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Reproductive and Child Health Programme-2
Project Implementation Plan
I
DEPARTMENT OF HEALTH AND FAMILY WELFARE
GOVERNMENT OF CHHATTISGARH
- 2.-'
• **
Reproductive
And
Child Health
Programme- 2
PROGRAMME IMPLEMENTATION PLAN
FOR CHHATTISGARH STATE
Revised Draft after Gol Review
Department of Health and Family Welfare
Government of Chhattisgarh
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RCII 2 Draft PIP Chhattisgarh
Table of Contents
1. Summary-------------------- ------------------------------------------------2. Process of Plan Preparation---------------------------------- ------ ---3. Time Frame------ ----------------------- ---------------------------------4. Background and Current Status-------------------------------------5. Situation Analysis---------------- ---------------------------------------6. Lessons Learnt From RCH-1 implementation-------------------7. RCH-II programme Objectives and strategies-------------------7.1. Vision Statement------------ ---- ----------------------------------7.2. Technical Objectives, Strategies And Activities-----------Maternal Health----------- -------------------------------7.2.1.
Child Health---------- ---- -------------------------------7.2.2.
7.2.3.
Family Planning----------------------------------------—
7.2.4.
Adolescent Health—------ -------------------------------Urban RCH------------------------------------------- ----7.2.5.
Tribal RCH------- -------- ---------------------- ----- —7.2.6.
7.3. Cross-cutting Themes and Institutional Strengthening -—
Infrastructure--------------------------- ------------------7.3.1.
7.3.2.
Training------------------------ —
Ensuring Quality of care in FRUs and 24 hour PHCs—7.3.3.
Strengthening Routine Sub-Centre services------------7.3.4.
Public
Private Partnerships------------------------------7.3.5.
NGO Participation in Service Delivery-----------------7.3.6.
Community Level Care------------------ ---------------7.3.7.
Behaviour Change Communication.------------ ------ —
7.3.8.
Panchayat Capability Building & Intersectoral
7.3.9.
Coordination.----------- ---- -------- --------------------7.4. Equity/Gender-------------------------------------------------7.5. Convergence/Co’ordination------------------------- --- -----7.6. Financial Management---------- —------------------------7.7. HMIS-----------------------------------7.8. Work Plan---------------------------------------- ---- ----- ----
3
11
11
12
28
40
8. Programme Management Arrangements----------------
128
42
42
43
48
51
53
55
71
75
84
95
99
102
109
111
117
119
126
127
127
127
127
8.6. HMIS-------------------------------------------------------------------8.7. Financial Management ..............................
129
131
132
133
134
135
137
9. Budgets------------------------------------------- ----------- ---- —
10. Budget Summary
138
165
8.1.Strengthening State Health Society and Directorate. —
-
8.2. Building Management Capacities-----------------------------8.3. Strengthening State Institute of Health and Family Welfare
8.4. District Level Planning and Management Capacity-----------
8.5.Strengthening SHRC-------------------- --- --------------------
RCH2 Drali PIP Chhattisgarh
1.
Summary
1.1 Background and Current Status
Chhattisgarh State is committed to a vision of reducing IMR to less than 30, MMR to below
100 and TFR to 2.1 by the year 2010. These goals will be attained by following processes that
empower local communities that are affordable, and provide equitable access to health care
services, that are gender sensitive and directly and indirectly contribute to the reduction of
poverty in the state. For this the state plans major interventions to strengthen current
programmes in maternal health, child health, family planning, adolescent health, urban health
and tribal health programmes. The state's current demographic and health profile is given in the
table below:
Table 1: Demographic and Health Profile of Chhattisgarh
Indicators
i CG
2000
2003
India
2000
_68___
2003
*IMR Total ________________________________ 22_
23__
64____
*IMR Rural__________________________________ 25__
_85__
69____
'24__
HMk Urban__________________________________ _49__
' 44
_51__
40____
* Birth Rate Total______________________________ ' 26.7
' 25.8
25____
25__
*Birth Rate Rural______________________________ 29.2
' 26.5
27.6
26.6
' 22.6
*Birth Rate Urban_____________________________ ' 22.8
' 20.7
19.9
* Death Rate Total_____________________________
9.6
_8___
8.5
8.1____
1 9.7
* Death Rate Rural_____________________________ I 11.2
! 9.3
8.7____
* Death Rate Urban
7.1
7.2
6.3
6.1
**Population in million ( 2001)___________________ 20.79
1027
**Population Share (%)_________________________ 2.02
100
**Decadal Growth Rate during 1991-2001 (%)______
18.06
21.34
**Change in decadal growth rate (% points)_________ ' -7.67
-2.52
**Female Literacy Rate 2001 (%)_________________ ' 52.4
54.28
**Rise in Female Literacy Rate since 1991 (% points) ' 24.88
15____
**Decadal decline in the number of illiterates (million) ' 2.07
31.96
**Sex Ratio__________________________________
990
933
**Population Density___________________________ 154
324
Tribal Population (%)__________________________ ' 34
***Couple Protection Rate (%)___________________
I 39.9
48.1
***Couple Protection Rate by Spacing_____________
i 35.4
***Couple Protection Rate by Sterilization_________
***Full ANC_________________________________
! 12.89
***Institutional Delivery________________________
j 21.05
***Safe Delivery______________________________
41.9
42.13
' 57.58
***Children Fully Immunized (%)________________
53.3
--Based on *SRS-2002, **Census 2001 and ***Key RCH indicators I1PS-
RCH ? Draft PIP Chhattisgarh
1.2
Situation Analysis:
The reasons for the relatively poor performance in many of the key R.CH indicators have been
identified. They include the following:
1. Gaps in infrastructure: This is most acute at the Subcentres and the PHC level.
2. Gaps in Training: Training is based on funding from national programmes and most are
short one or two day meetings. There has been a longer 12 day round for MPW-F that has
been very useful but there is no plan in operation of building up the requisite skills in each
facility and no training roster by which every employee is regularly trained. A training
policy to achieve this has been drawn up.
3. Inability to provide a dispersed net of quality referral services in the Public Health
Sector: The goal was to have one centre for every lakh population Or about MO to 180
such centres at the state level, where quality referral services like comprehensive
emergency obstetric care, Institutional care for the sick neonate and sick child and
Sterilization operations on a regular basis, and diagnosis and treatment centres for
infertility, STIs and RTIs are available. Yet despite the attempt Jo make at least 54 FRUs
functional under RCH-I, there are only about 14 such centres in the entire state in the
public health system and there are over 7 districts without any such centres. The last year
has seen an EAG scheme initiative to create at least 32 more FRUs but this is not
completed and the inputs are sub-critical. A referral system complete with ambulance and
communication that needs to be linked to referral centres has not been attempted and in its
absence the distribution of some grant to each panchayat has not even been utilised.
4. Inadequate institutions for institutional delivery: Only one in four Sub-Centres have
adequate space for institutional delivery and even in these achieving institutional delivery
has been difficult due to inability to make referral arrangements and due to a conflicting job
description of the ANM that needs her to be away on most days. These problems are not
there with Sector PHCs but due to lack of focus and weakness in design the Sector PHC
has yet to become a 24-hour site of institutional delivery and basic emergency care.
5. Medically Underserved Areas: There are still many sectors that because of vacancy or
absenteeism have not had a doctor in the last year and there are also many sections where
because of geographical constraints and workforce issues or programme design issues there
have been very poor delivery of paramedical services. Some of these areas are remote hilly
tribal areas and others are medium and large urban or semi urban concentrations.
6. Community Level Care organization: because of the geographical dispersion of the
population (4500 subcentres to cater to 54,000 hamlets and 26,000 villages) and because of
inadequate Health seeking behaviour first contact curative care for manyof the life saving
interventions at the village level and for prompt referrals needs an outreach that extends to
every hamlet on a Daily basis. This is most critical for preventing infant deaths though it
will also have benefits for all other RCH and other disease control components. Current
care arrangements include the ftJitanin, the traditional Dai, the depot holder and the Jan
Swasthya Rakshak. The traditional Dai performs a very limited range of functions even
within care at child-birth. The depot holder has a very limited outreach and function both
because he is being a male and due to the process of selection and support. The Jan
Swasthya Rakshak and RMP provide irrational and wasteful care even though some
percentage of lives saved may be attributed to their function. The options therefore are to
strengthen the Panchayat role and build on the Mitanin programme. The Mitanin by virtue
of being" a woman, selected by the community at the hamlet level addresses both these
gender and equity imbalances also.
s | I ! V «.
kCH 2 Draft PIP Chhattisgarh
7. Weak urban health systems: Urban Health Systems are particularly weak and access to
poor is limited. Though there is an abundance of public and private facilities in this area the
critical weakness is in access to basic health programmes and secondary level care that is
affordable for the urban poor.
8. Inadequate Health awareness: Though in many areas of RCH demand factors are not the
critical step, they continue to play an important role. More investment in BCC strategies
and a greater focus of BCC campaigns are called for.
9. Programmatic and Financial Management Issues: Management of RCH programmes both programmatic and financial need improvement. Part of the problem is qualified
manpower for these purposes at the state and district levels and part of the problem is
governance related.
1.3
Proposed RCH-II Plan:
Goals: The main goals of the RCH programme are a reduction of the IMR from the current 73
io 35 by the year 2007, of MMR from about 400 to about 150 by the year 2007, an increase of /
CPR to 65% by the year 2007 and a reduction of total fertility rate to 2.1 and net reproduction
rate to 1.0 by the year 2010. The goal also envisages making adolescent health care facilities /
and safe abortion services easily accessible to all.
The goal also includes achieving these targets in a manner that is affordable to the poor and
such that it is equitable and so that the services are gender sensitive and are people friendly.
Strategies:
For Maternal Health:
i. Focus on quality antenatal care in Sub-Centres by better support and training to MPW
(F). Institutional delivery only to the extent possible.
n. Focus on 24-hour institutional delivery with essential and basic emergency care in all
Sector PHCs and in every CHC, with referral linkages from the subcentre and villages to
ensure that all pregnancies are channelized to these centres.
in. Focus on select CHCs (100 across the state) becoming venues for comprehensive
emergency obstetric care by closing all hardware gaps and a major thrust in multiskilling.
iv. Bringing in private sector partners to close gaps in basic and comprehensive emergency
obstetric care.
V. Bringing in NGOs to close gaps in para-medically under-served areas.
vi. Building up transport and referral systems.
vii. Building up community care and support systems centred around the Mitanin Programme
so as to improve health awareness and demand for institutional services, improve link
between ANM and those in need of her sen ices as well as to facilitate the delivery of
maternity benefits and referral arrangements.
For Child Health:
i. 100% immunisation including the booster dose by strengthening subcentre level services
and its supervision.
n. Prompt and appropriate community level care for all sick children and neonates and
prompt referral where indicated.
in. Regular House visits and counselling by community level care givers for preventive and
promotive health of children and the reduction of child malnutrition.
iv. Adequate referral arrangement and secondary care facilities for sending a sick child or
neonate when it requires hospitalisation.
i
RCH 2 Drali PIP Chhattisgarh
v. Reducing cost of care especially on inessential and hazardous drugs and therapies so as to
favourably impact on poverty levels.
For Family Planning:
i. Ever}' district hospital would provide terminal sterilization services at least twice if not
thrice a week.
n. Hundred CHCs would provide sterilization on a fixed day of the week.
iii. The above block CHCs and 16 district hospitals would also be capable of providing safe
MTP services.
iv. The above block and district hospitals would also have adequate diagnostics for referral
level STI/RTI services.
v. In three months of the year all the remaining blocks would have at least three sterilization
days in their CHCs. In the coming years these would also change to fixed-day weeklyonce service availability.
VI. Every village would have one social marketing outlet, which would have supplies of
condoms and OCPs without interruption throughout the year. These would be managed
by partnership with a private distributor network with subsidy to make it viable to operate
in low off take areas.
Vll. All 24 hour PHCs would have one fixed-day of the week where IUD insertion would be
available and other contraceptive follow up would be encouraged. Emergency
contraception would also be available on 24 hour basis.
viii. All 24 hour paramedical and medical staff would be trained to provide basic clinical and
counselling services for RTI and STI with basic investigations (side laboratory level).
ix. Every hamlet would have at least two volunteers who would have a limited stock of the
supplies available- either collected from the village distribution point or from the health
department.
x. A focused IEC campaign would continue to build up demand for these services.
For Adolescent Health
i. BCC programmes.
ii. Open adolescent counselling services with referral access to essential services at the CHC
and district hospital level.
iii. Major effort to screen for and manage anaemia and malnutrition in adolescence and
where relevant for sickle cell anaemia.
iv. Peer education programmes in schools and some areas in the villages.
For Cross -Cutting Programme/Institutional Themes:
The interventions needed in each of the above technical areas are overlapping. As activities
they can be summarised into eight cross-cutting activity groups. These are:
i. Infrastructure Development integrated with its proper utilization.
ii. Training.
iii. Operationalizing FRUs in at least 50 blocks in two years (Definition of FRUs in this
context is to be able to deliver Emergency Obstetric Care, Care of sick neonates and sick
children, regular FP sterilization services, safe abortion services, adolescent health care
and care for RTIs/STIs)all blocks in five years and conversion of all PHCs to 24 hour
PHCs which can perform institutional delivery.
iv. Strengthening routine Sub-Centre functioning inch the coordination of functionaries
around the weekly nutrition and health day.
v. Public Private Partnerships to close gaps in medically underserved areas.
RCH 2 Draft PIP Chhattisgarh
vi. NGO participation in service delivery.
vii. Community level care and improved service utilization (to bring about a halving of IMR
in three years), including better provisioning of drugs and supplies for this level of care.
viii. Behaviour Change Communication.
ix. Village and Panchayat level capability building to support the entire programme as given
above.
For Programme Management Arrangements: This shall occur at five levels. These five
levels and their functions are given below. Each of these five bodies requires careful planning
at the level of governance, specifically in allocation of powers. They need to be able to
function with a higher degree of autonomy, decentralisation of powers and professionalism.
The RCH proposal also proposes ways and means and budgetary estimates to strengthen each
of these levels.
Level_____________________
Strengthening of the Directorate
Measures________________________
Administration and Workforce Issues
Infrastructure creation
Procurement and Distribution through a
separate cell for the same
Strengthening of the State Health Society
Implementation of all technical components of
the programme
Monitoring and evaluation
Financial Management related to programmes:
NGO Programmes
Public Private Partnership Programmes______
All Training Programmes and capacity
development in all employees______________
Implementation of Programmes of RCH
District and Block Level Plan development.
Mitanin; Community level capacity building;
Operational Research and Policy related
Studies: Assistance in Policy development & in
Public Private Partnership programmes; NGO
run programmes & dist/sub-district local health
plan development
Operationalizing the State Health and
Family Welfare Society_______________
Strengthening of the District Health
Societies___________________________
Strengthening of the State Health Resource
Centre
RC1I 2 Draft PIP Chhattisgarh
Budget Summary:
1 SI.
1
2
PIP Component
Building adequate
infrastructure for
ensuring RCH
services at
appropriate levels.
Training
Infrastructure
Training of
paramedicals
Training on
adolescent health
& STIs
Training of
medical officersCME
Multiskilling
medical officers
Training for ISM
staff
2005-06
2006-07
2007-08
2008-09
/
2009-010
Total
Section
607750000
1067347500
667839375
468733050
385315481
3196985406
7.3.1
I 31200000
3392000
7123200
7479360
7853328
57047888
7.3.2.1
’
11500000
12075000
12678750
13312688
13978322
63544759
7.3.2.2
3510000
3685500
7195500
7.3.2.2
5000000
5250000
5512500
5788125
6077531
27628156
7.3.2.2
4427500
4648875
4881319
5125385
5381654
24458733
7.3.2.2
7500000
7635000
2507925
2548321
2590737
22781984
7.3.2.2
63137500
36686375
32703694
34253879
35881572
202663020
28204000
29383200
30852360
32394978
34014727
154849265
7.3.3
24000000
25200000
26460000
27783000
29172150
132615150
7.3.4
324000
340200
357210
375071
393824
1790305
85614000
89894700
94389435
99108907
104064352
473071394
7.3.5
50000000
21000000
22050000
23152500
24310125
140512625
7.3.5
4000000
8000000
12000000
7.3.5
139614000
118894700
I
|
Total Training
3
I
4..
5
6
Ensuring Quality
of care in FRUs
and 24 hour PHCs.
Strengthening
Routine SubCentre services.
Social Marketing
for Family
Planning Service
Public Private
Partnerships in
Obstetric care
PPP in Referral
transport
/Ambulance
____ Services
PPP in Laboratory ,
_____ Service_____
TOTAL on Public
Private
Partnerships
silRC
116439435
122261407
128374477
625584019
RCH
I SI.
7
I 8
I 9
I 10
'll
I
I 12
13
14
15
16
I 17
I 18
| 19
^20
I 21
nrufi PIP Chhattisgarh
PIP Component
2005-06
NGO participation
20000000
in service delivery
Community Level
196888300
Care (Mitanin)
CHV/Mitanin
120000000
____ drug kit____
Behaviour Change
20000000
Communication.
Panchayat
Capability
Building &
44105000
Intersectoral
Coordination
Adolescent Health
18030000
2006-07
2007-08
2008-09
2009-010
Total
Section
21000000
22050000
23152500
24310125
110512625
7.3.6
206732715
217069351
227922818
239318960
1087932144
7.3.7.1
113400000
119070000
125023500
131274675
608768175 ! 7.3.7.2
21000000
22050000
23152500
24310125
110512625 |
7.3.8
(
45580250
47129263
48755726
50463512
236033751
7.3.9
30903075
32448229
34070640
144883444
7.2.4
78787783
82727172
86863531
395470213
7.2.5
7.2.6
Urban Health
Tribal Health
( mostlyincluded
in other sections
esp in training
section)_________
Strengthening
state health
society and
directorate.
Building
Management
capacity at the
Directorate and in
the District
Strengthening
district health
societies.
Strengthening
State Institute of
Health and Family
Welfare.
Strengthening
SHRC.
HMIS
Financial
Management
Improvement
72055742
29431500
75035984
19800000
8538000
5329800
5596290
5876105
45140195
13508000
5258400
5521320
5797386
6087255
36172361
8.1
2600000
2635000
2671750
2710338
2750854
13367942
8.2
10400000
9240000
9702000
10187100
10696455
50225555
8.4
14500000
6300000
6615000
6945750
7293038
41653788
8.3
3998000
4197900
4407795
4628185
4859594
22091474
8.5
41628200
19349610
20317091
21332945
22399592
125027438
8.6
1004000
378000
396900
416745
437582
2633227
8.7
Total
1461546742
1845929334
1466673202
1306598569
1264164274
7344912121
I
RCH 2 Draft PIP Chhattisgarh
Note on budget:
The budget makes the following assumptions:
Current funds from ministry of family welfare, especially for Sub-Centres (MPW Female
wages and their drug and equipment kits) will continue and RCH-I1 is additionality over the
same.
The amount set aside for budgeted BPL reimbursements and for payments for sterilisation
under the PPP programmes both in rural and urban areas would expand if demand flows above
the 25% estimate and all sterilisations done under PPP can be reimbursed at rates quoted in our
state’s PPP approach.
sniu •
10
RC11 2 Draft PIP Chhattisgarh
2.
Process of Plan Preparation
RCH -II design team was formed in January 2003 with the Director Health Services and the
Director, State Health Resource Centre. In February 2003 both of them along with the
Secretary Health attended the Health Sector Reform workshop hosted by the EU in Goa where
the approach to the preparation of the state PIP was explained by the national design team for
RCH-II.
Subsequently, a one-day consultation with various stakeholders was held in Raipur. This
workshop helped to identify priority areas for the RCH-II programme. Participants included all
the Directors and Joint Directors of the Directorate, the Consultants in RCH, Officials from the
Government of India, Officials from UNICEF, DANIDA and EU who are the three donor
agencies active in Chhattisgarh, and Subject Consultants in specific areas.
In early June the Director Health Services, Dr AK Sen, the Joint Director- RCH. Dr Pramod
Singh, the Director SHRC and the secretary health attended the Cluster level Workshop on
RCH-II that was held at Kolkata. This workshop explained the log frame aspect of the RCH-II
project.
Then based on these inputs a design team was constituted and each member was asked to write
and submit their inputs on various components. These included Dr. Subhash Pandey, Deputy
Director RCH on RCH-I review, Dr. Jayaprakash on establishment aspects, Dr. Pramod Singh
on institutional areas, Dr. Rajni Sao and Dr. Nilanjana Singh on Maternal Health, Dr. Ajay
Dani on Child Health, Dr. K. Madangopal on training areas and Dr. Sundararaman on
Infrastructure Development. The design team completed their work and submitted their inputs.
On July 10th there was a one-day workshop to review these inputs. Many of these inputs had to
be revised subsequently during the workshop.
Subsequently in August 2004, the SHRC’s four person resource team ofjDr. T. Sundararaman,
Mr. V. R. Raman, Dr. Premanjali Deepti Singh and Dr. Kamlesh Jain was asked to finalize the
draft plan for RCH-II using all the inputs from all the processes that had so far taken place.
This draft was then discussed by the key functionaries of the state RCH society (same as state
health society) and the Directorate of Health Services on September 8th and then finalized by
the government. It was decided in this meeting to take the inputs from the national design team
and the union ministry of department of family welfare also before the final submission.
3.
Time Frame
First Phase: Two years - 2005- 2007 presented with budget estimates.
Second Phase: In the next plan period - 2007 to 2010 - Currently a projection made with
budgets to be finalized later.
SI II."
R('! I 2 Orn"
4.
(■hh,iilis!?;irli
Background and Current Status
Chhattisgarh
No. of distts-16
No. of Blocks-146
Population: 207 lakhs
Tribal Population: 34 %
Sex Ratio: 990
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RCII 2 Draft PIP Chhattisgarh
4.1
Socio —Economic Profile including Administrative Divisions:
The new state of Chhattisgarh was carved out of erstwhile Madhya Pradesh on the first of
November 2000. Its population by census of the year 2001 is 207. 95,956. The state constitutes
2J13%j2fthetotal populatipnoflhe country but occupies 4.11% of its land area. It is the ninth
largest state and the 17 most populous state of India. This obviously implies a population
density per square kilometre (154) which is about half of the average population density of the
nation (324).
Of this land area abouM0%js covered with forests and the whole land is criss-crossed with
numerous swift flowing'rivers all of which can flood during the intense monsoons.
As part of Madhya Pradesh the area that became Chhattisgarh had only 7 districts. With state
hood the number of districts multiplied to 16. The state has 98 tehsils, 146 blocks, 20,978
villages. The state has 97 urban centres but the urban population constitutes only 20.08% of the
total population.
The state has a comparatively good sex ratio of 990 women per 1000 males in the year 2001
and this is an increase from the sex ratio of 1991, which was 985.
The state has one of the largest concentrations of tribals with 32.46% of the total population
constituted of tribals. Scheduled castes account for another 12.2% of the population. The rich
ethnic and linguistic diversity of the state is also notable.
In terms of literacy rate the state has attained a total literacy rate of 65% with 78% for males
and 49% for females. There has been an ahnost_20 % increment in the last decade in this
figure. Despite this, its rank in the literacy score-card is 23 out of 35 states and union territories
of India.
7
---- ------------
4.2. Performance by Demographic Health Indicators:
The state has a crude birth rate of 25.0, which is the same as the national rate. Thus it is
performing better relative to many other EAG states as regards parameters in fertility control.
Its total fertility rate is 2.79, which is better than the all India figure of 2.85.
The population growth rate at 18.06% is distinctly better than the national growth rate of
21.34% and has shown an over 7% decadal drop as compared to only a 2.62% drop at the
national leveljhe significance of such a large drop in population growth rate is diminished
when we find that the crude death rates and infant and child mortality rates are significantly
higher than the national averages.
The crude death rate is 8.7 as compared to a national 8.1. The infant mortality rate is 73 —
much higher than the national 64 and if we look at the rural desegregation of IMR it stands at
85 - the third worst index amongst states. The situation in under - 5 mortality is even more
alarming with the Chhattisgarh rate being 122.7 as compared to a national average of 94.9. We
13
RCII 2 Draft PIP Chhattisgarh
note that by international standards and even the standards of states like Kerala and Tamilnadu
the national averages are impermissibly high, meaning that the distance this state has to
traverse is not to be judged by the national average - but much-further than that.
We however note that by SRS data in the last three years for which data is available there has
been an improvement in our IMR figures - from 79 to 77 to 73 in the year 2002.
4.3. RCH outcomes and Service utilisation:
4.3.1. Maternal and Neonatal Care:
The determinants of these demographic health indicators are many and include levels of
poverty and access to basic commodities like food, water and sanitary facilities as well as to
higher educational levels and lesser inequities. However even within prevailing
macroeconomic indicators good health services can bring about substantial improvements.
The key indicators regarding maternal and neonatal health provision are percentage who have
received full ANC check ups, institutional delivery, and skilled care at birth (safe delivery);
access to emergency obstetric services, percentage receiving postnatal care and the outcome
indicators: percentage of low birth weight babies and maternal mortality. (Dai training and
number of births attended by trained Dai remains important in areas where there is little or no
penetration of health services but its impact on maternal mortality is negligible.) Not all these
figures are available but one can see from the taoie below that we have a long way to go.
Table 2:
400+_______
MMR___________
12.8%
ANC Check ups
21%_______
Institutional Delivery
42.03%
Safe delivery______
ANC Registration
97%_______
20%_______
Postpartum Care
Source: NFHS
4.3.2. Child Health Services:
The key indicators for child health services provision are: Immunization rates, child
malnutrition rates, and IMR, and under 5 mortality rates.
Table 3:
IMR Total
73_____________
IMR Rural
' 85_____________
~_51______________
IMR Urban
Under 5 Mortality
122_____________
Immunisation
57.58%_________
Source:NFHS, SRS 2002
4.3.3 Family Planning Services:
The most important key indicator is the couple protection rate and the outcome indicator is the
total fertility rate and birth rate. Other goals are age at marriage and age at first child and
average spacing interval and family size. The access to emergency contraception and safe MTP
services is also an important component.
4
RCW2 Draft PIP Chbttisgarh
Talk 4:
* Birth Rate Total______
25
* Birth Rate Rural______ 26.5
* Birth Rate Urban_____
22.6
Couple Protection Rate (%)
39.9
Couple Protection Rate by
4.5
Spacing_____________
Couple Protection Rate by
35.4
Sterilisation___________
Total fertility rate
2.79______
Median months of spacing
3 1.6 months
% of women who had birth
73.8% (?)
in 15- 19 age group_____
Source: NFHS-99, SRS 2002**
4.14. Adolescent Haith:
Her development of indicators has been poor. Some of the most important indices would
relte to malnutritioi measured by BMI, prevalence of anaemia and incidences of violence
against women. Pregpancy in adolescence also needs to be addressed as a major issue. We note
thatsome of the problems on which we have data all tend to peak in the late twenties. However
theadolescence age swhen it sets in and when it starts building up. Available data on this is as
follows:
Talk 5: Issues related to adolescence health
gegr..pwh.„i, Over all for women
of ado]
Mcator
■
.
•
Anemia_______
Mid___________
Mrierate_______
Soerc__________
Nrtritional
Status__________
- Mean BMI
%below 18.5
BMI___________
RPs___________
vaginal discharge
+tching
+ Lower abd. pain
VWence________
%beaten or
untreated_______
NOT Involved in
derision making
wfere it affects
then___________
%ef women who
h^first child in
15t> 19 age group
Sarce: NFHS
<7.5
C.l
M.5
19
72.6(25 to 29)
49.2_____________
22.9_____________
0.5
68.7%
B.9
W.9%
48%
E.7%
*12.7%
*14.2%
37% of married have
some RTI of whom 68%
have not sought advice
E.6%
21.4 (30-39 age)
17.4%
15.8%
15.8 (15 to 19 age
group)
7.9%
73.8%
18.1 years - median age
of first child.
.
RCII 2 Draft PIP Chhattisgarh
4.4.
Public Health Systems Analysis
4.4.1 State Level Implementation StructureSee the Organogram in next page.
Chhattisgarh has a fair sized network of health facilities in the public sector as shown below.
Table 6: Public Sector Health Facilities at a Glance
S
.No.
District
Bloc
ks
Distt.
Hosp.
Civil
Hosp.
CHC
PHC
HSC
C.l).______
Distt.
Hosp.
No. of Beds
Civil
Hosp.
CHC
PHC
100
350
82
540
18
360
18
1
Raipur
15
1
11
47
461
2
Surguja
19
1
18
65
488
188
3
Bastar
15
1
12
57
317
269
4
Dantewada
11
1
9
34
204
(100)
296
12
5
Jashpur
8
1
27
195
109
210
22
6
Kawardha
4
1
2
12
96
(100)
60
36
7
Raigarh
9
1
2
5
40
249
2
117
76
150
46
8
JanjgirChampa
9
1
1
6
25
210
1
(100)
38
180
68
9
Dhamtari
4
1
1
3
11
138
100
6
90
16
10
Bilaspur
10
1
1
10
42
282
(100)
6
306
23
11
Mahasamund
5
1
1
4
14
143
(100)
32
126
12
Durg
12
1
2
10
46
353
1
330
45
276
34
13
Raj
nandgaon
9
1
6
25
220
1
225
180
55
14
Ranker
6
1
5
21
162
150
36
15
Koria
5
1
5
21
106
I (100)
150
12
16
Korba
5
1
3
29
194
100
90
18
Total
146
16
116
516
3818
3514
496
2
2
12
10
3
100
80
130
j------------
18
: 1638
(600)
413
Figures in bracket indicate that facility is under construction.
However a number of facilities do not have the minimum infrastructure needed for optimal
functioning. Whereas almost all district hospitals will become 100 bed institutions soon . as we
go more peripherally we find the gaps widening. Thus by population norms the state should
have 180 CHCs for the rural areas. In practice CHCS are not by population norms but by
administrative blocks. Still, excluding 16 district headquarters, we should have 130 CHCs.
ORGANOGRAM SHOWING CURRENT ADMINISTRATIVE STRUCTURE & LINKAGES
TO PROGRAMME MANAGEMENT
MINISTER, HEALTH & FAMILY WELFARE
I
SECRETARY. HEALTH & FAMILY WELFARE
4-
I
I
DIREC TOR OE
I IT.Al . I II
SERVICES
DIRECTOR
()l I S Ms
DIRECTOR OE
MEDICAL
EDUCATION
EOOD
I)RU(i
CON TROLLER
3___ _
J STATEHEALlffi
*■
S'OcfETYsO
■
«
_J
JOINT
DIRECTORS
See ( ** ) last
column
i
T
f
Wdanida
MTTANTN
tea
./eSIHFW
S
D1STR1C I
CIVIL
SURGEON
DISIRICT
C MO
-T]
LEPROSY |BLINDNESS
Cl ICs
BMO
PROGRAM
OITICER
1-OR LACH
PROGRAM
See («) last
column
OISIRK'T
HOSPITALS
AIDS
& CIVIL
DISTRICT SOCIE^p:
HOSPITAL
DISTJUCT
TRAINING
CENTRES
WITH CMOIN-C.
PHCs- MO
SUB-CENTRES
-
-
'B: ■
-
PROGRAMME Of|i>
IN EACH)
R.t !■:
! Vail PIP ( hhattisgarh
The gaps in PHCs are more acute. Out of 748 sectors, only 516 got sanctioned PHCs- a gap of
234 PHCs. In subcentres, the gaps have been closed recently by sanction of another 875 Sub
Centres. The situation regarding health infrastructure is given in tables 7 to 9.
Table 7: Health Sub Centres in Chhattisgarh
Sanctioned
HSC
Govt.
Building
Run in
Panchayat
Bhavan/Any
Other
Building
New
Buildings
after state
formation
S.No.
District
Block
Head
office
1
Raipur
15
461
82
379
0
9
Sarguja
19
488
I 18
370
0
Bastar
15
317
21 1
106
0
4
Dantewada
11
204
89
115
0
5
Jashpur
8
195
152
43
0
6
Kawardha
4
96
40
56
0
7
Raigarh
9
249
194
55
0
8
Janjgir-Ch'ampa
9
210
37
173
0
9
Dhamtari
4
138
44
94
0
10
Bilaspur
10
282
40
242
0
11
Mahasamund
5
143
51
92
0
12
Durg
12
353
105
248
0
13
Rajnandgaon
9
220
110
110
0
14
Ranker
6
162
123
39
0
15
Koria
5
106
42
64
0
16
Korba
5
194
20
174
0
146
3818
1458
2360
0
Total
Another 850 HSCs have been sanctioned w.e.f. 2004-2005. All of them have no buildings as
yet.
si l|?(
18
RCII 2 Draft PIP Chhattisgarh
Table 8: Primary Health Centres in Chhattisgarh
S.No.
District
Sanctioned PHC
Govt. Building
Rented and in other
building / Without any
building
1
Raipur
47
33
14
Sarguja
65
46
19
Bastar
57
37
22
4
Dantewada
34
25
9
5
Jashpur
27
20
7
6
Kawardha
12
10
2
7
Raigarh
40
18
22
8
Janjgir-Champa
25
12
13
9
Dhamtari
11
6
5
10
Bilaspur
42
23
19
11
Mahasamund
14
3
11
12
Durg
46
34
12
13
Rajnandgaon
25
14
11
14
Kanker
21
17
4
15
Koria
21
11
10
16
Korba
29
18
11
Total
516
327
191
2
3
4-------
We note that there are totally 748 sectors in the state. Of these, only 516 have sanctioned
PHCs. The need to create 232 more PHCs to reach the required norms of the planning,
represent the single largest unaddressed infrastructural challenge of the state.
19
RCH 2 Dralt PIP Chhattisgarh
Table 9: Community Health Centres in Chhattisgarh
S.No.
District
Sanctioned CHC
30 bedded
CHC
according to
norms
1
Raipur
H(3)
3
8
2
Sarguja
18
3
15 ■
3
Bastar
12(1)
2
10
4
Dantewada
9
3
6
5
Jashpur
7
6
Kawardha
2(1)
7
Raigarh
5(3)
2
8
Janjgir-Champa
6(2)
3
9
Dhamtari
3
1
'j
10
Bilaspur
10
6
4
11
Mahasamund
4
12
Durg
10
6
13
Rajnandgaon
6(4)
3
14
Ranker
5(1)
15
Koria
5
16
Korba
3(1)
Total
116(16)
Run in PHC/any other
building
4
5
2
34
82
We note that another 16 PHCs needs to be upgraded to CHCs and sanctioned as such. These
are indicated in brackets.
Fully Operational and Utilised: It is difficult to estimate How much of these facilities are
fully operational and functional, because of varying levels of utilisation. It is more appropriate
to look at the constraints of utilisation. Infrastructure constraints are indicated in tables 7 to 9.
But even where infrastructure is in place manpower could be a problem. The tables 10 and 11
present the situation in manpower.
SI lb*.
'.'J
RCH 2 Draft PIP Chhattisgarh
Table 10:
RCH Manpower in Chhattisgarh:
Staff Nurse
S.
No
District
c
c
Raipur
2 Sarguja
Bastar
4
5
-o
■o
03
CO
1
LEV
Dantewa
da__
Jashpur
I
c
s
.o
Q
C
T3
GJ
C
_c
c
O
CJ
o
ex
c
s
C5
CO
>
MPW(M)
71
68
3
71
68
81
28
53
90
81
34
16
18
82
36
20
16
36
18
8
2
.o
GJ
OS
c
03
CO
>
MPW(F)
TJ
W
o
i
c
.o
C3
C
03
a______
a
1
>
co
s
316
142
434
429
5
9
406
387
19
557
526
31
77
5
317
287
30
317
296
21
61
43
18
205
195
10
205
187
18
18
41
38
3
172
120
52
256
228
28
9
0
20
17
3
101
73
28
102
75
27
73
57
16
50
46
4
211
189
22
307
244
63
36
23
13
57
44
13
213
153
60
215
175
40
28
19
9
25
17
8
139
83
56
154
192
0
113
116
0
84
81
3
282
254
28
301
281
20
25
23
2
24
20
4
149
87
62
149
125
24
106
103
3
67
63
4
298
259
39
438
436
2
34
35
0
41
40
1
214
177
37
254
258
0
49
28
21
35
38
0
155
132
23
162
162
0
21
14
7
26
17
9
124
80
44
124
83
41
13
764
13
590
0
174
40
814
40
730
0
84
113
3557
113
2905
0
652
119
4094
119
3816
0
278
8 JanjgirChampa
9 Dhamtari
10 Bilaspur
11
12
Mahasa
mund
Durg
I____
13
14
Rajnand
gaon
Ranker
15
Koria
16 Korba
Total
03
>
458
6 Kawardh
7 Raigarh
*q
.2
21
RCH ? Draft PIP Chhattisgarh
Table 11: RCH Manpower in Chhattisgarh
Anaesthetist
s.
No
•o
District
.o
•1
1
Paed
Gynae
c
cs
Q
e
c
s
.2
*<«
E
E
c-»
Q.
C
>
3
0
1
0
o
X
>
CO
•Z3
O
E
O
Medical officer
c
es
I
I
c
>
1
124
116
8
•2
I
on
c
o
•-i
>
GC
E
E
CJ
1
Raipur
0
0
0
2
Sarguja
0
0
0
4
0
4
3
0
2
142
121
21
3
Bastar
1
1
0
6
1
5
5
1
4
131
114
17
4
Dantewa
da
4
u
4
0
4
1
0
1
79
62
17
5
Jashpur
0
0
0
2
1
1
0
1
73
52
21
6
Kawardh
a
0
0
0
0
0
0
0
0
0
31
23
8
7
Raigarh
0
0
0
0
5
0
0
0
0
84
75
9
8
JanjgirChampa
0
0
0
2
0
2
2
1
1
62
62
0
9
Dhamtari
1
1
0
1
1
0
2
2
0
35
33
2
10
Bilaspur
1
0
1
7
2
5
6
1
5
144
128
16
11
Mahasa
mund
0
0
0
2
1
1
2
0
2
43
39
4
12
Durg
1
1
0
5
4
1
6
6
151
152
0
13
Rajnand
gaon
0
0
0
4
0
4
5
0
5
98
79
19
14
Ranker
0
0
0
2
1
2
2
0
2
70
70
0
15
Koria
0
2
2
0
2
2
0
2
37
30
7
16
Korba
0
0
0
0
0
0
0
0
0
32
29
3
Total
11
3
8
46
20
31
38
5
33
1336
1185
152
22
RCH 2 Draft PIP Chhattisgarh
Table 2: RCH Manpower in Chhattisgarh____
Lab Tech
S.No. District
In
Sanctioned
position
x Raipur_____
2
2
4
2
6
2
8
9
10
11
12
13
14
15
16
Sarguja
Bastar_____
Dantewada
Jashpur____
Kawardha
Raigarh
JanjgirChampa
Dhamtari
Bilaspur
Mahasamund
Durg______
Rajnandgaon
Ranker____
34
54
Sanctioned
4
14
20
14
12
9
13
14
4
8
J_
7
T
9
4
11
5
14
9
7
5
4
149
_8_
4
10
5
1
0
36
28
25
3
26
16
10
8
37
5
3
26
11
13
47
18
27
Koria______
_21
Korba_____
14
436
Total
Vacant
30
33
32
18
9
46
21
4
16
I
44
12
41
17
25
14
14
355
BEE
In
position
2
4
2
1
6
1
2
7
0
81
13
8
7
13
6
9
3
4
125
Vacant
1_
2
1
4
2
1
0
1
3
0
_2
0
24
We can see Specialist vacancies are a serious problem. We however note that a number of
specialists (Anaesthetist: 42, Gynaecologists: 48, and a number of paediatricians and others)
are serving as medical officers currently available within the system.
Transfers of these to fill up specialist vacancies with regular promotions to specialist post will
help but only to a point. A rough estimate is that about one third of these specialists would be
willing for such transfers where they are needed.
Even where manpower is in place a number of problems especially of workforce management,
human resource development and the rational deployment of systems impede the progress of
the programme. These are discussed in length in the study report on these same topics brought
out by SHRC .The executive summary of this report is annexed and the main report can be had
at request.
