disti icl
hospitals, it might not be possible to operationalise these units, special!) as there
is no provision for hiring additional nursing staff to pro\ ide such care lor sick
newborns in institutional settings.
•
'1 argeling personal hygiene of mothers should be a key communication
intervention mothers often contaminate the food of the neonate and child.
•
It has been observed that exclusive breastfeeding is not followed c\ cn in
government institutions. A major effort will be required to orient all ward ayahs
and other employees of hospitals to promote executive breast feeding.
Programmes such as BFHI require constant promotion. Many institutions w hich
were identified as baby friendly became “baby unfriendly” once kc\ persons were
transferred or retired.
d'he role of the ANMs in home care of the sick neonate is not clear. An ANM is
supposed to be responsible for 5 villages and organize activities lor various
national health programmes. A careful review of the visit schedule and activity
•
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UNFPA/Commerits on RCH2/June 03
planning for ANMs may be of help to assess feasibility of her conducting such
home \ isits.
Adolescent Health:
■ It is encouraged to note an adolescent health initiative featuring in l<( 112. ()nc
appreciates that this is a new programme area and accordingly needs to be
upscaled phase wise.
• feasibility of VCT and deaddiction services at sub-district level exclusivelx foi
adolescents needs to be reviewed. Provision of these services will need
professional counselors, which might not be available al sub district le\ cl.
- The package of services for adolescents should be designed keeping m mind the
needs of unmarried adolescents.
• The role of periodic school health check ups for early detection of problems need
to be highlighted, considering the fact that school enrolments arc going up even in
rural areas. Il is unfortunate that the old school health programme docs not gel any
mention in the PIP.
■ 1 he PIP does suggest counseling activities for adolescents in the outreach
settings, yet to operationalise these in rural areas will be challenging. Appn>pi iatc
capacity building measures could be reflected in the document.
■ The entire approach for communication activities for adolescents appears to be
keeping in mind the reproductive roles i.e. “preparedness” for parenthood and
there is very little appreciation of empowering processes. Also in specific
domains, gender dimensions need to be reflected.
I rban Health:
MTP services for early abortion can be provided at first tier health centers. Similarly
adolescent health clinics can be organized once a week.
Tribal Health:
Establishing mini sub-centres in conformity with mini AWW centre is a welcome
suggestion. As these mini sub centers will be staffed by ANMs, the document needs
to be clear about the salary support to be provided in the programme
( ominunity Mobilization:
The purpose of 3 days training for Satisfied Acceptors Couple is not cleai Are thc\
supposed to conduct house to house visits or organize group meetings'.’ I here is no
inter sectoral convergence mechanisms suggested for community mobilization.
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UNFPA/Comments on RCH2/June 03
\iinrxui c 2
( OMMENTS ON PROGRAMME MANAGEMENT MODALl I ll s \M)
INTERVENTIONS
(‘apacity a mi l inplenientation Modalities:
RCH 1 was unable to achieve many of its objectives largely due to a lack of capacity
w ithin public system. RCH2 is likely to experience similar constraints unless major
investments arc made for strengthening management capabilities at the state, district
and sub district level. Decentralization, local specific programme design, and new
interventions can only succeed if capacity and accountability are improved. R( 112
design would need to address these factors.
Nevx Mee han isms:
The PIP makes a strong plea for having state facilitators at national level and district
facilitators at state level. These are supposed to be focal points for a cluster of stales
and districts. It is implied that the present structure of GOI Regional Directors and
Zonal Directors/Joint Directors/Deputy Directors within states will not have an\ role
to play in RCH2. On the other hand, there is general acknowledgement of existing
weaknesses in delivery of the programme at district level, which also need to be
addressed. Programme support to such collateral mechanisms bypassing existing
svstems and structures might not be very well received. The role of the President ol
the District IMA in the recruitment committee is unclear. At anothei level, lor doctors
on contract basis, a remuneration of Rs. 12000/- is suggested, flow ex er m the slate ol
MP such recruitments are cuiTently being made on the basis of 15,000 per month
and people still either do not join or leave after a few months. It may not be realistic
to expect a graduate allopathic doctor to work for Rs. 12000 - in rural areas.
