mh and rch plan merged
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MATERNAL HEALTHReview Meeting
Bhopal
July 2, 2010
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ACTION TAKEN REPORT
S. No. Decision taken in the last meeting of
Secretaries & Mission Directors
Action Taken Report
1 Comprehensive Plan for a district withfocus on supervision, monitoring and dataanalysis
District Plan for RCH initiated insample districts
2
Defining protocols for institutional delivery,SBA and home delivery
An Operational Guideline forMaternal and New Born Care hasbeen developed and disseminated.
3 Adequate amount of resources for management and supervision
National level: SupportiveSupervision structure finalised.State level: Consultation held withStates for State / District / Statelevel Supportive Supervisionstructure.
4 Quality of services not matching thedemand in the service
With the establishment of Centraland State level supervisorystructures, the quality of servicedelivery will improve.
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1. Delivery Statistics
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Delivery Statistics All India Expected deliveries 266.05 lakhs
Reported deliveries 196.08 lakhs Institutional deliveries 142.86 lakhs 54%Source: HMIS
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Institutional Deliveries: 2009-10
Source: HMIS; % against expected deliveries
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Institutional Deliveries: 2009-10 NE States
Source: HMIS; % against expected deliveries
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Institutional Deliveries:Non HF states 2009-10
Source: HMIS; % against expected deliveries
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Home Deliveries by Non-SBA: 2009-10
Source: HMIS
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2. Facility Operationalisation
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FRUs: Operationalisation till 2009-10
Source: ROPs
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24x7 Facilities: Operationalisation till 2009-10
Source: ROPs
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Observations and Issues
Data from states shows that not all FRUs fulfil the critical criteria offunctionality
Similar observations are made during various state visits/ JRMs/CRMs. Facilities usually designated and reported as FRU/ 24x7without the required inputs/ complement of services in place
Further, variations seen in the figures of operational facilities inpresentations/ different reports (e.g. HMIS, NRHM bulletin, etc.)
State No. of FRUsreported functional
No. of FRUs fulfillingALL 3 critical criteria offunctionality
Assam 60 55
Punjab 168 79Orissa 78 45
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3. Training
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Training Progress till 2009-10: LSAS
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Training Progress till 2009-10: EmOC
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Training Progress till 2009-10: SBA
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Capacity Utilisation of Training Centres EAGStates and Assam
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Capacity Utilisation of Training Centres Non-HF States
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Posting of LSAS & EMOC trained doctors at FRUs EAG States
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Posting of LSAS & EMOC trained doctors at FRUs NE States
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Posting of LSAS & EMOC trained doctors at FRUs Non-HF States
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MH Training Expenditure 2009-10
Source: ROP 2009-10 and FMRs
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Issues All States
Quality of training needs improvement Doctors trained in LSAS and EmOC need to be posted at FRUs on priority.
Posting order for the doctors should come along with the nominations
LSAS and EmOC trained doctors should be issued a G.O. for practicingspecialised skills, since there are several instances of them being usedagain as GDMOs
Bihar and Uttar Pradesh QACs not operational; no alternative monitoring mechanism
No planned monitoring visits by state/ district program officers for monitoringquality of training and implementation of technical protocols
Rajasthan
TIER 1 & TIER 2 examinations for LSAS not conducted in most centers Number of cases that each candidate anaesthetized is below the minimum
criteria set in GOI guidelines; No candidate has undergone CPR training
Gujarat Monitoring of training quality through SIHFW to be revitalised
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Issues J & K
EmOC trainees unable to practice skills at the dist. training centre, sincetrainers are posted to sites other than training centre; quality of training ofconcern; exams postponed no action to resolve the issue
SBA and BEmOC ToT conducted however training not conducted as perprotocols
West Bengal
Monitoring of training quality through SIHFW to be activated SBA training quality needs special attention
Assam, Meghalaya, Sikkim & Tripura QACs functional, but monitoring activities need further strengthening
Manipur QACs in place, but not fully operational
Mizoram QACs in place, but not fully operational
All 8 MOs trained in LSAS yet to undergo 3rd tier exam
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4. Janani SurakshaYojana
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JSY Expenditure 2009-10
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Expenditure 2009-10 JSY vs. RCH II SupplySide : JSY Focus States
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Expenditure 2009-10 JSY vs. RCH II SupplySide: Non-Focus States
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Quality of Care focus states
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JSY Focus States
Penetration of JSY = proportion of JSY beneficiaries out of deliveries at public institutions
Reach of ASHAs = proportion of ASHAs receiving JSY benefits out of JSY deliveries at publicinstitutions
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5. Maternal Death Review
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Status of implementation of MDR
S.