This report covers the following areas :
• Institutional Arrangements
• Organisational structure
• Accountability of staff
• HRD, rationalisation of services and workforce issues
• Training
• Logistics
• The report does not cover the HMIS, which is discussed in section 8 on Programme
Management Anangements.
23
RCH 2 Draft PIP Chhattisgarh
4.5. Private and NGO services:
The private sector and not for profit hospitals in the state are many. The latter include public
sector hospitals of a number of mines and public sector companies. Their district wise
distribution is as follows.
Table 13: Health Facilities run by NGOs.
Pvt sector
Not for profit
SI.
District
Public sector
______ nursing homes
sector
T
Bastar______ ___________ 7
1
0
2
Bilaspur______
36
4
2
Dhamtari_____
1
_____ 0
V
Janjgir______
2
2
0
5
Korea_______ ___________ 2
0
2
6
Raigarh______ ____________1
0
0
7
Raipur______ ___________ 44
1
0
8
Rajnandgaon
___________ 7
1
0
9
Mahasamund
___________ 8
3
0
10
Korba
___________ 5
0
3
11
Kawardha_____ ___________ 6
0
0
12
Sarguja______ ___________ 4
1
1
n
13
Durg_______ ___________ 18
14
Jashpur______
1
1
0
15
Ranker______ ___________ 1
0
0
16
Dantewada_____ ___________ 0
0
2
Total_______ __________ 147
17__________________
13
The above figures are indicative. A more recent update
upuate or
of mese
these figures is neeoeo
needed especially tor
for large urban areas.
Between districts and within districts the private sector is very much concentrated in a few
centres.
Not for profit hospitals are of two’types- Mission run hospitals and other NGO run hospitals.
The Ramakrishna Mission runs a major one in Narainpur in Bastar district. The Christian
Missions have a major hospital at Dhamtari and smaller ones in Bilaspur, Rajnandgaon,
Baitalpur(2), Mungeli, , Tilda and Champa(2) and Jagdishpur. The Catholic Missions have
hospitals at Kunkuri, Raigarh, Ambikapur, Charoda and in Dalli Rajhara(Durg). The Public
sector undertakings running hospitals are SECL, NMDC, NTPC, BALCO and Railways.
We note that comprehensive emergency obstetric care is available in 25 out of 29 not for profit
and public sector hospitals. Of the other NGO hospitals the Jan Swasthya Sahyog hospital at
Ganiyari, Bilaspur and the workers union run Shaheed hospital are the two most outstanding
examples. One more NGO run hospital is there in Mahasamund.
We note that about 50% of the private sector units are concentrated in just two cities and even
the others are concentrated in districts which also have fully functional state run facilities. On
the other hand public sector units and NGO units are largely distributed in areas of very poor
private sector and public sector penetration, and offer a major space for participation.
24
RCH 2 Draft PIP Chhattisgarh
4.6.
Donor Assisted Programmes In The State:
There are only two such donor-assisted health sector programmes in Chhattisgarh. They are 15
crore Chhattisgarh Basic Health Services Improvement Programme funded by DANIDA and
the 16 crore Sector Investment Programme funded by the European Union.
DANIDA: Danida programme has been used for training of Dais, for strengthening training
institutions and management capacity building and for improving drug logistics.
European Commission: The Sector Investment Programme funds has been used to set up a
State iipnltb Resource centre that has conducted a number of studies and initiated a wide
number ol health sector reforms - other than coordinating and guiding the largest ongoing
community health volunteer programme which is known as the Mitanin programme.
UNICEF: UNICEF contributes strengthening ongoing programmes. Other than it has printed
the ANM registers for the current year and provided Rs 10000 per district as a mobility fund to
improve supervision and Rs 25000 per district for catch up immunisation. It has also supported
closing equipment,gaps in subcentres for 32 priority blocks. It is supporting the Mitanin
Programme also- by printing of monitoring formats and strengthening focus activities on
nutrition by providing weighing machines.
Global Fund: Through the central government the state has programme funding in malaria ,
tuberculosis and HIV control .The programme designs are identical nation-wide. Some of the
fifnding for these programmes received by the centre are from the World Bank and from the
Global fund against the three diseases.
4.7
Programme Expenditures under RCH-I:
The following table gives in brief the physical and financial achievements of RCH-I
programme. Though this scheme .was initiated in 1997, the scheme allocation for the new
Chhattisgarh state was carved out in thcTyear 2000 and the budget and activities shown below
are therefore for the period April 2001 to March 2004 a three-year period. In April 2004 it was
decided to extend this scheme^one year till the RCH-II was written up,
Table 14: RCH-1 Expenditures_______________
Item
Target ( from 2001 cumulative) Achievement
Financial
Financial
allocation: achievement
Contractual
For 14 C distts:(except Raigarh 494 + ANMs
1071 lakhs 844 lakhs+++
appointment of field
/Jashpur): 1012 ANMs
+76 staff nurse
staff:
plus staff nurses 146
+23 lab. techs
plus lab techs 32( 2/dt)______
Contractual
6 consultants (IEC, finance,
4- (except child 18.72
100%
appointment for
monitoring, child health,
health and asst
SCOVA________
maternal health asst stats.)
stat off.)______
Major civil works
66 CHC renovations + 5 dt
Completed
639 lakhs
100%
hospitals renovation
RCH camps for
290 camps were planned till
290 held
196 lakhs
100%
outreach of all RCH
march -04
25 .
RC1I 2 Draft PIP Chhattisgarh
Item
Target ( from 2001 cumulative) Achievement
services esp. FP.______
Cold chain maintenance Funds for Vaccine transport.; for Used for the
frig mech. mobility, for ILR
purposes stated
repair/& for inj. safety- kerosene
for sterilisation______________
Vaccine handlers trg.
Training for MPWs &. ANMs
Completed as
and supervisors______________ scheduled
I EC
Hoardings , and kalajathas were Completed
main focus_________________
Referral transport
For gram panchayats to transfer 1418 pts used
emergency cases : funds given to services; 7
8054 GPs in 14 distts.
distts.
> Refunded
money_____
Outreach immunisation 4 distts (durg , Koriya. Raipur
Limited
and Mahasamund) outreach
response, only
camp: sessions where there are
partly utilised.
no functional SCs___________
Em. Obs. Care
This was supplied to FRUs for
54 FRUs were
FRU kits- equipment
equipping them for EmObs Care supplied
24 hour delivery in
CHC/PHCs
incentive for night shifts for
doctors and nurse
Community incentive
scheme
2 lakhs per distts for 1 GP
which has max. Achievements in
FP________________________
Targets fixed for trg, main funds
from Danida________________
largely used, for health sector
reform and Mitanin programme
Dai training
any increase in
institutional
delivery needs
evaluation:
Fully utilised;
about half the
expected done
EC supported SIP
54,000 Mitanins
in place and
functional and
evaluated._____
EAG- FRU :Trg/ PPP 2 Civil works in 32 blocks for
Civil works and
blocks / Mitanin 2
improving PHCs and CHCs; plus Multiskilling
books
Multiskilling some 30 persons in done.
QG and anesth.;also trg and PPP
condoms
For one time condom purchase
This was done.
Small amt of
money returned
Parivar melas
More as IEC, small outreach role Completeduncertain
impact.______
Review meeting and
This is for strengthening
money utilised
mobility support
supervision
NSVT___________
PNDT
IEC on sex —selective abortion
Done-
Financial
allocation:
Financial
achievement
27.79
81%
100%
380
100%
42.15
6%
21.12
54%
80
100%
40
80%+++
14.68
50% +++
1095
100%
575
478
106
100%
35
100%
5.58
80%+++
3.0
12.0
100%
23.5%++
26
RC! I 2 Draft PIP Chhattisgarh
Item
Target ( from 2001 cumulative) Achievement
Laparoscope's repair
Stabilisation of popln.
25 to be repaired____________ All repaired
Workshop to be done and action
plan drawn up______________
To facilitate coordination of
Utilised
6.0
NGOs_____________________
this was for pregnant women as procured and
26.16
a step in maternal care________ distributed.
for training n non scalpel
Being
3.65
vasectomy technique
_____ undertaken.
For compensation to patients
Been put on hold 120
who opt for terminal FP methods at request from
as incentive
centre to revise
plan.________
To set up programme
Plan made
50(200)
management for state led
awaits approval
franchisee_________________
ANM, LHV, supervisor, medical Very useful trg- 84.35
officer for 12 days each
only part
lakhs
covered for
logistic reasons
TOT done, dt officers providing Trg expected to 1.9
trg for MOs and ANMs
start soon.
NGO coordination
DD kits
NSVT trg.
Funds for
contraception/
sterilisation
PPP for RCH service
RCH Trg.
Trg for ISMs
Financial
allocation:
12.0
20
Financial
achievement
75%
0%
100%
100%
100%
Pendingplan
0%
65%-H-
0%
4.8. Details of administration and finance of RCH-I:
Almost all components of RCH-I are organised by the joint director RCH , assisted by the
deputy director RCH and one financial consultant, one maternal health consultant and one
consultant on IEC and another one on data analysis. This has been very inadequate for the
management of such a large programme. There has been no distinction in implementation
between the state health society and the directorate as the same officers perform both
administrative and programmatic functions. This weakness of staff reflects in every aspect
from quality of monitoring to the realisation of utilisation certificates in a timely manner.
The EC supported SIP has however been outsourced to a state health resource centre which has
been built up as an additional technical capacity to assist the directorate and this has been
useful to design, launch, monitor and support an innovative and complex programme with a
high rate of expenditure - almost all of it at the community level.
At the district level the programme is under the district RCH society. Here too the district RCH
society has no staff, and the same district chief medical officer assisted by an immunisation
officer - who is often holding charge in addition to clinical duties manages the entire
programme. Even accounting help is limited.
There is a need to make a major investment in management structures if in future larger
programmes need to be better run.
27
RCII 2 Draft PIP Chhattisgarh
5.
Situation Analysis
The reasons for the limited achievements despite the existing health systems has been analysed
in detail in the SHRC’s study group report on rationalisation of health services, workforce
management and human resource development report. This has been summarised in section 4
above and the executive summary of this report is annexed.
We would now re-examine the question from the viewpoint of each health goal. There are five
broad health goals we are examining - maternal health, immunisation, neonatal and child
health care, adolescent health and family planning services. A large part of the constraints in
improving these services are overlapping.
In each of these five technical domains the over coming of these constraints invariably requires
action at four levels. These are:
i.
Measures for increasing public awareness and promoting appropriate behaviour
change.
ii.
Need to have community level care arrangements so that basic care which is simple
and life saving is received almost immediately on any day of the week.
iii.
Building up a system such that a skilled woman paramedical on a regular 24 hour
basis so that essential health service inputs of RCH are accessed -like immunization
antenatal care, skilled care at delivery. This includes both options- strengthening the
ability of the public health system and building up public private partnerships.
iv.
Building up a functional referral system with the nodal point being a well equipped
and functional secondary care centre so that secondary medical care (largely defined
by the ability to manage a Caesarean section and provide
in-hospital care for a
sick neonate or child) is accessible to all. This too includes both options:
strengthening existing public health system, and supplementing with private sector
partners where-ever it is required and possible.
We give below the specifics of how the constraints operate in each domain of RCH.
5.1. Maternal Health:
The immediate causes of maternal mortality are well known. They are sepsis, haemorrhage,
obstruction, anaemia, toxaemia and unsafe abortions. The larger social determinants of these
are also equally well known - they include educational status of women, poverty levels, social
inequities and access to quality care.
We would now re-examine these causes from an intermediate operational set of issues. Thus
maternal mortality in such an analysis may come from:
1. Inability to follow optimum health practicesa. Eat the right foods in right quantity,
b. Take adequate rest while retaining optimum activity,
c. Protect oneself from infectious disease
d. Be able to access health care facilities due to a supportive environment.
28
RC1I 2 Draft PIP Chhattisgarh
The above factors may occur due to:
• Lack of education and awareness.
• Burden of work due to poverty
• Inability to afford increased health determining inputs - esp. more food of better
quality, more rest, safe water and sanitation etc.
• Lack of money to pay direct and indirect costs of maternity care e.g. visits to a nurse,
transport in an emergency, pay for drugs or other treatment prescribed etc. (The loss of
wages of woman and her accompanying person should also be costed)
• Poor support from family and community due to discriminatory attitudes that fail to
prioritise women's health issues.
2. Inability to access good quality antenatal, natal and post natal services:
This in turn is due toa. Lack of nurse (refers to female MPW or ANM) to providing quality ante-natal care at
an appropriate time in vicinity of her home.
• Vacancies: Some areas are paramedically underserved due to a vacancy situation
related to workforce management and governance issues.
• The Up-down Problem: The ANM is posted there but does not stay there and visits
are occasional. Again workforce management and poor supervision related issue.
• The Geographical Constraint: Distances to be covered by ANM are high and the
ANM visits only about once a month - and the high degree of coordination needed to
ensure that the mothers meet the ANM during this brief visit is not present for at least
some of the population. Thus there are only 4800 ANMs but over 54000 hamlets. Each
ANM has to cover approximately 10 to 15 hamlets over a 5 to 25 km distance.
• The Quality of Care Constraint: The antenatal visit occurs but antenatal care is
limited to registration, iron and folic acid tablets and TT injection .All other
dimensions- identification and advice on high risk, blood pressure and weight
measurements, urine and blood examination are just not done. This is largely a training
& supervision issue but may occur as a consequence of equipment and facilities.
b. Lack of skilled birth attendant in vicinity of home (trained midwife, nurse or doctor):
Many lives can be saved if the skills to conduct a safe normal delivery are present, along
with the skills needed for management of the first level of complications (uterine massage,
injection of oxytocics, intravenous hydration and antibiotics, antihypertensives and
anticonvulsants, assisted deliveries etc.) and the ability to identify the need for referrals in a
timely manner. This level of skills is not provided by a Dai - even if trained. It needs a
trained midwife or nurse at least. Since most often this is available in an institution this
goal is usually realised only by encouraging institutional delivery. Constraints operational
are all those mentioned in 2a - vacancies, up-down problems, the geography problem and
quality of care issues. Up-down problem can be particularly harmful since care at delivery
requires physical availability for 24 hours. In addition lack of adequate skills in some
ANMs is also a problem. Another problem in access to this care is the high charges that
skilled delivery entails as compared to the traditional Dai. On an average the going
informal rate for skilled birth attendant even within the public health system is Rs 400 to
Rs 700 - in rural Chhattisgarh.
29
RCU 2l)raft PIP Chhattisgarh
c. Lack of facility providing institutional delivery on a 24 hour basis:
• The Sub-Centre: The Sub-Centre is not usually a site for institutional delivery. In two
thirds of sub centres the lack of buildings rules it out as an option. But even in the one
third that has a building the ANM is available at the headquarters only once or twice a
week during working hours. The rest of the days she is on tour. In addition she is often
not staying there. Equipment gaps may also contribute to poor service. Lack of
communication and referral linkages also discourages the staff from taking a risk- as
timely referral becomes necessary in 5 to 15 % of cases. It is difficult to predict which
(Tase would need such referral and if the referral is made late then the ANM is held
responsible. Thus the Sub-Centre would be insisted on as site of institutional delivery
only if there are two ANMs posted there (who between them can see that there is
someone at the headquarters on at least 5 days of the week) and only if good
communication and referral arrangements are built there. Where these two are possible
the completion of infrastructure as per norms would result in improved outcomes. For
the rest we intend to encourage it but not insist on it.
•
PHCs: Even most PHCs are not functioning on 24-hour basis and not providing
institutional delivery facilities. Here infrastructure is adequate. Total number of staff
would be high and out of proportion to the few numbers of patients attended to. On an
average only 25 patients may be seen in a day. However the paramedical are
categorised into 8 categories - dresser, compounder, laboratory assistant, sector
supervisor male, sector supervisor female, staff nurse and MPW (female) and MPW
(male) - the last two from the built- in Sub-Centre. The class IV staff also is
categorised into 5 categories. Usually one or other of these posts is vacant or not even
created and this makes for the perception that manpower availability is the single most
important constraint. Except for the MPW (F) given the OPD attendance all the above
staff are employed for not more than two hours of work every day- including the sector
doctor. Almost no one sees institutional delivery as her responsibility. They see
themselves as assisting the medical officer whose availability, skills and leadership at
this level is very difficult to attain.
•
CHCs: CHCs have also similar problems to that of the PHC described above-but less
so. In many CHCs some institutional delivery happens. But due to low availability of
C-section facilities there is reluctance to take up cases. Paramedical staff is adequate for
this purpose as other than LHV and ANM there are staff nurses also available.
•
Private sector facilities: Private sector facilities are usually not available or too costly
for the majority. However there are a number of NGO run hospitals that provides
adequate care at affordable costs. Public sector undertakings run facilities are many and
provide good quality free care to their workers but are unaffordable and also difficult to
access for non-employees.
30
Ri ! 1 2 Draft PIP Chhattisgarh
d. Lack of facility to which one can be referred:
“an institutional delivery location the distance of which is within one hour ” For
complications when higher (secondary) medical care' is needed. (Emergency obstetric
care including blood transfusion), such referral facilities are necessary. The current
approach to this is to develop all district hospitals and all CHCs as sites of such
secondary medical care.
However the large gap between the skilled manpower needed for this and that which is
available makes it essential to have a short-term goal. This goal was set for RCII-1 as
setting up 54 FRUs. However even this has not been realised and there are only some
15 hospitals including 9 district hospitals, three civil hospitals and three block level
CHCs which have this capability as of now.
The constraints have been of infrastructure, equipment, supplies, manpower and skills.
These constraints are largely not one of absolute unavailability but emanating from
mismatches between the provision of one element and the other. Thus one has
gynaecologists posted where there are no operation theatres and operation theatres
where neither gynaecologists nor surgeons available. One has shadowless lamps and
Boyle’s apparatus without functional OTs where many OTs are there whose
functionality is constrained only by this gap.
Private sector hospitals and not—for profit hospitals providing these services especially
in the further districts are also few. On one hand these private sector hospitals are not
enough to service the needs of the poor in the state. But we also note that the not for
profit sector has at least 29 hospitals where they would be willing to undertake BPL
cases with reimbursement by the government. In none of these centres today referral
reimbursement is ongoing. If these were included the number of centres where the state
is able to provide health care facilities would be tripled. And this would be easy to
initiate because monitoring need not be as stringent in these non-commercial hospitals.
With some checks one can allow flexibility in rates charged even as reimbursement
rates are kept consistent. The unregulated environment of the private commercial sector
will require close monitoring and fixed rates packages.
e. Lack of transport facilities:
From the home or from the site of institutional delivery timely transport to a secondary
centre during an obstetric emergency can be life saving. In most places however, even
where there is a secondary medical service some transport is either not available or is
that a hired vehicle is so costly that this acts as one of the biggest barriers to access of
health care. (Public transport is not an option in such situations.) There is a fund kept
with the panchayats for such referral. Many panchayats have not received the funds, or
where they have received it have little idea of the rules governing it and further in times
of emergency the fund is difficult to access. Because of very poor systems designs the
fund has gone unutilised and this failure of utilisation is blamed on the panchayats.
31
RCH2Drah PIP Chhattisgarh
f. Lack of a trained person who can visit the mother on the day of child birth and
again within a week:
The post-partum mother and the neonate requires a visit by a trained volunteer in the
first day after birth and at least once more in the first week of the neonate's life. Given
geographical constraints it is not possible for the ANM to do so. Only a trained
community level caregiver like the Mitanin can do so.
g. Social issues in access:
Sometimes the nurse is there and resources are not a problem but there is a poor
motivation to provide services or a reluctance to accept services even when the
knowledge and attitudes are alright. These gaps are cultural gaps and represent a certain
passive discrimination - of caste or creed, or of gender. They are not necessarily
perceived as such. Thus the nurse who is available only during the peak working hours
may attribute the lack of response from a hamlet to their ignorance or even stupidity.
And the hamlet may attribute her failure to come at a convenient time or her rudeness
as a form of denial. Even at the level of hospitals rudeness, having to wait for
unreasonable periods of time, lack of privacy for examination of women are some
examples of discriminatory practices that reduce access. Their actual contribution to
reduction of access is difficult to quantify.
Safe MTP:
Here considerable work has been planned and there is a training programme ongoing.
But this training needs to be extended in duration and expanded to many more centres
as part of our thrust in strengthening a large network of FRUs.
5.2. Child health:
Poor outcomes in child health are related to the following:
a Inability to follow adequate preventive measures and appropriate health seeking
behaviour:
Constraints here are same as in discussion on maternal health above.
b. Immunisation:
The problems of the ANM as described for maternal health all apply. These are the
vacancy situation, the up down problem, the geographical problems and the quality of care
issues. The coordination between anganwadi worker, Mitanin and ANM has taken the
institutional form of the weekly Nutrition and Health Day ( or health mela day) and this
concept is being built on.
c. Care for sick child:
Here the main problem is the difficulty-indeed impossibility of meeting the sick child and
providing care in a prompt manner. In most areas the ANM can visit a habitation only once
or twice a month. She herself is available in headquarters only once a week. The family
cannot afford not going to work just to seek care until the child becomes too sick and such
a delay can be fatal. The only way to bridge this gap is a community level caregiver who
provides appropriate first contact care and knows when to refer.
32
RCU 2 Draft PIP Chhattisgarh
There are currently three types of community level caregivers. The Mitanin is a volunteer
selected by the community, based at the hamlet level and trained over 18 days. Her focus is
on preventive care. For optimum functioning she requires considerable investment in
continued training and support. If this is available she would be the ideal care giver.
The second category is the depot holder. Almost always a male, this is often chosen by the
ANM in consultation with more influential sections of the Panchayat. He is often content to
have a few drugs adequate for his household and immediate circle’s needs. The community
does not know or use the drugs deposited there and the lack of pressure for more drugs
means less problems for the health functionaries of that level. There is zero training for
depot holders. Many districts have moved to making Mitanins the drug holders - but the
attraction of having a male dispensing drugs and the local patronage it allows - has been a
powerful reason for continuing with this cadre.
The third is the Jan Swasthya Rakshak and RMP. These are almost synonymous except that
nrst category went through a six month training about eight years ago. These are also
almost always males from influential sections and they are liberal with the use of drugs,
and injections including steroids and antibiotics.
undoubtedly they would be saving
lives in some sick children their overuse of drugs is on the whole debilitating and a major
cause of rural impoverishment.
Though the rational choice between the three categories is clear one has to contend with
pressures against women from underprivileged sections who are spokespersons of their
community asking for accountability from the system as against the pressures for men
dispensing medicines linked by patronage to the local elite. The Mitanin Programme
therefore requires special support from above to survive and deliver health outcomes.
Potentially, as studies from Jamkhed, Mandwa, Ghhadcharauli, SEWA rural etc shows, it
can lead to a fall in current IMR in further 3 years.
d. Care for sick neonate:
Birth weight recording and postnatal care visits are almost not happening except where
institutional delivery is in place. Therefore there are no reliable records of percentage of
children with low birth weight- which is essential to generate an action plan on neonates.
Postnatal care quality is also in question. Again the role of the community level caregiver
becomes paramount. Here in addition to the three categories of caregivers discussed for the
sick child we also have the trained traditional birth attendant. Unfortunately TBA in
Chhattisgarh has a limited role in cutting the cord and burying the placenta. She is seldom
invited or involved in any form of antenatal, natal or postnatal care - much less the care of
a sick neonate. Some of. them have become Mitanins and received more comprehensive
training but the majority would have little role to play. The Mitanin’s role has been defined
as a six point programme- ensure 1.breastfeeding in the first hour, 2.ensure adequate
mothers diet, 3.weigh the new bom, 4.promote measures to keep the baby warm especially
if underweight, 5 facilitate BCG and polio drops and 6. Most important if the child is less
than 2 kg or is not feeding well referring at once for institutional care. The depot holder and
JSR as men are not resorted to for such care nor do they offer it. They are irrelevant to this
goal.
33
RCU 2 Draft PIP Chhattisgarh
e.
Institutional care for the sick neonate and sick child:
W
A good percentage of sick children would require institutional c
i
include neonatal sepsis, child hood pneumonias and severe dchy
diarrhoea and significant prematurity. In all such cases institutional Ca.
saving. Institutional care is best done at the 130 CHCs and 16 district hospital.
even in 54 designated FRUs this level of care has not been possible to organise.
district hospitals and 3 civil hospitals and 2 CHCs provide C-section level services ano
only some of them can provide for the sick neonate and childcare.
The skill gaps are however the most critical and they are due to lack of the appropriate
speciality specialist. In the management of the sick child the gap is of getting a
paediatrician's service and these can be overcome by ensuring that specialist is utilised in
her speciality work and by multi-skilling of medical officers to provide sick neonate and
child care.
5.3 Family Planning:
Thv cental issue of family planning services is the enormous unmet need for all categories of
services. Demand side management is also a problem but when unmet needs are so high there
is little to be gained from further demand side inputs: We identify the constraints as follows:
a
b
c
Condom and OCP supply:
The actual quantities that need to be made available are so huge and the distribution
points are so extensive that departmental mechanisms of distribution alone are usually
inadequate. They need supplementation by major social marketing networks.
Chhattisgarh currently has very few such networks and they cover only a small part of
condom and OCP usage. The aim should be to strengthen public distribution systems
while simultaneously going in for large-scale social marketing.
IUD insertion:
Here lack of skills and facilities at the subcentre level remain the central problem. The
lack of building and/or an examination table at the subcentre would mean that the next
available site is the PHC. About one third of the ANMs require retraining and
confidence building to undertake this adequately. Most LHVs are very competent in
this process and the ANMs who need training can be trained on site.
Female sterilisation:
Here the demand far outstrips supply. Though there are over 50 laproscopes operational
only 30 laparoscopic surgeons service the 146 blocks of the state. If the Supreme Court
orders are strictly followed and only 20 cases are done per day and the surgeons operate
every week then too only 31,200 cases can be done in a year. As against this, potential
unmet demand can be said, to be over 7, 65.000 couples. (At least half of all target
couples; target couples is calculated as total no of eligible couples minus 25% for those
already covered and 60% of the remaining for estimating those with more than two
children - are called the target couples). Community needs assessment surveys also
arrive at similar estimates of unmet needs. According to this survey, the number of
eligible couples who are unprotected is 14, 73, 906 (out of a the total number of
34
RCH 2 Draft PIP Chhattisgarh
37,73,852 eligible couples) and of these unprotected couples, those requiring
sterilisation may be estimated as at least 8.84 lakhs (plus about 2 lakhs new couples
every year). Of this unmet need for family planning by terminal methods, at least 3550% have one member desirous of limiting family size which works out to 3.09-4.42
lakhs. Yet today, we are covering only 1.15 lakhs per year. Most surgeons arc doing
far less than 52 sterilisation days per year but about 100 cases per day. The only
solution is to get much more laparoscopic surgeons and conventional tubectomy
surgeons on the job. But for Laparoscopic Tubectomy, multi-skilling is a poor option.
Without an emergency situation, operating on a healthy normal situation, and without
the ability to convert into an open surgery, the risks of multi-skilling would far
outweigh benefits. The aim should be to make sure that in all 16-district hospitals and
at least in 100 CHCs spread carefully across the state female sterilisation operation is
available on one fixed day every week for all 52 weeks of the year. This would include
a major increase in conventional tubectomy where multi-skilling is a viable option. This
would increase capacity of the system to provide this procedure for 120640 women. In
addition in three months of intensive work one sterilization day per week may be
organized in the remaining 46 blocks to cox er another 27600 couples (at 50 couples per
day). The remaining gap would require major effort at public private partnerships - but
even then this gap would be difficult to close. To meet this gap in surgeons would
require assistance from private and the not-for-profit sector.
We note that currently the number of sterilizations done in the year 2003-04 is 115,298
that are still far short of requirements even though to meet the need (not merely the
targets) the number of cases done per day crossed 100 in many centres. Unless we
multiply the centres offering at least once per week services to about 150 we would not
be able to close the gap. This we should aim to reach in about 5 years.
d
Male sterilization:
Here demand side management is a problem. Only 3% of all terminal methods or even
less are male targeted- reflecting a deep gender bias in the way the programme gets
implemented. However even in this area there is a supply side constraint.
But at the same time well advertised fixed day service for this most simple of surgeries
has yet to become available. This can be multi-skilled into medical officers too and the
creation of 50 CHCs and 16 district hospitals where this service is made available on a
fixed day in every week is easily possible to meet. Once this is in place IEC activity to
step up demand may also be organised. The aim should be to increase male
sterilisations as a percentage of all sterilisations from the current 3 % to at least 30 %.
e Emergency contraception: Though the importance of this is realised in theory its
availability and dissemination of information is extremely poor. Every 24 hour PHC
needs to be able to provide it.
35
RCII ' Draii PIP C’hhadisgarh
5.4.
Adolescent Health:
There are almost no programmes in this area. What happens in-thc ICDS programme is more of
a token and makes no significant difference. The needs are many. There is a very high degree
of under-nutrition and anaemia at this age. If they are not addressed al once the girl is soon
married - before she is out of adolescence and then pregnant. This is too late to correct
anaemia or malnutrition adequately. Also growth stunting occurs at this stage if the girl is
malnourished. Physical and mental development potential and stress due to poor health is also
more.
In addition adolescence is a period of higher exposure to violence, to sexually transmitted
diseases and to pregnancy associated morbidity and mortality. These need not only counselling
at the individual level but also social mechanisms of support and women's empowerment to
address.
5.5
Urban Health:
There is a 40-lakh population in urban areas as per the 2001 census. Of these the big cities
account for about 20-lakh population. The rest are distributed in smaller municipalities.
We also note that there are a number of towns with a population of less than 10,000 who do not
qualify to be treated as towns because they are not municipalities and a few who have over
grown the 10.000 number but have not yet been declared as municipalities. These are still
being covered by the rural health system and they represent some of the major para-medically
under-served areas. Typically they would have a subcentre, but their population per subcentre
norm would be adverse. Our strategy for these areas is to place an extra ANM there, which
would be adequate for our purposes.
The section on urban health therefore focuses only on the municipalities and corporations.
Here the current strength of only 20 urban health posts and 18 dispensaries is merely
inadequate to meet the health needs of more than 13 lakh urban poor. Paradoxically there are
large number of hospitals and private clinics- but for the poor in this area of health, there is not
a single approach. In fact both IMR and crude death rate have gone up, although marginally in
the last three years- by SRS data.
5.6
District and Sub-district Variations:
There are large variations in literacy across the districts and even inside districts. These have a
direct bearing on health status and the utilisation and spread of health services. Sometimes the
low literacy level is not causative, but affected along with health in the overall under
development of the area. Specifically the tribal districts of Dantewada, and Bastar, Koriya and
Sarguja and Jashpur show these problems. There are also blocks within the other districts
which have such poor performance.
Within blocks forest villages and other geographically remote areas tend to be underserved.
Semi-urban concentrations, which are still administratively under rural areas, also have
relatively poor coverage.
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RCU 2 Draft PIP Chhattisgarh
5.7
Human resources development:
There has been an active round of training under RCH-1. In particular we note that a wellplanned, two-week training programme covered all MPW (F). However, neither their
supervisors nor male MPW's were exposed to this. There has been however a very favourable
response to this training and the need is to persist with such a programme every two years for
all categories of paramedics.
On the whole other training programmes are few and are driven exclusively by the vertical
health programmes of the day. As a result whatever trainings are there are arbitrary in choice of
trainees and fragmented in strategy and are largely driven by expenditure patterns in such
vertical programmes. Most of trainings are of one or two days and relate to a single disease or
an immediate campaign. It goes on like one day on leprosy or two days on HIV family
counselling or one day on blindness control and so on. Some persons have received much such
training in many areas while some have received none. The vertical orientation leads to closely
associated work of other diseases not being taught- even in much longer capability building
trainings. Thus sector supervisors were trained on blood smear examination for malarial
parasites but doing a differential count on that same slide would not be emphasised.
Almost no training is based on building competencies to attain a level of clinical service in a
given facility. Thus even though there is a perception within the senior cadre of a lot of
trainings having been given in the last two years the system cannot guarantee that at a
particular level - e.g. SC or PHC or CHC the level of capabilities needed is now available. It
may not even be able to state what level of coverage has been achieved and what the gaps are.
The goal of the training plan here shall be to ensure that all the requisite skills to attain a
specified quality of care for a given facility becomes available at that level. This is true for
para-medicals as well as for medical officers.
5.8
Inequity /gender:
The basic philosophy to addressing equity and gender issues has been the creation of a public
health system that provides universal access. Universal access would thereby ensure access for
the poorest and for those excluded by reasons of gender or social marginalisation. The reasons
to support this approach have been the difficulty in distinguishing those below the poverty line
(BPL) from those above it and the limited meaning of such a distinction when poverty levels
are set so low by international standards. Any system of making a distinction converts being
classified as BPL into a privilege, which the privileged sections of the community are quickly
able to appropriate, thus still eliminating the poorest. Also it brings in a lot of conflict between
the poorest and the not so poor.
On the other hand there have been recent studies showing that the poorest are still not able to
access the free public health services and that patterns of access show persistent gender and
socio economic disparities. This has been compounded by user fees and by invisible charges.
Also demand patterns seem to be lower in poorer, less illiterate sections. Informal exclusions
by health care providers of most marginalized sections because of the ’cultural gap' between
them and the communities they serve also limit access. Private care access is on the other hand
costly and often irrational and at the village level technically illegal. These can contribute to
exacerbating inequities instead of ameliorating them. Chhattisgarh state has attempted to
address this problem in four ways:
37
RCII 2 Draft PIP Chhattisgarh
a) Facilitate access by the poor and make services more accountable to the poorest by
community level mobilisation. The Mitanin programme by selecting a woman from
every hamlet sees that even marginalized hamlets has a spokesperson and that too a
woman who facilitates service delivery to these sections. Since the Mitanin programme
follows health rights approach accountability is addressed though perhaps not yet
redressed. There has been considerable success in this but weak drug supply to
Mitanins and poor referral services still remain a problem to her effectiveness.
b) Equity issues are sought to be addressed by improving quality of services and insisting
on 100% coverage in antenatal care, immunisation, institutional delivery, access to
emergency care services etc.
c) Affirmative action in the form of special programmes addressed to the needs of the
poor and women and marginalized communities. Special programmes for the urban
poor, for adolescent women, for tribals, for RTIs etc also seek to address equity issues.
Many of these programmes were planned but in practice have yet to take off. Those that
have taken off like the referral fund for BPL patients to be shifted during an emergency
or the National Maternity Benefit Scheme have poor levels of utilisation because
systems that squarely recognise and address grassroots power equations have been slow
to develop.
d) Recognising that for a number of reason the majority of people - even the poor still
access private health care service, public private partnerships where the poor can get
affordable care and even free care have been mooted but are yet to be operationalized.
5.8
Logistics:
The essential drug list is in place and is largely implemented. Sporadic procurement and a suboptimal quota based distribution system was the rule. However as part of the DANIDA
supported programme, every district has had a warehouse, and storekeepers and officers have
been trained in drug and supplies logistics. A computerised inventory system has been
developed by a consultancy with DSPRUD but is not yet fully operational. The problem with
consumables is equally of concern and laboratory chemicals seem the worst affected but even
gauze and bandages, needles and needle holders could be in short supply repeatedly. These
would correct with the distribution system becoming fully operational.
In equipment there are two types. We have relatively low investment equipment like
Haemoglobinometer or BP apparatus and infant weighing machines- which, if used, will need
replacement frequently. These minor equipments need to be absorbed into the same
distribution system.
As for costly equipment like ECG and ultrasound and X-rays, which require replacement lessup to once in ten years- but which require trained manpower to operate and considerable
consumables as well- the problem is matching for infrastructure, skills and services provided
so that these are adequately utilised.
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RCH 2 Draft PIP Chhattisgarh
5.10. Other Issues:
The Mitanin programme is one major crosscutting innovation that has seen considerable grass
roots success. A detailed operational manual and its a rigorous sample study based interim
evaluation of the programme is available. This is also an initiative that would take a longer
time to succeed and it needs sustained support at all levels for at least another three to five
years.
Integration with ISMs is another goal. There is a large workforce and institutional and
infrastructure base within the health department that is willing to contribute to RCH goals but
has been used only minimally for this purpose. Under RCH-I a small sum in the order of 1.9
lakhs has been allotted, and even this is in the process of utilisation.
39
RCI1 2 Draft PIP Chhattisgarh
6.
Lessons Learnt from RCH-I
One of the first lessons of RCH-I is the need to invest in adequate staff and capabilities for
programme management. In the absence of any formal evaluation of RCH-I we list below
some of the impressions about the utility and implementability of various schemes that were
tried.
Contractual appointments:
This was very useful but there was difficulty in getting ANMs. As the ANM Training Centres
have re-opened, we expect no further problem. Also trained nurses are being given this
appointment. Two ANMs per subcentre in remote areas has been welcomed and the impression
is that they are doing much better. As of now regular posts also remain vacant. If regular posts,
now currently increased by 850 are filled, then all contractual ANMs could be absorbed.
However for making institutional delivery happen in every sector PHC where we already have
a LHV a contractual ANM would be useful. The contractual appointments for SHS/SCOVA
were also found useful.
Strengthening FRUs:
In the first round of civil works and equipment purchase to strengthen FRUs the inputs have
been sub-critical. Except at district hospital level almost no other FRU came into functioning.
In the second round with better planning and matching of equipments, with manpower and
skills and infrastructure work there is a greater likelihood of at least 15 more FRUs coming
into being - up from the current 14 for the state.
RCH Camps & Melas:
RCH camps and parivar melas as visible activities have had their positive side. However as
almost all services require follow up at regular intervals they are not viable ways of extending
the outreach of the basic health care facilities. However for a population deprived of any access
or whose access is limited this may be welcome. It is not clear that all RCH camps took place
for such areas. In the 4 districts where immunisation sessions were similarly targeted only for
under-served areas the outcome has been limited and there is little interest in pursuing it.
Whatever their value they would not be a substitute to the policy on medically underserved
areas that we are proposing for establishing regular services in such areas.
Cold chain maintenance:
This component was found useful and some regular component on this should perhaps be part
of the family welfare budget as it would be recurrent every year.
There are still unmet needs in the state as regards the cold chain. We need one major cold
storage equipment- a walk in freezer - costed at about Rs. 50 lakhs- from the GOI. Since this
is supplied always by the government of India exact costs would also be available with GOI.
Two walk in coolers are also desirable. Also we need to purchase 146 stabilisers; there is also
a need to insist on disposable syringe supply along with the vaccine. Supplying money for
kerosene is not as effective and its savings are also limited. The training for vaccine handlers
was useful and need not be repeated immediately.
40
RCH 2 Draft PIP Chliauisgarh
IEC Initiatives:
The IEC programmes were considered successful too and mainly took the form of kalajathas
and radio programmes and hoardings. The community incentive scheme requires redesign if it
is to be a motivation for weaker panchayats to do better and needs to be integrated with
Panchayat level health initiatives and capability building. Other items like DD kits.
Referral transport:
This in particular has had very poor utilisation with most districts returning the funds. The need
of the hour is to develop systems by which a woman in need or a panchayat chief who wants to
help can call an ambulance at once and transport to a reliable FRU. In the absence of vehicle or
secondary centres and insufficient investment in informing people about the scheme, the
programme has done very poorly. The incentives for 24 hour delivery in PHC/CHCs also
suffer from design issues.
Family Planning Incentives:
The material incentives for contraception //sterilisation funds remain unused because they have
been put on hold pending instructions. They are possibly best integrated into private sector
reimbursement.
Public-private partnerships have been designed but this has not been launched.
Strengthening Management:
Serious bottle necks in management capacity and even absolute numbers of management
personnel available crippled the programme. Capacities were low not only in public health
management but also in financial management. The construction of buildings in routine
channels also was to slow down programme implementation in many crucial areas. The
creation of a state health resource center helped planning and technical expertise availability
and community oriented programmes immensely- but this was built up under the SIP only in
the last two years of the programme.