I)istrict H<ispital:
RCH2 makes a departure from the past by expanding the role of district hospitals
I lowever, staff suggested to fulfill this role is far from adequate aftei taking inb •
cognizance the huge clinical workload. It is supposed to be clinical training site loi
providers. IEC hub and also the site for steering quality assurance. If the district
hospitals are to play a role in these activities, major revamping of hospitals and their
administrative structures would be required, with special reference to cxlramuial
responsibilities.
(om in unity Health (ent res:
The C’HC is to supervise all PHCs in the area under their jurisdiction, Il is suggested
that the person incharge of the CHC have a public health background . \s most states
have not sanctioned post, of anesthetist at CHCs, to ensure lull complement of staff
may be a problem. Contractual arrangement might not work in the I \( i states given
past experience. In fact, upscaling remuneration might also not help. a> most ol these
doctors ha\ e very lucrative private practices in cities.
Primary Health Centers:
In the absence of adequate staff, 24 hrs delivery services might not be ensured. Manx
Pl ICs do not have residential facilities for staff. Similarly, most new Pl 1( s (30.000
population PI l( s) do not have six beds, especially in TAG stales. The suggestion lor
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UNFPA/Commerits on RCH2/June 03
making the ISM practitioner head of the PHCs will seriously compromise the existing
judicial pronouncement banning cross-prescription across different systems of
medicine. If a staff nurse is required to provide delivery services and no additional
staff is available supervision of sub centers might suffer. It may be more practical io
focus on al least one facility per block to make it ready for conducting 24 hrs
deliveries and for managing obstetric complications that do not need surgical
interventions.
Suh Centres:
I here arc gross inadequacies in male workers across the states. Such vacancies might
not be filled in the near future. Also given the current situation and police
environment it would not be reasonable to expect ANMs to treat K I Is. S ITs anti
malnourished cases, especially grade III and IV malnutrition. Visit .schedule and
activity planning for ANMs and male workers needs to be addressed, to ensure that
they meet requirements of other national health programmes. Given the fact that
“Updown" is an accepted phenomenon for peripheral health workers, limning then
duration ol actual work, any addition to the current activities of ANMs should be
critically examined.
\ illage Lexel:
A new band of community based workers (Village Link Workers) in addition to
existing AWW /TBA and depot holders eg JSRs/JMCs is suggested 11 is not clear if
this worker will be based al the hamlet or Village or a cluster of villages. I here
appears to be some role conflict with AWW and it will be necessary to plan to ax oid
duplication. Il is suggested that these workers be trained for vaccination or Ma.
Sul ph administration, when even doctors are hesitant to inject Mag Sul ph Gixcn the
experience ofC'HWs and their demand fortraining in injections, such iniliatixo needs
to be critically reviewed in light of the past experiences. An analysis of outreach
sessions w ith special reference to increased access and, quality of services, and
possible convergence across different sectors as envisaged in the NPP, may help to
strengthen outreach and improve coverage for preventive and promolixe health
interventions.
hifrastriictiii e:
The PIP does not give much information about the purpose ofThe newborn can
centre. 11 needs to be clarified how this space will be used for care of new born at
( 1 K’s. and if these arc proposed as day care centers. If this is the case, separate >lal1
will have to be assigned to manage this newborn care centre.
Training:
A perusal of training to be conducted in the districts including training of communily
based workers, i.e AWWs, TBAs, Link Volunteers etc., indicate nearly 2()()O-3()OO
person to be trained, for varying durations (2 weeks to 3 months) in each district.
Similarly health workers, doctors and specialists will also undergo training lor
x arying duration. The operational feasibility of such an ambitious training programme
at the district level should be assessed. There are also competing demands on training
systems from other national health programmes. There is consensus that training docs
not automatically lead to improved performance. Given the current training
capacities al state and district levels, disruption on the service prox ision is likeh as a
9
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UNFPA/Commerits on RCH2/June 03
result of pulling out of staff for varying periods. Training interventions should Ik
need based rather than norms based, as has happened in the programme in Ithe
1 ,past.
