A postulate of Proposed Gujarat State Plan ofOperation RCH Phase - II A postulate of Proposed...
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Transcript of A postulate of Proposed Gujarat State Plan ofOperation RCH Phase - II A postulate of Proposed...
A postulate of Proposed A postulate of Proposed Gujarat State Gujarat State
Plan ofPlan of Operation Operation RCH Phase - IIRCH Phase - II
ByProject Director
RCH
The Process
• Constituting the State Design Team• Adapting Successful Practices • Using Marginal Budgeting for
Bottlenecks (MBB) tool for Resource Allocation
• Resource Mapping• Exclusive Method to analyse
priorities
The State Design Team
• The design team consists of• Experts within Govt. set up &
SIHFW• NGO representatives • UN agencies’ representatives• Experts from IIM Ahmedabad as
invitees
Approach of GoG
• Addressing specific needs in concern areas of:• Rural, Urban and Tribal Health• Environmental Health as a vital
issue• Role of adequate nutrition
Approach of GoG
• Focused Strategies: • Analysing components of IMR,
MMR and TFR dealing with bottlenecks.
Approach of GoG
• Holistic Approach:• Balanced integration with inputs
received in IPD, BDCS, EC Sector Reform
Approach of GoG
• Health and Human Development:• Thrust for Human Development
to maximise reproductive health and not just adopting target-oriented approach.
• Gujarat Vision 2010• Strong commitment
Our Vision 2010Our Vision 2010
Health Indicators
Sr. No. Indicator Current 2005 2010
Health1 Total
Fertility Rate
3.0 2.5 2.1
2 Life Expectan
cy at Birth
(Male)
61.5 65 71
3 Life Expectan
cy at Birth
(Female)
62.8 68 75
4 Maternal Mortality
Rate (1992-93)
3.89 1.5 Below 1
Sr. No. Indicator Current 2005 2010
Health5 Infant
Mortality Rate
60 40 16
6 Under 5 Mortality
Rate (1996)
20.4 15 Below 10
7 Children Immunization Rate
54 80 100
8 Couple Protection
Rate
54.5 65 70
9 % Institution
al Deliveries
55 70 80
Sr. No. Indicator Current 2005 2010
Health Infrastructure1 Sub –
Centers7274 7274 7490
(Rural)1200
(Urban)
2 Primary Health Centers
1054 1100 1229
3 Community Health Centers
254 260 307
4 Functional FRUs
44 100 307
Marginal Budgeting forBottlenecks
• An effort to identify the strengths and weaknesses of implementation of RCH program by means of HH study, Monitoring and validation study and Facility study in 5 districts
• All 3 studies in 40 clusters in each district
Marginal Budgeting for Bottlenecks• HH study: identified 6 families
with infant in a cluster
• MV study:15 PHC, 30 SC (1village in each SC) in 40 cluster area
• Facility study: BEmOC, BEmPaedC and FW at PHC, CHC, DH
HH study
• 40 Clusters by standard cluster sampling tech
• Proportional allocation for Urban and Rural
• Municipal Corporation not included
HH study
• Information for ANC, INC, PNC, Breast Feeding practices, Weaning, FW, Awareness for hygiene, nutrition, Home based management for fever and Diarrhea.
HH study
• A teams of 2 FHW, 2 MPHS (M/F) and 1 MO for each cluster
• 8 teams in each district x 5 days ( 1 for each cluster) = 40
• Orientation of all teams at SIHFW
HH study
• Pre-tested in field
• Participatory planning by District teams
• Data of about 7000 families entered and results are awaited [some results are available but yet to be validated]
Monitoring and Validation Study (MV study)• Team of 2 PG of Public Health/
Community Medicine• 3 Teams in each district x 5 days (1
PHC/ day) = 15 PHC• Orientation at SIHFW with
faculties of Medical Colleges• Questions related to PHC
infrastructure, FHW and TBA skills and availability, accessibility and use of services.