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RCU 2 Draft PIP Chhattisgarh
7. RCH II ProgrammeObjectives and Strategies:
7.1. Vision Statement:
Chhattisgarh state has adopted a document called Vision 2010. Its section on health care reads:
"Health relates to the well being of society. The State would ensure that its citizens are healthy
and have access to adequate health infrastructure. Emphasis would be laid on disease
prevention and provision of sanitation and hygiene services. Provision would be made to
provide free health care to the poor and disadvantaged sections and outbreaks of malaria and
tuberculosis would be brought down to minimum levels. Improvement in the health status of
the population would be one of the major thrust areas for social de\ elopment in the State."
In line with this vision the state has set itself the following goals - a ratio of 1: 800 for hospital
beds; and IMR of 35 per 1000, a fertility rate of 2.2 a life expectancy of 65 years for males and
68 years for females.
7.2
Technical Objectives, Strategies and Activities
7.2.1 Maternal Health
Objectives:
Reduce MMR from current 400 plus to about 100 in five years.
Strategies:
i. Focus on quality antenatal care in subcentres- Institutional delivery only to the extent
possible.
ii. Focus on 24-hour institutional delivery with essential and basic emergency care in all
sector PHCs and in every CHC.
iii. Focus on select CHCs (100 across the state) becoming venues for comprehensive
emergency obstetric care
iv. Bring in private sector partners to close gaps in basic and comprehensive emergency
obstetric care.
v. Bringing in NGOs to close gaps in para-medically under-served areas.
vi. Building up transport and referral systems.
vii. Building up community care and support systems so as to improve health awareness and
demand for institutional services, improve link between ANM and those in need of her
services as well as to facilitate the delivery of maternity benefits and referral arrangements.
viii. Focus on provide safe abortion services.
ix. Focus on treating RTI/STI.
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RCTI 2 Draft PIP Chhattisgarh
Activities:
i.
Block level planning to identify bottlenecks in achieving the above goals and then
accordingly:
♦ Closing infrastructure gaps in the above facilities
♦ Closing training/skills gaps in the paramedical and medical workforce with use of
multi-skilling where needed.
♦ Closing equipment gaps in the above-mentioned facilities.
ii. Streamlining procurement and distribution mechanisms for supplies.
iii. Community level awareness and basic care arrangements - through trained Dais,
Mitanins, and increased role for PRls and village level capacity building and an
incentivised referral arrangement for the Mitanin that would drive every pregnant woman
into the sites of institutional delivery.
iv. Building Increased awareness for service utilisation.
v. Putting in place a 24 hour ambulance service linked to venues of institutional delivery.
vi. Declaring areas as medically underserved and paramedically underserved and seeking
NGO/ private sector cooperation in these areas.
vii. Multi-skill training for the staff in institutions to be able to provide services of safe MTP
Services and to provide treatment in cases of RTI/STI.
viii. All the CHCs and district hospitals would also have adequate diagnostics for referral
level STI/RTI services.
ix. All 24 hour paramedical and medical staff would be trained to provide basic clinical and
counselling services for RTI and STI with basic investigations (side laboratory level).
Elaboration of strategic
MATERNAL HEALTH
Antenatal Care:
Here the central strategy is to improve quality of care. This requires improved training and a
monitoring and supervision system where quality is factored in. (See action plan on training)
The second issue is to improve coverage. Here the Mitanin programme and the coordination
with the anganwadi worker is the key. Strengthening these elements are more useful than any
other. Building panchayat and village level capacities would also help. (See action plan on
Mitanin programme, and on building village and panchayat level capabilities)
The third issue is .to improve coverage in paramedically underserved areas. Here the policy
approach for medically underserved areas should be applied. In most cases this requires either
contracting in an NGO that would undertake this or identifying and training a Mitanin with
adequate basic qualification from that area for a longer course and then appointing her as a
block level cadre in that same area.
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RCH 2 Draft PIP Chhattisgarh
•
Institutional Delivery:
The goal of institutional delivery has two reasons. Firstly that skilled care adequate to give
oxytocics and manage a first level of complications is available. Secondly that referral is
easier. In the subcentre the second is not readily available and even the first would require
more skill building to achieve. However the ANM providing care is better than that of the
traditional birth attendant’s and she providing care at the home and her providing care at the
subcentre the differences and advantages are minor. Where there is no place at the house then
the subcentre has advantages. The subcentre may also have an advantage if it is better situated
for referral linkage. However as discussed earlier, the non-availability of ANMs on most days
makes it an unreliable site for the care seeker once labour pain starts.
Therefore the strategy proposed keeps the Sub-Centre as an optional site of institutional
delivery - where facilities are available for a sudden need but where delivery is not insisted on.
Instead the focus of our strategy is on maintaining sector PHCs and CHCs as the main venue of
institutional delivery. The advantages of this approach are thata) The PHC and CHC can be staffed and made functional as 24 hour functional centres.
b) institutional delivery of adequate quality can be assured.
c) All elements of emergency obstetric care can be assured except for blood transfusion and
caesarean section.
d) Quick referral and transport arrangements to an FRU are guaranteed.
In a block of one lakh population we can estimate the number of deliveries to be about 2500
per year or about 208 per month. Of this if we achieve 50 per month at the CHC and 30 per
month at the 3 PHCs we would have achieved a total coverage of 67% as compared to the
present 22% coverage. Further to close the remaining gaps - we can equip upwards the
Ayurvedic hospitals esp. in sectors without PHCs and we can make use of a few designated
subcentres that have buildings by making it two -ANM subcentres. (Please note that most
blocks are meant to have four sector PHCs but in practice they would have anything from one
to three PHCs only - seldom would they have four).
Also we propose to encourage nurse professionals and community midwifes in the private
sector to set up a facility as part ofa franchisee arrangement.
•
Making a sector PHC function on a 24 hour basis with quality care:
In the primary health care centre however it is possible to over come all the limitations that
make the subcentre an unsuitable venue for the PHC. There are usually three women
paramedical available there - the sector supervisor (female) or LHV and the ANM of that
subcentre and often the staff nurse. In practice many sector PHCs have only two of the three
women needed. If one ensures that another ANM is posted in the subcentre that is usually
located in the sector PHC- then it is relatively easier to insist on the centre being open 24 hours
with the three women on a shift arrangement- so that the PHC is never locked and never in the
dark.
Obviously their needs to be a functional labour room, toilets and two to six beds along with all
the equipment and supplies needed. In most PHCs this is available and where it is not it can
easily be so equipped within the next three years - taking on 50 blocks every year.
Of the many male para-medicals of different categories - dresser, compounder, laboratory
technician, MPW, supervisor - male, leprosy worker (NMA or NMS)- who are available there
44
RCil 2 Draft PIP Chhattisgarh
three of them should be multiskilled to provide assistance to all the PHC functions on a 24 hour
basis and also placed on an 8 hour shift.
The plan also includes both male and female worker are trained on the standard treatment
guidelines for para-medicals and the list of 27 drugs drawn up for the subcentre are made
available there. In such a situation The 24 hour's centre would be cost effective and able to
handle all basic curative care and first aid level emergency needs in a competent manner. Our
understanding is that if the PHC is not seen as a reliable site of providing basic curative care
and if it does not have referral arrangements for all common illness and especially
emergencies, it would lose credibility as a reliable site to take one’s wife to when she is in
labour.
Thus the goal is that with existing paramedical staff, sometimes needing supplementation by
the appointment of one more woman paramedical the sector PHC becomes a 24 hour
paramedical run facility with a doctor on call /or in remote areas visiting the facility from the
CHC. The paramedical act of the state of Chhattisgarh empowers the 18 month trained male
and female para-medicals to provide such care and the very effective and innovative Hindi
Standard Treatment Guidelines for para-medicals makes it possible to assure quality care at
that level.
It is also possible to link all the PHCs with the CHCs and the ambulance service by phone so
that an ambulance can be called and reach within the hour and reach the patient to the
secondary referral centre within the next hour. For all these reasons the achievable goal must
be to make the sector PHCs the main sites of institutional deliver}’ with subcentres being the
preferred sites of antenatal care and provision of skilled care at birth - only occasionally doing
institutional delivery.
Finally to kick-start the system we may offer Rs. 100 per delivery as night duty allowance to all
those who have achieved at least 10 deliveries in a month in the institution. There is already a
provision for this - but by linking it to a 24-hour duty and set of performance indicators we
would get more returns of this current budgetary allocation. The financial implication of this
would be Rs. 1.5 lakhs per block per year, which is affordable. To the ANM beginning to work
night shifts it is Rs. 1000 per month to up to Rs. 3000 per month, which would be attractive.
Those ANMs who do not take as much interest or where caseloads are sub-critical would not
get rewarded.
•
CHC as site of institutional delivery:
In addition and for the same reasons stated above all CHCs can be venues of institutional
delivery. They already have the staff and infrastructure to do so. Indeed they should have a
quota of 50 deliveries per month to reach and be provided with supportive monitoring till they
achieve this goal.
•
Private Sector partnerships:
In addition to what sector PHCs and CHCs can cover we need to cover 60 to 100 births per
block per month. Where the public sector is not able to cover this we need to encourage and
support nurse professionals and community midwifes to set up such practice.
Single doctor private clinics and private nursing homes in the vicinity can also be roped in to
close this gap. Notifying medically underserved areas would considerably assist in the process.
45
RCH 2 Draft PIP Chhattisgarh
There are two approaches proposed. One is just providing reimbursement for existing providers
when they see BPL patients. The other the promotion of new centres with not only credits
arrangements but also by funnelling patients to them so that they have adequate volumes at the
pre-fixed rates to make the enterprise viable. This requires a franchisee chain arrangement.
The recurrent cost to the government for about 50 births per month per block for those who are
BPL would be about Rs 30.000 per month or Rs 7.2 lakhs per year (@ Rs 1200 a normal
delivery). More details on these issues are given in section on public-private partnerships.
Referral Incentivisation:
For the public-private partnership to succeed, also to maximise health seeking behaviour
changes that brings women for institutional delivery, we need an incentivised linkage with the
Mitanin programme.
If we assume that of the 2500 births almost 2000 would be through referrals. We can budget
for Rs 1 lakhs per block for incentives to Mitanins for having made the referral. This would
strengthen both the Mitanin programme and the cause of institutional delivery. Where she has
been unable to secure institutional delivery, if maintains record and reports of birth weight
alone she would get Rs 25 as incentive. As each Mitanin would have about 6 deliveries in their
area - this Rs 300 they get per year is not a big amount. But in panchayats where 100%
institutional delivery is reached they could get another small group monetary incentive. (An
expansion of the capital base of a SHG savings group would be such an example.)
Mitanins would be given coupons that they would pass on to the pregnant women. This coupon
would be given to the private sector or public sector unit they choose to go to. The “Managed
competition” that results in a setting of quality regulation and incentives for both sectors,
would make choice to the patient and for a better quality of care and outcomes.
We note that this scheme of incentives and reimbursement - at the public, and private and
community level requires a good monitoring system in place. About 10% of the total costs of
reimbursement plus incentives and another 10% for administration and financial management
of reimbursements would be advisable. The incentives and reimbursements would need a
parallel system that is more accountable and efficient. The Monitoring system for the private
sector partners would also monitor the incentives in public sector. This is not duplication but a
built in check and balance needed to guard against false claims. The details have been worked
out in the PPP module developed.
Ambulance Services:
Current ambulance services are not available 24 hours and would require three drivers per
vehicle to make it so available. The vehicle at the CHC is used for ferrying stores from the
district more often and for shifting patients less often. The use to shift patients from CHC to
district hospital is more common then shifting a patient from village to CHC or back or from
PHC/Subcentre to CHC.
While retaining the larger ambulance currently available for CHC- to district transport, the
suggestion is that for every tehsil one vehicle- smaller, rugged one which can traverse the
narrow village roads- be made available to an NGO or charitable organisation or ex servicemen’s group. The ambulance is provided with a cell phone/wireless and it also builds up
a system by which anyone who can access a telephone can call it at once from anywhere. They
46
RCH2 Draft PIP Chhattisgarh
can charge per km basis for APL patients and for BPL patients. Fowould pay as they have referral funds already in place and under
To maintain viability of the service they can also provide nonpatients from village to CIIC for other activities like blindness
transport of patients coming for sterilization etc and they can charb
sharing it between the passengers and deducting what money they get
that particular scheme’s implementation. We would initially start these s<
blocks where emergency care is being initiated with linkages to the neighbouring
there are no emergency obstetric services available.
1
Services in Treatment of RTI/STI
•
•
All the CHCs and district hospitals would also have adequate diagnostics for referral
level STI/RTI services.
All 24 hour paramedical and medical staff would be trained to provide basic clinical and
counselling services for RTI and STI with basic investigations (side laboratory level).
Safe Abortion Services
•
•
•
All the block CHCs and district hospitals would also be capable of providing safe MTP
services.
Train General Medical Officers (MBBS) to perform MTPs and to examine and treat for
STI/RTIs. Since we are anyway investing in Multiskilling for emergency obstetric care
this is a small extra effort and can be provided after the earlier training has fructified.
Incentivisation of Community level caregivers for MTP referrals:
This is on the lines of the referral arrangement for Emergency obstetric care.
47
RCH 2 Draft PIP Chhattisgarh
7.2.2 Child Health
Objectives:
a. To reduce IMR from 73 to 35 by the year 2008
b. To reduce rural IMR from 85 to 40 by the year 2008
c. To reduce child malnutrition levels
Strategies:
a. 100% immunisation including the booster dose
b. Prompt and appropriate community level care for all sick children and neonates
c. Regular House visits and counselling by community level care givers for preventive
and promotive health of children and the reduction of child malnutrition.
d. Strengthening and supervising the subcentres for its routine services esp. immunisation.
e. Adequate referral arrangement and secondary care facilities for sending a sick child or
neonate when it requires hospitalisation.
f. Reducing cost of care especially on inessential and hazardous drugs and therapies so as
to favourably impact on poverty levels:
Activities:
Immunisation:
• Maintenance of the cold chain: This remains central to the concerns of child health. The
cold chain is in place but yearly there would be a set of equipment that would require
repairs and even replacement.
•
Logistics of vaccine and disposables supply: This too is in place - but is rather weaker
for disposable syringes. The aim is to supply vaccines with equivalent amounts of
disposables.
•
Monitoring systems: Insistence on regular first level supervision (i.e. of ANM by LHV)
and by a cluster sample check by every second level supervisor (by BEE/BMO/ district
immunisation officer) and sample survey review by an external professional marketing
research agency should all be institutionalised .It is also important to identify and notify the
10% least accessible hamlets and villages in each block so that special verification of this is
possible.
•
Medically underserved areas: There are still many areas where there is an ANM vacancy
or high absenteeism or geographical constraints. These areas are proposed to be notified
and the option best suited for these areas are to be put in place in consultation with the
janpad (block) panchayats. The choices for immunisation service delivery are betweena) Mobile clinics visiting the haats (community market places) linked to Mitanins bringing
the patients in.
b) NGOs as service delivery agency. Special incentives package for government staff to
go there and remove it from the notified list would also be in place.
Coordination with Mitanin and Anganwadi worker and ANM: Immunisation is the
main and along with antenatal care often the only point of contact between the ANM and
the persons she serves. To maximise these opportunities she is provisioned and encouraged
to provide first contact curative care, and seek cases for referral for tuberculosis and
leprosy case detection and for correctable blindness. Close coordination with the Mitanin
•
48
RCH 2 Draft PIP Chhattisgarh
and the anganwadi system provides her the community support she needs to complete both
immunisation and when she visits for immunisation - all these other activities as well.
Without such help even meeting all her immunisation and antenatal clients would become
impossible. Strengthening the Mitanin programme is therefore also critical to successful
outcomes.
Community Level Care For Halving Rural IMR: The estimated number of children below 5
in a population of 5000 who -on any given day- are: newborn; or have diarrhoea; or have ARI
or even pneumonia; or have fever is in the range of 25 to 50 children. (This is calculated
assuming 10% of the population is of children below 5 - it is actually a bit higher and that 5 to
10% of them would have one or other of these four situations).
Good community level care means that in all four of the situations given below the child must
be seen on the same day as when the event occurs.
For neonates a trained volunteer must visit on the day of birth for there are six actions to be
achieved. These are breastfeeding in the first hour, adequate food for mother, keeping the baby
warm, weighing the child, referral for the low birth weight and sick neonate, and immunization
with BCG and polio drops. A second and third visit in the same week for referral if the neonate
is sick is also a must.
For a child with diarrhoea ORT has to be instituted immediately and monitored to see whether
dehydration corrects or needs timely referral.
For most ARI the goal is really home remedies and protection from unnecessary and costly
care. Yet if there are any danger signs, which should be recognised on the very day of its
occunence prompt referral, with some stopgap antibiotics could be life saving.
And in Chhattisgarh where malaria is one of the major causes of child deaths a blood smear
examination on the first day of fever and an appropriate presumptive treatment of malaria is
also mandatory.
Without such care in these four situations reduction of rural infant mortality to the goal of 30
would take decades to realise. But with such intervention - even with limitations in referral
back up halving of the current levels of rural infant mortality placed at 85 is possible within a
three to five year period.
If we assume that these 25 to 50 cases are spread over 10 to 15 hamlets we can realise that it is
impossible for the ANM to attend to these cases on the first day or even the first week of
illness. But then we must also remember that often these cases are highly clustered in time. For
example, in the rainy season there could be one out of four children affected on a given day. In
a more developed state the population is less dispersed and the families could access health
care providers — at least on payment. In situation like Chhattisgarh this gap is filled in by a
huge army of RMPs who are poorly trained or more often completely untrained, totally
unregulated, and are fairly high cost health care providers (high costs relative to real needs
though they may be cheaper that qualified doctors charges). They tend to intensively treat
trivial self-limiting illness and refer - later than is advisable - all cases that need definitive
treatment. Trying to train them into adopting rational and ethical practice when there are no
systems of regulation, and where their role models are MBBS doctors whose practice is similar
in costs (though less hazardous) and where they have already got habituated to the high returns
of unethical practice is not a feasible option. The Mitanin (community health volunteer) is the
only hope.
49
RCII 2 Drali PIP Chhattisgarh
Since the Mitanin is in place in almost every hamlet of the state what is needed is to persist
with it with a strong support system with continued training, some degree of incentivisation of
her work and a good referral arrangement and secondary care support. With these three steps
and an extension of the programme to urban areas it would be possible to reduce the under-5
child mortality by half in less than three years. That is from a current rural IMR of 85 to about
40 to 50. The rigorously documented data from 100 village NGO led experiences of Jamkhed.
Mandwa, Ghadchiroli, SEWA, RUHSA and many other programmes all show that such a
reduction from high levels (varying from 80 to 150) to about 30 to 40 in three to five years is
possible to guarantee in a well administered community health worker programme provided
some cardinal conditions are met. These seven conditions of success have been set out in the
note on the Mitanin programme.
In addition to these four day-1 interventions the community level caregiver would visit and
counsel the family of every child with malnutrition at least once every month and ensure that
the child has access to food supplements where this is relevant. Since malnutrition is the single
most important underlying cause of death, this is essential for the reduction of IMR. Also by
visiting and counselling of families with normal children in the age group of 6 months to one
year malnutrition can be dramatically reduced from the community by its primary prevention
(see UNICEF’s best practices report for 2001).
Counselling would be also a form of interpersonal communication based BCC. It would aim
for reaching out to all families with a set of 75 health education messages that would cover all
the basic health awareness elements. Over three years every household should be able to recall
all these messages and the potential for behaviour change is the maximum in such an approach.
Referral Arrangement and Secondary Level Care: When a sick neonate is identified or a
sick child is identified a nurse, MPW or doctor can provide a good level of primary level
curative care. However a few children - about 50 neonates per 1000 children bom and another
30 in the first year and yet another 25 to 30 in the next four years would require a secondary
level care to save lives. This would require hospitalisation and injecteable fluids and drugs. In
neonates esp. where caesarean section is being done it may require baby warmers and
incubators. Therefore it is important to develop such a facility within two-hour access of any
village.
The facilities that were developed as sites for comprehensive emergency obstetric care should
as well be developed as sites for institutional treatment of the sick neonate and child. This
requires appointing, contracting in or multiskilling medical officer through a two-month crash
course to be able to undertake intensive paediatric work. In addition it needs development of
laboratory services -either completely in house or with public private partnerships. The
proposal is to develop 100 CHCs and 16 dist hospitals as such sites and supplement there with
private sector partners.
The referral and ambulance arrangements: These are the same as for maternal care. By
using the same anangement for sick neonates and children we make the service more viable
and cost effective.
Public Private Partnerships: These are also opened up as in the provision of emergency
obstetric care- and some work would be required to cost the wider range of services and
costing packages that treatment of sick neonates and children would apply.
50
RCH 2 Draft PIP Chhattisgarh
7.2.3
Family Planning
Objectives:
At least cover 50% of unmet needs for terminal methods in the first two years and 100 % of
unmet needs by 5 years.
Strategies:
• Every district hospital would provide terminal sterilization services at least twice if not
thrice a week.
• 100 CHCs would provide sterilization on a fixed day of the week.
• In three months of the year all the remaining blocks would have at least three sterilization
days in their CHCs. In the coming years these would also change to fixed day weekly
once service availability.
• Every village would have one social marketing outlet, which would have supplies of
condoms and OCPs without interruption throughout the year. These would be managed
by partnership with a private distributor network with subsidy to make it viable to operate
in low off take areas.
• All 24 hour PHCs would have one fixed day of the week where IUD insertion would be
available and other contraceptive follow up would be encouraged.
• Every hamlet would have at least two volunteers who would have a limited stock of the
supplies available- either collected from the village distribution point or from the health
department.
• A focused IEC campaign would continue to build up demand for these services.
Activities:
• Building up referral secondary institutions: The closure of gaps in infrastructure,
equipment and supplies is as described for maternal care.
•
Multi-skill training for the staff in institutions to be able to do these surgeries: For
tubectomy, for vasectomy. Since we are anyway investing in Multiskilling for emergency
obstetric care this is a small extra effort and can be provided after the earlier training has
fructified. Also once one is experienced in C-section, conventional tubectomy if not
laparoscopic should be possible. For laparoscopic tubectomies, we would be looking at
hiring more surgeons rather than Multiskilling qualified surgeons who require only
tubectomy training would be provided this training. For general medical officers (MBBS)
a one month course covering safe MTP, conventional tubectomy, vasectomy, STI/RTI
would be designed and at least 250 doctors provided such trainings over next 3 years.
•
Incentivisation of Community level caregivers for FP referrals and collective
achievements in spacing: This is on the lines of the referral arrangement for Emergency
obstetric care. It should be able to provide another Rs 300 to Rs 500 per Mitanin per year
if even Rs 50 is paid for every tubectomy or vasectomy case referred. An incentive may
also be considered to be shared amongst panchayat members and Mitanins where all
births have had at least a three-year gap and no birth before the age of 19 or within one
year of marriage if the marriage is before 20. Since very few would qualify the
budgetary outlay needs be very limited at the cash award could be high.
)*
hxJH- 10 5
09136
s(
e
51
RCU 2 Draft PIP Chhattisgarh
•
Preparation and Signature of MOU on Social Marketing with three to five
distributors: Two stockists would cover 8 districts each. This includes NGOs who are
interested. They are selected from those responding to an advertisement. They are
provided the contraceptive supplies and a seed money( about six months costs as shown
in the budget below) for start up. A government sponsored or appointed body would do
the evaluation. If they have achieved volumes and stated goals then they would qualify
for further adminstratve subsidies as indicated in the budget given below. The exact terms
of such a social marketing arrangement has to be worked out an MOU signed with the
selected distributors /market chains. The aim would be a 100% coverage of all villages. A
well-organized IEC campaign by the state would help them in achieving viability for the
marketing chain.
Social marketing to initiate would need a budget support which is estimated as follows:
Social Marketing Budget
Particulars
Stockist Overhead
Sales Force Cost
Warehousing/godown
Administrative cost
Total
Unit
Unit
cost per
month :
200506
200607
2007-08
200809
200910
Total
2
3000
2000
0
5000
72000”
192000
0
60000
324000
75600
79380
201600 211680
0
0
63000 66150
340200 357210
83349
222264
0
69458
375071
87516
233377
0
72930
393824
397845
1060921
0
331538
1790305
I
1
T
1. Two Stockist will cover total 16 districts one will be located at Raipur and other one at
Bilaspur
2. Overheads to the stockists mainly relate to cover-up rent for godown and administrative
cost
3. One Sales person will cover two districts and therefore for 16 District their will be
eight persons.
4. Rent for godown is not taken into account as State Government will provide for that.
5. The administrative cost will include report compilation, follow up etc
6. Since the product is offered free of cost -other costs can be recovered from the sales
windows/ agenices recrutied after selling the products- on a commission on sales basis.
•
IEC campaign: The IEC campaign is being discussed here in the family planning section
but it is needed for all aspects of the RCH programme. The key messages in each area
need to be identified by a process of qualitative and quantitative surveys. Then these
messages should be integrated with the ongoing programmes. Then using a variety of
media of which folk media would be the most powerful these important messages should
be carried forward again prioritizing those areas where there is a programme linkage.
Thus an IEC campaign on the use of condoms or OCPs will be based on addressing why
people are not using it today and it will also inform where these are available and how
they can be accessed. In other words IEC would not be stand-alone but would be
integrated with ongoing programmes.
52
RCH 2 Draft PIP Chhattisgarh
7.2.4 Adolescent Health:
Objectives:
1. Reduce malnutrition and anaemia amongst adolescent's especially adolescent girls.
2. To reduce percentage of marrying in this group from 35% to 5%.
3. To increase the awareness regarding pitfalls of early marriage and child bearing, regarding
family planning and nutritional requirements of adolescents.
4. Increase awareness of ones own body and control over it - including fertility control and safe
sexual practices.
5. Provide easily accessible and friendly health care services and counselling for adolescents.
Strategies:
1. BCC programmes.
2. Open adolescent counselling services with referral access to essential services at the CHC and
district hospital level.
3. Major effort to screen for and manage anaemia and malnutrition in adolescence and where
relevant for sickle cell anaemia.
4. Peer education programmes in schools and some areas in the villages
Activities:
1. An NGO will be identified and asked to hold an adolescent clinic providing counselling
services once a month in the Govt PHC/CHC/Urban Health Centre.
2. They will also be asked to provide training to create peer educators in high schools of that
Block. Sponsored activities by sanitary napkin and brassiere manufacturers, including guest
lectures could be organized in feasible locations.
3. NGOs will be involved in community outreach programs to disseminate information to
adolescents in groups through various methods including sports events and film shows in
villages.
4. Vocational training institutes and other adolescent hangouts will also be targeted for activities
by NGOs to maximize the chances of having an interface with the out of school adolescent.
5. In all CHCs esp. where NGOs do not have a presence, a staff member will be given training,
preferably LHV level to counsel and have a designated day of the month, which is
disseminated by ANMs and Mitanins to the public.
6. Camps will be organized to-do screening of adolescents for anaemia. All girls in 15-19 age
group will be targeted for this activity. Mitanins will be sensitised to ensure complete coverage.
This will address iron deficiency in this generation and prevent sickle cell anaemia in the next.
7. IEC campaign through print and mass media to reinstate messages to postpone childbearing
and marriage age and to focus on nutritional needs of the adolescent girl.
’ 53
RCH2Drali PIP Chhattisgarh
Budget:
Adolescent Health
Head
Unit Cost
Training Counsellors
5nos* 15days*Rs 200 By
15000
( NGQs & Govt Staff)
Training peer educators
20nos*5days*Rs lOOBy
10000
(NGQs & Govt Staff)
______ 1EC activity:______ 10000
Honararium for counsellors
12000
_______ 5*200* 12_______
Overheads contingencies
8000
_____ Total for block_____ 55,000
Mass screening/counselling
programme in a block for all
children and adolescnet for
iron def.& sickle cell trait
1000000
and disease (Ten blocks in
first year then twent) oIocko
in each subsequent year for
four years)
2007-08
2008-09
2009-010
Total cost
8431500
8853075
9295729
9“60515
10248541
21000000
22050000
23152500
2-1310125
100512625
180300(1 29431500
0
30903075
32448229
34070640
144883444
Nos.
2005-06f 2006-07
146
2190000
146
1460000
146
1460000
146
1752000
146
146
116S000
8030000
10
1000000
0
Total
Note: The aim is to limit the mass screeding to a few blocks every year- since it is very effor intensive .At the end of five years we
would complete only 90 blocks which are considered having the highest prevalence of anemia- both sickle and iron deficiency. We
would estimate which are the most prevalent blocks during the first year based on instrituional data and camp based data as sickle
detection centers have been set up in all the districts.
Mass screening/counselling programme in a block for all .Children and adolescnets for iron deficiency .&
sickle cell trait and disease
Details of Budget for a normative block of one lakh population
Break-up for Rs. 10,00,000 for a normative block is given below.
Approx population in age group 0-25__________
40% of the population
Approx population to be tested__________________________ 40,000____________
6.00,000
Cost per test (Hemoglobin + solubility including confirmation @ Rs. 15 per test
if positive__________________________________________
1EC and mobilization to get people to participate in__________
Meeting and Kalajtha 100 villages____________________ (Rs 1000) per village*
Logistics at block level - vehicle, camp arrangement________ 400camps*Rs400
1,00,000
Documentation______________________________ ________
20,000
Total____________________________________
9,00,000
Overheads 10
Grant total
10%
1,60,000
90,000
9,90,000
Approximated to 10,00,000
54
RCI1 2 Draft PIP Chhattisgarh
7.2.5 Urban RCH
Objectives:
To improve the health status of the urban poor community by provision of quality primary health
care services with focus on RCH services and to achieve population stabilisation.
Situational Analysis
There is a 40-lakh population in urban areas as per the 2001 census. Of these the big cities account
for about 20-lakh population. The rest are distributed in smaller municipalities.
Population range
Numbers
Total population
A
>2 lakhs
: 4
20.98,879
B
> 1 to 2 lakhs
“6
7,79,708
C.
70,000 to 1 lakh
5
4,17,388
D.
40,000 to 70,000
4
2,02,476
E.
15,000 to 40,000
90
4,91,154
F
< 15,000
14
1,54,902
TOTAL
55
41,44,507
(Note that Korba with population of 191245 is included in A and Khatgora of 175,718 is included in B.
Also note that Janjgir of 72,318 and Champa of 37,951 are included as one urban area under category B.)
We also note that there are a number of towns with a population of less than 10,000 who have not
yet been declared as towns because they are not municipalities and a few who have over grown the
10,000 number but have not yet been declared as municipalities. These are still being covered by
the rural health system and they represent some of the major para-medically under-served areas.
Typically they would have a sub centre, but their population per sub centre norm would be
adverse. Our strategy for these areas is to place an extra ANM there, which would be adequate for
our purposes.
The section on urban health therefore discusses the situation in three contexts- the large
corporations, the municipalities and the nagar panchayats.
The large corporations and municipalities present a situation of high inequity in health care. At one
end there are numerous tertiary care institutions and private nursing homes providing specialist
services that a section of the population is able to access. At the other end are large slums,
sometimes geographically proximate to the most advanced medical facilities, which are unable to
access even basic immunisation and institutional delivery services.
55
RCH 2 Draft PIP Chhattisgarh
Even within the poor in the slums there are categories like the migrant rickshaw pullers, the
homeless, the street children etc who face special problems of marginalization and consequent
invisibility within the system.
The health status of the poor here is also determined by the extremely unsanitary and unhealthy
living conditions that obtain in the slums- far more than in any comparable rural area. Poor
working conditions and issues of pollution also affect health. Along with this there are issues of
alcoholism and substance abuse that affect small sections of the population.
Behind the deprivation of basic entitlements of the poor also lies the fact of their illegalisation.
Often they are staying in illegal settlements, but paying high rents and has no protection against
eviction. Since the settlements are illegal their ability to secure their civic rights is even more
difficult.
The small urban areas are still more of the nature of overgrown villages that have not recognised
that the administration of a town calls for a different set of approaches. In many areas sewers and
drainage systems are not in place and health outreach services are organised in the same lines as
the rural areas- though the problems may be different.
Reflecting these facts the data reveals that both IMR and crude death rate have gone up, although
marginally in the last three years- by SRS data.
The Urban Health Infrastructure:
This exists in five categories:
Here the current strength of only 20 urban health posts and 18 dispensaries under the chief medical
officer’s jurisdiction.
Other than these under the civil surgeon’s jurisdiction are another set of dispensaries and clinics
and hospitals.
A third aspect is the number of municipality or corporation run dispensaries and a few hospitals.
Some of these are ISM institutions
In addition there are few ISM clinics run directly by the state directorate of ISMs.
Also most urban centres are district or block headquarters and by virtue of these host a district
hospital or a block PHC (CHC) which is being upgraded to 30 bedded hospitals.
The distribution of these centres is shown in the table in annexure 1.
56
RCH2lWt PIP Chhattisgarh
Objectives:
•
•
To improve the health status of the urban poor community by provision of quality primarv
health care services with focus on RCH services and to achieve population stabilization.
To ensure that investments in health contribute to poverty reduction by reducing out of
pocket expenditure on health care amongst the poor.
Strategies:
1. Careful identification of beneficiary families and vulneraoie families through a participatory
mapping exercise followed by a door to door survey
2. Community Level care givers covering 100 beneficiary households intensively and touching
on all households in their area.
3. Paramedical and basic medical services, through a network of urban health centres- without
fresh infrastructure creation -each catering to 5000 population. Utilize both NGO and
Private sector partners for this. This may mean an urban health centre for about 10 to
15.000 households.
4. Urban secondary referral services through a linkage with the CHC/district hospital or PPP
arrangements with a network of private clinics for emergency obstetric care, institutional
care of sick child, safe MTP services, FP sterilization services, adolescent health care and
counselling and diagnosis and management of RTIs /STIs/ infertility. These sen ices are
subsidized for the poor and at reasonable cost for the rest with a provision for exemption of
the poorest in special emergency situations.
5. Linkages will also be made available to district hospitals and teaching hospitals.
6. Peer caregivers for special highly marginalized groups - the homeless, the street child and
the commercial sex workers etc- reached out through NGO programmes.
7. Peer education programmes in urban schools for adolescents and in adolescent frequency
zones for out of school adolescents.
8. Designing a programme for social health insurance cover for the urban poor to cover all
institutional health needs.
Elaboration of Strategies:
1. Identification of Beneficiary (poor) and vulnerable beneficiary (marginalized poor)
families.
•
The entire area under a municipality or corporation should be distributed between urban
health centres so that no part of the population is left out. Thus each UHC will have a
geographically demarcated ’’section” to cater to.
•
Within the UHC-coverage population the UHC may in a participatory process with all
stakeholders participating, identify those who are in need of intensive coverage. The ULB
may be assisted by an NGO. Those under intensive coverage would be known as the
beneficiaries. This may be undertaken annually. The criteria for identifying a beneficiary
population- may include an income ‘criteria supplemented by an asset measure so as to
arrive at a measure of those who are below the poverty line.
57
R( ; 2 Draft PIP Chhattisgarh
•
In addition within the category of the beneficiary the programme would identify a sub
category called the vulnerable beneficiary. These would have an additional criteria of
marginalization in addition to poverty- suggested criteria are nature of occupations- e.g. rag
pickers, rickshaw pullers, conservancy staff etc. handicapped, beggars, as also destitute and
homeless, migrants and women headed households where only the woman is the earning
member . This may be further discussed at the community level. Involving a sensitized
organisation to facilitate in identification of the “vulnerable” beneficiary would also be
useful. The purpose of having additional criteria to only income as a criterion is the
recognition that there would be some categories that are so powerless that they would slip
through the safety net- unless an easily visible criterion brings them in.
•
The sanctioning and deciding authority would be the ULB- but the ULB would have much
better data and better criteria at its disposal.
•
This mapping of communities and beneficiaries is the first step and separate funds are
earmarked for this .Both ULBs and NGOs are involved in this.
2. Community level care givers (Urban Mitanins)
The Mitanin Programme currently is not covering urban areas. This initiative would be
introduced to select and deploy one Urban Mitanin for a group of 100 “beneficiary”
households. Her major functions after training would be:
a) To provide health education.
b) To ensure delivery of paramedical services esp. immunization and antenatal and postnatal
care.
c) To promote referral for institutional delivery, for FP sterilization and for institutional care
for sick children and neonates.
a. The Mitanin may visit non-beneficiary households in that section also but that would be
only twice a year along with the female paramedical workers at the time of pulse polio
preparations for collecting information and ensuring that all basic services are being
availed of.
b. The Mitanin would be selected by the community that she would serve. She would be
trained by a training team under the guidance of the state level Mitanin programme.
c. The Mitanin would not be paid an honorarium but would be compensated on days of
training as well as paid incentives for select tasks.
d. The Mitanin shall be fluently literate with at least an 8lh class education.
e. The exact numbers of Mitanins needed would emerge only after the participatory mapping
and the surveys are completed.
f.
The Mitanin programme is supplemented by and supported by a number of community
level processes.
58
RCH 2 Draft PIP Chhattisgarh
Community participation in planning, and implementation needs to be enhanced considerably.
There are three ways in which this would be done:
a. Form a women’s health committee - especially or only in those habitations where
performance is low by criteria like how many are unable to utilize the secondary care
centre because of costs, nor visit sub-centre for ante natal care etc or any group that
constitutes a vulnerable beneficiary. This could be a health and development committee.
This could be any pre- existing non- party forum that is acceptable. It could be a self help
group. The women's health committee should have a secretary or coordinator in whom we
need to invest some capability building through training and support processes. This would
help her keep the group together, reinforce messages to the group and organize self help
groups etc. The women’s health committee would help the Mitanin in needs assessment
and disease surveillance and vital events registration.
b. Ward level committees that identify the most - poor based on objective criteria and help to
plan interventions that are intersectoral - especially improving living conditions, working
together with the municipality, also need to be reinforced and where necessary initiated.
c. Organisation of occasional community level mobilization event is desirable- a public
show, a drama programme, a meeting where the key messages are reiterated, the
participatory structures are strengthened and the services offered by the ULB are informed
of. Such an event is almost mandatory if the community has to get actively engaged with
the participatory institution being created and the Mitanin plays the role of organisation and
empowerment. The major part of the funding for this is with community contribution.
3. Paramedical and basic medical services through the Urban Health Centres:
a) There shall be one urban health sub centre for every block of 10,000 populations. This can
go up to 15,000 populations in smaller municipalities of up to 40,000 sizes.
b) Shall have one female paramedical (ANM) per urban health centre that shall provide first
contact care at the centre and shall also make home visits. If there are more than 3000
beneficiary families in that area then the urban sub-centre would have one additional
female paramedical. If there are more than 6000 beneficiary families in that area there
would be two additional female paramedical. Thus if the 10,000 families covered are all
beneficiaries (poor) then the sub centre has 3 ANMs and if less than 3000 are beneficiaries
the sub-centre has one ANM. This same norm applies even if the urban health centre has
population coverage of 15,000. If out of the 15,000, more than 9000 are beneficiaries than
the sub-centre would have 4 ANMs. The rationale is that the beneficiary would require
greater follow-up and often household level care.
c) There would be one male para-medical in all urban health centres. This would not vary
with population coverage as his role would be largely of a multi-skilled assistant in the
urban health centre .
d) Shall have part time medical officer for attending to PHC level care.
e) Shall have same list of drugs as recommended for sector PHC.
f) Shall have a part time basic laboratory assistant.
59
RCU 2 Draft PIP Chhattisgarh
Sgrvices Organized at and from the Urban Health Centres
•
Quality antenatal care reaches 100% ( with all 9 components- counselling, physical esp.
abdominal examination, weight record, anaemia estimation, urine examination, BP
measurements, iron and folic acid administration, TT immunization and referral linkages for
medical referral sought at least once in the third trimester)
•
100% immunizations against six killer diseases within 12months of birth
•
Prophylaxis against vitamin A deficiency, intestinal worms, and prevention and treatment of
anaemia in children.
•
Better vector control and reduced vector borne disease.
•
Help in implementation of all the national diseases control programmes.
•
Better quality of water supply, ensuring safe water use at community level and domestic level
and promotion of hygienic measures all to lead to reduced diarrhoea disease with low cost
interventions and prompt and appropriate care, reducing household expenditure on recurrent
diarrhoea.
•
Easy access at cost to contraceptives in every habitation and sub-group.
•
Promotion of spacing, age of first child would continue to have urgency.