I’rocurement and Logistics:
Provision of a logistics management agency to handle all logistics related operations
is a welcome change. A major challenge will be to achieve convergence in supplies
for the peripheral institutions across different national health programmes.
MIS:
General Indicators are suggested. It is not clear how information on mans disliicl
level impact indicators will be collected, given the inadequacies of CPS m I A(.
slates. To calculate most of the indicators from HT1 surveys, a large sample will be
needed, which will have financial implications.
A long list of Indicators has been suggested for process related indicators. A cursory
look at these indicators conveys that such information is not amenable to I-IMIS
There are no quality related indicators for RTIs/STIs, e.g partner management,
reoccurrence rate etc. Some of the indicators are again numbers i.c. numbers ol
condoms and pills distributed in a month by RHPs rather than numbers of acceptors
continuing and newly enrolled in the programme. There is very little justification loi
monitoring the number of sterilizations and IUD insertions after Ml I’, though
acceptance of any contraceptive would be a useful indicator. There is no reference l<
any indicators for monitoring gender equity in programme delivery On the whole
this section needs substantive revision, with a view to build on data routinely
available in the programme MIS, without overloading the system.
Different set of Indictors is suggested in the annexure especially in the M( )l mode!
How would information on the number of district hospitals providing 24 l()(
services be linked to the programme inputs. There is little discussion on indicators
that could be used to monitor responsiveness, client sensitivities, gender sensitivity
and equitability of services. In the past, use of information systems has resulted in a
programme that has focused on achievement of certain levels of performance. I<( 112
needs to discuss how this will be prevented in the future.
J)<>nor Coiivergence:
( Nl'PA is not supporting specific interventions for child health as reflected in (he
donor matrix.
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UNFPA/Comments on RCH2/June 03
Knnexiirc 3
STRENGTHENING THE DOCUMENT WITH ADDI I IOS Al
INFORMATION
I he follow ing additional information could be considered for inclusion
Programme rationale should be firmly routed in an epidemiological analysis of key
reproductive health problems. The document does not currently prox ide iliat kind ol
analysis except in the section of newborn care.
Results of the rapid district HH surveys are quoted to substantiate achievements ol
RCH. However this is not clear as data for the two reference lime pci iods pertain to
the same set of districts. A matrix depicting findings of district surveys on key
indicators in 1998 and 2002 could be given to indicate degree of change
As the assessment reports fortraining and for the MNGO scheme arc now available,
some salient findings may be quoted. This is important given the fad that substantial
investments in capacity building of health care providers arc being suggested in
RCH2. The information base in the matrix depicting performance of different R( 11
interventions could be strengthened.
I here is little information on service provision for RCH by the prix ate sector.
Considering that in RCH2 there will be greater efforts to engage the pi i\ ale sector in
service delivery, some information on private sector penetration, range ol surx n as
offered etc (especially in the EAG states), will be useful.
1 here is no reference to quality of interventions in RCH. Given the lad that the
reproductive health approach entails on emphasis on quality, information on qualilx
parameters of the programme will provide useful insights on programme areas that
need to be strengthened.
District societies were set up in the first phase of the programme to give impetus to
decentralization. The document is silent on structures, governance, management and
capacities of district societies. Since a similar arrangement is being proposed imdei
the new programme, an assessment will provide inputs for calibrated changes.
Analysis of trends in percentage expenditure of State Gross DoiticsIk Product
(SGDP) on health and family welfare sector is absent. It will be enlightening to know
more about the unit cost of operationalsing a SC/PHC. Per beneficiary cost ol scr\ ices
such as Safe Motherhood/Child Survival and Contraceptives delivery at different level
of service delivery would also be helpful. Such analysis will also be vital for
addressing questions of equity in access to services, and quality. Analysis at tlu
national level should also highlight the unit cost ofproviding a package of basic R( 11
services at different levels.
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