Monitoring and Validation Study (MV study)
• Observations and suggestions by teams are included
• Field tested and includes validation for records and beneficiary
• Overview indicates good skills but need for refreshing
Facility Study
• Initial plans for CHC and DH, PHC included later
• Information specifically for BEmOC and BEmPaedC, scope for assessing skills of personnel
• Could be done in one pilot district
Facility Study
• Planned for other districts also
• Overview indicates need for filling up the posts and updating the skills
• Field work: 16 –26 January 2004
Some findingsSome findingsofof
Marginal BudgetingMarginal Budgetingforfor
BottlenecksBottlenecks
Household Water Source121%
583%144
8%
60232% 1087
56%
Pipeline in house
Public tap
Open Public Well
Other Sources
Public tap/ Hand Pump
Time required for collection of water
54532%
24214%
22614%
16510%
21413%
19812%
805%
1-5 minutes
6-10 minutes
11-15 minutes
16-20 minutes
21-25 minutes
26-30 minutes
31+ minutes
Types of Toilet Facility
124766%
58631%
111%
70%40
2%
No facility
Personal drainage line
Public toilet with drainage
Common drainage well
Common drainage line
Ante-Natal Care Recieved
YES77%
NO23%
% Distribution of ANC Service Provider
52%44%
4%
Doctor
Nurse
Dais
Training Status- TBA
Trained57%
Un-trained43%
Pregnancy period wise % distribution of the first ANC check-up
After 6 months, 26.54
4-6 months, 30.86
First 3 months, 42.6
% distribution of ANC check up received in times
Don't remember, 0.0062
Four times +, 0.2346
Three times, 0.21Two times, 0.2962
One time, 0.253
% Distribution as per services provided at first, second and third ANC examination
None 6.24% 3.54% 1.26%
Foetal Heart Sound 0.0506
Weight Measurement 0.0088 0.0633
Blood Pressure 2.51% 9.73% 1.26%
Abdomen Examination 91.25% 85.84% 86.10%
ANC 1 ANC 2 ANC 3
% Distribution of ANC cases examined by nurses and doctors in Private and Government sector
86
14
22
78
DOCTOR % NURSE %
PRIVATE GOVT.
Other information made available under MBB study• PROVIDER OF INC
• PLACE OF BIRTH
• Cleanliness of Place of delivery, environment offered to the new born
• PNC Provision, number of visits and their timeliness
Other information made available under MBB study• BREAST FEEDING AND
TIMING
• Breast Feeding and use of Colostrums
• Period of Breast Feedin
• Method of Washing Hands
• Use of Mosquito Net
Other information made available under MBB study• Amount of Food and Liquid Given
to Child and Knowledge Quotient• Diarrhea episodes • Source of ORS Pack• Place of Purchase of Medicine• H/O fever episode and Blood
Smear Taken• Vit A instituted and its frequency
Priority fixing
• Diligent use of community based link couple for family and community level care in rural areas and for family and community level care in urban areas.
• Promotion institutional deliveries by providing incentive to TBAs.
Priority fixing
• Increase in institutional deliveries. Staff nurses would be engaged on contractual basis in all PHCs for round the clock services.
Priority fixing
• 100 facilities will be identified (from among District Hospital, Sub district hospital, community health centers and labeled as FRUs) and upgraded for provision of comprehensive emergency obstetric care, New born care, laparoscopic sterilization operation and MTP service
Priority fixing
• Up gradation of 250 facilities (from among CHCs/PHCs) for provision of basic emergency obstetric care, new born care, abdominal TL, MTP and STI/RTI services
Priority fixing
• Up gradation of 1500 facilities (from among PHCs/SCs) for institutional deliveries, FP services, NSV and basic newborn care.
• 250 centers to be developed to provide STI/RTI diagnostic and treatment facilities
Priority fixing
• Strengthening State Project Management Unit and District RCH society thorough employing resource persons, consultants and other necessary human resources.
Priority fixing
• Advocacy for issues of PNDT act, NSV, adverse sex ratio and gender mainstreaming through creating state level forum with active participation of NGOs and other institutions.