•
Growth monitoring at least once in six months (and once in three months for very sick child),
and anaemia assessment with adequate family counselling and supplementation to ensure that
below three years child malnutrition levels show a consistent decline. Nutrition measurement
and counselling to extend to adolescents and adult women and pregnant women also.
•
Good quality primary health care based on graded standard treatment protocols available at the
household level based on 10 drugs through Mitanins , at the sub centre level based on a 25
drug package through the ANM - supplemented by the part time medical officer. Such care is
to be linked by a two way referral system to the secondary care centres and some special
clinics of the state hospitals. This would therefore include STI/RTI/HIV dimensions of care. It
would also include many non reproductive dimensions of women’s health. This would also
include primary care for mental health. The cost of the package would be the same as the
current Mitanin- ANM- sub centre system - with the addition of training costs and some
increase in drugs costs.
•
A special clinic for adolescents organized in the sub centres that would link educational and
vocational opportunities and counselling to better adolescent health and their access to
services.
•
Adequate disease surveillance by a system that centres on the data generated by the Mitanin
but incorporates inputs from private practice, from the state health department hospitals and
also the secondary care centres.
•
Good quality referral linkage to the secondary care services ( first referral unit) and ambulance
services with efforts to see that at least 50% of the poor ( beneficiaries as redefined) would
resort to these or to other nor for profit hospitals who offer comparable costs as the better cost
and better quality option.
60
RCII 2 Draft PIP Chhattisgarh
•
Promotion of Creche facilities for babies of the working mothers linked to better pre school
child education programme and a universalized ICDS programme that covers the entire
beneficiary population.
•
Promotion of Community level collective action supplemented by inputs from the municipality
to ensure basic living and working conditions in all the habitations .Provision of women’s basic
education and vocational training to help them in self employment, to enhance their self
efficacy and to enable them to take decisions with regards to sexual and reproductive health.
•
Peer education programmes to reach out to specially vulnerable sections;
•
Extensive awareness generation and community mobilization through IEC to supplement and
make the above interventions effective.
•
Monitor health status and provide first level response to mini and major epidemics.
•
Optional - consider including disability identification and support in the Mitanin package of
sendees.
Clinigal^
The Urban Health Centre should provide an adequate quality of curative care by ensuring that
a) The part time medical officer be trained on a standard treatment guidelines that covers a
number of specialties at the level that an MBBS doctor with basic laboratory support can
handle
b) The ANM and MPW should be trained on a paramedical level standard treatment guideline
with a slightly larger set of drugs than the Mitanin would provide services on all days at all
times.
c) Good quality counselling and diagnostic facilities for RTIs/ STIs ( where the ANM plays a
key role) would be available
d) Basic infrastructure as needed for adequate privacy to examine patients and provide
counselling to them is either leased in or built up, and for one room for laboratory work( if
this is opted for).
e) That a laboratory that can estimate level of anaemia, do a routine urine examination
(albumin, sugar, microscopy), and examine sputum for AFB and blood smear for malaria is
built up. The ANM can be trained in a one month course to do these tests. In which case the
additionally, is only the training cost and the microscope and a very small co on
consumables. We note that this level of laboratory work forms part of the MBBS course
and medical officer may need a one week training refresher so that he/she can adequately
supen ise the male paramedical worker to do these tests himself when need arises. A good
basic laboratory manual with pictures would also facilitate this.
f) The timing of the urban health should be considered and in tune with the convenience of
the population.
61
RCTI 2 Draft PI P Chhattisgarh
4. Urban Secondary Care Centres (or first referral units)
The Urban secondary care service centre shall provide for
a) Institutional delivery
b) Emergency obstetric care
c) Institutional care of sick child
d) Safe MTP services
e) FP sterilization services
0
Adolescent health care and counselling
g) Diagnosis and management of RTIs /STIs/ infertility
The urban secondary care centre would be one of the following:
...
A CHC or district hospital able to provide all these sendees
b. A private sector (commercial or not for profit centre) facility which is able to provide all
these services - with which an MOU guarantees a minimum quality and fixed rate of
services.
5. Referral Linkages with district hospitals and tertiary care centres:
All large corporations have district hospitals and or tertiary care centres like medical college
hospitals. These hospitals are meant to cater to higher level of care for the entire district or
state. However they are often flooded with patients requiring primary care from the adjoining
urban areas. This overcrowding not only leads to less attention to patients requiring specialist
care and tertiary services, it also means a poorer quality of primary care for those seeking it at
such a location. Also a lot of waiting time, delay in providing services and patient
dissatisfaction.
The main reasons for this are that the urban health centres have very low functionality. Even
when functional such a high proportion of patients get referred up that it makes more sense for
patients to seek care only at the higher centre.
To present this we need
a)
A higher quality of curative service at the urban health centre - discussed above.
b)
A good referral linkage that is two way - so that some categories of patients can be
followed up at the urban health centre and so that patients referred up have a special
clinic or green line to go through at the district hospital.
c)
The linkage may also be to accredit private sector partners if the rates have been fixed as
proposed under the draft PPP policy framework.
62
RCI1 2 Draft PIP Chhattisgarh
6. Peer Educator Programmes for special highly marginalized groups-:
Though health needs are most in marginalized groups, they are often the most difficult to reach
out to. Such groups include a. homeless, b. the street child c. the commercial sex workers and d,
seasonal migrants.
I he proposal is to reach out through NGO programme to these groups. Each identified such
marginalised community would be interacted with and a number of peer educators would be
chosen from this group. I here are criteria that apply in making such a choice- they should be on
the group, having a good communication skills and commanding peer respect, and yet capable of
critical thinking etc( there are techniques of peer educator identification that apply here). Then the
peer educator is trained. Then deployment and acceptance within the peer group is another distinct
technique-laden step and finally feedback and support of their function.
Peer educator programmes would have a RCH focus as well as focus on all the national health
programmes including HIV.
7. Peer education programmes in urban schools for adolescents and in
adolescent frequency zones for out of school adolescents.
Adolescents are another group where peer educators convey messages more effectively. Adults
tend to be judgmental and are not able to relate adequately to the adolescent context. This is most
so in areas related to sexual health but is also true of many other areas of health care. This is also a
vulnerable period for addictions and violence.
Peer education programmes in schools require.
a. correct identification of peer educator
b. training
c. introduction as peer educator into the group
d. Follow up and support.
Peer educators for out of school adolescents are even more of a priority. It follows the same steps
as delineated above - though each step is even more complex to achieve in practice. One example
of deployment of peer educator is to set up a cafe in locality frequented by adolescents, and
provide a space or comer, for information and basic supplies along with the advertised presence of
peer educators there. The cafe managers themselves could double for this role.
Many such innovations are possible. At the planning level the key elements are
A. Identifying an NGO with good innovation skills
B Careful study of the group that has to be addressed and working out details within the
budgetary allocation available for the same.
63
RCTI 2 Draft PIP (’hhattisgarh
8. Designing a programme for supplementary social health insurance scheme
The issue of concern is making the quality health services available to the vulnerable population of
the society which is estimated to be around 10% of the total population. However taking the
resource constraints into consideration, a feasible alternative is to design and implement a model in
which the health care cost for the poor is met through cross subsidy without any substantial loss to
the healthy and affordable masses. This scheme is an endeavour to meet the purpose of making the
health facilities available to the poor, by optimal resource utilization and cross subsidization.
The scheme proposes to cover around 17 lakhs'.population in Phase I i.e. first year. It could be then
extended to the remaining population in the subsequent years depending on the claim experience
of the first year. The premium amount of Rs. 600 per family (for a family of 5) will be paid by the
beneficiary (propose) from Class I, ( non-poor) while those belonging to Class II will pay only
50% of the premium( poor ) i.e. Rs. 300 per year , the remaining amount will be borne by the
government. However the premium for the vulnerable class i.e. from Class Hi will be paid by the
government with a prerequisite that the beneficiary enrolls as a member of a Self Help Group with
a nominal payment of Rs. 10 per month, which will be utilized to provide loans to meet the
indirect costs of health care at the time of need.
The proposed scheme offers cover up to a limit of Rs. 20,000 per family for only secondary level
care. This payment will be made directly to the health care provider as a third party payment and
the beneficiary is not entitled to any cash benefits or reimbursements. This will also ensure
continual monitoring of the process.
Not all hospitalisation needs are addressed. Only a package of services is provided such cover.
These would however include a. institutional delivery, caesarean sections, hysterectomies or
equivalent gynaecological surgery, acute abdomen, hydrocoele, hernia, circumcision,
haemorrhoids, RTI/STI identification and family planning services- broadly secondary care needs
or first referral unit services.
The third party payment would be made to the Rogi Kalyan Samiti if it is a CHC or district
hospital that the patient chooses to go to. Or it would be made to a private sector provider who is
functional under the proposed Mitan Kendra or Mitra Chikitsalay scheme. This scheme therefore
requires the new state PPP policy and Mitan Kendra scheme to be in place.
The Mitanins would help and urban health centres would help in administering the scheme. The
scheme itself should be worked out with a health insurance agency.
The budgetary requirement is to pay the costs of social insurance for the poor in the first year and
half the costs in the second year. From the third year the system should be able to meet its own
costs. (See annexure 2). Though budgetary calculations have been shown for the entire state, we
could even launch this in small units a few category D, C, B and A towns as a pilot and then go
ahead to expand this to the whole state.
A key variable is how much of those who are not beneficiaries would enroll. The option is that if
this is run by the ULB to make the deduction part of ULB revenue or to leave it optional. Both
variants would be piloted. .
64
RCH2l)rali PIP Chhattisgarh
Service entitlements of the population:
The entire population in the geographic area would receive a minimum package of services. These
include:
a.
Pulse polio
b.
Annually two visits to record vital events and child immunization status and check out on
notifiable diseases.
c.
A system in place of notifying any of a short list of notifiable diseases brought under a
community- based component of the disease surveillance programme. This needs to be very
simple system- like ten post cards left with a volunteer for every group of houses or sub
group or distinct community grouping.
d.
One can add sampling drinking water quality testing with a low cost kit.
e.
Similarly one can add - weighing all children below three once in six months- but this would
require community support. Not insisted upon- except where they are poor but for some
reason have not made it to the beneficiary group.
f.
Enrolment in a social insurance package which would provide for a limited range of
secondary health care - but which would cover all RCH secondary care needs. The premium
could be deducted with property tax or enrolment could be made optional. The estimated sum
is Rs 600 per family per year.
For the beneficiaries: the package could be (in addition to the general list above):
a.
ensuring quality antenatal care at the sub-centre and post-natal care at the house
b.
ensuring immunization at the sub-centre
c.
ensuring access to temporary methods of contraception at the sub-centre
d.
Ensuring access to sterilization on a fixed day of the week in one or two places in each
municipality.
e.
Ensuring access through a subsidized social insurance package to emergency obstetric care at
nominal or free rates at a designated centre for emergency obstetric care, sick neonatal care
and institutional delivery and a larger package of inpatient care for common childhood
emergencies of the sick child - diarrhoea with dehydration ; acute respiratory infections:
acute fevers,
f.
Ensuring access to specialist services at the secondary centres at subsidized rates through the
subsidized social insurance package.
g-
Peer counselling programme for adolescents with adolescent clinics combined with activities
to attract adolescents once a month at the sub-centre level.
h.
Treatment equivalent to the “normative" rural sector primary health centre level based on a
50 to 75 drug list - and backed by basic ( what is known as side-lab) diagnostics at the sub
centre - so that the PTMO is fully utilized. The package of services and level of services that
would be available here should be notified and accompanied by a standard treatment
guidelines built for this level.
65
RC11 2 Draft PIP Chhattisgarh
i.
Six monthly weighing of all children with nutrition counselling for the family for families
with children in the 6 to 12 month age group or with children on any grade of malnutrition.
For grade III and IV children medical visit and monthly or quarterly weighing may be added
on.
J-
Extension of ICDS services to these areas.
For the vulnerable beneficiary (in addition to all the above)
a.
Door step delivery of primary health care may be retained as a goal - but now it must be
seriously operationalized. This would mean that for this group we should ensure
i.
Regular visit from a Mitanin
ii.
Providing immunization at the home - if they are not coming to the sub-centre even
after two months behind scheduled time
iii.
Providing antenatal and post natal care at the home.
iv.
Providing for a better quality of first contact curative care at the doorstep with 10 drugs
and a standard treatment protocol for Mitanins and at the urban health centre with 25
drugs and the paramedical standard treatment guideline.
v.
Total exemption of all payments ( or to be precise third party payments) at the
maternity homes and other secondary care services along with a state paid social
insurance mechanism linked to self help groups.
b. Creation of community level structures and credit mechanisms to meet health needs. (This is
needed for all beneficiaries - but is critical for this group.)
c. Ensuring flexibly and innovatively run day care centres along with child weighing as suggested
for the earlier group.
d.
Collective community initiated and municipality supported initiatives to improve local living
conditions.
e. Peer educator programmes through trained volunteers from within the groups- esp. for most
difficult even within the vulnerable.
Provision of Urban Health Care Services:
In category F townships the proposal is to have the existing sub-centre renamed an urban health
centre and provided ANMs as per the norms stated. The Mitanin programme would also be
introduced in these areas. The CHC would act as the secondary care site.
In category E towns one would need to convert the existing sub-centres to urban health centres
and add in more urban health centres as per the norms stated above- one per 10,000 with number
of ANMs as per the beneficiary population. No part time doctors need be placed in these health
centres and no separate administrative arrangement is required in E and F category.
In category D and C towns one would need to open a number of urban health Centres, have
ANMs and other staff as per newly stated norms, including a part time doctor and have an urban
health administration unit, headed by a public health officer. The CHC would play the role of the
secondary care centre but where the potential to provide better care is available in the private
sector the secondary care could be entrusted to them as per the Mitan Kendra PPP policy. (In
special situations even the entire urban health package could be contracted out - if an NGO is
willing to play this role.) This is particularly applicable to mining towns where there public sector
undertaking or company run health facilities. In company towns, mining towns and collieries we
may negotiate similar packages with their hospitals where they can contribute part of the co. The
company town's main organised working population is already under medical coverage in almost
all cases. The scheme is only for unorganised labour and casual labour and services that spring up
around these areas and which cannot afford or access the services provided for organised labour.
66
RCIF 2 Draft PIP Chhattisgarh
In all these towns, especially where we have not for profit facility playing the secondary care role
a “ Supplementary Social Insurance Approach” linked to self help groups shall be included into the
programme to cover the health needs of the poor and the vulnerable.
In category B and A towns we have four options to the provision of these services:
a)
Recruit a secondary care service provider who is able to provide the entire package for a
population of about one lakh, work out a unit cost for services and reimbursement package and
sign an MOD for the same.
b)
Make separate package for paramedical and community level care and a separate package for
secondary level care. Though the first is the preferred route the second may be required where
we have no takers for the first.
c)
The urban local bodies that want to take up and run such a programme may also do so. The
budget overheads are adequate for Ims. They would contract in a secondary referral centre and
the other services would be directly under them or they could contract the entire package out.
d)
We can also consider a similar package being run by the government with cost recovery as for
the PPP where there are no private or NGO takers for such services. The secondary care in such
a situation would be by the district hospital and the CHMO office would run the urban health
centres under an urban health officer post created specifically for this task and equivalent to a
BMO in designation.
In all these towns too the beneficiaries would be brought under a “supplementary social
insurance programme approach” linked to self help groups and Milan Kendra.
SETTING THE PROGRAMME INDICATORS:
The quantifiable objectives proposed are therefore the following 10 indices- all of them to be
presented with segregate for three socio-economic classes - two of them within the beneficiary
group( the poorest about 10% being seen separately from the rest of the beneficiaries and called
vulnerable beneficiary) and with segregate where relevant for gender :
■ Infant mortality rate
■ Under three or under 5 child malnutrition rates
■ Anaemia in women, especially in adolescents
■ Birth weight of babies
■ Age of first child and spacing intervals
■ Percentage of births which are third order or higher
■ Percentage using institutional delivery
■ Case detection of tuberculosis and case holding to match up to the RNTCP norms.
■ More innovative indices to include cost of care and resulting household indebtedness and
disease burden should also be developed, if investment in health care as poverty alleviation is
taken up as a serious goal.
■ Number of days of work lost due to illness per earning member
■ Out of pocket co of institutional deliveries for the poor.
■ Out of pocket cost for management of three recurrent childhood trivial illness- fever, diarrhoea,
and respiratory infection- of the poor.
■ Number of poor who had to borrow at usurious rates for meeting either of above co.
67
RCH 2 Draft PI P Chhattisgarh
ESTIMATING NEEDS AND COST
An estimate of the urban poor based on poverty data is about one thirds- or about 12 lakhs, (of the
urban population of the category A to D towns).
The estimated need for urban community level caregivers would be 2,400. In addition we would
seek about 10% of that number of peer educators- roughly 240.
Urban health centres needed - again category A to D towns would be 120 with at least 260 ANMs
and one male worker in them. In category E& F about 60 urban health centres would have to be
created or as is more likely the sub-centres would need to be upgraded to urban health centres.
And there would be about 10 secondary referral centres needed.
The package for training and deploying a community caregiver is roughly about Rs 4000 per year
per caregiver excluding drugs. Incentives would be from referrals and form part of the costs of the
urban health centres and the secondary referral centres. Though the total amount would work out to
Rs 1.04 crores this is only an investment of about Rs 30 a household - which is a small but essential
investment to set up the household and community le\’cl processes that are crucial to the success of
the programme. There is already a major demand for extending the Mitanin programme to urban
areas and since the systems for training and supporting the Mitanin programme has been developed
its extension to urban areas would pose few problems.
The package for training and deploying a peer educator is also approximately the same cost of Rs
4000 per year. It includes approx 20 days training per year, and for each day of training Rs 75 is cost
for fooding, Rs 25 is cost of material and Rs 100 is cost of compensation/incentive.
The urban health centre cost would about Rs 2.6 lakhs per year. This excludes infrastructure costs
though it includes rental costs. Approx two ANM @ Rs 5,000 per ANM per month, Rs 30,000
package for minor equipments and training, a Rs 50,000 per year for infrastructure repairs or rent
and incidents. Redeployment of existing staff would be able to cover the cost of the third ANM and
male attendant and where needed state will fill the gap. The part time medical office if utilized then
Rs 5000per month or Rs 60,000 per year will be paid.
The understanding is that all civil dispensaries CMO run centres, and ULB run centres and ISM run
centres come under a common ULB management that has a health officer deputed from the
directorate of health services to manage it. This would minimise the needs for infrastructure.
However in some areas where new clinics are needed they would be taken on rent. Existing
infrastructure up gradation needs would also be attended to.
For the secondary referral centres the costs are being projected as Rs 1.2 lakhs per year for
overheads and general subsidy. We are proposing using existing public hospital for private sector
where the note the rate have been fixed in accordance with state PPP Mitan kendra policy.
The cost of reimbursement for institutional delivery for the BPL population would range between
one crore (at 25% efficiency) to four crores (at 100% efficiency). This cost would not be charged in
per cases basis, but included as part of an insurance charge so that after two years it is sustainable.
The government therefore only pays the premium for the poorest 10% of the BPL section and 50%
of the premium cost for another 30%.The other 60% of the population in the locality- is given the
option of joining in. The proposal is that we initiate this innovative social insurance approach in only
about one fifth of the total urban areas for the category A to D towns. The social insurance premium
payments shown are estimates for the pilot programme in the first year. In the first year it is
68
RCH 2 Draft PIP Chhattisgarh
proposed to cover 33,333 houses in category A Urban areas, 13,333 households in category B urban
areas, 6667 households in cateory C towns and , 3333 househols in category D towns. Of these
houses appox 10% would have 100% premium paid by the govt ( category III) while another 30%
would have 50% premium paid by the govt and the remaining 60% are voluntarily recruited in. This
budget is needed only on the assumption that 60% do not voluntarily or mandatory join the scheme
with full payment- which in the first two years is the likely scenario. If on the other hand they join,
which we hope to achieve from the second year onwards no further subsidy is needed as it would be
self sustaining. However since the first year we are taking up about one sixth of the estimated urban
poor population- it would be useful to have a similar sum available to expand the programme to
more and more urban areas each year. ( For mote details see annexures of the Urban RCH proposal).
This can be contracted out to an NGO but preferable decentralised to an ULB with a 10% of
overheads, for their management. The state management costs would have in turn another 10%. for
monitoring and support. This does not include cost of drugs and Supplies for Community Care
Givers and Urban Health Centres which would be from district funds. The state level mangement
cost is high as this is a very experiment0’ approach and it is going to require considerable
management inputs- both consultants and regular to make it viable.
For implementation and day to day monitoring the programme one Health Administrator (post
graduate in management with experience in health sector) per one lakh urban population in category
A and B. Monthly emoluments per Health Administrator will be Rs 20.000.
69
Rd I 2 Draft PIP Chhattisgarh
Urban RCH
Budget:
Unit
Cost
Rs
10,000
Rs
20,000
Head
Participatory Mapping
for A category
!
Participatory Mapping
for B, C, D categories
Health Administrator for i
Rs
A, B categories ( for one '
20,000
_______ year)________
Community care givers ! Rs 4000
j Rs 4000
Peer educators
Urban health centers
Secondary centers
:
Rs 2.6
lakhs
Rs 1.2
lakhs
Social insurance for pilot
ULBs (govt, paid
premium in first two
600
years for category III
____ beneficiaries)
Social insurance for pilot
ULBs (govt, paid
premium in first two
300
years for cateogry II
beneficiaries)
Total
Overheads and
management cost for
10%
ULBs/state management
_________Net________
State level co for
10%
management, training
and monitoring
Total Programme Cost
Nos.
2005-06
2006-07
4
210000
0
15
280000
0
29
7000000
7350000
2,400
10080000
240
9600000
960000
120
31200000
32760000
10
1200000
1260000
5667
3400200
3570210
19000
5700000
5985000
59550200
2007-08
2008-09
2009-10
Total
62013210
65113871
68369564
71788042
71788042
5955020
6201321
6511387
6836956
7178804
32683489 |
65505220
68214531
71625258
75206520
78966846
359518375
6550522
6821453
7162526
7520652
7896685
35951838 j
72055742
75035984
78787783
82727172
86863531
395470213 i
1008000
The urban health centre cost wou' d about Rs 2.6 lakhs per year. This excludes infrastructure costs though it includes
rental costs. Approx two ANM @ Rs 5,000 per ANM per month, Rs 30,000 package for minor equipments and
training, a Rs 50,000 per year for infrastructure repairs or rent and incidents. Redeployment of existing staff would
be able to cover the cost of the third ANM and male attendant and where needed state will fill the gap. The part time
medical office if utilized then Rs 5000per month or Rs 60,000 per year will be paid.
The social insurance premium payments are estimates for a pilot programme. To understand which this has to been
along with the Milan kendra PPP proposal. And the urban RCH proposal annexed. In the pilot phase it is proposed to
cover 33,333 houses in category A Urban areas, 13,333 households in category' B urban areas, 6667 households in
cateory C towns and , 3333 househols in category D towns. Of these houses appox 10% would have 100% premium
paid by the govt ( category III) while another 30% would have 50% premium paid by the govt and the remaining 60%
are voluntarily recruited in. This budget is needed only on the assumption that 60% do not voluntarily or mandator)
join the schemewith full payment. If on the other hand they join then from the next year onwards no further subsidy is
needed as it would be self sustaining. However since the first year we are taking up about one sixth of the estimated
urban poor population- it would be useful to have a similar sum available to expand the programme to more and more
urban areas each year. The state level mangement cost is high as this is a very experimental approach and it is going
to require considerable management inputs- both consultants and regular to make it viable. For mote details see text.
70
RCH 2 Draft PIP Chhattisgarh
7.2.6 Tribal RCH
Constraints/Situation:
Chhattisgarh large tribal population of about 32% has considerable cultural, ethnic and linguistic
diversity. Inadequate recognition of this has been a major constraint in the success of most health
programmes in this area. Very high levels of malaria, tuberculosis and malnutrition and alcoholism
present unique challenges. Many of the problems relate to livelihood issues. Health systems cannot
address these issues but investing in health gives a better chance for tribal development
programmes to succeed. Geographical constraints to access are also a major issue. There is also a
lack of epidemiological profiling of disease patterns in these communities.
Objectives:
• Integrate the cultural, ethnic and linguistic diversities and specifications into health planning
esp into BCC strategies.
• Build up incentives for employees to work here and alternate systems of health care delivery
for underserved areas.
• Build up an epidemiologic profile of diseases in these communities.
Activities:
a) Build up two regional Tribal Health & Family welfare training centres- one at Ambikapur
to cater to the tribal sections of Jashpur, Raigarh, Koriya, Korba and Sarguja and the other at
Jagdalpur to cater to the tribal section of Bastar, Dantewada, Ranker and parts of Dhamtari.
In the northern districts the tribes that are present are the primitive tribe of the Hill Korbas
and Sahriyas and Baigas and the Oraons and Gonds.The dialects spoken are Sagdi and
Oraon.
In the Southern districts there are six major tribal groups- the Gonds, the Muri as, the
abhujmurias, the halbis, the battaris and the Kamars ( more central) and many smaller tribal
groups. Halbi is understood by most- but Chhattisgarhi and Hindi are not. Health
communication in these areas has been very poor due to the lack of understanding of
language and even more important of their cultural practices and value systems. There is a
very large cultural gap between health care providers and the people they serve. We also
have very few members of these tribes themselves involved as health employees. Community
participation is low. It is to correct these distortions that the two regional H& FW training
centers are proposed. The differenes between then northern group of tribals and the southern
groups are so marked that the same center will not do. The third Regional HFWTC is at
Bilaspur( already in existence) would also have these same areas of work but with focus on
non tribal areas and the Chhattisgarhi language.
These centers will become the major training centers for all BCC activities and for
developing suitable health communication materia for these tribal areas.
Other than BCC and communit training the three cneters would also undertake training for
LHVs and HAs (male and female sector supervisors- six months training programmes). This
is essential pre-promotion training. The major gap this proposal addresses is the lack of any
training facility in the state for LHVs and HAs. By current norms, a six-months training is
required.
71
RCII 2 Draft PIP Chhattisgarh
Proposed size :
Training space plus accommodation for 60.
Staff Sanctioned :
One head, three subject specialists, six trainers and supporting staff.
The other activitcs proposed under the tribal health plan arc:
b) Notify medically and paramedically under-served and unserved areas in these districts and
follow the process outlined to choose between mobile clinics or fixed services run by NGOs.
janpad panchayat run services and PPPs to cover these areas. The budget for the same is
expressed along with the section on NGOs and on PPPs.
c) Build up an epidemiologic profile of disease pattern in the primitive tribal groupsAbhujMurias, Kamars, Hill Korbas etc as well as in other sections and use this to write up
more specific proposals in the coming years. To link specfic sector PHCs to research
institutions for this work so that there is an element of operational research and capability
building embedded in this.
d) Incorporate cultural aspects of Health Communication into BCC programmes along with
epidemiologic insights into both in-service training programmes and BCC programme
design. The incoporation would be done at the tribal training centers and the budget for the
field level programmes would come from the BCC budget.
Budget For Secction 7.2.6 Tribal RCH
Head
Training,PPP,NGO
Programmes, BCC
Epidemiologic studies
Regional Training Centre at
Jagdalpur and Ambikapur
Total
Unit Cost
Nos.
2005-06
2006-07
2007-08
2008-09
2009-010
Total cost
in respective sections
1,500,000
See below
in 7.2.6.I.
8
60,00,000
60,00,000
13800000
25,38,000
53,29,800
5596290
5876105
33140195
198,00,000
85,38,000
53,29,800
55,96,290
58,76,105
45140195
12000000
72
RCH 2 Draft PIP Chhattisgarh
SI
A
1
2
3
A
B
1
2
3
3
Sub table 7.2.6.1. Regional Training Centres for Tribal Areas :
Head _ •
Descriptions
| 2005-06 __________ _
Non Recurring Exp.
Refurbish existing
Building,
centre at Bilaspur- Rs.
500000
Furniture &.
Fixtures
5 lakhs____________
For establishing 2
more centres in
Jagdalpur and
10000000
Sarguja: Rs. 50 lakhs
_____ each______________
Computers-2;PrintersEquipments
1800000
1
Photocopier-1
Projectors,Sound
Systems &
Accessories
Rs. 6.00,000/ centre*3
1 vehicle each for a
Vehicles
1500000
_____ centre. 3*5,00,000
Total______________ 13800000
2006-07
2007-08
2005-06
Recurring Exp.__________
Salaries
1 * Rs 15000* 12months
567000
270000
1 Principal
*1*3 RTCs
3*Rs 10000*12
3 Expert
1134000
540000
months*3 RTCs
Faculties
6*Rs 8000*12
1814400
864000
6 Trainers
months*3 RTCs
1 Data Entry
l*Rs4000*12
151200
72000
Operator/
months* 3 RTCs
assistant
1 *Rs 4000*12 months
151200
72000
1 Driver
*3 RTCs
1 vehicle*Rs5000*12
189000
90000
POL
months*3 RTCs
Workshops&
material Prodn.
Lumpsum 3 lakhs * 3
RTCs
450000
945000
2008-09
2009-010
Total cost
595350
625118
2057468
1190700
1250235
4114935
1905120
2000376
6583896
158760
166698
548658
158760
166698
548658
198450
208373
685823
992250
1041863
3429113
Office
10,000*12 months*3
Expenditures
1371645
416745
378000
396900
180000
RTCs
and
Comtingencies
33140195
5596290
5876105
5329800
2538000
13800000
_______________ Total
Note: In 2005 -06 and first 6 mnths of 2006-07 since building is under construction no running
costs are shown. From second half of 2006-07. running costs- salaries, actvities, travel are
budgetted for).
73
RCH 2 Draft PIP Chhattisgarh
7.3
Institutional Strengthening:
Introduction:
The central problem of infrastructure in the public health system of Chhattisgarh is the peculiar
combination of a highly inadequate infrastructure with a gross under utilization of the same. This
is the central problematic- the matching of investment with utilisation- that the infrastructure
development plan of RCH-II addresses.
The discussion of technical strategics shows that the same set of issues recur in each technical
domain and strategies needed are so closely overlapping that they cannot be discussed independent
of each other. We have therefore chosen to look at the activities within eight activity groups. These
are:
7.3.1. Infrastructure Development and Utilisation
7.3.2. Training of all different types for both paramedical and medicals
7.3.3. Strengthening 100 CFICs to become FRUs for set of secondary services- this includes
basic & emergency obstetric care, institutional care for sick neonates and sick children.
STI/RTI. adolescence counselling and health care services, safe MTP services and fixed
day for tubectomy and vasectomy services.
7.3.4. Strengthening routine subcentre services.
7.3.5. Public-private partnerships.
7.3.6. Service delivery & NGOs.
7.3.7. Community level care- Mitanin Programme
7.3.8. Increasing drug kits
7.3.9. Panchayat and village level capability building
7.3.1
Infrastructure Development for the Public Health System in Chhattisgarh:
Infrastructure - Current Situation and Gaps: There has been a major effort to bring all district
hospitals to 100 bed levels. Since 9 new districts were created after the formation of Chhattisgarh
in almost all a CHC or a civil hospital was built up to district standards or an altogether new 100
bed hospital was built. Ancillary buildings are required in many of these hospitals- for incinerators,
for garages, for residences and for supplementary services. However since the new buildings that
have been built are yet to become fully utilized, and many constructions are to be completedfurther new immediate infrastructure needs at the district level would be small and can be managed
within state funds.
The Community Health Centres: By population norms of one CHC per lakh population we need
180 CHCs even if we leave out the 40 lakhs population of large urban towns. The system is
however currently aiming for only one functional CHC per block. This gap between number
required by two different ways of estimation gets reflected in a number of blocks where the
population is close to two lakhs and the CHC is physically too far away from over half the
population (e.g. Podi-Uproda). The recommendation is that as an interim measure to upgrade some
of the PHCs in these blocks at a suitable location and these upgraded PHCs are be made capable to
perform 24 hour medical officer attended emergency services sans operation facilities and link it
up with the main CHC of the block.
If we assume a block per every CHC as our immediate goal then the state requires 130 CHCsassuming that the district hospital would play the CHC role in urban areas. However noting that
urban areas are medically underserved there is a need to retain the CHC- for serving the local
population with a range of public health and specialist outpatient services and decreasing the load
on the district hospital. In which case the number of CHCs to plan is 146. The sanctioned strength
as now is 121.The distribution of this is shown in table 2.
74
RCH 2 Draft FTP Chhattisgarh
Table 15: Distribution of CHCs.
District
c:r
W
___________ Bastar
___________ Bilaspur
__________ Dantevvada
__________ Dhamtari
____________ Durg
___________ Janjgir
___________ Jashpur
___________ Kanker
__________ K award ha
____________ Korba
___________ Koriya
_________ Mahasamund
___________ Raigarh
____________Raipur
_________ Rajnandgaon
___________ Sarguja
____________ Total
-
/fRo-
■J
i^o'ofBiocks
Or "9^"" '
____________ 15
____________ 10
____________ 11
____________ 4
____________ 12
____________ 09
____________ 8
____________ 7
____________ 4
____________ 5
____________ 5
____________ 5
____________ 9
____________ 15
____________ 9
____________ 19
146
MOHCs sanctioned
plwrblockswith
civil hospitals
12(4- 2)
10
_________ 9_______
_________ 3_______
________ 10
_________ 6_______
_________ 7_______
_________ 5_______
_________2_______
_________3_____
_________ 5_______
4
_________5_______
________ 11
_________6_______
________ 18
116
CHCs with new 30
bedded structure
6
3_
1
6
3
0
2
2
3
3
3
34
Of those CHCs, which are sanctioned, many do not have the requisite infrastructure. The situation
regarding this is also seen in the table above. This table has taken number of beds as the single
criteria of adequacy. Thirty bedded CHCs are almost all newly built and accompanied by all
infrastructure requirements. There are also a fair number of older CHCs with beds varying from 11
to 30. Most of these were earlier PHCs, now re-designated as PHCs. Though they have beds they
are not folly functional yet.
CHC infrastructure requires a number of facilities other than the beds - the operation theatre, the
labour room, the X-ray rooms, the laboratory, the stores, the toilets and bathrooms, waste disposal
systems etc - and so on. Many of these facilities require extensive renovation and repairs. In many
such facilities the building is very old and cracks have appeared in walls and the ceiling often
drips. The ceilings have to be renovated and made waterproof. Cracks would have to be attended
to and walls strengthened along with fresh painting to give it a presentable appearance. The floors
especially in the delivery room and in the toilets and in the operation room would have to be nonporous. Years of lack of investment in maintenance have given them a dilapidated look even
where the building itself is not damaged.
Basic cleanliness is also a problem and facilities for waste disposal remain very weak. At least
some areas must be marked off for deep burying or landfill and fenced off. If this is not done
disposal of placenta, MTP products and other body fluids etc becomes difficult and unethical and
dangerous. Incinerators would be required in larger facilities.
Toilets are either not there or in a state of utter disrepair and poor maintenance. Moreover a
minimal bathing facility is needed for patients wherever in patients are considered. For example
any woman giving birth to a child would like to have at least a wash and a convenient room- for
that is not a luxury, it is basic right. Similarly when we are talking of a 24-hour service it is equally
important to provide a staff toilet separate from patient toilets.
75
RCU 2 Draft PIP Chhattisgarh
A facility- extension of a veranda like space where patients and their attendants can wait is also
needed if it does not already exist. Power supply is not a problem in most CHCs studied. Those
that do have a problem all have generators as back up. However electrical fittings are usually
needed and sometimes-fresh wiring is urgently needed. At present more than 50% do not have
telephone access and none of them have a functional Internet access.
Staff quarters are also major lacunae. In the infrastructure study staff quarters were there in many
CHCs (92.5%) had some doctors accommodation but never adequate for all doctors. About 70%
had nurses’ quarters and 52% had some paramedical quarters, 70% had some quarter occupied by
clerical staff and 37% had some quarters occupied by class 4 staff. Again never was the
accommodation enough for all.
Under RCH-1, EAG civil works for renovation has been done in almost 70 CHCs. We need to
upgrade these CHCs into 30 bedded secondary care centres with functional OTs. The state
government is funding another 30 such new buildings. The immediate gap to reach our goal of
100 CHCs as secondary care centres is 30.
Adequacy of Primary Health Centres: Of the primary health centres the infrastructure position is
more complex. First there is a large gap in sanctions. This leads to a tremendous overload of
coverage area on existing PHCs and CHCs. This is shown in the table 3 below.
Sectors and PHCs
District
Sector
Sector
Av. Popn/
Av
Sectors
Sanctione
PHCs
PHC
Popn
without
d PHCs
final
/Sector
PHCs
without
own bldg
Bastar_____
65
54/57
24115
20034
11
20
Bilaspur*
66
49/42
40674
30197
17
19
Dantewada
47
34/34
71909
15299
13
9
Dhamtari
24
14/11
50255
29315
10
4
Durg*_____
65
48/46
58370
49104
17
12
Janjgir*
46
, 22/25
59825
28612
24
13
Jashpur
33
25/27
30124
22822
8
7
Ranker____
34
24/21
27138
19156
10
4
Kawardha
19
10/12
58467
38978
9
2
Korba*____
44
29/29
35601
23464
15
11
Koriya_____
23
18/21
32525
25455
5
10
Mahasamund
37
15/14
62901
25500
22
11
Raigarh
35
38/40
33291
36145
-3
22
Raipur*
89
44/47
68387
33809
45
14
Rajnandgaon*1
36
22/25
58264
35606
14
11
Sarguja____
85
64/65
30792
23184
21
19
Total
748
510/516
40776
27952
238
189
Where PHCs are sanctioned there is large gap in adequacy of infrastructure.
Adequacy of PHC infrastructure: If we define a sector PHC as having the capacity to conduct
institutional delivery on a 24 hour basis for high risk cases - all the above - labour room, a small 2
to 6 bed ward, toilets and bathing facilities for patients, staff toilets, communication facilities for
accessing referral etc are all essential features. Clearly this has not been achieved in most sector
PHCs. Of 516 PHCs, as many as 189 (36.62%) have no PHC government building. The
infrastructure study that had a sample size of 59 PHCs showed that most were in some type of
government buildings- but this> was largely Sub-Centre building having been recently upgraded to
PHCs.
76
RCU 2 Draft PIP Chhattisgarh
This is barely adequate for PHC function and an extension of one or two rooms is desirable. PHCs,
which are in government buildings built for that purpose, have good infrastructure with about 6
beds, which can be even pushed upto ten beds. PHCs in panchayat and rented buildings or using
space built for an ISM facility have usually got inadequate space for basic functions. Most PHCs
have power supply and of these many (61.37%) reported that it was regular. But almost all needed
better electrical fittings and wiring to be adequately usable. Water situation was less than
satisfactory. Though most had a water source only one fourth had running tap water connected to
an over head tank. A well or bore well was the commonest situation and was present in roughly
half the PHCs. About one fourths report that their source is absent or inadequate. Telephones were
present in one thirds of the PHCs studied.
Only one third had staff toilets and of these one third 11% were considered of adequate
maintenance. Most other PHCs had one toilet without separate provision of staff. The condition of
one thirds of these was rated as poor and the rest as fair. None were considered as of adequate
maintenance. One thirds of PHCs had in addition some bathing facilities. Accommodation in
PHCs is also a major issue. In remote areas the lack of accommodation makes it impossible for
doctors to be resident there - as there is often no suitable rented accommodation either.
This proposal therefore seeks renovation of existing sector PHCs and new PHCs in all those
sectors which do not have a sector PHC as of now.
Adequacy of Sub-Centre Infrastructure: This is difficult to assess. The government annual
report for 2002-2003, records that overall for the state, 1458 out of 3818 sanctioned SCs or 38.19%
of Sub-Centres have a government building. Government buildings usually had five rooms- a
outpatient room of about 8ft square, a hall of about 22 ft* 8ft used for conducting deliveries and
labour, two rooms of about 8ft square for residential purposes, a store- often used as kitchen and
two small toilets and two verandas (of about 700 esq.) one of which functions as a waiting room
for patients. Whereas in rented buildings, there is usually a single room, of about 100 to 150 sq ft,
with little other facilities. In other cases, the stores were kept in the ANM’s own accommodation,
for which also the government paid no rent. 57% of govt buildings were rated as being in good
condition, about 26% fair and the rest poor. In contrast in rental buildings only about 30% rated
good condition and an equal amount rated fair - the rest being perceived as poor condition.