No.
Activity No. of
States
Implemented by
1 Issue Govt. of orderby the States
14 AP, Assam, DNH, Goa, Jharkhand, Karnataka,Kerala, MP, Meghalaya, Mizoram, Rajasthan,
Uttarakhand, TN, Delhi
2 Issue of Guidelines
to the district /facilities
15 AP, Chhattisgarh, DNH, Delhi, Haryana,
Jharkhand, Karnataka, Kerala, MP,Meghalaya, Rajasthan, Sikkim, TN, UP and
Uttarakhand3 Constitution of State Committees
11 AP, Assam, Chhattisgarh, DNH, Delhi,Jharkhand, Kerala, MP, Manipur, Rajasthan,
UP4 Constitution of
DistrictCommittees
9 AP, Assam, Jharkhand, Chhattisgarh, Kerala,MP, Manipur, Rajasthan, UP
5 Orientationprogramme
8 Assam, Jharkhand, Karnataka, Kerala, MP,Rajasthan, TN, Delhi
Based on information received from 30 States/ UTs
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Nearly 12,500 maternal deaths reported
3 out of 5 maternal deaths classified as Other Need for greater orientation of service providers on correct classification
and entry of maternal mortality data.
States to fast track setting up of MDR mechanisms
Source; HMIS
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APPROACH to RCH PLANNING FOR HIGH
FOCUS DISTRICTS
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Identified High Focus Districts represent approximately 35%of population but account for over 41% of births and closeto 50% of IMR and 60% of MMR.
MOHFW identified 264 backward districts based on health
and socio-demographic parameters for focussed attentionto:
Reduce regional disparities
For faster attainment of health goals
MOHFW constituted 8 teams of officers to visit a sample of
districts in the high focus states to prepare RCH sub-plans
Background for District Planning
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Assam Dhubri GoalparaBihar Muzzafarpur SamastipurChhattisgarh Bilaspur Kawardha
Jharkhand Deogarh DumkaM.P Umaria Annupur Orissa Kandmal NayagarhRajasthan PaliU.P. Kanpur Dehat Unnao
Sample Plans
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ight Principles of the district:lan1. Invest resources in strengthening those facilities which are functional and
managing case load.
2. Also identify areas where access is the issue and develop/strengthenfacilities there.
3. Estimate precise training load: ExternalTrainers/Training.
4. Prioritise those providers for training who are providing the bulk of theservices and where access has to increase.
5. Work out the facilities where human resource gaps must be closed as apriority.
6. Strengthen home based care- for deliveries in select sites and for neonates
everywhere.7. Differential financing- more funds to those facilities which require more.
8. Provider incentives- both for volume of work and for those in inaccessibleareas.
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District Planning :BilaspurChhattisgarh
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PLANNING PROCESS
Participatory planning with district and state officials
Analysis of block-wise data to identify service delivery and
utilisation
Field visit observations, data analysis, projected service demand.