Goal/ Outcome/ Output/ Activities
GOAL: IMPROVING QUALITY OF LIFE OF PEOPLE OF GUJARAT THROUGH MAXIMISING WOMEN AND CHILD HEALTH AND ACHIEVING POPULATION STABILISATION
OUTCOME: 1 REDUCED NUMBER OF MATERNAL DEATHS
OUTPUT 1: PROPORTION OF WOMEN WITH DIRECT OBSTETRIC COMPLICATIONS DELIVERING AT EmOC FACILITIES INCREASEDStrategic Intervention 1.1Comprehensive Emergency Obstetric Care facilities are operational
Goal/ Outcome/ Output/ Activities
Strategic Intervention 1.2Basic EmOC facilities are operational during programme period on 24x7 with trained medical officer and 2 staff nurses
OUTPUT 2: INSTITUTIONAL DELIVERIES’ RATE IS INCREASED Strategic Intervention 2.1: Essential Obstetric Care facilities are made availableStrategic Intervention 2.2:Referral Transport for routine deliveries and for Referral of obstetric emergencies by planned transport optionsStrategic Intervention 2.3:Community support system is developed by communityStrategic Intervention 2.4:As per Janani Suraksha Scheme, provide monetary incentive to families and TBAs for accompanying pregnant women for deliveries at institutions
Goal/ Outcome/ Output/ Activities
OUTPUT 3: UNIVERSALISE ANTENATAL COVERAGE FOR PREGNANT WOMEN Strategic Intervention 3.1: Ensure minimum 3 antenatal check ups of all pregnant womenInvolve ANM, TBAs, link couples and AWWs
OUTPUT: 4 HOME DELIVERIES ARE SAFE AND CLEAN (WHEREVER INSTITUTIONAL DELIVERIES ARE NOT FEASIBLE)Strategic Intervention 4.1:Remaining untrained TBAs are trained and skill attendance is encouraged for home deliveredStrategic Intervention 4.2:TBA kits are periodically replenished
OUTPUT: 5 WOMEN RECEIVEIVING POST-PARTUM CARE ARE INCREASEDStrategic Intervention 5.1:Contact on day 1, 2 and 7 and then at 6th week and link with visits for neonates care for integrated mother-child care
Goal/ Outcome/ Output/ Activities
Strategic Intervention 5.1:Conduct audit of maternal deaths in the community in transit or in the hospital
OUTCOME: 2 REDUCED NUMBER OF INFANT DEATHS
Goal/ Outcome/ Output/ Activities
OUTPUT: 1 IMPROVE CARE SEEKING AND REFERRAL OF SICK NEONATES WHO CANNOT BE MANAGED AT HOMEStrategic Intervention 1.1:Improve facility-based care for complex newborn care with visiting specialist doctors, strengthen facilities and increase their utilizationStrategic Intervention 1.2:Basic newborn care facilities are operational during programme period with trained medical officer and 2 staff nursesStrategic Intervention 1.3:Normal new born care is strengthened at all health care facilities through supply of essential life saving drugs, gloves etc. Strategic Intervention 1.4:Educate families, improve skills of AWWs, link couples and ANMs in diagnosing newborn sickness facilitate transportCommunity support system for referral of sick neonates is developed by village community
Goal/ Outcome/ Output/ Activities
OUTPUT: 3 ROUTINE IMMUNIZATION AND OUTREACH SERVICES STRENGTHENED Strategic Intervention 3.1:Reaching out to every child through mobility support for ANM, strengthened cold chain and sterilisation facilities, and series needles through support fund Strategic Intervention 3.4:Strengthen Delivery System through refurbishing cold chain and sterilization equipment Strategic Intervention 3.3:Contracting ANMs on need base for outreach sessions and on specific vaccine daysStrategic Intervention 3.4:Conduct social research/ participatory research with community and ANMs for increased efficiency of ANMs and immunisation
Goal/ Outcome/ Output/ Activities
OUTPUT: 6 REDUCING THE GAP IN HEALTH SYSTEMS OF TRIBAL VS GENERAL PEOPLE Strategic Intervention 6.1:Orientation of Tribal Healers for childhood illnesses and their management through improved treatment seeking behavioursStrategic Intervention 6.2:Local folk artists of tribal areas are made capable of mobilising people to seek for treatment and understand childhood illnesses