Subcentres with government building most have adequate water supply- usually bore-wells with
hand pumps. But one fifth report some problems, which are large enough to compromise quality of
service. These gaps need local solutions. As such the system in place is neither able to take note of
such gaps periodically nor is it able to respond to the needs adequately. At present any gap notified
via the BMO to the chief medical officer and he funds earmarked for this to each district are not
known at the year’s beginning. There is no set procedure, which takes care of such gaps.
. 77
RCH 2 Draft PIP Chhattisgarh
Table 17: Sub-Centres with buildings:____________
Vi'
Bastar
Bilaspur
Dantewada
Dhamtari
Durg
Janjgir
Jashpur
Ranker
Kawardha
Korba
Koriya
Mahasamund
Raigarh
Raipur
Rajnandgaon
Sarguja
Total
317
282
204
138
353
210
195
162 .
96
194
106
143
249
461
220
488
3818 -
Number with own
_____ buildg____
211
40______
______ 89______
______ 44______
______ 105
______ 37______
______ 152
______ 123
______ 40______
______ 20______
42
______ 51______
______ 194
______ 82
______ 110
______ 118
1458
Number which
need bldg.
106
242
115
94
248
173
43
39
56
174
64
92
55
379
110
370
2360
Training Infrastructure: This is dealt with in the section on training.
Understanding Infrastructure Under-utilization: Utilisation at the district hospitals is
good in most district hospitals. In contrast, utilisation at the other three levels- CHC, PHC and
subcentre is a problem. Many of the 30-bedded CHCs are not functional and almost none of them
has full bed occupancy. Most operation theatres built have not become functional. Very few PHCs
are doing any institutional delivery and almost none are doing so on a 24 hour basis. This is true
also for subcentres. The causes for such underutilisation are listed below :( Not in order of
importance).
1. Poor location of facilities —geographically and in relationship to social sectors and markets
reduces access.
2. Inadequate manpower and therefore non-availability or very poor quality of services.
3. Inadequate skills - especially in some critical areas- e.g. emergency obstetrics or
anaesthesia or laboratory work- makes it impossible to provide many services for which the
infrastructure is built.
4. Inadequate health care provider motivation and poor quality of client - provider interaction
reduces attendance.
5. Costs of care - both legal and illegal - have an adverse impact on attendance.
6. lack of prompt referrals and poor referral arrangements also leading to poor utilization
7. Poor health awareness also contributes.
Whatever are the reasons, such underutilisation is a waste of scarce resources and a major de
motivation for both the state finance and for donors to invest in more infrastructure.. The obvious
lesson is that any planning for increased investment in infrastructure must simultaneously address
the above issues. (Note: infrastructure underutilisation has been studied in detail in the SHR.C
study on rationalisation of health services).
78
RCH 2 Draft PIP Chhattisgarh
Addressing infrastructure utilisation in parallel to infrastructure creation:
The Proposal:
The main objective must be to close the gaps in infrastructure in parallel to closing the gaps in
skilled manpower and equipment through careful block level planning. This in itself has to be done
as part of a participatory process to be closely followed by management and motivational inputs so
as to improve quality of care.
The strategy that we propose to follow is to take about 50 blocks per year so that at the end of the
two years 100 well distributed blocks other than the district hospitals have been addressed and all
gaps in infrastructure, skilled manpower and equipment are closed.
In each block closing infrastructure gaps would require the following order of intervention:
1. Repair and renovation and completion of work of existing CHCs so as to make it capable
of functioning like an FRU i.e. with a functional major OT and with 30 beds. This has been
done in 70 CHCs.
2. Repair and renovation of existing PHCs so as to make them capable of giving a level of
care defined by its ability to conduct 24 hour institutional delivery. This has been done in
30 CHCs.
3. Construct 30-bedded CHCs where there are not already such a CHC in place.
4. Construct a PHC in those sectors which have no PHC currently and where no ISM building
can play this role. This may be done only after the PHC for that sector is sanctioned along
with its implications for manpower.
5. Construct subcentre buildings for all subcentres where such a building is not in place.
In parallel to each of the above steps, a number of steps would be done.
SI.
Infrastructure action
Parallel actions
No.
1
Repair and renovation( if
Purchase of equipment needed,
needed new )buildings for
Basic Emergency obstetric care skills and sick neonate care
CHCs
skills are in place in all 100 blocks and in addition
anaesthetist and CS and blood transfusion capability in
place for 50 blocks .
Motivational inputs and block planning_______________
2
Repair and renovation of
Purchase of equipment, to close gaps.
PHCs.
Ensuring that 3 female and 3 male para-medicals are
available and multiskilled.
Ensuring basic laboratory is functional.________________
Constructing new 30Sanction for CHC and staff.
bedded CHCs__________
The rest is the same as in the first row_________________
4
Constructing new PHCs.in
Sanction of new PHCs with staff for same.
sectors without PHCs
The rest is the same as row 2,_______________________
5
Construct Sub-Centre
Two ANMs or one ANM and one MPW is in place and is
buildings_____________
providing quality care______________________________
6.
Construction of residences
Whenever all the above s are completed and service
delivery has improved - both in quantity and quality.
79
RC1 r 2 Draft PIP Chhattisgarh
Between the two years, we also need to address few key “systems” problems. These are:
a) Ambulance services-at least in 50 blocks - but each serving three blocks for getting sick
neonates and children and for those needing emergency obstetric care to the hospital in
time.
b) Designing a viable referral system.
c) Getting access to blood organized.
d) Adequate laboratory services for that level to provide STI services, safe MTP.
All these are budgeted for independently.
Making the above services happen goes far beyond merely closing the above gaps. It is really a
function of leadership and support and team building. It requires organizational, motivational and
technical inputs. The specific steps needed would include workshops, evolution of quality
indicators, incentives and disincentives packages, and addressing systems issues.
At the end of the two years 100 blocks chosen would have facilities that provide adequate quality
of the following:
a) 24 hour access to Basic Emergency Obstetric Care Services at the sector level.
b) Comprehensive Emergency Obstetric Care services( in at least 50 CHCs and 16 district
hospitals which are designated FRUs- in the other 50 blocks only basic emergency
obstetric care is promised, though even here comprehensive care would be aimed for.
c) Institutional neonatal and sick child care in the 100 CHCs.
d) fixed day every week for tubectomy and vasectomy surgery at the CHC level in the FRUs
e) Utilisation of referral facilities, so as to get adequate points to these.
f) Safe MTP services available in all 100 centres.
g) Improved RTI/STI services in all 24-hour sector level PHCs and adequate secondary level
RTI/STI services with diagnostics in the 66 FRUs.
h) Better quality ANC and post partum and neonatal care in all blocks.
It is only after the performance is assessed annually and found to be favourable that more
investment would be made in the next year. In the second year further infrastructure inputs for
second level priority infrastructure- i.e. residential accommodation for staff at PHCs and CHCs can
be organized matched to already achieved above quality and quantity indicators and to revised
goals.
Budgetary Estimates:
A. PHCs and Subcentres:
For one normative block: Unit cost of one new PHC is taken Rs 18 lakhs and of one Sub-Centre
is taken as Rs 5 lakhs.
Averaging state figures to a notional normative district and block we may state the following: An
average block would have four sectors of which two would not have PHCs sanctioned OR would
be sanctioned but still need fresh buildings and only two would have adequate buildings needing
repair and renovation only. The average block would also have about 20 Sub-Centre level
facilities—of which only about 7 would have buildings.
80
RCH 2 Draft PIP Chhattisgarh
We may cost a new PHC building at Rs 18 lakhs and a new Subcentre Rs 5 lakhs. Thus the cost of
closing PHC and subcentre gaps worked out block wise would be Rs 36 lakhs for PHCs and Rs 65
lakhs for subcentres - or about Rs 95 lakhs per normative block.
The normative block would have 7 subcentres with buildings. At Rs. 10000 per subcentre, we cost
Rs. 0.7 lakh per block for renovation of these subcentres. The normative blocks would have 2
sector PHCs for which we cost repairs @Rs. 1,82,500 per PHC (50,000 for labour room, 1,00,000
for water, 10,000 for wiring, and 22,500 for toilets) or Rs. 3,65,000 per block.
Table : Budget for Subcentres and PHCs in a normative block.
ITEM
Unit Cost
Estimated No in One Block
Total Cost
Old Sub centres Renovation/Repair
10,000
7
70,000
Old PHCs Renovation/Repair
182,500
2
365,000
New Sub centres Building Construction
500,000
13
6,500,000
New PHCs Building Construction
1,800,000
2
3,600,000
Total
10,535,000
We would be sanctioning this 105 lakhs only to those blocks which have drawn up in parallel a
plan to not only close infrastructure- equipment- manpower-skills gaps but actually understood the
need to record increased quality services.
Considering development of 50 blocks every year, 350 subcentres will be renovated, 650 new
subcentres will be constructed., 100 PHs will be renovated and 100 PHCs will be constructed.
For 146 blocks:
Before construction of new facilities the following planning steps would be undertaken:
1. All sectors, which have no PHCs, would be identified. Sanction for new PHCs would be
sought. However since as a sector it already has its complement of paramedical staff the
PHC building can be proceeded with and the sector PHC may be managed by the male and
female health supervisors. Residential accommodation however will wait formal sanction
of the medical officers post and achievement of quality of care..
2. In the above we would identify those sectors, which have an ISM facility, which can be
upgraded or renovated to give a functional PHC that can undertake at least 24-hour
institutional delivery. The existing ISM facility manpower would be integrated with the
sector PHC so as to give minimum staff strength needed at the earliest.
j. Then we would map out the ideal location of the sector PHC in the remaining sectors and
plan to build a new structure there. This would relate to ease of access to population it
serves- geographical distances, public transport availability and market and social access
factors.
4. To do all the above in 50 blocks each year so that in three years the entire state is covered.
One may have to do more or less than 30 as the funds requested are or 50 PHCs every year.
5. The same process would be repeated for the Sub-Centres.
81
RCH 2 Draft PIP Chhattisgarh
B. CHCs:
The cost of renovation of a CHC is Rs.4.00 lakhs as per estimate. This would include Rs300000 for
civil works (Renovation of building, painting, improving of appearance, patient waiting,
accommodation, compound wall etc) and Rs. 1,00,000 for electrical, plumbing work and other
repairs. Already 70 CHCs are renovated. Only 30 more are needed to reach 100 CHCs aimed for.
But in Parallel to renovation, we need to build new CHCs as per norms we have laid down. For this,
we propose 15 CHCs per year The Budget is shown in table below.
Budget Estimate for CHC
iteKK6
_____________________
)ld CHC Renovation/Repair
:• • ' --
Unit Cost(Rs.)
400,000
lew CHC Construction
5,000,000
Total
5400000
C. Closing residential accommodation gaps:
For one block; A sector PHC requires three quarters (IF, 1 H, and one I) with a unit cost of 10
lakhs. In a block we assume 4 sectors - other than the CHC a block would cost Rs 40.00 lakhs.
Staff quarters required at the CHC is 4F, 2G, 2H and 2 I type quarters - a total of 15 quarters that
may be costed at Rs 50 lakhs. Thus together staff quarters in a block reach 90.00 lakhs. We are
planning to close the staff quarters gap only in the second year where first year targets not only in
construction but also in levels of care provided have improved. This would act as an incentive for
completing the first year work and for building up the systems and motivation for achievements in
the future also.
Infrastructure Gaps at a glance: Sub centes
>'
Total No.__________________
Govt Building needing
renovation-1050_____________
Need of New Subcetre
construction_________________
Adequate sub-center building:
Primary Health Centres
Total No.___________________
Govt Building needing renovation
Need of New PHC construction
4692(3818)
1458
2360(3234)
408
Community Health Centres
Total No.
Govt Building needing
renovation
Need of New CHC
construction___________
Adequate building already
130
40
60
30
720(516)
327
189+204
Figures in brackets was the number of sub-centers in existence in 2003-04. This year a further 874 has been
sanctioned. For PHC figures in brackets denote sanctioned PHCs-whereas estimation is for total number of PHCs as
per norms.
82
RCII 2 Draft PIP Chhattisgarh
Section 7.3.1 Infrastructure Development For The Public Health System
Budget For 50 Blocks in a yearITEM___________
Old Sub centres Renovation/Repair
_________ 350/year_________
No of SCs( only those needing
renovation)
Unit Cost
2085-06
2006-07
4007-08
10000
3500000
3675000
3858750
11033750
350
350
350
1050
Old PHCs Renovation/Repair 100/year
182500
18250000
19162500
100
100
325000000
341250000
650
650
650
180000000
189000000
198450000
567450000
100
100
100
300
6000000
6300000
4410000
16993333
15
15
10
40
75000000
78750000
82687500
86821875
420499875
15
15
15
15
60
No of PHCs (needing renovation)
New Sub centres Building
Construction 650/year
500000
No of SCs
New PHCs Building Construction
__________ 100/year__________
No of PHCs
1800000
CHCs Renovation/Repair 15/ Year
400000
No of CHCs
For new CHCs 15/year
5000000
No of CHCs
For Residential Accommodation in 50
9000000
blocks
TOTAL
2008-09
2009-010
20120625 1 5683050
Total cost
63216175
27
327
358312500 376228125 385315481
1786106106
100
650
634
3234
4500,00,000 472500000 496125000
607750000 f1067347500 667839375 468733050 385315481 3196985406
Appox 30 CHCs and 93 PHCs and 408 sub-centers are estimated as not needing renovation
Budget for Subcentres and PHCs in a normative block
ITEM
OB
Un
-S-
Estimated No in One Block
Total Cost'
Old Sub centres Renovation/Repair
10000
7
70000
Old PHCs Renovation/Repair
182500
2
365000
New Sub centres Building Construction
500000
13
6500000
New PHCs Building Construction
1800000
2
3600000
4 F; 2 G; 2 H, 2 I type @ a CHC( Rs 50 Ikhs
plus for 4 PHCs ( @ Rs 40 lakh)
9000000
Residences for one block
Total
195,35,000
83
RCH 2 Draft PIP Chhattisgarh
7.3.2. Training:
A.
Introduction and Goals:
The government of Chhattisgarh is in the process of adopting a training policy so as to ensure that
the public health system has the necessary knowledge and skills for its effective functioning. The
goal of the training policy is to ensure that all the health care facilities that deliver RCH services Sub-Centre, PHC, CHC, district hospital, and ISM dispensary and hospital- have the requisite
skills needed for full capacity utilization and effectiveness.
In this section, we are presenting training needs in medical technical domains needed for different
category of staff.
We are not discussing management and administration training - which is being dealt with under
component 4. We are also not discussing pre-service trainings, training of community health
workers, advocacy with stakeholders, and capability building of new players like Panchavati Raj
institutions.
B. Objectives Of The Training Action Plan:
1. Build up the minimum training infrastructure that shall be needed to have adequate skills built
up to achieve the training goals laid down in the training policy.
2. Chart out a paramedical training programme to provide multiskilled staff for PHCs, CHCs and
effectiveness of RCH services.
3. Draw up a training plan for medical officers as part of a CME programme.
4. Design a multiskilling programme for 100 CHCs to achieve the necessary skill sets needed for
running functional FRUs.
7.3.2.1
Plan on Training Infrastructure:
A. State Institute Of Health and Family Welfare
Present Status: Building under construction - to be completed by November 2005.
Proposed Functions : (Accommodation for 100 trainees at a time).
1. Training of Trainers for all paramedical; Training of trainers for multiskilling as well. (Esp.
laboratory)
2. Coordinating Continuing Medical Education Programme for medical officers.
3. Material development for Training
4. Operational Research
5. Assistance in Policy development.
6. Administrative training/ training follow-up for medical officers and Senior paramedical
7. Training Evaluation of all training programmes
8. Guiding and monitoring implementation of the training policy.
9. Supervision of the functioning of the regional training centres and DTCs
Staff Sanctioned: As delineated in Component 8.3, under programme management issues.
Budget: One crore already received for civil works. Further budget estimated for furniture and
fixtures and institutional development has been elaborated under component 8.3.
84
RCH 2 Draft PI P Chhattisgarh
B. Regional Training Centres-3:(Jagadalpur, Bilaspur,Anibikapur)
Present Status:
Currently one at Bilaspur. Two others at Jagdalpur and Sarguja proposed. The major gap this
addresses is the lack of any training facility in the state for LHVs and HAs. By current norms, a
six-months training is required. Also we need region-specific IEC material for the 3 main cultural
zones and these centres would be suited for this purpose.
Proposed functions: Accommodation for 60.
1. Training and planning and material development on IEC and cultural /communication aspects
and locale specific IEC training and programme design - specific to tribal culture, tribal
languages and tribal socio-economic context. Also training workers to be able to take forward
their programmes in such a milieu.
2. 1 raining ol trainers for community level workers.
3. Six month pre-promotion training for female and male supervisors
Staff Sanctioned : One head, three subject specialists, six trainers and supporting staff.
The detailed budget and proposals are given as part of the tribal health section:
C. District Training Centre (accommodation for 30)
Present Status: Currently 5 available, 11 more needed.
Proposed Functions:
1. Training of male and female MPWs and all other class III paramedical support staff.
2. Tele-training reception venue for CME/training for medical officers.
3. Training of ISMs staff for public health goals.
Staff Sanctioned : One district officer in charge, three trainers and supporting staff.
85
RCH 2 Draft PIP Chhattisgarh
SI
A
Budget: Accomodation for 30
7.3.2.I. Budget For Infrastructure : District Training Centres
Head
2005-06 | 2006-07
Descriptions
2007-08
1
Building,
Furniture &
Fixtures
2
Equipments
A
B
2008-09
2009-010
Total cost
2007-08
2008-09
2009-010
Total cost
Non Recurring Exp.
Refurbish existing
5 centres Rs. 1
500000
_____ lakhs_____
For establishing 11
more centres: Rs.
25 lakhs each.
27500000
(5* l,00,000)+(l 1 *
25,00,000)
Computers-1
Printers-1
3200000
Projectors
Sound Systems
6 Accessories
Rs. 2,00,000 per
centre* 16 centres
Maintainence of
Equipments
Total
31200000
Recurring Exp.
2005-06
2006-07
Salaries
1 Training Officer
On secondment
0
1
3 Trainers (MSw
qualified
proffessionals)
3*Rs 5000*12
months* 16 DTCs
1440000
3024000
3175200
3333960
10973160
2
1 Data Entry
Operator/Statistica
1 assistant cum
accounting clerk
l*Rs4000*12
months* 16 DTCs
384000
806400
846720
889056
2926176
1 Residential staff
l*Rs3000*12
months* 16 DTCs
288000
604800
635040
666792
2194632
Untied funds for
Preparatory
Workshops and
material
Lumpsum 1 lakhs
* 16 RTCs
800000
1680000
1764000
1852200
6096200
Office
Expenditures and
Contingencies
5,000*12
months* 16 DTCs
480000
1008000
1058400
1111320
3392000
7123200
7479360
7853328
4
Total (A+B)
31200000
|
3657720
57047888
(Note: In 2005 06 and first 6 mnths of 2006-07 since building is under construction no running
costs are shown. From second half of 2006-07, running costs- salaries, aetvities, travel are
budgetted for).
86 .
RCH 2 Draft PIP Chhattisgarh
73.2.2 Plan on Training Staff:
For full utilisation of this infrastructure investment requires a number of staff to be sanctioned. All
full time trainers shown above are for the paramedical and would be from nurse-tutors or from
other senior paramedical who have been trained to play the role of trainers.
Subject experts would be from social sciences, social work or any health science of any
communication background with experience in conducting and organizing training for health
programmes
For the SIHFW to start functioning it is suggested that a health management or HR development
consultancy be given so that the staff recruited for it are trained and the systems that are needed are
developed for the efficient functioning of the SIHFW as well as putting in place the entire systems
advocated by the training policy.
Proposed Staff Training Activities Under Rch-2
A.
Training of Paramedics
Training Needs:
• There are about 8,000 multipurpose workers -at the block, sector and Sub-Centre level.
They require regular training of at least 18 days once every two years. This is for refreshing
their knowledge and upgrading their skills and for multi-skilling them to be able to perform
their roles as both a supporting paramedical in the 24 hour PHC and as a MPW in a
subcentre.
• There are about 1500 supervisors who need to be trained and multi-skilled to act as
effective supervisors and as multi-skilled assistants in the PHC.
• Training and multi-skilling of pharamacists, compounders, uni-purpose leprosy workers,
dressers etc so that all of them can play an equal role as paramedical support staff in the
PHC is an important direction.
Content of training:
The syllabus for training paramedical (MPWs included) shall consist of:
i.
Knowledge of RCH areas shall include all essential obstetric skills for women Para
medicals (This is already done, needs only some strengthening).
ii.
Knowledge of National Programmes.
iii.
Ability to do basic laboratory work where relevant (especially male workers and
underutilised staff categories at PHC).
iv.
Ability to assist doctor to dispense medicines.
v.
First contact care and first aid/dressing skills based on the standard treatment guidelines
and drug formulary for paramedical
vi.
Interpersonal and community mobilisation skills along with better understanding of cultural
gaps in a multicultural and ethnically diverse society. This is particularly needed for
persons working in tribal areas. Also on mainstreaming gender and equity issues.
87
RCTT 2 Draft PIP Chhattisgarh
Approach:
Each district training centre shall make and maintain a record of each paramedical and support
employee and what trainings they have attended. It shall also have a list of the skills available in
each facility. Every district training centre will aim to ensure that over a five year period every
facility in its charge as the necessary skills needed at that level and that every employee in the
district has the minimum specified skill sets needed as part of that facility- so that the facility is
fully functional.
Centrally sponsored training programmes which fit into the above skill set requirement can be
reduced from these 18 days. Or else they have to be treated as additionality over and above these
18 days.
Trainers:
The trainers will be of three types. One are the full time trainers working in the facility-largely
drawn from senior public health nurses or nurse tutors or LHVs so are effective as trainers. The
second are from the same group who are trained as trainers but called in only for specific sessions
- otherwise attending to their main work. A third category may be NGO trainers - who must be
persons active in NGO work of their own - who are invited for specific sessions where they are
effective as trainers.
largely done at the SIHFW.
Training of trainers shr. 11
Budget:
SI
Head
1
Training of
Trainers
2
3
4
5
6
A
Descriptions
80 Trainers
@Rs. 1000 per
day* 15 days
Day allowance/
5000 trainees
Food and
@125Rs a
logistics for
day* 14 days
participants
Training Fees
80 trainers* 10
and Travel for
days *200
trainers
Travel for
participants(by
mother
departments)
Stationary and
5000*200 Rs
Training
per trainee
Material
Preparatory
activities,
correspondence,
Documentation,
Report
125
batches@3120
Preparation,
Monitoring,
Rs per batch
contingencies
and other
training related
expenditures
Grand Total
2005-06
2006-07
2007-08
2008-09
2009-010
Total cost
1,200,000
1,260,000
1,323,000
1,389,150
1,458,608
6,630,758
8,750,000
9,187,500
9,646,875
10,129,219
10,635,680
48,349,273
160,000
168,000
176,400
185,220
194,481
884,101
1,000,000
1,050,000
1,102,500
1,157,625
1.215,506
5,525,631
I
390,000
409,500
429,975
451.474
474,047
2,154,996 I
115,00,000
12,075,000
12,678,750
13,312,688 ■ 13,978,322
63,544,759
88
RCH 2 Draft PIP Chhattisgarh
B. Training Needs and Approach for Medical Officers and Specialists:
1. Continuing Medical Education scheme for medical officcrs: This shall be initiated to
upgrade the knowledge and skills of medical doctors. The CME shall be credit based and annual.
Every year a medical officer must gain at least 1000 points. Credit points can be gained in one of
five ways:
(a)
(b)
(c)
(d)
(e)
Completing reading of a web-based topic/CME publication and then sending a feed back form. This
could cover core topics like the management of immunisation, cold chain etc.
Attending CME programmes, organised by professional bodies.
Completing a professional periodical based feed back form that is filled in after studying the concerned
section or sections - a sort of questionnaire- but there is no pass and fail- only a proof of having read it.
Attending training workshops
Training postings in special clinics (private or public sector) for acquiring skills like specific surgen. or
doing ultrasound etc.
Of the above 300 points are from core areas and are compulsory and 700 are optional. The core area topics and
publications are specified by the department and must be covered by all. The optional areas are what
the individual medical officer chooses to benefit by.
The SIHFW will lay down the credit points for various programmes (example 50 points for a CME
attended. 200 points for study of a department CME publication etc) and th;, .an be publicised by both the
department body and the professional body conducting the CME. The state unit of any nationally
recognised professional body like IMA. API, FOGSI, ASI. and IAP are all automatically recognised bodies
for this purpose. Others would need to be accredited.
The SIHFW in collaboration with the training cell in the medical colleges would bring out the CME
publications for the core credit points and also a CME periodical. The SIHFW would administer the CME
programme. Acquiring necessary 1000 CME points per year would be essential for promotion.
Budget
| Descriptions | 2005-06 | 2006-07 | 2007-08 | 2008-09 | 2009-010 | Total cost |
Expenditure For CME For Medical Officers
Preparation and production Rs 500 per
of CME material
doctor * 1000
525,000
551,250
578,813
607,753 2.762,816 ;
doctors______
500,000
Postage per doctor per year 6 times/year*
Rs 20 * 1000
doctors *2
1.326,152
240,000
252,000
291,722
years________
264,600
277,830
Course
lump sum,
coordinators/evaluators
negotiated
6.630,758
honorarium /salary
1,200,000 1.260,000 1,323,000 1,389,150
1,458,608
based on task
Full time support staff
Rs 20,000 * 12
months* 2
2.652,303
529,200
480,000
504,000
555.660
583,443
years________
CME contact programmes
Rs 250 per
over two years
person * 5
programmes
/year * 2years*
1000 persons
2,500,000 2,625,000 2,756,250 2,894,063
3,038,766 13.814,078
Preparatory activities,
Lump sum
correspondence,
Documentation, Report
Preparation, Monitoring,
contingencies and other
80,000
84,000
442,051
88,200
97,241
expenditures__________
92,610 __________
5788125 | 6077531.25 27.628,156
50,00,000 5,250,000
Grand Total
5512500
SI Head_________ _____
1
2
3
4
5
A
89
RC1 r 2 Draft PH5 Chhattisgarh
2. Skill Sets for CHCs and Multi-Skill Training For Specialists:
Functional CHCs require much higher degrees of skills than are currently available, especially as
specialists are not available in most CHCs and even in many district hospitals.
Multiskilling general medical officers for specialist skills in specific priority areas become
essential. Multiskilling has begun with short-term courses in anaesthesia and emergency obstetric
care- but this would be extended to many more skills till every CTIC and district hospital has the
minimum skill sets required as per the declared norms.
A related issue is that with some further inputs specialists like general physicians and general
surgeons can handle more complex but essential procedures. A general surgeon being trained in
laproscopy is one such example. This training would be a function of the training centres proposed
in the two medical colleges. Other tertiary care centres could be accredited for this purpose.
At present, 32 CHCs are covered under this where a 6 months course on Obstetrics/Gynaecology
and a 6 months course on anaesthesia completed. This proposal intends to cover further 70 under
the same. An extra 30 would be desirable to cover dropouts, transfers etc. Other than this, two new
courses are introduced in all these 100 blocks under this proposal- a 2 months course on sick
neonatal/paediatric care. Also planned to train another 200 doctors for a 1 month course on
conventional tubectomy, safe abortions and RTIs is also proposed.
Doctors are to be given travel costs and a Daily allowance, and allowance. In a year we can do a
maximum of three batches of 5 persons each for all these courses in an institution. These courses
would be run in 4 such institutions- Medical Colleges in Raipur and Bilaspur, BSP Hospital in
Bhilai and Dhamtari Christian Hospital in Dhamtari. 5 faculties of concerned Medical College/ the
designated centre will be given an honorarium. The cost of strengthening the seminar room and
guest arrangements and contingency expenditures also would be given.
Another round of training for adolescent counselling and for nurses and paramedicals on
laboratory works. In the first year, training on adolescents would be taken up and training on
laboratory skills in the next year.
90
RCH 2 Draft PIP Chhattisgarh
Budget for training for Skill sets for CHCs (and Multiskill Training for Specialists)
Skill Sets for CHCs and Multi-Skill Training For Specialists:
______
SI-|W 1 Bffead
| Descriptions | 2005-06
2006-07 | 2007-08
1
Day Allowance for Doctors
For Course on
180 Days® 150
Emergency OB
Rs * 15 doctors
810000
850500
893025
Care
*2
180 Days® 150
For Course on
Rs * 15
810000
850500
893025
Anaesthsia
doctors*2
For Course on
60 Days® 150
Sick
Rs *15
270000
283500
297675
Neonatal/child
doctors*2
care___________
For Course on
mini Laproscopy/
30 Days® 150
conv.
Rs *15
135000
141750
148838
I tubectomy/safe
doctors*4
I abortions/RTl
| Travel and Book
Total 150
Allowance for
2
doctors® 2000
300000
315000
330750
participant doctors
Rs
for all courses
Honorarium for Teaching Faculties
6 months@2000
For Course on
Rs *5
1
Emergency OB
360000
126000
132300
faculties/institut
Care
ion* 3 inst* 2
6 months@2000
For Course on
Rs *5
2
360000
126000
132300
Anaesthsia
faculties*3
inst*2
For Course on
2 months@2000
Sick
3
Rs *5
120000
42000
44100
Neonatal/child
faculties*3* 2
care___________
For Course on
1 months® 1000
mini Laproscopy/
Rs *5
4
conv. tubectomy/
60000
21000
22050
faculties*3 inst*
on safe
4
abortion/RTI
Training Facilities
5
Lump sum
800000
840000
882000
esp. dummies
Net
4025000
3596250
3776063
1
Contingencies &
related
expenditures
@10%
Lump Sum
Total
2008-09
2009-010
Total cost
937676
984560
4475761
937676
984560
4475761
312559
328187
1491920
156279
164093
745960
347288
364652
1657689
138915
145861
663076
138915
145861
663076
46305
48620
221025
23153
24310
110513
926100
972405
4420505
3964866
4163109
18925287
402500
359625
377606
396487
416311
1892529
4427500
4648875
4881319
5125385
5381654
24458733 ;
91
R(. H ' Draft PIP Chhattisgarh
B. For Training of Nurses and paramedics on adolescence health/STIs.
SI
Head
1
Training of Trainers
2
3
4
5
Day allowance/ Food
and logistics for
participants
Training Fees and
Travel for trainers
Stationary and
Training Material
Contingencies &
related expenditures
(10%)
2005-06
2006-07
Total cost
80 Trainers
@Rs.l000 per day*
8 days
640000
672000
1312000
3000 trainees @125
Rs a day* 6 days
2250000
2362500
4612500
320000
336000
656000
150000
157500
307500
150000
157500
307500
3510000
3685500
7195500 w
Descriptions^1- M
80 trainers* 20 days
*200
3000*50 Rs per
trainee
75 batches® 2000
Rs per batch
Grand Total|
„ ,
After two years future programmes will conducted with budgets provided for regular retraining of
paramedicals. This is only for the initial training to introduce this component into the system.
92
RCH2Draft PTP Chhattisgarh
D.
Training for ISM Staff;
As part of the effort for mainstreaming ISM facilities and staff to help in reaching public health
goals in RCH area a 21 day training programme would be prepared and all the staff would be
trained in it.
The training would be for Ayurvedic officers and for paramedical staff and appropriate syllabus
would be developed for the same.
The training content would include immunisation, antenatal care, basic obstetrics care, integrated
management of childhood illness and combining systems for child malnutrition and micronutrient
deficiency management.
Preparation would be done at the directorate of ISMs in coordination with the SIHFW and
implementation would be by the DTC in cooperation with the district ISM officer.
Tudget
Head
I SI
I Material
Production
2 Training of
Trainers
I
2a
Training of
Trainers
3
Honorarium
for state
training
faculties
Expenses for
training all
categories of
staff______
.Expenses for
training all
categories of
staff______
Day
allowance
Honorarium
For Trainers
Day
allowance
Honorarium
For Trainers
Other
Training &
related exp.
4
4a
5
5a
6
Descriptions
11 OOpersons a:
Rs. 300
80 Trainers*
Rs. 1000
(food / acc) per
day* 25 days
80
Trainers* 1000
Rs. per day* 5
days_______
20 faculties
@5000 Rs.
2005-06
2006-07
2007-08
2008-09
i 2009-010
Total cost
330000
345500
676500 '
20,00,000
2100000 |
4100000
100000
105000
4500000
4500000
400000
420000
441000
1261000
110250
115763
121551
552563
30 Days@
Rs300 *500
trainees
9000000
10 Days© Rs
300 *500
doctors/staff
1500000
1500000
1500000
4500000
80 trainers
*250 Rs* 15
days/trainer
300000
300000
600000 i
80 trainers
*250 Rs* 10
days/trainer
200000
200000
200000
600000
297675
2507925
312559
2548321
328187
2590737
1491920 '
22781984 1
Lump Sum
Total
270000
7500000
283500
7635000
93
RCI1 2 Draft PIP Chhattisgarh
E.
Training for Administration, Management and Leadership:
The Plan on this has been elaborated with budget in component 7.
All programme officers, district officers and block medical officers need a formal induction in
public health management, some aspects of hospital administration and in epidemiology.
The SIHFW/Directorate of Health Services shall enter into an MOU with a health management
training institution for a three month course of distance education with some contact classes that
shall be made available to all medical officers with administrative responsibility. All block medical
officers and programme officers must take this course within the next three years. After three years
appointment to all administrative posts for medical officers are open only to those who have served
three years as block medical officers and they must take this course before being eligible for
promotion.
A more rigorous and through course on public health management of two year duration would also
be encouraged and for this purpose the state would sponsor candidates to heath management
institutes with which it would have an understanding.
94
■
RCH 2 Draft^IP Chhattisgarh
7.3.3.
Ensuring Quality of Care in FRUs and 24 hour PHCs
Constraint being addressed:
Provision of infrastructure, plus manpower plus training plus equipment does not add up to
increased quantity or quality of services. Between central and state government, over the RCH-I
and RCH-II programmes there has been an investment of about Rs 10 crores into infrastructure of
these 100 CHCs. For this investment to be converted into actual improvements in services, we
need to invest in some management and motivational processes and resolve along the way a
number of systems issues that arise.
Experience in RCH-I, especially in the 32 blocks under EAG programme shows that most of the
employees in these blocks were not even aware that their blocks were part of such a programme.
Developing ownership and quality standards was an even more distant reality. Elsewhere in this
proposal we have proposed for closing infrastructure and training gaps in these 100 CHCs. In this
section we are putting forth the proposal for closing minor equipment gaps, and for building up the
necessary management and motivational inputs needed to achieve desired quality of care levels.
Objectives:
In this situation, we are providing fund for:
a) Improved quality of care in 100 CHCs and all 24 hour PHCs and subcentres in these
blocks...
b) Ensure that all 100 CHCs and PHCs in these blocks are functioning as 24 hour PHCs.
c) Ensure that the linkages needed to ambulance services, referral funds in the panchayats,
Mitanin programme and private sector partners that are needed to reach the RCH-II goals
are built up.
d) Ensure that all employees in the block are part of the process of building up quality and not
only the top few- for it cannot be done thus.
e) Ensure that the services provide for equitable access and are woman friendly and
adolescent friendly.
Understanding is that when we have sunk Rs 10 crore in closing ‘hard’ gaps in 70 blocks, a further
Rs 50 lakhs in management & motivational process is well worth it.
Moreover the entire thrust of the RCH-II proposal is about ensuring quality referral services in
these 100 blocks. The total investment that relates to it under different heads is over a 100 crores.
We are also committed to performance based funding and outcome based programming. Without
investing in such a management and support process we would neither get the outcomes nor even
be able to know whether we are moving towards it - making it impossible to actually have
performance based funding. Earlier when funds for strengthening FRUs were sanctioned this
amount was cut out resulting in weak support. We are learning from this now.
Key Operational Elements:
a) Design quality of care standards and quality of care indicators as applicable to PHC and
CHC and subcentre. This includes indicators for gender sensitivity and for equity in access.
b) Participatory micro planning to ensure that all employees in these blocks understand the
quality standards and identify constraints in closing the gaps: including gaps in minor
equipment.
c) Initiate and support block level group processes that will address motivational and
attitudinal issues.
95
I
RCH 2 Draft PIP Chhattisgarh
d) Close gaps in infrastructure, manpower and skills and equipment along with measured
improvements in quality.
e) Address all local level “systems” problems- like linkages to a functional ambulance
service, designing a viable referral system, getting access to blood organized, ensuring that
the referral fund with the panchayat is fully utilised. It also requires motivational and
management inputs.
f) Along with this we would have to closely monitor and support the blocks to achieve
volumes and quality standards- during and after the infrastructure is built and equipment is
bought and manpower is trained
g) Provide support and trouble shooting to the team.
a) At the end of the two years these 100 facilities should provide adequate quality of the
following: Access to Basic and comprehensive Emergency Obstetric Care Services and to
Comprehensive Emergency Obstetric Care services: Better quality ANC and post partum
and neonatal care, institutional neonatal and sick child care, Reduce unsafe abortions;
Improved RTI/STI services with utilisation of referral system and ambulance and
laboratory services needed to support this set of interventions.
The key to achieving all this is would be:
a) Hiring in a management group/ resource team to conduct the block level workshops and
monitor the programme. This group must be in place before the funds for the blocks is in
flow:
b) The management group would hire ten field coordinators and train them so that they can
each monitor and support 10 blocks.
c) This group would not replace the district’s authority on the blocks- but it would supplement
it and give its feedback to the district and state RCH societies so that they would act on it.
For this to be useful - it is essential that this team and this group not be internally selected
and paid but have an element of externality so that they could be objective and where
necessary even critical of what is being done. We have found such an arrangement
extremely useful to monitor and support the Mitanin programme which is also executed by
the RCH societies but with SHRC providing the support.
Budget Estimate:
A.Block Level Micro planning- Requires one meeting with field visits in each block at the
outset of the programme.
(Before any expenditure on infrastructure or training is made.)
Budget for planning initiatives
Item
Unit Nos.of _
2005- 200&Q7
Cost Bioci® 06
Microplan 2000 100
200000 I
2007-08
2008-09
2009-010 Total
200000
96
RCH 2 Draft PIP Chhattisgarh
B. Dissemination of quality/standard & motivational meeting to help employee attain desired level
and block level review.
Budget
Unit Total cost 2005-06
2006-07
2007-08
2008-09
2009-010 Total
• St
Cost
for
100
o >>
J.
a
blocks
w
o -a
|g|
1
9
J®
C5
.e
<D
2
100
1
100
2.000,000
o E
s
c.
2100000
2000000
2205000
2315250
2431013
11051263
Management team to conduct workshops and help set & monitor quality indicator.
10 Field coordinators would be appointed for 100 blocks. One Programme coordinator, a person
with experience or aptitude in public health management would be appointed for coordinating this.
Yearly Budget for management for state.
Item
Programme
coordinator
Field
coordinator
Travel &
Total
D.
Nos;
Unit
cost/Month
1
20,000
240,000
252,000
264,600
277,830 |
291,722
1,086,152
10
5,000
600,000
630,000
661,500
694,575
729,304
2,715,379
50,000
support_________
| 7T~
600,000
630,000
661,500
694,575
729,304
2,715,379
1,587,600
1,666,980
1,750,329
7956909
2005-06
•'W
W
2006^07
2007-08
2008-09
2009-010
Total
Equipment Gaps in 70 blocks.
We note that this money would not go for infrastructure or for
for training.
training. However
However it
it may
may be
be
used beside equipment on minor supplies gaps and block level needs e^g. referral forms that
are found essential after a micro planning exercise or review meetins. Since these are
matched against constantly improving quality and quantity of services the wastage
elements should be minimal.
Estimated Budget for equipment/ critical supplies.
Item
Nos.of
blocks.