Identification of facilities for upgradation
Delivery points at all levels of care identified for
strengthening, including clustering of sub-centres in
under-served areas, based on spatial distribution and
delivery load
Facility-wise gaps identified at all levels
Private facilities roped in wherever available
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DELIVERY STATISTICS: 2009-10
Total Population 22,95,243
CBR 26.1
Expected pregnanicies per year 65897
Total reported deliveries in nos (from HMIS) 64839
Reported deliveries as % of expected pregnancies 98.4%
Actual Delivery as numbers and as % of expectedpregnancies:
Institutional 28398 (43.1%)
Home 36441 (55.3%)
Home deliveries by SBA (assisted by health personnel) 12090 (18.3%)
Home deliveries by non-SBA (not assisted by healthpersonnel/ unassisted)
24351 (37%)
Total Unreported deliveries 1058 (1.6%)
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Delivery Points
FACILITY TOTAL NO.INDISTRICT
CURRENTDELIVERYPOINTS(2009-10)
PROPOSEDDELIVERYPOINTS 2010-11
PROPOSEDDELIVERYPOINTS 2011-12
Med College Hosp 1 1 1 1
DH 1 1 1 1
CHC 11 11 11 11
PHC 75 51 55 70
Sub-centre 357 80 80 80
Private provider* 35 + 35 38 43
TOTAL 480 + 179 186 206
Focus is on strengthening existing delivery points
since utilisation is low
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Delivery Points
FACILITY TOTAL NO.INDISTRICT
CURRENTDELIVERYPOINTS(2009-10)
PROPOSEDDELIVERYPOINTS 2010-11
PROPOSEDDELIVERYPOINTS 2011-12
Med College Hosp 1 1 1 1
DH 1 1 1 1
CHC 11 11 11 11
PHC 75 51 55 70
Sub-centre 357 80 80 80
Private provider* 35 + 35 38 43
TOTAL 480 + 179 186 206
Focus is on strengthening existing delivery points
since utilisation is low
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( - )nnual Budget Summary 2010 2011udget Head ( )mount Rs in LakhsHuman resource .100 32
Infrastructure .260 55Training .139 29
Referral .0 00
PPP .0 00Others .62 53
rand Total .62 68
Budget
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Need Assessment in the 15 districts in 8 states
visited by central team
(analysis done of RCH sub-plans for 15 districts)
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Large HR gaps are seen across allthe districts.
Major requirement is for ANMs and
staff nurses
Several districts have proposed aSupervisory cadre for enhanced
supportive supervision.
Other paramedical staff, e.g. X-Ray,
OT, and ECG technicians, etc.
have also been proposed.
Account for 1/3rd of the budget
required per district.
S.No. Category ofStaff AdditionalRequirement1 Specialists 154
2 MedicalOfficers
289
3 Staff Nurses 7074 ANMs 588
5 Labtechnicians
111
6 ForSupportiveSupervision
66
7 Rural HealthPractitioners
29
8 AYUSHpractitioners
55
HR Gaps
T i i G
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In light of the focus on increasingcoverage of safe delivery servicesby skilled providers, the largestrequirement is for SBA training ofstaff nurses and ANMs.
Additional training sites areproposed to be strengthened tocater to the increased load.
Districts have also proposed multi-skilling of medical officers to fillgaps in critical specialties.
The other major training proposed isfor IUD insertion.
Training accounts for 11.5% of thebudget required per district.
Training Gaps
S.No.
Training Load for 2010-11
1 SBA 1674
2 BEmOC 308
3 LSAS 22
4 EmOC 51
5 MTP 105
6 F-IMNCI 620
7 IUCD 5938 NSV 10
9 Mini Lap 23
10 Lap Sterilisation 3
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INFRASTRUCTURE Includes
Repair/ renovation of existing structures (OTs, labour rooms, boundarywall, water supply, etc.)
Construction of new health facilities (predictably, gaps are large inthese backward districts and states)
Blood storage centres, sick newborn care units (SNCU), newbornstabilisation units (NBSU), ASHA waiting halls in high volumefacilities, etc.
EQUIPMENT
Additional beds, MVA kits (for safe abortion services), generators,equipment for blood storage units, newborn baby corners, NBSUs,SNCUs, etc.
Account for 40% of the budget required per district
Infrastructure Gaps
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Likely Additional
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Budget Head Total for 13districts
Unit cost/district
Projected costfor 235 districts
Human resource 16.68 1.85 435.60
Infrastructure 29.11 2.24 526.15
Training 5.16 0.64 151.48
Referral Transport 0.95 0.12 28.00
PPP 0.73 0.37 85.78
Others 2.83 0.36 83.09
Grand Total 55.46 5.57 1310.10
Amount in Rs. Crore
Likely Additional
Requirement for 235 Districts
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Preparation of similar sub-plans for other backward districts
Steps already underway to involve development partnersand other agencies to provide support to states instrengthening planning and monitoring
Increasing training capacity to handle increased load
States to prioritise interventions in these districts:Ensure strengthening of facilitiesRationalise staff to ensure these facilities have fewer
gapsProvide incentives to staff to work in these facilitiesPrioritise trainingSet up/ strengthen supportive supervision systems
WAY FORWARD
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Thank You
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