Equipment
35
Unit
2005-06
2006-07
2007-08
2008-09
2009-010
Total
70,00.00 i 70.00,000
73,50.000
7717500
8103375
8508544
386,79,419
Cost
97
RCTI 2 Draft PIP Chhattisgarh
E. Performance Incentive ( modified Night Duty Allowance)
Item
Nos.of
blocks.
Unit
Cost
2005-06
2006-07
2007-08
2008-09
2009-010
Total
Performance
incentive
(Night Duty
Allownce)
100
1,50,000
1,50,00,000
15,750,000
16,537,500
17,364,375
18,232,594
8,28,84,469
2009-010
Total
Total Budget in Operationalizing & quality care of FRUs. /Year
Ensuring Quality of Care in FRUs and 24 hour PHCs
Item________
Block Level
Microplanning
2005-06
Motivational Meeting
2000000
2100000
2205000
2315250
2431013
11051263
Field level Programme
Management
1440000
1512000
1587600
1666980
1750329
7956909
Filling of Equipment
Gap (35 block /year)
7000000
7350000
7717500
8103375
8508544
38679419
Performance Incentive
15000000
15750000
16537500
17364375
18232594
82884469
Total
25640000
26712000
28047600
29449980
30922479
1405,72,059
Contingencies, fees to
firm etc( 10%)
2564000
2671200
2804760
2944998
3092248
14057206
Grand Total
28204000
29383200
30852360
32394978
34014727
1548,49,265
2006-07 ,
.2007-08
2008-09
200000
200000
98
r
RCH 2 Draft PIP Chhattisgarh
7.3.4. Strengthening Routine Subcentre Level Services:
Constraints being addressed:
Much of public health moves around the ANMs and her functioning. Yet there are many issues
that need to be addressed for her to be effective. Issues related to infrastructure, training and
quality of care processes have been discussed in previous sections. Issues related to community
level processes and private sector inputs will be discussed in the next few sections. In this section
we only flag four constraints the overcoming of which are critical to better functioning - just at the
subcentre level.
These constraints are:
a) Continuing out- of- pocket expenditure on stationary & travel with lack of adequate
arrangements for facilitating mobility.
b) Continuing gaps in cold chain maintenance and supply of disposables needed to improve
quality in immunisation.
c) Lack of supportive supervision.
of adequate
basic drugs
d) Lack
1
.
- & supplies needed to respond better to the peoples felt health
needs.
e) Lack of objective data to identify gaps and reward achievements. (All data that the system
uses is generated at this level by these very functionaries. So identifying their failures
through the same data is obviously impossible)
____ _________________ .
’
•
Objectives of the programme:
a) Reduce out of pocket expenditure and facilitate mobility.
b) Improve quality of supervision and make it supportive.
c) Bringing in better systems of internal and external data verification.
d) Improve cold chain functioning.
AAxx^iOve the quantity of drugs supplied to her.
Proposed strategies/activities:
a) Print all the stationary needed for her and provide. A number of registers is not
printed/supplied as date, but these supply needs are maintained by her. This also improves
quality of records, which are weak now.
b) Give an option of availing for a bank loan for buying a motorised two- wheeler with a
down payment of Rs 2000 from the government but subsequent payments made by her or
getting a cycle at about same costs.
c) Conduct a special programme for medical officers and supervisors on supportive
supervision - so that they play a more active role in helping ANMs and MPWs in
overcoming field level problems and addressing gaps. This will also teach supervisions on
how to undertake cluster sampling in their area so as to verify data. I he cluster sampling
database that they need- cumulative population table- would also be prepared for each level
of supervision. The supervisors would be required to submit a cluster sample verification
report once every six months. The budgetary provision for this is against actually
conducting their training and getting two sample surveys done per supervisor every year.
d) Contract in a firm for providing annual evaluation by sample survey of key RCH indicator
for each district.
e) Expand the ANM drug kit to include 25 drugs and improve its regularity of supply. Let it
match the Hindi Standard Treatment Guidelines that we have already prepared. (To ensure
regularity of supply the funds may be given to the state government tor drug procurement99
RCH 2 Draft PIP Chhattisgarh
if by then adequate procurement and distribution systems are in place. If this does not meet
with the quality benchmarks already established for drug procurement and distribution then
the drugs may be supplied as kits as is currently done) This drug list prepared by the state
essential drug committee is shown in table below.
f) Ensure that a certain sum of money is sanctioned under family welfare every year for cold
chain upkeep (refrigerator mechanic mobility and repair costs and some replacement costs)
and hard ware gaps. Currently two walks in coolers are needed at state level and at block
level voltage stabilisers are needed.
Budgetary estimates:
Budget for Strengthening Routine Subcentre Level Services:
Item
Stationary
Mobility
Unit
cost
300
2000
Total
2,400,000
10,000,000
2007-08
_______
2,646,000
2,520,000
10,500,000 11,025,000
2,778,300
11,576,250
2,917,215
13,261,515
12,155,063 ' 55,256,313
Quantities
2005-06
8000
5000
2006-07
2008-09
2009-010
Supervision
quality and
sample
surveys
2000
5000
10,000,000
10,500,000
11,025,000
11,576,250
12,155,063
55,256,313
16dt
annual
external
evaluation
100000
16 dists.
1,600,000
1,680,000
1,764,000
1,852,200
1,944,810
8,841,010
25,200,000
26,460,000
27,783,000
29,172,150
132,615,150
Expanded
ANM drug
kit
Rs
12000
5000
Cold Chain
upkeep
l.Olakhs
16 dists.
Total costs
(Excluding 6 crores
that could be direct
central govt costs)
6crores
(To be
supplied
by central
govt under
FW)
161akhs
(Plus
major
equipment
costs to be
borne by
central
govt.)
240,00,000
Note: Cost of equipment supplied by Gol is not included in the budget.( a walk in freezer at Rs
50 Ik is the main requirement- and two walk in coolers are also deisrable).
100
i<Cll 2 Draft PIP Chhattisgarh
Chhattisgarh Essential Drug List: The Revised ANM drug kit
(To be used by ANM and male MPW)
The state government has adopted an essential drug list for ANMs and MPWs. A specific
paramedical training manual based on just these drugs is available in Hindi and has already been
widely used in the state. It expands the ANMs role to that of the nurse practitioner, which the
Chhattisgarh paramedical act specifically empowers. The manual and this list has been specifically
prepared and approved by the government with the understanding that in distant villages and even
in many sectors where doctors both in public and private are hard to come by the ANM and the
MPW is the only source for rational, ethical modern drugs and treatment. Unfortunately though
most aspects of these reforms have been implemented this ANM drug kit has not been revised. The
quantities received currently are also grossly inadequate.)
1. Albendazole
2. Aluminium Hydroxide
3. Amoxycillin/co-tnmoxazole
4. Bisacodyl
5. Calamine Lotion
6. Calcium Carbonate
7. Chlorhexidine
8. Chloroquine
9. Chlorpheniramine
10. Chloramphenicol applicaps
11. Dicyclomine
12. Domperidone
13. Ferrous Sulfate+Folic Acid
14. Furazolidone
15. Gamma BHC lotion
16. Gentian Violet 1% solution or
other skin antimicrobial.
17. Methylergometrine tablets. .
18. Methylergometrine—Injection
19. Metronidazole
20. Miconazole 1% cream.
21. Oral Rehydration Salts
22. Paracetamol
23. Primaquine
24. Sodium Bicarbonate
25. Vitamin A liquid.
26. Vitamin B complex
Doctor Initiated Drugs (DID)
1. Anti Leprosy Drugs
2. Anti tubercular Drugs
3. Folic Acid for Sickle Cell Disease
4. Oral Contraceptives
5. Salbutamol for bronchial Asthma
6. Tetracycline eye ointment for
trachoma
DID- these drugs are under prescription by the PHC medical officer and the ANM only
stocks these so that the patient need not go to the PHC every’ week but can get a supply for
the duration of the prescribed treatment. ( they can be reflected as PHC stocks and need not
come as part of the ANM drug kit).
101
VaJM- 10 V
09136
RCH 2 Draft PIP ( hhattisgarh
7.3.5. Public Private Partnerships:
7.3.5.I. Public Private Partnerships for Essential & Emergency Obstetric Care:
Constraint being addressed:
Chhattisgarh does not have a very good infrastructure of secondary level hospitals even at
the block level. Most blocks have do not have facilities for emergency obstetric care. There
are no operations rooms, and very few trained surgeons and even less anaesthetists, and no
facility for blood transfusion in most blocks. Many newly created district hospitals also lack
these facilities. Of the 16 district hospitals only 9 undertake regular caesarean sections and of
the 146 block hospitals only some 54 including the 7 district hospitals where section is not
regularly undertaken have been designated as FRUs (first referral units). Of the 54 FRUs less
than 10 have developed adequate emergency obstetric care capability. The RCH-II proposal
plans to increase the number of FRUs to 116 within the government sector of which at least
66 will be functional at the C-section level. Even then there would be a large supply side gap
that needs to be closed.
Similarly we have seen in the section on family planning that about 50% of the current
demand for FP sterilization services can only be met by a much-expanded public sector
provisioning of such services.
This is true of institutional delivery also. Of 2500 deliveries in a normative block of one lakh
population a meaningful estimate will still be able to provide for only 1500 institutional
deliveries. The current level of institutional delivery attained in Chhattisgarh remains a very
low 13.8%.
The only way the state can reach its stated goals is if the private sector can be won over to
sub serve these goals too in a manner that the poor are able to afford and access these
services. However even is we do manage to recruit the private sector fully there are many
areas where private sector penetration is too low to help reach these goals. Any policy
approach to public private partnerships must therefore have three objectives:
a) it should supplement, not replace the existing and maximally increased public sector
provisioning of RCH services.
b) Existing private sector providers must be brought in to provide these services with
adequate quality and affordability.
c) there must be an effort to extend outreach of the private sector to those areas where
currently it is not operational ensuring that it complements - not substitutes private
sector expansion.
The debate between which should be prioritised - public sector or private sector provisioning
is to be reviewed in the context where even with maximal expansion of both we may still fall
short of our targets. As demand for services expands with the Mitanin programme urgent
measures are needed for supply of services to catch up with it. . Supply will not rise to meet
demand if left to the mediation of the market place alone. Health care for the poor especially
in geographically dispersed population is a recognized area of market failures and the state
would need to intervene to facilitate the growth of the supply of these essential services.
When we address private sector expansion we also need to flag three important corollaries:
102
*
R( H 2 Draft PIP Chhattisgarh
a) Such expansion esp. if it is done with state support must carry with it the means of
regulation.
b) Considerable flexibility and innovation in programme management and financing
would be needed to fix costs and prices and adjust theih periodically so that the needs
of equity and access are addressed and they system as a whole is sustained.
c) There must be a net increase in service delivery - not merely a shift from one sector
to the other.
The PPP proposals stated below builds in all these elements. Not all of these are detailed
here - but the SHRC has prepared a detailed set of papers and MOU drafts on the basis of
which this is done. We wish to acknowledge here that we have drawn considerably on the
Janini experience in doing so, without being bound by it.
Objectives of Programme:
• To enter into partnership arrangements with the private sector such that the private
sector can contribute to emergency obstetric care.
• To encourage health care providers in the rural areas to contribute to the provision of
maternal care services and postnatal care- especially in remote medically underserved
areas. The focus is on institutional delivery with referral back up
Key Operational Elements:
1. Identify private and not for profit hospitals who are willing to participate.
2. Develop quality standards and register/accredit private sector partners who have
achieved this level. Help those who have not to attain it with training and consultancy
inputs
3. Develop a system of reimbursement of the below poverty line patients attended to in
these centres. For FP services all patients can be reimbursed. For other services only
BPL patients would be reimbursed.
4. Assist doctors/NGOs to set up services in medically underserved areas by assuring
them bank credit, and more patient volumes, by franchising and brand image build
up, and by developing a system of referrals by which cases can be channelled to
them. They would be part of a franchisee chain - state led called the Mitan Kendras.
They would pay a franchisee fee in some contexts. They would charge pre fixed rates
for all patients - even though they would be reimbursed only for BPL patients.
5. Build partnership arrangements with existing secondary care centers to provide RCH
care to BPL patients- who are referred there.These Mitr Chikitsalays can charge what
they want for other patients but for BPL rates would be fixed.
6. Enter into MOUs with individual doctors willing to lend their services to public
health facilities( Mitr Chikitsaks)
7. Link with Referral fund placed at the Panchayat's disposal and with ambulance and
laboratory services placed in their area.
8. Arrange for monitoring by a two tiered system - contracting this out and insisting that
25% of all patients be met and interviewed to verify that no excess payments were
made.
9. Develop a link with local accounting/audit firms and banks through which payments
can be made with minimum delay.
103
I
RCII 2 Draft PIP Chhattisearh
Budget Requirements for One year :
Approximate Case Load and Reimbursement Costs in a district where one EmOC center has been recruited as a
partner:____________
Item
Per Unit£ost
Total Cost
Nos. Per Month
per mnth
C-section__________
5__________
6000
30,000
Institutional deliveries
30_________
1500
45,000
Sterilisations_______
50_________
800
40,000
Others____________
50_________
200
1.000
A. Total Monthly
Reimbursement
1.16,000
B. Total Annual
13.92 lakhs
Reimbursement cost for 50 PPP centers:
Rs 696 Iakhs( 81. 31%)
Please note referral refunds costs may be included .This fund also lies underutilised.
Programme Management Costs:
A. Variable Programme Costs: shown below for 50 franchisees:/partners
1. Monitoring and Accounting Support
Monitoring 1st level
| Appox 25% cases:
Monitoring 2nd level
Accounting costs
Total for one month
Total for 12 months
Appox 5% of cases
Rs 100 per case or
100oof A
2% of A_______
2% of A
11,600
2320
2320
16,240
1,94,880
1. Monitoring & Accoounting Support for 50 partners per year:
2. Upgradation of Skills & Improvements in clinics & 0.6/partner:
B> Fixed Programme Costs
1.. Programme Administration Costs:
One CEO, 3 prog, officers and one CA firm /per mnth
Travel Costs for state office
Office costs for state office
5 field officers @ Rs 6000pm:
5 filed officers travel and support costs
Total programme management costs per month
Per year
2. Promotion Costs:
Brochure /ads/visits:
Accredittation visits: 200 partners* 1500
Training expenses 100* Rs400/day * 10 days
Melas - other promotional activity:
Initial restructuring, brand image promotion,
Total Promotion Costs per year:
97,44,000
Rs 30,00,000
Total Annual PPP Programme support Costs
Rs 160.14 lakhs (18.69%)
Rs. 85,000
Rs. 15,000
Rs. 30,000
Rs. 30,000
Rs 10,000
1,60,000
19,20,000
Rs 1,50,000
Rs 3,00,000
Rs 4,00,000
Rs 5,00,000
Rs 53,50,000
104
•VII 2 Draft PIP Chhattisgarh
otal Annual PPP in emergency obstetric care : budget in brief
ITEM
Unit
cost
(Rs.)
Nos.
2005-06
Reimbursements
50
696,00,000
Programme
Management
1
160,14,000
Total
856.14
856,14,000
2006-07
2007-08
2008-09
2009-10
Total
89894700
94389435
991,08,907
1040,64,352
4730,71394
This projection makes the assumption that we would have only 50 partners and that their total reimbursement
needs would be only in the range of Rs 13 92 lakhs per year per partner - adjusted for inflation. In practice we
expect to increase by about 25% every year. More important we expect to introduce insurance as a complement
to this programme. The exact budget estimats for this would be known later - but we are planning to do it
within current programme management costs.
Institutional Mechanisms:
An appropriate management consultancy or special mechanism under State Health Society or
the SHRC to be given the nodal role.
105
RCU 2 Draft PIP Chhattisgarh
73.5.2. Public Private Partnerships for Ambulance Services
Constraint being addressed:
Currently transport of patients to the CHC is a big constraint. The CHC ambulance takes
patients to districts hospital. It also helps in movement of stores. Its 24-hour availability to
bring patients from the village is not happening. But a 24-hour service needs to be created to
bring high-risk cases from the village to the CHC. There is a fund at the village provided to
the panchayats to be used for transport of patients in an obstetric emergency. But this fund is
not used due to lack of systems or information needed for its use.
Log frame Reference# Technical Domains:
Maternal health
Child health
Family planning
shifting of emergency obstetric case to secondary referral centre_____
shifting of sick neonates and children to referral centre____________
Shifting of FP cases needing sterilization operation to the venue of the
surgery.
Objectives of the Programme:
• Increase cases for institutional delivery; especially bring in all high-risk cases.
• Ensure existing referral funds with panchayats are used and build up system for its
full utilization.
• Improve ambulance services for all purposes intra-block
Key Operational Elements:
• The proposal is to identify an NGO and give them an ambulance.
• They can get service fee for high risk BPL cases reimburses from referral funds. They
can charge APL patients. They must have phone connectivity and must be evaluated
for promptness, fairness and courtesy of sen ices.
• Philanthropic organizations may provide the services for free.
• The services would be available for 24 hours.
Budget estimate for ambulance services:Cost of per ambulance 10 lakhs fixed/block. Recurrent cost 5 lakhs per year. A referral fund
also should be given to the panchayat so that people who deserve it or who are below poverty
line can utilize that benefit. Information should be reached up to panchayat level
systematically. This we estimate eventual requirement - as for about 200 women at Rs 1000
a woman or about Rs 2 lakhs. For hundred blocks it would work out to Rs 200 lakhs.
Year wise Budget estimate: 2005-2006: 500 lakhs and for 2006-2007: 200 lakhs
ITEM
Unit
cost
(Rs.)
Nos.
2005^200® /fYear2(|^0p7^
Ambulance
1000000
30
30000000
Referral
fund
200000
100
20000000
.
SO0M0W,
Total
...
21000000
2007-08
2008-09
2009-10
Total
22050000
23152500
24310125
110512625
.j 22050000
23152500
24310125
140512625
Institutional Mechanisms: State level nodal agency to operationalize the PPPs.
106
RC11 2 Draft PIP Chhattisgarh
7.3.53. Public Private Partnerships for Laboratory Services.
Constraint being addressed:
Currently there are very few laboratory technicians’ posts and even in this there are many
vacancies. These over all the CHCs but there is no laboratory service in most PHCs. This is
the situation even for basic tests like urine albumin or blood haemoglobin which does not
need much skill but is currently not being done. Even if all sectors had working PHCs this
would not be enough to meet the needs of anaemia testing, and testing of blood smears and
sputum examination - if all those who needed such tests came forward for it. As of today
even with poor utilization it takes over 15 days for a blood smear examination to reach back
to the patient. We need to create an even more decentralized laboratory system. Log frame
Reference & Technica Domains addressed:
I__________
Maternal health
Child health
Laboratory support for comprehensive emergency obstetric care
Management of sick children__________________
STI/RTI management____________
Additional benefits in tuberculosis and malaria control programmes may
outweigh the benefits to RCH programme._______________________
Objectives of Pr^^mme:
• The goal of this component is to provide the equipment, the human power and most
important the systems so that basic laboratory facilities are accessible within 24 hours
for the entire population in the block.
• Promoting a widely dispersed network on laboratory services in the private sector
through an innovative partnership programme.
• In addition to this, to train local NGOs and Mitanin preraks in laboratory work which
they can do later on a payment by fee basis.
Key Operational Elements:
• All basic blood urine stools sputum examination including microscopy made
available at roughly one centre per 10,000 population i.e. about one centre per 2 to 3
subcentres.
• Many of the trainers in the Mitanin programme are youth in search of livelihoods.
Some of them who may be interested may be provided the training and start up
equipment for the start of basic package of laboratory services.
• Appropriate manuals would be made available
• Eventually, organise a network providing more advanced tests at a CHC level
franchisee arrangement.
Budget Estimates:
For the first year we can give some counter guarantee - like fee payment once they have
done the blood haemoglobin levels of all women or sputum of all persons with chronic cough
in the hamlets in their area etc. This work will in turn help them establish themselves. For
this we are putting aside Rs 5000.
This training work would be outsourced to technical institutions in partnership with specific
NGOs who can play this role. This would be on a trial basis and confined to some 150
persons in the first year).
107
RCII 2 Draft PIP Chhattisgarh
They would be paid 100 Rs per person per day during training days. We will give them 30
days training for laboratory work. In the first year we would be giving training to 500
persons, then next year 1000 trainees will be trained so that 1500 trainee will be built up with
in two years for lab tech support in PPP system.
Budget for Technical support under PPP:
ITEM
Unit
Cost/day
Lab tech
(Training of
Master
Trainers)
100/-
Establishment
Total
Training
days
30
f-
Nos.
20042005
500
1500000
20052006
Total
4000000
Establishment
Lab tech
(Training of
Master
__ Trainers)
Unit
cost
5000/-
100/-
500
30
2500000
100
3000000
8000000
5000/-
1000
5000000
4000000
8000000
12000000
Institutional Mechanisms: State level nodal agency to operationalize the PPPs.
108
R( 11 ? I )r ifi PIP Chhattisgarh
7.3.6. Grant - in- aid scheme for NGOs
Constraint being addressed:
Health requires inputs from all sections of society. The government cannot work on this in
isolation. While there is considerable scope to involve civil society in facilitating and
monitoring public health systems there is also a need to support independent identity and
action of NGOs. Their role in advocacy for better health care has been a critical input to
ensure that health care reaches the poor. Such advocacy work is best done independent of
state funding: However, organisations and individuals who devote themselves to advocacy
may need support and the state should also draw upon their commitment to improve
services- especially outreach to special vulnerable groups like remotely located tribal
communities or urban homeless and in special problems like adolescent health care.
Log frame reference:
Improving service delivery & reach medically underserved areas for maternal health, child
health, family planning, adolescent health, urban health and tribal health.
Objectives of Programme:
1. Involve NGOs in service delivery so as to increase access to care in remote medically
and paramedic ally underserved areas and to especially vulnerable sections of society.
2. Involve NGOs in provision of specific services or to special groups that are unable to
get due priority within public provisioning of health care.
3. Involve NGOs in health education work.
Key Operational Elements:
a. Develop a data base of NGOs and their work and objectives.
b. Identify and notify remote and underserved areas. - Both medically underserved
sector and paramedically underserved sections.
c. Identify key areas of RCH that currently not addressed adequately by the public
health system even in areas of adequate staff strength and functionality.
d. Identify marginalised and vulnerable sections and issues that cannot be reached to by
the subcentre- PHC - CHC system - like the homeless, like migrant workers, like
remote forest areas and develop special strategies for them.
e. Negotiate and enter into MoU with NGOs specifying work outputs and process
indicators by which they would be monitored and building in the monitoring
mechanisms for the same.
Budget Estimate:
Rs 200 lakhs per year.
A medically underserved sector would be roughly contracted out at Rs 10 lakhs per year
excluding drugs and vaccines. All paramedical services would be expected including the
paramedical level curative care package. Part time medical services would be expected. Out
of this 10 lakhs, Rs 3.6 lakhs (30 thousand pm) would go to 30 community level workers for
1:1000 population paid at Rs 1000 per each CLVs or six ANM equivalents at Rs 5000 each
with voluntary Mitanins for help. Another 0.96 lakhs would go for a supervisor @8000 pm.
109
R('ll 2 Drub PIP Chhattisgarh
Remaining money would be used for organising weekly medical camps attended by doctors,
other programme costs, administrative costs and contingencies. The programme costs would
vary as supervision costs and training cost would also vary.
The cost of drugs and supplies would be home by the state in kind who would give them 30
CHV kits and five ANM kits. In each year only 15 relatively under - served areas would be
taken up and this would be evaluated before recasting the programme for the next three
years. About 10% of the above costs would go into state level monitoring of the programme.
The remaining 35 lakhs is for special groups or areas — like primitive tribals or migrantswhere detailed programmes would be worked out.
Budget for NGO grant-in aid per year: 200 lakhs.
ITEM
Unit cost
(Rs.)
Nos
2005-06
2006-07
2007-08
2008-09
2008-10
Total
30 CLVs /ANM
equivalents
3.60 lakhs
15
5,400,000
5,670,000
5,953,500
6,251,175
6,563,734
29,838,409
1 Supervisor
0.96 lakhs
15
1,440,000
1,512,000
1,587,600
1,666,980
1,750,329
7,956,909
Medical
Assistance and
camp
expenditure for
100 one day
camps
2.00 lakhs
15
3,000,000
3,150,000
3,307,500
3,472,875
3,646,519
16,576,894
Staff Training
1.20 lakhs
15
1,800,000
1,890,000
1,984,500
2,083,725
2,187,911
9,946,136
1.74 lakhs
15
2,610,000
2,740,500
2,877,525
3,021,401
3,172,471
14,421,898
0.50 lakhs
15
750,000
787,500
826,875
868,219
911,630
4,144,223
10 lakhs
15
15,000,000
15,750,000
16,537,500
17,364,375
18,232,594
82,884,469
1,500,000
1,575,000
1,653,750
1,736,438
1,823,259
8,288,447
3,500,000
3,675,000
3,858,750
4,051,688
4,254,272-
19,339,709
20,000,000
21,000,000
22,050,000
23,152,500
24310,125
110,512,625
Referral
transports,
equipments,
programme
support and
contingencies
NGO level
management
costs
Total
State level
Coordination,
Monitoring and
Evaluation
Allocation for
special areas
Total
10%
Institutional Mechanisms:
State NGO management Cell.
110
RCH 2 Draft PIP Chhattisgarh
7.3.7. Community Level Care: Mitanin —II Programme
Constraint being addressed:
The Mitanin programme is a key strategy of reducing infant mortality of improving service
delivery, of community participation, of health education as also of making all current child
survival and safe motherhood programmes more effective. It addresses lack of awareness
about causes of infant and maternal mortality and morbidity, about right to RCH services as a
basic right, about how to access services. It also addresses problems in outreach of services
to a dispersed population and to ensure adequate community participation. The Mitanin
programme has over the last two years attained its goals of creating a trained volunteer in
every single hamlet of the state. This community selected hamlet level volunteer has been
able to intervene and bring about significant changes in health seeking behaviour and health
practices. For her work to translate into major declines in child mortality and morbidity there
is a need to sustain the programme for at least three more years. Since her work also involved
building up accountability, the health system at local levels would require continual
persuasion and partner ship with civil society at all levels to sustain this programme.
Log frame Reference & Technical Domains addressed:
Maternal health:
Child health:
Family planning:
Adolescent health:
RTI/STIs
Urban health:
Tribal Health:
Most important
Better access to ANM for antenatal care and referral to institution for
delivery and postnatal care in the community itself__________________
First contact care for sick neonates, infants and children: and the
reduction of child morbidity and mortality. Counselling on child
malnutrition. Potential to halve current infant mortality rate based on
extrapolation of data from similar programmes
_____________
Better access and encouragement for spacing and delaying the first child,
motivation for terminal methods_____________________________
Campaign against anaemia and malnutrition, against violence and
women related issues; first contact care and counselling for minor
women health issues, education about the body and its normal functions,
Education,- first contact care.____________________________
All the issues touched upon above___________________________
All the issues touched upon plus the fact that she is the only health
caregiver who can speak the language of many tribal sections._________
Key strategy of promoting equitable access, of addressing gender
imbalances: The hamlet level approach ensures outreach to every
section. The woman as care giver, with emphasis on selection by women
makes her access to women much more (other community care givers
like depot holders, RMPs, JSRs are almost completely men.
Ensuring accountability: addresses health services from a health rights
viewpoint..
Indeed because of her role in accountability and addressing gender
imbalances and equity issues the programme requires definite assistance
against vested interests at all levels.
Cross- cutting strategy: touching on all technical issues and many of
the institutional goals as well.
111
R( II 2 Draft PIP Chhattisgarh
Background:
The Mitanin Programme was announced in November 2001 and inaugurated in the state in
May 2002. After a long process of planning, and development of training material and some
experimentation in pilot blocks the first phase of the programme- when it was expanded to 80
blocks— was launched in January 2003. Since it takes six months to select Mitanins- it was
in June 2003 that training for Mitanins began in these first phase blocks. In January 2004
the programme was further expanded to all blocks in the state and by June 2004 Mitanins
have been selected in the entire state. By march 2005 Mitanins would have trained and
deployed in all hamlets of the state.
The Mitanin programme has been able to largely attain the operational objectives it set itself.
This is evidenced from the monitoring data, from the impression on numerous field visits.
Further the programme has undertaken a rigorously organized internal evaluation (external to
the programme implementation agencies at the block and district level) programme to
validate the claim on achievement of operational goals. The results for a sample of 1250
Mitanins from 25 blocks are available and these confirm that the programme has met its
operational (process indicators) goals.
Results from other pioneer community health volunteer programmes like Jamkhed and
SEARCH programme show that for these process indicators to translate into programme
outcomes defined by improvements in health outcomes especially a reduction in infant
mortality the whole process has to be sustained for three to five years. Jamkhed for example
achieved a dramatic reduction of the IMR from 140 to about 50 in five years and after that
another 20 points over the next 15 years. The cunent rural infant mortality being 85- it
should be possible for similar reason to reduce it dramatically to 50 in the coming three years
provided all the processes set up are not only sustained, but also strengthened. The hard
scientific rationale of such a claim is explained in the text. This proposal also looks at the
modifications and improvements that are needed in the current programme design of the
Mitanin programme so as to make it more effective.
The total budgetary implication is about Rs 3500 per Mitanin per year, which is about Rs 14
lakhs per year per block or about 20 crores per year for the state. In the continuation phase
also no payment is envisaged for- the Mitanin but for each day of training she attends she
would get Rs 50 as livelihood compensation- i.e about Rs 600 per year for 12 days of
training.
Operational Objectives of Programme:
1. Sustain and support a trained woman volunteer in every hamlet supported by a
women’s health group i.e. approximately 54,000 Mitanins .
2. Ensure that 100 key messages on RCH reach every single household in the state in
the appropriate language and idiom.
3. Ensure that every single sick child of fever, diarrhoea, and ARI gets visited on the
very first day of illness with appropriate first contact care and referral where
indicated.
4. Ensure that every newborn is visited and weighed in the first day after birth and
visited once more in the first week and appropriate messages and referral are done.
5. Ensure that all pregnant women are counselled on general measures and access to
antenatal care, and referred to an institutional delivery facility for childbirth.
6. Ensure that tackling child malnutrition becomes a priority on the local panchayats
agenda and families and local bodies are empowered to tackle it.
112
RCI1 2 Draft PIP Chhattisgarh
7. Ensure that outreach of all key RCH services are facilitated by better peoples
knowledge, by assistance to health department staff in service delivery and by
community participation and advocacy.
8. Sensitisation and capability building in women and panchayats and link with other
health related sectors locally..
9. By all the above measures linked to improvements in the facility to reduce the infant
mortality rate by the year 2007 to below 35( currently 73)( the technical possibility of
doing so has been demonstrated adequately in smaller models)
The programme will largely involve six dimensions:
a) Continued training and support to the Mitanins so that ongoing facilitation of service
delivery by Mitanins and community basing of all health programmes is sustained.
b) Strengthening and deepening the health education and counselling work at the
household level by equipping the Mitanins with charts, posters and other tools of
monitoring.
c) Strengthening the access of the poor to essential curative care through adequately
provisioned Mitanins linked to improved peripheral primary and secondary medical
care facilities, by a functional referral system.
d) Incentivisation of the Mitanin’s work so that there is enough encouragement and
recognition of their work at both the family and at the community level.
e) Inter-sectoral integration at the habitation and panchayats level with related sectors and
strengthening local planning at panchayats level.
f) Better outcome monitoring and closing all gaps to achieve an effective health outcome.
Indicators:
1. Every Mitanin already trained for 18 days receives every year a further 12 days of camp
-based and 24 days of on-the-job village level training.
2. Every household has attained adequate knowledge in a set of 100 key health messages
as verifiable by a random survey and that in certain key messages there is a major
change in practices at the family level.
3. Establish effective access to basic drugs in every hamlet through the Mitanin and that
she is backed by a referral chain from Mitanins to ANMs and primary health care
centres to CHCs so that sick neonates, children, adolescents and women esp. in
pregnancy get timely referral when needed.
4. Ensure that a set of inter-sectoral interventions planned and coordinated locally and
with the panchayats shall lead to a local plan that shall include food security, safe
drinking water and sanitation, early childhood care services and school health services
and access to health care services and health education.
5. The effectiveness of all the above should be visible by a measured decline in child
malnutrition rates, decreased low birth weight rates, decreased anaemia in women and
decreased micro-epidemics and decreased epidemic deaths in gastroenteritis, childhood
acute respiratory infections and malaria. Baselines for this are being generated and
should be ready by December 2004.
Sample surveys should show decrease in IMR by at least 50% at the end of three years and
all the indices like Child malnutrition prevalence. Anaemia in women, Birth weight of
113
RCII 2 Draft PIP Chhattisgarh
babies, IMR and MMR, Tuberculosis/ Leprosy prevalence. Malaria incidences, should have
declined.
Budget per year:
SI
Head
Exp. per
block
per year
2005-06
1
2006-07
2007-08
2008-09
2009-10
Total
170349259
178866722
187810059
853775230
26746347
28083664
127666947
Training
12 Day Training
for 400 Milanins
Field Training
and Support for
Milanins
Dt. Trg. of
Trainers*
State Training of
DRPs*
Training
Material *
Skills/and
Capacity
Building *_____
Total
1
1.2.
1.3.
1.4
1.5.
1.6.
1
672000
268800
48000
29500
30000
10000
1058300
154511800
2
162237390
Social Mobilisation
zT
122250
2.4
15
Folk Media
Trg for above
campaign*
Electronic
Media*
Print Media*
Training CDs *
2
Total
158250
2.2
2.3
16000
10000
5000
5000
3
23104500
24259725
25472711
Administrative and Others
3.1
Admin: block
level
60000
3.2
Admin/support
Dt level.
24000
Total
84000
12264000
12877200
13521060
14197113
14906969
67766342
Admin/support
State Level
48000
7008000
7358400
7726320
8112636
8518268
38723624
Grand Total
1348550
19,68,88,300
206732715
217069351
227922818
239318960
1087932144
4
Administrative and Other Expenditures at block ,District and state level include travel,
coordination meetings, monitoring, events, correspondence, overheads and contingencies)
Note: The star marked (*) expenditures are been incurred at state level, thus the cost shown pier
block is notional.
Institutional Mechanism: The programme will continue to be led by the directorate,
coordinated on its behalf by the State Health Resource Centre and will be organized at the
district level by the District RCH (health) society.
<
. 5" L- f
I O
0
114
RCH 2 Draft PIP Chhattisgarh
7.3.7.2 The CHV or Mitanin Drug Kit:
(The Cost of Supplies for Community Level Care)
Constraints being addressed:
The mid-term evaluation of the Mitanin programme, which analysed the work performance
of a randomly chosen sample of 2500 Mitanins, shows that the single greatest weakness in
the programme is the supply of basic drugs to hew Even a drug like chloroquine which is in
abundant supply and which has no controversy regarding its provisioning at the village level
was found not too have reached in the majority of Mitanins. ’The Mitanin programme
anticipated this bottleneck and was so designed that it would survive it. However there is a
dramatic drop in effectiveness of the Mitanin if she is not supplied with the requisite tools.
When as a course correction we released the list of drugs shown below packed in drug kit
back along with pictorially labelled bottles and drugs- the dramatic improvement was there
for all to see. However refill of these kits after two months has again become a problem.
Objectives:
Ensure effectiveness of community level care givers by dedicating a CHV drug kit and
regular refills of supplies for the same, for her dispensation in the hamlet.
Activities.
Each CHV (Mitanin) would be supplied with a drug kit with two months supply of drugs.
Each month one-month supply of drug or whatever has been consumed- whichever is less
would be supplied to her as refill of the kit.
In epidemics and special need situations the state government would increase the supply
through the CHMO.
The kits can be supplied as kits by the central government, or if the state meets acceptable
benchmarks in procurement and distribution processes - it may be supplied as funds.
Labelling the drugs pictorially on the picture code we have written up along with pictorial
instructions that are already in place would maximise utility of these kits.
Budget estimate:
The cost of drugs that the programme consumes is estimated at Rs 150 per month per
Mitanin- who handles a normative 50 households of about 250 populations. Another Rs 200
per Mitanin is the cost of the kit bag and pictorially labelled bottles. This a normative block
of 100,000 populations has about 400 Mitanins. The state as whole is now have around
59000 Mitanins and another 1300 urban Mitanins are proposed. Thus a total of 60,000
Mitanins who cater to approximately 150-lakh beneficiaries -which is the lower 75% of the
population. The rest would not need coverage by this programme. We note that though the
cost of drugs proposed may seem high, it works out to only Rs 2000 per Mitanin or Rs 8 per
beneficiary household per year.
Budget at a Glance:
Item
Drug Kit For
Mitanins
Drug Supplies
for 12
months@ Rs.
150
Total
Unit
cost
Nos.
2005-06
2006-07
2007-08
2008-09
2009-010
Total
200
60,000
12,000,000
0
0
0
0
12,000,000
1,800
60,000
108,000,000
113,400,000
119,070,000
125,023,500
131,274,675
596,768,175
120,000,000
113,400,000
119,070,000
125,023,500
131,274,675
608,768,175
115
RCH 2 Draft PIP Chhattisgarh
The monthly kit would have the following contents (for 50 households or a population of
250 or in a rural area):__________________
S.No.
Contents
Quantity/kit
1
Paracetamol Tab 500mg
70 Tabs
2
T
6
T
8
9
10
11
12
13
14
15
n
17
Paracetamol Syrup (60 ml bottle)
Albendazole 400 mg_____________
Cotrimoxzole Tab 400+80 mg_______
Cotrimoxzole Syrup 200+40 mg(60 ml)
Metronidazole Tab 400mg
Antacid Tab_____________________
Gentian Violet Lotion______________
Gamma BHC (100 ml)_____________
Gauze
Bandage________________________
Slides__________________________
Cotton
Spirit
Lancets
Chloroquine
Iron and Folic Acid tablets
2 Bottles
5 Tabs
_____ 60 Tabs____
2 Bottles
110 Tabs
60 Tab
_____ 1 Bottle____
____ 1 Bottles
_____ 5 Piece_____
1 Packet( 12 piece)
25 Nos.(1/2 packet)
1 Roll
1 Bottle
25 Piece
100
100
The above amount estimated for the kit as elaborated below is with an assumption that
chloroquine and IFA tablets are filled in, but from different programme budgets.
116
RCII 2 Draft PIP Chhattisgarh
7.3.8.Behaviour Change Communication:
Constraints being addressed:
Lack of awareness about causes of infant and maternal mortality and morbidity, about right
to RCH services as a basic right, about how to access services are all continuing problems though unlike popular perception they are not what is limiting health care services. However
if the supply of health services expands as envisaged in this RCH-II proposal the hitherto
unmet demand for services could shift to an excess supply situation. Per se this is welcome
except that there is a lot of unmet needs that have not yet become unmet demands. In short,
expanding demand for services and encouraging better health practices at the family and
the community level remains central to achieving our goals.
Due to considerable linguistic and ethnic diversity and different social and economic settings,
it messages inappropriate when applied across the state. Need to build up capability for
developing district and even block level community specific IEC material and integrating this
with different forms of IEC needs to be.
Log frame reference:
BCC in following areas immunisation; Resort to safe delivery, utilization of all existing
services, promotion of breastfeeding, promotion of FP methods, adolescent health.
Objectives of Programme:
• Developing IEC material and campaigns specific for different client groups- by social,
linguistic and ethnic characteristic and conducting effective multimedia IEC campaign
based on this.
• Creating folk art based plays, songs and skits so that key messages are conveyed in
culturally appropriate way and in relation to existing practices.
Key Operational Elements:
• Identify suitable partners for conducting the programmes in the village level and for
creating BCC strategies.
• Defining the focus of IEC based on study of local health needs and health beliefs.
• Development of appropriate material based on defining client groups and their cultural
specificities.
• Organising scriptwriters, and choreography workshops for developing folk art based
material.
• Organizing kalajatha and other locale specific IEC programmes, including programmes
in melas and village markets; posters and wall writings in the blocks. Organising radio
programmes, TV programmes and hoarding centrally.
• Building up the regional family welfare training centres- existing and proposed as
centres of BCC strategy and of integration of ethnic specific messages into all health
programmes.
117
RCH 2 Draft PIP Chhattisgarh
Budget Estimate:
i Item
I
Cost
per unit
Qty
One strategy development
material
and
three
workshops
development
done twice: a year 20
persons * 10 days * 300
plus 40.000 for related
expenses
100,000
8
800,000
840,000
882,000
Block level campaigns
which are folk art based
100,000
146
14,600,000
15,330,000
16,096,500
Radio programmes - three
regional specific 15 part
radio programmes broad
cast thrice a year
500,000
3
1,500,000
1,575,000
1,653,750
event
State level
inaugurations/
announcements etc
100,000
3
300,000
315,000
20,000,000
>21,000,000
i Total
2005-06
2006-07
2007-08
2008-09
926,100
2009-010
TOTAL
972,405
4,420,505
17,746,391
80,674,216
1.736,438
1,823,259
8,288,447
330,750
347,288
364,652
1,657,689
22050000
23152500
24310125
110512625
16.901,32
Institutional Mechanisms:
• IEC bureau of the directorate
• Identifying appropriate agency (3 regional HFWTCs one existing and two proposed)
for support to districts in material development.
• Identifying NGOs for village level campaigns
• District Health (RCH) Societies are implementing agencies
• Block level cultural teams formed for Mitanin Programme.
• Mitanin Programme would also use this input extensively
118
RCH 2 Draft PIP Chhattisearh
7.3.9. Panchayat Capability Building & Intersectoral Coordination:
Constraint being addressed:
Inter-sectoral areas need to be coordinated with - water and sanitation, food supply , ICDS
programmes, poverty alleviation programmes- as all of them directly impact on health
outcomes. Panchayats cooperation is needed for the success of many health sector
programmes. Eventually as part of constitutional mandate they have to play the role of local
governance for the health sector. There is currently no programme to build capabilities for this.
The programme design needs to incorporate capability building of panchayats, a system of
locally measurable indicators, and a system of rewards and disincentives.
Log frame reference:
Institutional: Improving Management Structures at all levels: Reference to PRIs and their
enhanced role in health and even their taking charge of ANMs. Effective capability building is
needed.
Intersectoral: Effective coordination mechanisms at all levels to achieve multisectoral goals.
Objectives of Programme:
• Incentive for high Build the capability of panchayats and village level institutions in
health and in assisting/goveming health care services.
• ouild up local inter-sectoral coordination in the form of panchayats and village level
planning.
• Popularise a simple tool by which panchayats can understand their own performance so
as to improve it and by which people can judge them.
• Identify weak and vulnerable villages for special attention from the district government.
• Provide an performing panchayats by according them with recognition.
Key Operational Elements:
• Develop a health and human development index applicable for hamlets and panchayats:
This should include all health services and health related services. It would largely
reflect health and health related inputs but some outcome measures are also proposed.
• The index also incorporates equity and gender concerns.
• The index is capable of being modified at the district level by the district collector/
district panchayat to reflect the district’s priorities and availability of funds without
sacrificing over all development goals. The index must have its developmental “goal
posts” set at the district level. Note: that as the programme becomes repeated it would
tend to become mechanical. However by increasing the role of district and even gram
panchayats in the design of the HDI we hope to be able to rescue it from slipping into a
mechanical top- down exercise.
• Then train villages and panchayats elected persons and employees in understanding the
indices and how it works. Ensure that 50% of persons so trained are women.
• Provide the panchayats with a fund for working on improving these indices as part of a
comprehensive village level plan. This would come from the panchayat department.
• Train also Mitanins and NGOs in this health and human development index. One NGO
is commissioned for each block to train the panchayats and to train the Mitanins and to
train the preraks. Unless there is a specific reason the same NGO, which is undertaking,
the Mitanin programme in that area would be given this task. Where there is no NGO in
this role - as in about 80 blocks an NGO can be recruited. The NGO is provided funds
according to the number of GPs each block has so that it can appoint a full time
facilitator cum trainer for every three to five panchayats.
119
RCH 2 I)ra11 PlP (’hhattisgarli
Compile the index according to the manual- first hamlet wise with aggregation at
village and panchayat level.
• Rank each panchayat according to each subject and then on the whole- to get subject
ranks and total rank on the panchayat report card.
• Reward the successful top rankers and provide support to the weakest panchayats and
vulnerable vulnerable villages where all the above services are weak..
Note: the index is adapted from an index developed under an UNDP sponsored programme in
three blocks of Uttar pradesh being organised by the Bharat Cyan Vigyan Samiti. It is as yet
not adequately field-tested and there may be more modifications as we go along. The principle
however is the same as the role of HDI in the international context.
One must however note that certain indict that are the cornerstone of the international HDI
like IMR and MMR and death rates are not included in the calculation of the Panchayat level
HDI as they are “tips of icebergs" which when we come close to do not allow meaningful
planning or estimates. Also they are “loaded” with administrative implications and tend to get
falsified. There is much more thrust on input indicators and these can convert to more outcome
indicators once both performance and means of verification improve. The model of the HDI
calculation score card along with instructions is annexed.
•
liuuget isstimate :
Section 7.3.9. Panchayat Capauility Building & Intersectora Coordination
Item
2007-08
2008-09
2005-06
2006-07
2009-10
Qty
Development of
index/manual and
dissemination___________
70000
3500000
Training of 3 functionaries
per GP-2 one day camps Rs
70 per day for 2 days______
30000
4200000
Training of village and
hamlet reps- 2 one day camps
per year Rs 70 per day for 2
days__________________
60000
8400000
One NGO per block as
overheads for conducting the 1000
training providing support
GP
and assisting govt officers in
cluster
compiling the index. Rs
s of 10
1000 pm/per cluster * 12
GPs
months
12000000
each
______ __________ Total
28100000 29505000 30980250 32529263 34155726
5% overheads at state level
for training of trainers,
development of materials etc.
1405000
1475250
1549013
1626463
1707786
Incentive of one 0.5 lakh
rupees to two best
panchayats of each block 0.5
lalkhs * 2______________
146
14600000 14600000 14600000 14600000 14600000
Grand total
47129263
44105000: 45580250
48755726
50463512
Total
1552,70,239
236033751
120
RCU 2 Draft PIP Chhattisgarh
Programme management needs a designated lead agency at the state level who would manage
all the funds, train all the NGOs who are the trainers, help distts to adapt the HDI for their
needs, monitor the training and ensure that the basic rules are being followed. This would
require about 30 field coordinators and two programme coordinators to drive the process.
We see this programme as synergising with the Mitanin programme to ensure that the
demand for services is fully created and that the panchayats are fully involved in the
programme. In the course of two years they should be ready for considerable
decentralisation ofprogrammes and powers.
THE SWASTHYA PANCHAYAT SCHEME ( DRAFT)
THE HEALTH & HUMAN DEVELOPMENT INDEX
Name of hamlet/Village/Panchayat—-------------------------- -----------____________________________ HEALTH SERVICE INDICATORS
BASIC HEALTH SERVICES
SI
Indicator
1
IMMUNIZATION
COVERAGE
< 3 YEAR OF AGE
2
3
4
5
6
Criteria
GoalPosts
&SCORE
Maximum
100%
Minimum
0%
no. <3 years
% completely
immunised
ESSENTIAL
ANTENATAL CARE
Total no.of
pregnant
women
No of women
who got full
% of women getting
antenatal care as itenatal care as defined
defined
Maximum
100%
Minimum
0%
INSTITUTIONAL
DELIVERY
Total no.of
pregnant
women
Total no of
women who had
instituitional
delivery
% of pregnant women
who had institutional
delivery.
Maximum
100%
Minimum
0%
WEIGHING OF
NEWBORN WITH
IN THREE DAYS
Total no. of
births in the
year
No. of newborn
weighed within
three days
Percentage of newborn
weighed within three
days
Maximum
100%
Minimum
5%
BREASTFEEDING
IN FIRST HOUR
Total no of
births in the
last year
No of newborns
who were
breastfed in the
first hour
Percentage of newborns
who were breastfed
within an hour
Maximum
100%
Minimum
0%
REPORTING OF
BLOOD SLIDE
Approx no of
blood slides
sent in last 3
monts
Average time taken for reporting of blood
slide
Maximum
over 30
days
Minumum
1 day
% of fully immunized
lildren
121
RCII 2 Draft PIP Chhattisgarh
—-’T
Total number
of hamlets
No. of hamlets
with
shop/person
having
unbroken supply
of chloroquine
last year
% of hamlets
Maximum
100%
Minimum
0%
Total number
of hamlets
No. of hamlets
with
shop/person
having
unbroken supply
of
OCP+condoms
last year
% of hamlets
Maximum
100%
Minimum
0%
No of target
couples for
sterilisation
services
(>2
children)
Total no. of
couples with at
least one of
them wanting
FP operation:
No. who
wanted to
get FP
operation
done last
year but
could not
%of
unmet
demand
for FP
operation
Maximum
100%
Minimum
0%
10
FIRST DAY VISIT/
CONSULTATION
OF MITANIN
IN 4 CONTEXTS
Total no of
hamlets with
Mitanin
Number of
hamlets where
Milanins make
first day visits/or
are consulted at
least 50% of the
time
% of functional Mitanin
hamlets
Maximum
100%
Minimum
0%
11
PANCHAYAT
LEVEL HEALTH
COMMITTEE
No. of panchayat level health committee meetings held in
the last year
7
8
9
12
AVAILABILITY OF
CHLOROQUINE
AVAILABILITY OF
SPACING
METHODS
ACCESS TO
STERILISATION
SERVICES
WOMEN HEALTH
COMMITTEE
Total no. of
hamlets
No. of
hamlets with
active
women’s
committee
that discusses
health issues
% of hamlets with active
womens committee that
discusses health and or
developmental issues
Max 12
Minimum
0
Max 100%
Min 0%
122
RCH2Draft PIP Chhattisgarh
13
14
15
16
17
18
19
20
STAGNANT
WATER
HEALTH RELATED SERVICES
WATER & SANITATION
No.
of hand No.of
hand %
without
pumps
pumps
stagnant water
SAFE
DRINKING
WATER
Total
no.
families
of Total
USE OF DOMESTIC/
COMMUNITY
TOILET
Total
no.
families
of Total
ANGANWADI
no.
of
using
families
drinking
> safe
water as defined
no.
of
families
where
all members are
using domestic/
community toilet
FOOD SECURITY RELATED
Total no. of
Actual No.getting
children eligible
diet regularly
for anganwadi
Percentage
. of
families
using Maximum
safe
drinking 100%
water
Minimum
25%
Percentage
of
families
where
where
all
members
are
using domestic/
community toilet
Max imum
: 50 %
Minimum
0%
Percentage of
Anganwadi
beneficiaries
MIDDAY MEAL
Total no. of
primary schools
Total no. of
schools giving
cooked midday
meals
Percentage of
schools giving
midday meals
PDS FUNCTIONING
Total no. of BPL
families eligible
for lower cost
grains
No. of families
getting grains
from PDS shop
Percentage of
beneficiaries
ANTYODAYA
YOJNA
Total no. of BPL
families eligible
for free grains
No. of families
getting free grains
from PDS shop
Percentage of
beneficiaries
Total no. of
children in 6-14
age group
No. of children in
age group not
going to school
Percentage of
school going
children
SCHOOL
ENROLLMENT
Maximum
100%
Minimum
0%
123
RCH 2 Draft FTP Chhattisgarh
21
CHILD
MALNUTRITION
HEALTH STATUS
no. of
Total no. of
children with
children below 3
gr I or above
with wt record.
malnutrition*
% of children
malnourished
Max 200%
Minimum
0%
♦
(Note: count each child with grade 2,3 or 4malnutrition as 2 child with malnutrition)
Total no. of
Total no. of
LOW BIRTH
newborn who
Percentage of babies
babies with
22
WEIGHT
were weighed
with LBW
LBW
last year
23
24
25
26
AGE OF
MARRIAGE
SPACING
INFANT DEATHS
OUTBREAK OF
WATER BORNE
DISEASE
Max 100%
Min 10%
Total no. of girls
married last year
No. of girls
married
below 19 year
of age
100% - % of married
women below 19 year
of age
Total number of
births last year
which were
second or > child
No. of
children bom
with more
than 36
months
difference
% of unspaced second
or third children bom
Max 100%
Minimum
0%
Total number of
births last year
Any deaths of
any child
below one
year
% of infant deaths
Maximum
20%
Minimum
0%
Diarrhoeal
outbreaks(More
jaundice
than three cases of outbreaks (as
a disease in same defined)
week )
Sum of water brone
disease outbreaks
Maximum
4
Minimum 0
Max 100%
Mini 0%
Other suggested indices for inclusion if means of verification at least by sample survey can be
organised for each hamlet:
• Anaemia levels in pregnant women
• Anaemia levels in adolescents
• Malnutrition levels in adolescents
• API
• Infant spleen index
• Number of births which were the fourth child or more: and how many of them was due
to the rest having been only girls:
• Number of births in those waiting for FP services.
124
RCII 2 Draft PIP Chhattisgarh
The score of each item is made by the formula: (Actual value - Minimum value)
(Maximum value - Minimum value).
The maximum and minimum values for each item are given in the score card above but can be
re-set at the district level to express their priorities and possibilites. Means of verification are
given in accompanying note:
Hamlet score card :
Health services/practices Score
Water and Sanitation Score
Food Security Score
Schooling score
Total Health And Related Services Score
Child Malnutrition Score
Health Outcome Score
Max score 12
Min score 0
Max score 3
Min score 0
Max score 4
Min, score 0
X’JlMZk DvUlC
1
Min score 0
Max score 20
Min score 0
Max score 1
Min score 0
Maximum 0
Minimum 6
The above is aggregated item by item to measure the village health development index and
again aggregated item by item to get panchayat health development index. Then an equity
scorecard is also built in to reflect the intra panchayat variation between hamlets.
125
RCH 2 Draft PI P Chhattisgarh
7.4
Equity/ Gender:
See also discussion on the Mitanin programme and 5.7 in situation analysis.
We have already discussed the over all current situation regarding gender and equity concerns
and the approach the state has to addressing these issues( see section 5.7) In this we posit that
the main ways of addressing these issues are:
a) a strengthened comprehensive primary care public health system with affirmative action
to ensure that the weaker sections have access to it. The Mitanin programme, the process
of panchayat level HDIs with, identification of vulnerable panchayats, and the ethnic
specific BCC programme design would be all examples of such affirmative action. These
are discussed in detail in the respective sections. Even amongst this the critical input is
the Mitanin programme.
b) In the quality of care component (7.3.3) by including gender and equity concerns into the
quality standards and indicators and by investing in adequate central (i.e. from state and
district headquarters) processes to monitor and support this taking place we hope to make
the 100 FRUs and all the 24 hour PHCs we are investing on as more equitable in access
and woman friendly.
c) In the public private partnerships (7.3.5.) the complete reimbursement provided to below
poverty line families is a major contribution towards equity concerns.
d) In the urban health project the focus of communit}- level care and primary care at the one
third below the poverty line is also a major focus on equity.
e) In the adolescent health component (7.2.4) the special emphasis on issues of violence
against women, on anaemia and malnutrition, on awareness of the body and control over
it are specifically designed to address major gender concerns.
f) Not reflected in the proposal but needing to be flagged here is the special initiative by the
state to have a grievance redressal forum for women employees of the department recognising that such a forum is needed for their morale and more effective functioning.
126
RCH2l.)ralt PIP Chhattisgarh
7.5. Convergence/Coordination:
State Level. At the state level the State health society, which has the chief secretary as vice
chairperson and other department secretaries provided co-ordination. Based on assessment of
its functioning its inter-sectoral nature should be strengthened.
District Level: At the district level the district health society is providing Intersectoral
coordination and coordination with NGOs as well. The Intersectoral nature of this needs to be
strengthened .
Village and Panchayat level: At the panchayat level we have outlined in section 7.3.9 the
investment being made for better inter-sectoral coordination. More than any other single
measure such a comprehensive approach where health outcomes are matched to all
intersectoral service inputs would be the major innovation of this programme.
Indeed the district level co-ordination forums would derive a purpose driven by the insights
and work that emerges from the HDI process.
7.6.Financial management:
The State Health Society would be in charge of programme funds at the state level and the
district health society at the district level.
Components relevant to their domain would be managed by arrangements within this umbrellathe SIHFW for training, The SHRC for Mitanin programme the directorate for infrastructure
and so on.
At the district level it would be the district health societies.
In the section on programme management the proposal for improving financial management
is included.
7.7 HMIS:
Section on HMIS given with programme management:
7.8. Work Plan:
This is indicated in the discussion on each item. As every item needs its own work plan and as
there are five implementing agencies and the mechanisms of each have to be firmed up - the
work plan is best made at that stage.
127
[\( 'H 2 Dr.ilr PIP Chhattisgarh
8.
Programme Management Arrangements:
This shall occur at five levels.these five levels and their functions are given below.________
Level_____________________
Functions_____________________________
Strengthening of the directorate
Administration and Workforce Issues
Infrastructure creation
Procurement and Distribution through a separate
cell for the same .
Strengthening of the State Health Implementation of all technical components of the
Society
programme
Monitoring and evaluation
Financial Management related to programmes:
NGO Programmes
Public Private Partnership Programmes
Operationalizing the State Health and All
Training
Programmes
and
capacity
Family Welfare Society___________ development in the directorate staff
Strengthening of the District Health Implementation of Programmes of RCH
Societies
District and Block Level Plan development
Strengthening of the State Health Mitanin and other community level capacity
Resource Centre:
building and Community basing of Programmes
Operational Research and Policy related Studies:
Assistance in Policy development
Assistance in
Public
Private Partnerhsip
programmes.
Assistance in NGO run programmes.
Assitance to districts in plan development and at
block and panchayat levels.
0,1
3
128
RCH2Draft PIP Chhattisgarh
8.1. Building up skills and manpower in State Health Society and
Directorate:
Lack of skills and manpower at the directorate are a continuing problem at a time when there is
a sharp increase in programmes. RCH-II woulcF represents a major increase in programme
outlay and this would require a corresponding increase in skills and manpower. Coordination
between State Health Society and Directorate is also essential.
Objectives of Programme:
Increase manpower and skills available at the directorate for programme implementation of
RCH-II , and other donor funded special programmes operationalised through the state health
society.
Strategy:
Create a programme Planning and monitoring cell , which acts as the office secretariat for the
state health society and for the RCH-II programme. This should have four consultants
recruited from the open market and four officers of deputy director rank allotted from within
the directorate. The four consultants would be qualified in public health management with or
without medical background.
The eight member monitoring team would be backed by two finance professionals and two
data analysts with software expertise for building up and sustaining a computerized MIS.
_____ Budget Estimate:
Non Recurring Exp.
1
Office set up
and furnishing
Lump sum
1000000
2
Computers,
Photocopier &
Accessories
Computers-11
Printers-3
Networking
Photocopier-1& Accessories
1100000
3
Vehicles
8 Vehicles
(4 for Advisors and
4 for Deputy Directors on
secondment)
6400000
Total
8500000
A
1
B Recurring Exp.
4
Salaries
2005-06
2006-07
2007-08
2008-09
2009-010
Total
4*Rs 30000* 12months
1440000
1512000
1587600
1666980
1750329
7956909
2*25000*12 months
600000
630000
661500
694575
729304
3315379
8*4000*12 months
384000
403200
423360
444528
466754
2121842
3 Staff for Data
Enlrj; analysis,
and assistance
3*4000* 12months
144000
151200
158760
166698
175033
795691
POL
8 vehicles* 10000* 12 months
960000
1008000
1058400
1111320
1166886
5304606
Lumpsum
400000
420000
441000
463050
486203
2210253
90000*12 months
1080000
1134000
1190700
1250235
1312747
5967682
13508000]'
25258400
5521320
5797386
6087255
36172361-
4 Advisors
2 Fin.
consultants
8 Drivers
5
6
6
B
Printing&
Stationary
Office Exp and
conting.
Total
129
RCH 2 Draft PIP Chhattisgarh
8.2.Building management capability at the directorate and in the districts:
Public Health management and administration capability needs to be enhanced at all levels- the
state, the district and the block. Currently most persons at this level are clinicians who are
assigned public health and management functions and learn their skills on the job. The whole
emergence of health administration as a separate professional domain goes unrecognised This
leads to costly administrative lapses and inefficiencies and most programmes fail to expend
their budgets and /or deliver expected outcomes.
At the state level the state health society and the directorate need to have capability building .
We also need to strengthen the two support institutions - the state institute of health and
family welfare and the state health resource centre.
At the district level we need to strengthen the district health societies and in the blocks the
block medical officer. The strengthening at the district and state society level can be done by
the creation of an administrative cadre and specific public health management training and by
the direct recruitment of health management and social work professionals;
Strategies:
Create administrative cadre
Build adequate health management capabilities in district and state level in department
professionals.
Recruit as consultants and outsourcing/in sourcing arrangements for performing key health
management tasks.
Activities:
1. All block medical officers, programme officers, district CMHOs and deputy directors and
above would be considered as health administrators.
2. All health administrators above would complete three months of a mandatory training on
health management. MOU would be reached with management institutions for this
purpose.
3. All those who are equivalent or above to chief medical officer will have an opportunity to
attend a one year course on health management. About 5 persons per year would attend
the course. Costs would be shared between trainees and the government.
si
Head
1
j Fees for 3 months
Management course
for health
administrators
250 HAs__________
Logistics for
Training
250HAs
2
Higher level health
management course
for state level
officials
25 SHAs_________
State Level
Monitoring and
Coordination
3
A
Grant Total
Descriptio
ns
50/year
@Rs.
10000
2005-06
2006-07
# 1
2007-08
2008-09
2009-010
Total
500,000
525,000
551,250
578,813
607,753
2,762,816
1,800,000
1,800,000
1,800,000
1,800,000
1,800,000 •
9,000,000
200,000
210,000
220,500
231,525
243,101
1,105,126
100,000
100,000
100,000
100,000
100,000
500,000
' 2,600,000
' "l,635,000
2,671,750
2,710338
2,750,854
13367,942
50/year
@400*90
days
5/year
@40000
Lumpsum
500000
130
RCH 2 Draft PIP ('hhattisgarh
8.3.Operationalizing the State Institute of Health and Family Welfare.
The state level training institution is needed to coordinate and lead all the training that is
proposed. It also will have some capacity in planning.
A state institute of health and family welfare is already under construction.
Objective:
To build up a management team for the SIHFW so that capability building can begin as
envisaged in the training policy document;
Strategy:
Establish a “Change Management Unit” headed by an HRD expert or recruit a director from
the open market for a three year consultancy. The CMU may also be outsourced to a health
management agency or reputed health NGO who has worked on health policy and health
administration issues. This unit shall recruit the expert staff, train it and build the systems
needed for a functional SIHFW. At the end of three years the management unit would transfer
the institute to the direct charge of the directorate and withdraw leaving behind the staff and
systems and having by then built the capability and linkages by which the directorate shall be
able to guide and be guided by the SIHFW. The SHRC could also be entrusted with this role if
found the best option amongst those who are considered for this.
The operationalisation of a policy and planning unit within this is also part of the functions of a
CMU.
Budget_______
A
Non Recurring Exp.
Building, Furniture &
Fixtures
Equipments
Vehicles
A
B
1
Total________ _______
Recurring Exp_______
Salaries_____________
1 Director____________
5 Expert Faculties______
1 Research & Publication
Officer______________
1 Illustrator cum Graphic
Artist_______________
1 Librarian cum
Documentation officer
1 Lab Assistant________
3 DEOs /Statistical
assistants____________
1 Registrar___________
1 Accountant_________
1 Residential officer and
Premises manager______
3 Drivers____________
5 supporting staff
14,00,000
Computers-15,
Printers-3
Networking
Photocopier-1
Projectors
Sound Systems
Accessories
3 Vehicles(2 four
wheeler and 1 mini
6 wheeler- 1 for
Director and 1 for
rest of senior staff, 6
wheeler for field
trips)
45,00,000
26,00,000
85,00,000
S2005-06?"
2006-07
2007-08
2008-09
2009-010
Total
1 *50000* 12months
5*30000*12 months
600,000
1,800,000
630,000
1,890,000
661,500
1.984,500
694,575
2,083,725
729.304
2.187.911
3,315,379
9,946,136
1 *20000*12 months
240,000
252,000
264,600
277,830
291.722
1,326,152
1 * 15000*12 months
180,000
189,000
198,450
208,373
218,791
994,614
1*10000*12 months
120,000
126,000
132,300
138,915
145,861
663,076
1*5000*12 months
60,000
63,000
66,150
69,458
72.930
331,538
3*4000*12 months
144,000
151,200
158,760
166,698
175,033
795,691
1 * 15000*12 months
1 * 10000*12 months
180,000
120,000
189,000
126,000
198,450
132,300
208,373
138,915
218,791
145,861
994,614
663,076
1 *8000* 12 months
72,000
75,600
79,380
83,349
87.516
397,845
3*4000*12 months
5*300Q.*12 months
144,000
180,000
151,200
189,000
158,760
198,450
166,698
208,373
175,033
218,791
795,691
994,614
131
RCt i 2 Draft PI P Chhattisgarh
2
POL
3
Preparatory Workshops
and material Production
Office Expenditures and
Comtingencies________
_________ Total______
Grand Total
4
3 vehicles* 10000* 12
months
360,000
378,000
396,900
416,745
437,582
1,989,227
Lumpsum
900,000
945,000
992,250
1,041,863
1,093,956
4,973,068
@75000*12
900,000
945,000
992,250
1,041,863
1,093,956
4,973,068
6000000
14500000
6,300,000
6300000
6615000
6615000
,6945750
6945750
7293037.5
7293038
33,153,788
41653788^
132
RCII 2 Draft PIP Chhattisgarh
8.4. District Level Planning and Management Capacity:
Districts are expected to generate plans but currently there are no systems dr capability
building programmes to make this happen.
Build a district level planning team and district level capabilities in district level planning.
Build a planning team composed of four programme officers, the block medical officers and
the chief medical officer. Also two or three from related sectors and two or three from the
private sector/NGOs working in health area.
Train the planning team through a three month programme- designed in consultation with a
health management institute. The course will largely be through correspondence but there
would be 15 days of contact programmes
Budget Estimate :
Non Recurring Exp.
2005-06 8006-07 2007-08 2008-09
2009-010 Total
A
cost
1
A
B
Untied grants
for setting up
office, buying
equipments etc
@ 1,00,000
per district
@ 1,00,000 per
district
Total______
Recurring Exp
1
2
3
4
5
Programme
1*8000*12months
Associates
Fin./Accounting
1*8000*12months
Assistants
Logistics for
25HAs@400*15d
Contact
ays
Training
Untied Grants
for Mobility for
15000*12 months
supporting
block teams
Monitoring and
coordination
Lump Sum
expenses
Total per district
Total for 16 District
100,000
0
0
0
0
.2005-06
2006-07
2007-08
2008-09
2009-010
Total
cost
96,000
100,800
105,840
111,132
116,689
530,461
96,000
100,800
105,840
111,132
116,689
530,461
150000
157,500
165,375
173,644
182,326
828,845
180000
189,000
198,450
208,373
218,791
994,614
28,000
29,400
30,870
32,414
34,034
154,718
550,000
10,400,000
577,500
9,240,000
606375
9,702,000
636693
10,187,100
668528
10,696,455
3,039,097
50,225,555
'
100,000
133
RCH
Prah PIP Chhattisgarh
8.5
Strengthening the SHRC:
Operational research, studies to guide policy planning and programmes to secure community
participation and sustaining the Mitanin programme requires the continued role of the SHRC.
The SHRC unlike the SIHFW is not a governmental institution but an institution representing
state civil society partnership. This requires that the department and government recognize and
welcome the key innovative and watchdog and advocacy role that civil society organizations
have played in securing health rights for the poor. This energy is harnessed to provide an
additional technical and managerial capacity for the department without compromising the
autonomy that is needed for the institution to remain a civil society organization. Thus the
internal organization of the SHRC is left- to the governing body formed by a consortium of
NGOs and government relationship is designed by periodical task assignments and reviews of
work done under MOUs and projects. The SHRC plays a key role in block level $nd panchayat
level capability building also largely by building up trainers and developing replicable models
of such planning. In this proposal itself, the SHRC has the following areas of programme
management: Mitanin Programme, quality management programme for 100 blocks, assisting in
PPPs and designing operational guidelines for urban health, tribal health and panchayat HDI.
Budget:
The entire amount of SHRC budget would be handed over to SHRC as a financial year
allocation, which would be given autonomy on running the institution as per the MoU. In
addition, programme funds would be transferred separately to SHRC, as comes necessary.
The total budget proposed per quarter is 10 lakhs rupees and Rs 40 lakhs per year.
Budget
SI
A~
Head_________
Recurring Exp.
T
Salaries
1 Director
2
3
7
B
3 Programme
Corrdinators
3 Programme
Associates_____
1
Research
Assistant______
I
Accounts
Manager______
I Accountant
1
Office
Assistant
Review
and
Planning
Workshops and
core
publications of
annual reports
and studies
Tour & Travel
Descriptions
2005-06
1 *50000* 12months
3*30000*12
months__________
3*15000*12
months_________
@6000*12 months
600,000
@10000*12
months_________
@8000*12 months
120,000
2007-08
2008-09
2009-10
ToH11
630,000
661,500
694,575
729,304
3,315,379
1,134,000
1,190,700
1,250,235
1,312,747
5,967,682
567,000
595,350
625,118
656,373
2,983,841
75,600
79,380
83,349
87,516
397,845
126,000
100,800
132,300
105,840
138,915
111,132
145,861
116,689
663,076
63,000
66,150
69,458
72,930
331,538
525,000
378,000
551,250
396,900
578,813
416,745
607,753
437,582
2,762,816
1,989,227
598,500
4,197,900
628,425
4,407,795
659,846
4,628,185
692,839
4,859,594
3,149,610
22,091,474
1,080,000
540,000
72,000
@5000*12months
96,000
60,000
Lumpsum
500,000
30000*12 months
47500*12
360,000
570,000
Office
Expenditures
and
Contingencies
Total for an year
2006-07
3,998,000
530,461
134
RCU? Draft PIP Chhattisgarh
8.6 Computerised Health Management Information Systems with
outreach upto block level.
Health management now is largely manual operation. Districts however have been equipped
with computers but their use as a management tool is still sub-optimal. Effective health
management requires that not only district s but that even blocks are equipped with computers,
customised software for health management and web-links and trained personnel to handle
these.
Objectives of Programme:
To ensure that a computerised health management system is in place that links all district
headquarters and at least 50 other CHCs within two years and in all CHCs within 5 years.
Strategy:
1. Ensure that every district has three functional computers and at least 50 CHCs have one
functional computer along with all necessary accessories including web-linkages where needed through wireless protocols by first year and all other CHCs to reach this
stage by next year.
2. Develop a customised health management and information system, complete training
and capacity building and operationalise the system within next two years.
3. Improved data collection and feed in at the peripheri - using “smart cards” is it cn be
made technically feasible. Improved use of the data and feedbacks at the centres- state
by fifth year. The Implementation of smart card based information/reporting system
would depend upon engaging a techno-institution for the development of the
technology and device for the same.
Activity:
Outsource to a health management firm. Their MOU will not only cover development of the
necessary processes but also developing capability to manage this at the state level in the state
level society and in the district health societies.
135
RC11 2 I kali PI P Chhattisgarh
Budget
S
I
A
1
2
B
Head
Computers and
Peripherals
@50000_______
For All District
Head Quarters
For 50 Blocks in
first year_______
For remaining 96
blocks in next
year___________
Smart cards for
all MPWs
(depending upon
the availability of
reliable
technology)_____
For 50 blocks in
first year_______
For remaining 96
blocks in second
year
Recurring Exp.
162 Data entry
operators______
Training of
Officials and
DEOs_________
Repair &
Maintenance
Insurance
Coverage for
electronic
equipments____
Maintenance of
equipments
Transportation
Description
2005-06
16*3*50000
2400000
50*1*50000
2500000
96*1*50000
4800000
@1500
4000*1500
6000000
5000*1500
7500000
162*3000*12
months_____
1*200000*16
dists
1*100000*16
@.5 % of total
price per
annum
162*Rs2500
per centre
162*5000 per
centre______
State level
Lump Sum
monitoring and
@100000’12
coordination
months
Total Recurring Costs for whole
state per annum_______________
Recurring cost For First Year 40%
of estimate___________________
_______ Total per year
Grand Total
23200000
2005-06
O006-07;
2007-08
2008-09
2009-10
5832000
6123600
6429780
6751269
7088832
32225481
3200000
3360000
3528000
3704400
3889620
17682020
1600000
1680000
1764000
1852200
1944810
8841010
116000
121800
127890
134285
140999
640973
405000
425250
446513
468838
492280
2237881
810000
850500
893025
937676
984560
4475761
1200000
1260000
1323000
1389150
1458608
6630758
13163000
13821150
14512208
15237818
15999709
72733884
5265200
5528460
5804883
6095127
6399884
29093554
18428200
41628200
19349610
19349610
20317091
20317091
21332945
21332945
22399592
22399592
101827438
125027438
136
RCII 2 Drub PIP Chhaili; wh
8.7. Improving Financial Management:
Health administration requires high degrees offinancial management and skills. The possibility
of using fund flow for optimising programme Banagement has also never been utilized. At the
current stage even getting utilization certifiaies in time and getting the next instalment of
funds released without breaks in the program® is difficult to manage. We therefore intend to
build in a component to strengthen the financial management of the programme.
Objectives:
1. To train one person at every block leveiin financial maangement.
2. To recruit where needed and further tnin one accounting professional at the district
health society level so as to efficiently lead finance management.
3. To have an efficient financial management arrangment for the health societies as well
as for the public private partnerships atlie state level .
4. To build up a computerised web-interfaced accounting system so that all districts and at
the state level- quarterly and eventually monthly financial statements are submitted and
there are no delays due to weaknesses iithe accounting system
Budget:
SI
1
. O7..
Head
| Descriptions
Recurring Exp.
Honarariums/
Fees
Annual
@30000*12 months
Contract to a including compiling
accounts
Senior
and
Chartered
preparing statements
Accountant
assistance in financial
firm as financial planning
and
management
management
unit__________ contingencies etc.
4
Consultant 4* 60 days * 1000 per
day
Trainers
(MBA/CA) for
district
level
training_______
Tour & Travel 4 persons*20000 Rs
lumpsum___________
for trainers
Training cost 162*250 per head per
for
162
day * 8 days. (incl.
Dist/Block level travel food stationary
Finance persons and material costs)
Total per year
2005-06^ >2006-07
2007-08
2008-09
2008-10 ;-r Total
360000
378000
396900
416745
437582
1989227
378000
396900
416745
437582
2633227
240000
80000
324000
1004000
137
R( !
)rali PIP Chhattisgarh
Budget Section
138
RCII 2 Dralt PIP Chhattisgarh
Section 7.3 Institutional Strengthening
Section 7.3.1 Infrastructure Development For The Public Health System
Budget For 50 Blocks in a year______________ ITEM_______________ Unit Cost
Old Sub centres Renovation/Repair 350/year 10000
No of SCs( only those needing renovation)
Old PHCs Renovation/Repair 100/year
182500
No of PHCs (needing renovation)
New Sub centres Building Construction
650/year
500000
No of SCs
New PHCs Building Construction 100/year
400000
No of CHCs
For new CHCs 15/year
5000000
No of CHCs
For Residential Accommodation in 50 blocks 9000000
TOTAL
2006-07
3675000
2007-08
3858750
350
350
350
18250000
19162500
20120625
5683050
63216175
100
100
100
27
327
325000000
341250000
358312500 376228125 385315481
1786106106
650
650
650
189000000
198450000
567450000
100
100
100
300
6000000
6300000
4410000
16993333
15
15
10
40
75000000
78750000
82687500
86821875
15
15
15
15
1800000 180000000
No of PHCs
CHCs Renovation/Repair 15/Year
2005-06
3500000
2008-09
Total cost
11033750
2009-010
1050
650
634
3234
420499875
60
4500,00,000 472500000 496125000
607750000 1067347500 667839375 468733050 385315481 3196985406
Appox 30 CHCs and 93 PHCs and 408 sub-centers are estimated as not needing renovation
139
RCI \ 2 Draft PIP Chhattisgarh
Budget for Subccntrcs and PHCs in a normative block
ITEM
Unit Cost
Estimated No in One Block
Total Cost
Old Sub centres Renovation/Repair
10000
7
70000
Old PHCs Renovation/Repair
182500
2
365000
New Sub centres Building Construction
500000
13
6500000
New PHCs Building Construction
1800000
2
3600000
4 F; 2 G; 2 H, 2 I type @ a
CHC( Rs 50 Ikhs )
plus for 4 PHCs ( @ Rs 40
lakh)
9000000
Residences for one block
Total
195,35,000
According to data available for -Total No. Sub centes
Total No.
Govt Building needing renovation
Need of New Subcetre
construction
Community Health
_______ Centres______
4692 Total No.
Govt Building needing
1458 renovation_____________
Need of New CHC
2360(3234) construction
Primary Health Centres
Total No.__________________
Govt Building needing renovation
Need of New PHC construction
130
40
60
720(516)
327
189+204
140
PJ II 2 Draft PIP Chhattisgarh
7.3.2.Training
_________ 7.3.2.I. Infrastructure : District Training Centres
SI
A
1
2
A
B
Head
Descriptions
2005-06
2006-07
2007-08
Non Recurring Exp.
2008-09
2009-010
Total cost
2007-08
2008-09
2009-010
Total cost
Refurbish existing
5 centres Rs. 1
500000
_____ lakhs_____
Building,
For establishing 11
Furniture &
more centres: Rs.
Fixtures
25 lakhs each.
27500000
(5*l,00,000)+(ll*
25,00,000)
Computers-1
Printers-1
3200000
Projectors
Sound Systems
Equipments
6 Accessories
Rs. 2,00,000 per
centre* 16 centres
Maintainence of
Equipments
Total
31200000
Recurring Exp.
2005-06
2006-07
Salaries
1 Training Officer
On secondment
0
1
3 Trainers (MSw
qualified
proffessionals)
3*Rs 5000*12
months* 16 DTCs
1440000
3024000
3175200
3333960
10973160
2
1 Data Entry
Operator/Statistica
1 assistant cum
accounting clerk
l*Rs 4000*12
months* 16 DTCs
384000
806400
846720
889056
2926176
1 Residential staff
l*Rs 3000*12
months* 16 DTCs
288000
604800
635040
666792
2194632
3
Untied funds for
Preparatory
Workshops and
material
Lumpsum 1 lakhs
* 16 RTCs
800000
1680000
1764000
1852200
6096200
4
Office
Expenditures and
Contingencies
5,000*12
months* 16 DTCs
480000
1008000
1058400
1111320
3657720
3392000
7123200
7479360
7853328
57047888
Total (A+B)
31200000
(Note: In 2005 -06 and first 6 ninths of 2006-07 since building is under construction no
running costs are shown. From second half of 2006-07, running costs- salaries, actvities, travel
are budgeted for).
141
RCinDr^hPiPC^hhutisgarh
Section 73.2.2
I
Head
Descriptions
80 Trainers
@Rs.l000 per
day*15 days
2005-06
2006-07
2007-08
2008-09
2009-010
Total cost
1200000
1260000
1323000
1389150
1458608
6,630,758
5000 trainees
@ 125Rs a day* 14
days
8750000
9187500
9646875
10129219
10635680
48349273
80 trainers* 10 days
*200
160000
168000
176400
185220
194481
884101
5000*200 Rs per
trainee
1000000
1050000
1102500
1157625
1215506
5525631
125 batches@3120
Rs per batch
390000
409500
429975
451474
474047
2154996
Training of
Trainers
I
Day allowance/
Food and
logistics for
participants
Training Fees
and Travel for
trainers
Stationary and
Training
Material
■>
3
I4
Preparatory
activities
correspondence
Documentation
Report
Preparation
Monitoring
contingencies
and other
training related
expenditures
I
Training of Paramedicals
Grand Total
11500000
12075000
12678750
13312688
13978322 63544759
The training details - who is trained and what is the content-- iis J
\ the corresponding
r„._o section. The number
given in
of days each trainer is needed is only ten days though the totaV number of training days
, 5 are 14. Training of
Trainers has a 15 day training.
B. For Training of Nurses and Paramedics on adolescence health/STIs.
SI
Head
Descriptions
2005-06
2006-07
Total cost
1
Training of Trainers
80 Trainers @Rs.l000 per day* 8
days
640000
672000
1312000
2
Day allowance/ Food and
logistics for participants
3000 trainees @125 Rs a day*6
days
2250000
2362500
4612500
80 trainers*20 days *200
320000
336000
656000
3000*50 Rs per trainee
150000
157500
307500
75 batches@ 2000 Rs per batch
150000
157500
307500
Grand Total ----------------------------------3510000
3685500
---------------------------------------------------
7195500
4
5
Training Fees and Travel
for trainers
Stationary and Training
Material
Contingencies & related
expenditures (10%)
After two years future programmes will conducted with budgets provided for regular retraining
of paramedicals. This, is only for the initial training to introduce this component into the
system.
142
R( H 2 Draft PIP Chhattisgarh
3.2.2. Bl Continuing Medical Education Scheme for Medical Officers
SI
1
2
3
4
5
6
Head________
Preparation and
production of
CME material
Descriptions
Rs 500 per
doctor * 1000
doctors
Postage per
doctor per year
6 times/year*
Rs 20 * 1000
doctors*2
years______
lump sum,
negotiated
based on task
Course
coord inators/eva
luators
honararium
/salary'________
Full time
support staff
CME contact
programmes
over two years
Preparatory
activities,
correspondence^
Documentation,
Report
Preparation,
Monitoring,
contingencies
and other
expenditures
Rs 20,000 *
12 months* 2
years______
Rs 250 per
person * 5
programmes
/year *
2years* 1000
persons
Lumpsum
Grand Total
2005-06'
2006-07
2007-08
2008-09
2009-010
Total cost
500000
525000
551250
578813
607753
2762816
240000
252000
264600
277830
291722
1326152
1200000
1260000
1323000
1389150
1458608
6630758
480000
504000
529200
555660
583443
2652303
2500000
2625000
2756250
2894063
3038766
13814078
80000
5000000
84000
5250000
88200
5512500
92610
5788125
97241
6077531
442051
27628156
143
RCI1 2 Drift PIP Chhattisgarh
7.3.Z.2 -B2 Skill sets for CHCs and Multiskill Training for Specialists
SI
1
Head
For Course on
Emergency OB
Care
For Course on
Anaesthsia
Skill Sets for CHCs and Multi-Skill Training For Specialists:
Descriptions
2005-06
2006-07
2007-08
2008-09
Day Allowance for Doctors
180 Days@150
Rs * 15 doctors
810000
850500
893025
937676
*2
180 Days@150
Rs *15
810000
850500
893025
937676
1 doctors*2
For Course on
60 Days@150
Sick
Rs *15
Neonatal/child
I doctors*2
care___________ I
For Course on
mini Laproscopy/
30 Days@150
conv.
Rs *15
tubectomy/safe
doctors*4
abortions/RTl
Travel and Book
| Total 150
Allowance for
2
doctors@ 2000
participant doctors
Rs
for all courses
Honorarium for Teaching Faculties
6 months@2000
For Course on
Rs *5
1
Emergency OB
faculties/institut
Care
ion* 3 inst* 2
I 6 months@2000
For Course on
Rs *5
2
Anaesthsia
1 faculties*3
2009-010
Total cost
984560
4475761
984560
4475761
270000
283500
297675
312559
328187
1491920
135000
141750
148838
156279
164093
745960
300000
315000
330750
347288
364652
1657689
360000
126000
132300
138915
145861
663076
360000
126000
132300
138915
145861
663076
120000
42000
44100
46305
48620
221025
60000
21000
22050
23153
24310
110513
800000
840000
882000
926100
972405
4420505
4025000
3596250
3776063
3964866
4163109
18925287
402500
359625
377606
396487
416311
1892529
4427500
4648875
4881319
5125385
5381654
24458733
I inst*2
3
4
5
1
For Course on
2 months@2000
Sick
Rs *5
Neonatal/child
faculties*3* 2
care___________
For Course on
i 1 months@1000
mini Laproscopy/
i Rs *5
conv. tubectomy/
faculties*3 inst*
on safe
4
abortion/RTI
Training Facilities
Lump sum
esp. dummies
Net
Contingencies &
related
I Lump Sum
expenditures
@10%
Total
144
RCH 2 Pralt PIP Chhattisgarh
D. Training For ISM Staff
SI
1
2
2a
4
4a
5
5a
6
Head
Material
Production
Training of
Trainers
Training of
Trainers
Honorarium
for state
training
faculties
Expenses for
training all
categories of
staff_______
.Expenses for
training all
categories of
staff_______
Day
allowance
Honorarium
For Trainers
Day
allowance
Honorarium
For Trainers
Other
Training &
related exp.
Descriptions
11 OOpersons @
Rs. 300
80 Trainers*
Rs. 1000
(food / acc) per
day* 25 days
80
Trainers* 1000
Rs. per day* 5
days________
20 faculties
@5000 Rs.
Training For ISM Staff:
Recurring Costs
2005-06
2006-07
2007-08
2008-09
2009-010
Total cost
330000
346500
676500
20,00,000
2100000
4100000
100000
105000
4500000
4500000
400000
420000
441000
1261000
110250
115763
121551
552563
30 Days@
Rs30(J “500
trainees
9000000
10 Days@ Rs
300 *500
doctors/staff
1500000
1500000
1500000
4500000
80 trainers
*250 Rs* 15
days/trainer
300000
300000
600000
80 trainers
*250 Rs * 10
days/trainer
200000
200000
200000
600000
297675
2507925
312559
2548321
328187
2590737
1491920
22781984
Lump Sum
Total
270000
7500000
283500
7635000
145
R(' H
I’-Hi
Chhattisgarh
Section 7.3.3 Ensuring Quality of Care in FRUs and 24 hour PHCs
Item
Block Level Microplanning
2005-06
2006-07
2007-08
2008-09
2009-010
200000
Total
200000
Motivational Meeting
Field
level
Management
2000000
2100000
2205000
2315250
2431013
11051263
1440000
1512000
1587600
1666980
1750329
7956909
7000000
7350000
7717500
8103375
8508544 .
38679419
15000000
25640000
15750000
26712000
16537500
28047600
17364375
29449980
18232594
30922479
82884469
1405,72,059
2564000
28204000
2671200
29383200
2804760
30852360
2944998
32394978
3092248
34014727
14057206
154849265
Programme
Filling of Equipment Gap (35
block /year)
Performance Incentive
Contingencies,
etc(10%)
fees
Total
to
firm
Grand Total
Details of each item- and how the budget for it has been estimated is given in the corresponding section:
146
RCII 2 Draft PIP Chhattisgarh
Section 7.3.4. Strengthening Routine Subcentre Level Services:
Item
Stationary
Mobility
Supervision
quality and
sample
surveys
16 dt annual
external
evaluation
Expanded
ANM drug
kit
2646000
11025000
2008-09
2778300
1 1576250
2009-010
2917215
12155063
Total
13261515
55256313
10500000
11025000
1 1576250
12155063
55256313
1680000
1764000
1852200
1944810
8841010
25200000
26460000
27783000
29172150
13,26.15,150
300
2000
Quantities
8000
5000
2005-06
2400000
10000000
2006-07
2520000
10500000
2000
5000
10000000
1 Ik
16 dists.
1600000
5000
6crores (To be
supplied by
central govt
under FW)
16 dists.
161akhs (Plus
major
equipment
costs to be
Mme by
central goM.)
Unit cost
Rs 12000
Cold Chain
upkeep
1 .Olakhs
Total costs
(Excluding 6 crores that
could be direct central
govt costs)
24000000
2007-08
Note Cost of equipment supplied by GoT is not included in the budget.(a walk in freezer at Rs 50 lakhs is the
main requirement and two walk in coolers are also desirable)
The Central government also supplies the ANM drug kit as of now and thisdi needs to be maintained and
strengthened as indicated in the text.
147
RCH 2 Draft PTP Chhattisgarh
Section 7.2.3 Family Planning
Particulars
Social Marketing Budget
Unit I Unit cost
per month
Stockist Overhead
Sales Force Cost
Warehousing/godown
Administrative cost
2
8
1
1
Total
I 3000
| 2000
: 0
i 5000
2005-06
2006-07
2007-08
2008-09
2009010
Total
72000
192000
0
60000
324000
75600
201600
0
63000
340200
79380
211680
0
66150
357210
83349
222264
0
69458
375071
87516
233377
0
72930
393824
397845
1060921
0
331538
1790305
7. Two Stockists will cover total 16 districts one will be located at Raipur and other one at
Bilaspur
8. Overheads to the stockists mainly relate to cover-up rent for godown and administrative
cost
9. One Sales person will cover two districts and therefore for 16 District their will be
eight persons.
10. Rent for godown is not taken into account as State Government will provide for that.
11. The administrative cost will include report compilation, follow up etc
12. Since the product is offered free of cost -other costs can be recovered from the sales
windows/ agenices recrutied after selling the products- on a commission on sales basis.
148
RCII 2 Draft PIP Chhattisgarh
Section 7.3.5 Public Private Partnerships
Section 7.3.5.1 Public Private Partnerships for Essential & Emergency Obstetric Care:
Budget Requirements for One year :
Approximate Case Load and Reimbursement Costs in a district where one EmOC center has been recruited as a
partner:
Item
Nos. Per Month
Per Unit Cost
Total Cost per
mnth_______
C-section__________
5____________
6000
30,000
Institutional deliveries
30___________
1500
45,000
Sterilisations_______
50___________
800
40,000
Others____________
50___________
200
1,000______
A. Total Monthly
Reimbursement
1,16,000
B. Total Annual
13.92 lakhs
Reimbursement cost for 50 PPP centers:
Rs 696 lakhs( 81. 31%)
Please note referral refunds costs may be included .This fund also lies underutilised.
Programme Management Costs:
A> Variable Programme Costs: shown below for 50 franchisees:/partners
1. Monitoring and Accounting Support
Monitoring 1st level
Appox 25% cases:
Rs 100 per case or
10% of A
Monitoring 2nd level
Accounting costs
Total for one month
Total for 12 months
Appox 5% of cases
2% of A_______
2% of A
1. Monitoring & Accoounting Support for 50 partners per year:
2. Upgradation of Skills & Improvements in clinics & 0.6/partner:
B> Fixed Programme Costs
1.. Programme Administration Costs:
One CEO, 3 prog, officers and one CA firm /per mnth
Travel Costs for state office
Office costs for state office
5 field officers @ Rs 6000pm:
5 filed officers travel and support costs
Total programme management costs per month
Per year
11,600
2320
2320
16,240
1,94,880
97,44,000
Rs 30,00,000
Rs. 85,000
Rs. 15,000
Rs. 30,000
Rs. 30,000
Rs 10,000
1.60,000
19,20,000
2. Promotion Costs:
Brochure /ads/visits:
Accredittation visits: 200 partners* 1500
Training expenses 100* Rs400/day * 10 days
Melas - other promotional activity:
Initial restructuring, brand image promotion,
Total Promotion Costs per year:
Rs 53,50,000
Total Annual PPP Programme support Costs
Rs 160.14 lakhs (18.69%)
Rs 1,50,000
Rs 3,00,000
Rs 4,00,000
Rs 5,00,000
149
R( 'I I 2 Draft PIP Chhattisgarh
Total Annual PPP in emergency obstetric care : budget in brief
Unit
cost
(Rs.)
ITEM
Nos.
2005-06
Reimbursements
50
696,00.000
Programme
Management
1
160,14,000
Total
856.14
856,14,000
2006-07
2007-08
2008-09
2009-10
Total
89894700 <
94389435
991,08.907
1040,64,352
4730,71,394
This projection makes the assumption that we would have only 50 partners and that their total reimbursement
needs would be only in the range of Rs 13 92 lakhs per year per partner - adjusted for inflation. In practice we
expect to increase by about 25% every year. More important we expect to introduce insurance as a complement to
this programme. The exact budget estimats for this would be known later — but we are planning to do it within
current programme management costs.
Section 7.3.S.2. Public Private Partnerships for Ambulance Services
ITEM
Unit
cost
(Rs.)
Nos.
Year
2005-2006
Ambulance
1000000
30
30000000
Referral
fund
200000
100
Total
Year 2006-2007
2007-08
2008-09
2009-10
Total
20000000
21000000
22050000
23152500
24310125
110512625
50000000
21000000
22050000
23152500
24310125
140512625
Section 7.3.S.3. Public Private Partnerships for Laboratory Services
ITEM
Unit
Cost/day
Lab tech (Training of
Master Trainers)
100/-
Unit
cost
Training
days
Nos.
20042005
30
500
1500000
500
2500000 !
20052006
Total
4000000
Establishment
Lab tech (Training of
Master Trainers)
5000/100/-
30
I
100
3000000
8000000
Establishment
Total
5000/-
1000
5000000
4000000
8000000
12000000
150
RCI f 2 Drali PIP Chhattisgarh
Section 7.3.6. Grant — in- aid Scheme for NGOs
Unit cost
(Rs.)
ITEM
30 CLVs
/ANM
equivalents
1
Supervisor
Medical
Assistance
and camp
expenditure
for 100 one
day camps
Staff
Training
Referral
transports
equipments
programme
support and
contingenci
es_______
NGO level
managemen
t costs
Total
State level
Co
ordination
Monitoring
and
Evaluation
Allocation
for special
areas
Nos
2005-06
2006-07
3.60 lakhs
15
5400000
5670000
0.96 lakhs
15
1440000
2.00 lakhs
15
1.20 lakhs
2007-08
2008-09
2008-10
5953500
6251175
6563734
29838409
1512000
1587600
1666980
1750329
7956909
3000000
3150000
3307500
3472875
3646519
16576894
15
1800000
1890000
1984500
2083725
2187911
9946136
1.74 lakhs
15
2610000
2740500
2877525
3021401
3172471
14421898
0.50 lakhs
15
750000
787500
826875
868219
911630
4144223
10 lakhs
15
15000000
15750000
16537500
17364375
18232594
828,84,469
1500000
1575000
1653750
1736438
1823259
8288447
3500000
3675000
3858750
4051688
4254272
19339,709
20000,000
21000000
22050000
' 23152500
24310125
1105,12,625
10%
Total
Total
A medically underserved sector would be roughly contracted out at Rs 10 lakhs per year excluding drugs and
vaccines. Thus the budget is for 15 such areas. All paramedical services would be expected including the
paramedical level curative care package. Part time medical services would be expected. Out of this 10 lakhs, Rs
3.6 lakhs (30 thousand pm) would go to 30 community level workers for 1:1000 population paid at Rs 1000 per
each CLVs or six ANM equivalents at Rs 5000 each with voluntary Mitanins for help. Another 0.96 lakhs would
go for a supervisor @8000 pm. Other expenses are medical camps attended by doctors, administrative costs and
contingencies. The cost of drugs and supplies would be borne by the state in kind who would give them 30 CHV
kits and five ANM kits. State level monitoring is 10% as considerable skill building/moniotring of the NGOs
would be required. The remaining 35 lakhs is for special groups or areas - like primitive tribals or migrantswhere detailed programmes would be worked out.
Budget for NGO grant-in aid per year: 200 lakhs.
CEL?
151
IaJ h - I OJT
09156
RCI12 Draft PIP Chhattisgarh
7.3.7. Community Level Care: Mitanin -II Programme
si
Head
Exp. per
block
per year
2005-06
1
1
1.2.
1.3.
1.4
1.5.
1.6.
1
2
2A
2008-09
2009-10
Total
154511800
162237390
170349259
178866722
187810059
853775230
26746347
28083664
127666947
Social Mobilisation
122250
2.4
25
2
Total
158250
2.3
2007-08
Training
12 Day Training
672000
for 400 Mitanins
Field Training
and Support for
268800
Mitanins
Dt. Trg. of
48000
Trainers*
State Training of
29500
DRPs*
Training
30000
Material *
Skills/and
Capacity
10000
Building *_____
Total
1058300
Folk Media
Trg for above
campaign*
Electronic
Media*
Print Media*
Training CDs *
2.2
2006-07
16000
10000
5000
5000
3
23104500
24259725
25472711
Administrative and Others
3.1
Admin: block
level
60000
3.2
Admin/support
Dt level.
24000
Total
84000
12264000
12877200
13521060
14197113
14906969
67766342
Admin/support
State Level
48000
7008000
7358400
7726320
8112636
8518268
38723624
Grand Total
1348550
19,68,88,300
206732715
217069351
227922818
239318960
1087932144
4
Administrative and Other Expenditures at block .District and state level include travel, coordination meetings,
monitoring, events, correspondence, overheads and contingencies)
152
RCII 2 Draft PIP Chhattisgarh
Section 7.3.7.2 The CHV or Mitanin Drug Kit:
Item
Drug Kit For
Mitanins______
Drug Supplies
for 12 months®
Rs. 150_______
Unit
cost
Nos.
200
60000
12000000
0
0
0
0
12000000
1800
60000
108000000
113400000
119070000
125023500
131274675
596768175
120000000
113400000
119070000
125023500
131274675
608768175
2008-09
2009-010
TOT/XL
2006-07
2005-06
2007-08
2008-09
2009-010
Total
Total
Section 7.3.8.Behaviour Change Communication:
Item
One
strategy
development and
three
material
development
workshops done
twice a year 20
persons
*
10
days* 300 plus
40000 for related
expenses
Block
level
campaigns which
are folk art based
Radio
programmes
three
regional
specific 15 part
radio programmes
broad cast thrice a
year___________
State level event
- inaugurations/
announcements
etc
Cost
per unit
Qty
100000
8
800000
840000
882000
926100
972405
4420505
100000
146
14600000
15330000
16096500
16901325
17746391
80674216
500000
2
1500000
1575000
1653750
1736438
1823259
8288447
100000
3
300000
315000
330750
347288
364652
1657689
210,00,000
220,50,000
231,52,500
243,10,125
1105,12,625
Total
2005-06
200,00,000
2006-07
2007-08
153
RCH 2 Druli PIP ( hhattisgarli
Section 7.3.9. Panchayat Capability Building & Intersectoral Coordination
Item
Development of
index/manual and
dissemination_______
Training of 3
functionaries per GP2 one day camps Rs
70 per day for 2 days
Training of village
and hamlet reps- 2
one day camps per
year Rs 70 per day
for 2 days__________
One NGO per block
as overheads for
conducting the
training providing
support and assisting
govt officers in
compiling the index.
Rs 1000 pm/per
cluster * 12 months
_____________ Total
5% overheads at
state level for
training of trainers,
development of
materials etc._______
Incentive of one 0.5
lakh rupees to two
best panchayats of
each block 0.5 lalkhs
♦2
Grand total
2006-07
2007-08
2008-09
2009-10
Total
12000000
28100000
29505000
30980250
32529263
34155726
1552,70,239
1405000
1475250
1549013
1626463
1707786
14600000
14600000
14600000
14600000
14600000
44105000
45580250
47129263 |
48755726
50463512
2005-06
Qty
70000
3500000
30000
4200000
60000
8400000
1000
GP
cluster
s of 10
GPs
each
146
236033751
See section 7.3.9. for details and explanations:
154
RCH 2 Draft PIP Chhattisgarh
Section 7.2.4 Adolescent Health
Head
Unit
Cost
Training Counsellors
15000
5nos* 15days*Rs 200 By
( NGOs & Govt Staff)
Training peer educators
10000
20nos*5days*Rs lOOBy
(NGOs & Govt Staff)
10000
______ IEC activity:______
Honararium for counsellors
12000
_______ 5*200* 12_______
8000
Overheads contingencies
55,000
_____Total for block_____
Mass screening/counselling
programme in a block for all
children and adolescnet for
iron def.& sickle cell trait
1000000
and disease (Ten blocks in
first year then twenty blocks
in each subsequent year for
_______ four years)_______
Total
2006-07
2007-08
2008-09
2009-010
Total cost
8030000
8431500
8853075
9295729
9760515
10248541
10000000
21000000
22050000
23152500
24310125
100512625
18030000
29431500
30903075
32448229
34070640
144883444
Nos.
2005-06
146
2190000
146
1460000
146
1460000
146
1752000
146
1168000
146
10
Note : The aim is to limit the mass screeding to a few blocks every year- since it is very effor intensive .At the
end of five years we would complete only 90 blocks which are considered having the highest prevalence of
anemia- both sickle and iron deficiency. We would estimate which are the most prevalent blocks during the
first year based on instrituional data and camp based data as sickle detection centers have been set up in all the
districts._______
Mass screening/counselling programme in a block for all. Children and adolescnets for iron def.& sickle cell
trait and disease
Details of Budget for a normative block of one lakh population
Break-up for Rs. 10,00,000 for a normative block is given below.
Approx population in age group 0-25____________________
40% of the population
Approx population to be tested__________________________ 40,000____________
Cost per test (Hemoglobin + solubility including confirmation @ Rs. 15 per test
if positive___________________________________________
1EC and mobilization to get people to participate in_________
Meeting and Kalajtha 100 villages_______________________ (Rs 1000) per village*
6.00,000
1,00,000
Logistics at block level - vehicle, camp arrangement________ 400camps*Rs400
1,60,000
Documentation
20,000
_Total____________________________________ __ _______
10%
Overheads 10
Grant total
9,00,000
90,000
9,90,000
Approximated to 10,00,000
155
RCll 2 Drali PIP Chhattisgarh
Section 7.2.5 Urban RCH
Head
Unit
Cost
Rs
10,000
Rs
20,000
Participatory Mapping
for A category
Participatory Mapping
for B, C, D categories
Health Administrator for
Rs
A, B categories ( for one
20,000
year)________
Community care givers
Rs 4000
Peer educators
Rs 4000
Urban health centers
Secondary centers
Rs 2.6
lakhs
Rs 1.2
lakhs
Social insurance for pilot
ULBs (govt, paid
premium in first two
600
years for category III
beneficiaries)_
Social insurance for pilot
ULBs (govt, paid
premium in first two
300
years for cateogry II
____ beneficiaries)____
Total
Overheads and
management cost for
10%
ULBs/state management
________ Net________
State level co for
management, training
10%
and monitoring
Total Programme Cost
Nos.
2005-06
2006-07
4
210000
0
15
280000
0
29
7000000
7350000
2,400
240
9600000
960000
10080000
1008000
120
31200000
32760000
10
1200000
1260000
5667
3400200
3570210
19000
5700000
5985000
59550200
20Q7-08
2008-09
2009-10
Total
62013210
65113871
68369564
71788042
71788042
5955020
6201321
6511387
6836956
7178804
32683489
65505220
68214531
71625258
75206520
78966846
359518375
6550522
6821453
7162526
7520652
7896685
35951838
72055742
75035984
78787783
82727172
86863531
395470213
The urban health centre cost would about Rs 2.6 lakhs per year. This excludes infrastructure costs though it includes rental costs.
Approx two ANM @ Rs 5,000 per ANM per month, Rs 30,000 package for minor equipments and training, a Rs 50,000 per year
for infrastructure repairs or rent and incidents. Redeployment of existing staff would be able to cover the cost of the third ANM
and male attendant and where needed state will fill the gap. The part time medical office if utilized then Rs 5000per month or Rs
60,000 per year will be paid.
The social insurance premium payments are estimates for a pilot programme. To understand which this has to been along with the
Milan kendra PPP proposal. And the urban RCH proposal annexed. In the pilot phase it is proposed to cover 33,333 houses in
category A Urban areas, 13,333 households in category B urban areas, 6667 households in cateory C towns and , 3333 househols
in category D towns. Of these houses appox 10% would have 100% premium paid by the govt ( category III) while another 30%
would have 50% premium paid by the govt and the remaining 60% are voluntarily recruited in. This budget is needed only on
the assumption that 60% do not voluntarily or mandatory join the schemewith full payment. If on the other hand they join then
from the next year onwards no further subsidy is needed as it would be self sustaining. However since the first year we are taking
up about one sixth of the estimated urban poor population- it would be useful to have a similar sum available to expand the
programme to more and more urban areas each year. The state level mangement cost is high as this is a very experimental
approach and it is going to require considerable management inputs- both consultants and regular to make it viable. For mote
details see correspondng section and the Urban RCH proposal.
156
RCH ? Draft PIP ('hhatlisgarh
Section 7.2.6 Tribal RCH
Head
Unit Cost
Nos.
2006-07
2005-06
Training,PPP.NGO
Programmes. BCC
Epidemiologic studies
| Regional Training Centre at
Jagdalpur and Ambikapur
Total
2007-08
2008-09
2009-010
Total cost
in respective sections
1,500,000
See below
in 7.2.6.I.
8
12000000
60,00,000
60,00,000
13800000
25,38,000
53,29,800
5596290
5876105
33140195
198,00,000
85,38,000
53,29,800
55,96,290
58,76,105
45140195 s
Sub table 7.2.6.1. Regional Training Centres or Tribal Areas :
______ Descriptions
Non Recurring Exp._____
Building, Furniture Refurbish existing centre
at Bilaspur- Rs. 5 lakhs
& Fixtures
Head
$1
A
1
Equipments
2
For establishing 2 more
centres in Jagdalpur and
Sarguja: Rs. 50 lakhs
each________________
Computers-2;Printers-1
Photocopier-1
Projectors,Sound
Systems & Accessories
Rs. 6,00,000/ centre*3
2005-06
500000
10000000
1800000
1 vehicle each for a
1500000
centre. 3*5,00,000
13800000
Total_______________
2005-06
Recurring Exp.___________
Salaries
______
l*Rsl5000*12months*l
1 Principal
*3 RTCs
3*Rs 10000*12 .
3 Expert Faculties
months*3 RTCs
6*Rs 8000*12 months*3
6 Trainers
________ RTCs_______
1 *Rs 4000*12 months*
1 Data Entry
Operator/ assistant _______ 3 RTCs
l*Rs 4000*12 months
1 Driver
_______ *3 RTCs
1 vehicle*Rs5.000*12
POL
months*3 RTCs
Vehicles
3
A
1
2
2006-07
2007-08
2008-09
2009-010
Total cost
270000
567000
595350
625118
2057468
540000
1134000
1190700
1250235
4114935
864000
1814400
1905120
2000376
6583896
72000
151200
158760
166698
548658
72000
151200
158760
166698
548658
90000
189000
198450
208373
685823
3
Workshops&
material Prodn.
Lumpsum 3 lakhs * 3
RTCs
450000
945000
992250
1041863
3429113
3
Office
Expenditures and
Comtingencies
10,000*12 months*3
RTCs
180000
378000
396900
416745
1371645
_________________________________
2538000
13800000
5329800
5596290
5876105
33140195
Total
~
;In —
(Note:
20055 -06 and first 6 ninths of 2006-07 since building is under construction no
running costs are shown. From second half of 2006-07, running costs- salaries, aetvities, travel
are budgetted for).
157
RC1I 2 Draft PIP Chhattisgarh
^Section 8. Programme Management Arrangements
8.1. Building up skills and manpower in State Health Society and Directorate
Non Recurring Exp.
1
Office set up and
furnishing
2
Computers,
Photocopier &
Accessories
Vehicles
A
B
4
2 Fin.
consultants
8 Drivers
3 Staff for Data
Entry &
analysis, and
assistance
6
6
B
Computers-11
Printers-3
Networking
Photocopier-1&
_____ Accessories
8 Vehicles
(4 for Advisors and
4 for Deputy
Directors on
_____ secondment)
Total
Recurring Exp.
Salaries
4 Advisors
5
Lump sum
POL
Printing&
Stationary
Office
Expenditures
and
contingencies
4*Rs
30000* 12months
1000000
1100000
6400000
8500000
2005-06
2006-07
2007-08
2008-09
2009-010
Total
1440000
1512000
1587600
1666980
1750329
7956909
2*25000*12
600000
months_____
8*4000*12 months
384000
630000
661500
694575
729304
3315379
403200
423360
444528
466754
2121842
3*4000*12months
144000
151200
158760
166698
175033
795691
8
vehicles* 10000* 12
months
960000
1008000
1058400
1111320
1166886
5304606
Lumpsum
400000
420000
441000
463050
486203
2210253
90000*12 months
1080000
1134000
1190700
1250235
1312747
5967682
Total
13508000
5258400
5521320
5797386
6087255
36172361
158
RCII 2 Draft PIP Chhattisgarh
Section 8.2 Building Management Capability at the Directorate and in the Districts
si Head
1
2
for
Fees
months
Management
course
for
health
administrators
250 HAs
Logistics
for
Training
250HAs
Higher
level
health
management
course for state
level officials
25 SHAs
State
Level
Monitoring and
Coordination
Descriptions
2005-06
2006-07
2007-08
2008-09
2009-010
500000
525000
551250
578813
607753
2762816
1800000
1800000
1800000
1800000
1800000
9000000
200000
210000
220500
231525
243101
1105126
100000
100000
100000
100000
100000
500000
2600000
2635000
2671750
2710338
2750854
13367942
Total
50/yca r
@Rs. 10000
50/year
@400*90 days
5/yca r
@40000
Lumpsum
500000
Grand Total
159
RC11 2 Dral'i PIP Chhattisgarh
Section 8.4. District Level Planning and Management Capacity
A
i
A
B
1
2
3
4
5
______ Non Recurring Exp.
Untied grants
for setting up
office buying
@ 100000 per
equipments
district
etc @ 100000
per district
Total
Recurring
100000
0
0
0
0
100000
2005-06
2006-07
2007-08
2008-09
2009-010
Total cost
1 *8000*12months
96000
100800
105840
111132
116689
530461
1 *8000* 12months
96000
100800
105840
111132
116689
530461
25HAs@400*15da
ys
150000
157500
165375
173644
182326
828845
15000*12 months
180000
189000
198450
208373
218791
994614
Lump Sum
28000
29400
30870
32414
34034
154718
Total per district
550000
577500
606375
636693
668528
Total for 16 District
10400000
9240000
9702000
10187100
10696455
Exp
Programme
Associates
Fin./Accounti
ng Assistants
Logistics for
Contact
Training
Untied Grants
for Mobility
for supporting
block teams
Monitoring
and
coordination
expenses
3039097
50225555
160
RCII 2l)raftPIPChhauisearh
Section 8.3 Operationalizing the State Institute of Health and Family Welfare
Head
Descriptions
2005-06
si
A
1
2
B
Non Recurring Exp.
Furniture & Fixtures
Equipments
Computers-15
Printers-3
Networking
Photocopier-1
Projectors
Sound Systems
& Accessories
Vehicles
3 Vehicles(2 four
wheeler and 1 mini
6 wheeler- 1 for
Director and 1 for
rest of senior staff,
6 wheeler for field
trips)
Total
Perticulars
1 Director
2008-09
2009-010
Total
600000
630000
661500
694575
729304
3315379
1800000
1890000
1984500
2083725
2187911
9946136
240000
252000
264600
277830
291722
1326152
180000
189000
198450
208373
218791
994614
1*10000*12
months
120000
126000
132300
138915
145861
663076
1*5000*12 months
60000
63000
66150
69458
72930
331538
3*4000*12 months
144000
151200
158760
166698
175033
795691
180000
189000
198450
208373
218791
994614
120000
126000
132300
138915
145861
663076
5*30000*12
months_____
1*20000*12
months
1*15000*12
months
1*15000*12
months
1*10000*12
months
1 Accountant
1 Residential officer
and Premises
manager
1*8000*12 months
72000
75600
79380
83349
87516
397845
3 Drivers
5 supporting staff
POL
3*4000*12 months
5*3000*12 months
—--
144000
180000
151200
189000
158760
198450
166698
208373
175033
218791
795691
994614
vehicles* 10000*1
2 months
360000
378000
396900
416745
437582
1989227
Lumpsum
900000
945000
992250
1041863
1093956
4973068
@75000*12
900000
945000
992250
1041863
1093956
4973068
14500000
6300000
6615000
6945750
7293038
41653788
2
3
2600000
2007-08
1 *50000* 12month
5 Expert Faculties
3
4500000
8500000___________
_____ Recurring Exp.
2006-07
2005-06
______ s_______
1 Research &
Publication Officer
1 Illustrator cum
Graphic Artist
1 Librarian cum
Documentation
officer___________
1 Lab Assistant
3 Data Entry
Operators/Statistical
assistants_________
1 Registrar
1400000
Preparatory
Workshopsand
material Production
Office Expenditures
and Comtingencies
Total
161
RCU 2Drali PIP Chhattisgarh
Section 8.5 Strengthening SHRC
SI
A
1
2
4
B
Head_____ Descriptions
Recurring Exp.
Salaries
1 Director
1 *50000* 12months
3 Programme
3*30000*12 months
Corrdinators
3 Programme
3*15000*12 months
Associates
1 Research
@6000*12 months
Assistant
1 Accounts
@10000*12 months
Manager
1 Accountant
@8000*12 months
1 Office
@5000* 12months
Assistant
Review and
Planning
Workshops
and core
Lumpsum
publications
of annual
reports and
studies
Tour &
30000*12 months
Travel
Office
Expenditures
47500*12
and
Contingencies
Total
2005-06
2006-07
2007-08
2008-09
2009-10
Total
600000
630000
661500
694575
729304
3315379
1080000
1134000
1190700
1250235
1312747
5967682
540000
567000
595350
625118
656373
2983841
72000
75600
79380
83349
87516
397845
120000
126000
132300
138915
145861
663076
96000
100800
105840
111132
116689
530461
60000
63000
66150
69458
72930
331538
500000
525000
551250
578813
607753
2762816
360000
378000
396900
416745
437582
1989227
570000
598500
628425
659846
692839
3149610
3998000
4197900
4407795
4628185
4859594
22091474
162
RCI1 2 Draft PIP Chhattisgarh
Section 8.6 Computerised Health Management Information Systems with
outreach upto block level.
S
I
Head
Description
Computers and
Peripherals
@50000_________
For All District
16*3*50000
1 Head Quarters
For 50 Blocks in
50*1*50000
first year________
For remaining 96
96*1*50000
blocks in next
year __________
Smart cards for
all MPWs
(depending upon
@1500
the availability of
reliable
technology)_____ I
For 50 blocks in
4000*1500
2
first year_______
For remaining 96
5000*1500
blocks in second
year
2005-06
A
B
Recurring Exp.
162 Data entry
operators______
Training of
Officials and
DEOs________
Repair &
Maintenance
Insurance
Coverage for
electronic
equipments
Maintenance of
equipments
Transportation
162*3000*12
months_____
1*200000*16
dists
1*100000*16
@.5 % of total
price per
annum
162*Rs2500
per centre
162*5000 per
centre______
Lump Sum
State level
@100000*12
monitoring and
months_____
coordination
Total Recurring Costs for whole
state per annum_______________
Recurring cost For First Year 40%
of estimate________________ __
________ Total per year_______
Grand Total
2400000
1
2500000
4800000
6000000
7500000
23200000
2005-06
2006-07
2007-08
2008-09
2009-10
Total
5832000
6123600
6429780
6751269
7088832
32225481
3200000
3360000
3528000
3704400
3889620
17682020
1600000
1680000
1764000
1852200
1944810
8841010
116000
121800
127890
134285
140999
640973
405000
425250
446513
468838
492280
2237881
810000
850500
893025
937676
984560
4475761
1200000
1260000
1323000
1389150
1458608
6630758
13163000
13821150
14512208
15237818
15999709
72733884
5265200
5528460
5804883
6095127
6399884
29093554
18428200
41628200
19349610
19349610
20317091
20317091
21332945
21332945
22399592
22399592
101827438
125027438
163
RCII
Draft PIP Chhattisgarh
Section 8.7 Improving Financial Management
S
LL
I 1
I
r
I
Head
Descriptions
Recurring Exp.
Honarariums/
Fees
Annual
@30000*12 months
Contract to a including compiling
Senior
accounts
and
Chartered
preparing statements
Accountant
assistance in financial
firm as financial planning
and
management
management
unit
contingencies etc.
7 Consultant 4* 60 days * 1000 per
Trainers
day
(MBA/CA) for i
district
level !
training
Tour & Travel 4 persons*20000 Rs
for trainers
lumpsum___________
Training cost 162*250 per head per
for
162 day * 8 days. (incl.
Dist/Block level travel food stationary
Finance persons and material costs)
Total per year
2005-06
2006-07
2007-08
2008-09
2008-10
Total
360000
378000
396900
416745
437582
1989227
378000
396900
416745
437582
2633227
240000
80000
324000
1004000
164
RCI1 2 Draft PIP Chhattisgarh
Budget Summary:
SI.
1
2
Programme
Implementation
2005-06
Plan Component
Building
adequate
infrastructure for
ensuring RCH
607750000
services at
appropriate
levels.____
Training
31200000
Infrastructure
Training of
11500000
paramedicals
Training on
adolescent
3510000
health & STIs
Training of
medical officers5000000
CME
Multiskilling
4427500
medical officers
Training for
7500000
ISM staff
Total Training
3
4„
5
6
Ensuring
Quality of care
in FRUs and 24
hour PHCs,
Strengthening
Routine SubCentre services.
Social
Marketing for
Family Planning
Service
Public Private
Partnerships in
Obstetric care
PPP in Referral
transport
/Ambulance
Services
PPP in
Laboratory
Service
TOTAL on
Public Private
Partnerships
2006-07
2007-08
2008-09
2009-010
Total
Section
1067347500
667839375
468733050
385315481
3196985406
7.3.1
3392000
7123200
7479360
7853328
57047888
7.3.2.1
12075000
12678750
13312688
13978322
63544759
7.3.2.2
7195500
7.3.2.2
3685500
5250000
5512500
5788125
6077531
27628156
7.3.2.2
4648875
4881319
5125385
5381654
24458733
7.3.2.2
7635000
2507925
2548321
2590737
22781984
7.3.2.2
63137500
36686375
32703694
34253879
35881572
202663020
28204000
29383200
30852360
32394978
34014727
154849265
7.3.3
24000000
25200000
26460000
27783000
29172150
132615150
7.3.4
324000
340200
357210
375071
393824
1790305
85614000
89894700
94389435
99108907
104064352
473071394
7.3.5
50000000
21000000
22050000
23152500
24310125
140512625
7.3.5
4000000
•8000000
12000000
7.3.5
139614000
118894700
116439435
122261407
128374477
625584019
165
)
RCI1 2 Drall PlPChliattisgarh
)
PIP Component
NGO participation
)
in service delivery
Community Level
Care (Mitanin)
iCHV/Mitanin
____
drug kit
IJ
Behaviour Change
lu
Communication.
Panchayat
Capability
11
Building &
Intersectoral
Coordination
L
Adolescent Health
b2
Urban Health
Tribal Health
( mostlyincluded
in other sections
esp in training
section)________
Strengthening
I
state health
1j
society and
directorate.
Building
Management
capacity at the
Directorate and in
the District
Strengthening
i,
district health
societies.
Strengthening
State Institute of
lo
Health and Family
Welfare.
Strengthening
SHRC.
hr
HM1S
Financial
Management
Improvement
Total
r.
r
2005-06
2006-07
2007-08
2008-09
2009-010
Total
Section
20000000
21000000
22050000
23152500
24310125
110512625
7.3.6
196888300
206732715
217069351
227922818
239318960
1087932144
7.3.7.1
120000000
113400000
119070000
125023500
131274675
608768175
7.3.7.2
20000000
21000000
22050000
23152500
24310125
110512625
7.3.8
44105000
45580250
47129263
48755726
50463512
236033751
7.3.9
18030000
72055742
29431500
75035984
30903075
78787783
32448229
82727172
34070640
86863531
144883444
395470213
7.2.4
7.2.5
19800000
8538000
5329800
5596290
5876105
45140195
7.2.6
13508000
5258400
5521320
5797386
6087255
36172361
8.1
2600000
2635000
2671750
2710338
2750854
13367942
8.2
10400000
9240000
9702000
10187100
10696455
50225555
8.4
14500000
6300000
6615000
6945750
7293038
41653788
8.3
3998000
4197900
4407795
4628185
4859594
22091474
8.5
41628200
19349610
20317091
21332945
22399592
125027438
8.6
1004000
378000
396900
416745
437582
2633227
8.7
1461546742
1845929334
1466673202
1306598569
1264164274
7344912121
166
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