Goal/ Outcome/ Output/ Activities
OUTCOME 3: COUPLES HELPED IN ACHIEVING THEIR REPRODUCTIVE INTENTIONS
OUTPUT 1: REDUCED CURRENT UNMET NEED FOR FP METHODS BY 75 % OF EXISTING LEVELS BY 2007Strategic Intervention 1.1:Comprehensive FP services with permanent methods of Sterilisation, NSV and spacing methods and safe MTP services are strengthened under one roof Strategic Intervention 1.2:Increased access to basic FP services of abdominal TL, safe MTP and IUD and other spacing methodsStrategic Intervention 1.3:Access to IUD insertion services improved at the sub centers and access to safe MTP services are increased Strategic Intervention 1.4:Access to non-clinical contraceptives increased through depot holders/link couplesStrategic Intervention 1.4:Improved quality of care for client satisfaction
Goal/ Outcome/ Output/ Activities
OUTPUT: 2 INCIDENT OF HIGH RISK SEXUAL BEHAVIOUR IN 15-49 YEARS REDUCED Strategic Intervention 2.1:Develop 250 health facilities (PHCs/CHCs) to provide quality RTI/STI case managementStrategic Intervention 2.2:Awareness generated on RTI/STI/HIV-AIDS among adolescent and CBO members
OUTCOME: 4 URBAN POOR AND SLUM DWELLERS RECEIVE BASIC HEALTH FACILITIES FOR BETTER LIVINGStrategic Interventions:Establish urban health centres in the towns not having any hospital, CHCs or PHC facilitiesEnsure staff, equipment and medicines are available at Urban Health Centres according to specificationsCreate community based female health volunteer to provide basic health services for minor illness and vaccinations
Resource Mapping
• Besides health statistics, it reveals:• Health and Medical Institutions• Para Medical Training• Medical Manpower• Nursing Staff• Various Health programmes in the
State• Workloads of FP activities• Ongoing surveys of monitoring and
validation and facility surveys will provide the latest information
Areas of concern
• Rural Health
• Low utilisation
• Lack of maintenance
• Rural poor unable to afford Medical expenses
• Lack of education/ awareness
Areas of concern
• Inadequate blood banks
• Paucity of well organised referral system
• Urban Health
• Convergence of Health and Urban Dept.
• Poor Health Status of slum dwellers
Areas of concern
• BPLs unable to secure basic necessity and medical facilities
• Lack of planned efforts
• Over crowding of secondary and tertiary care
• In adequate infrastructure
• Environmental Health
Areas of concern
• Difficulty in quality and quantity of ground water supply
• Excessive salinity, fluorides, nitrites in water
• Concentration of chemical industries
• Improper treatment of biomedical wastes
Areas of concern
• Natural and man made disasters
• Irrigations
• Nutritional Health
• % relying on exclusive breast feeding is less
Areas of concern
• Disparity in Nutritional status in various income levels
• Poor awareness of healthy/ nutritious food
• More focus still requires in under 2 years and the lactating ones
Method Adopted to Analyse Priorities
• Literature Review
• Prepared by various field organisations and institutions to reveal critical issues
Method Adopted to Analyse Priorities
• Carrying out practical studies in form of:• Rapid Household Survey• Monitoring and Validation
Survey• Facility Survey
Other Data Sources
• Data Sources by GoI
• Rapid Household Survey by GOI
• NFHS Survey
• SRS
• Other State Specific information
Action Plan
• Thrust Areas for Human Development Index are reduction in:• IMR• MMR • TFR
Different Levels of Interventions
• Community level
• Awareness Generation
• Trainings & Skill Development
• Strengthening CBWs including link couples and CBOs
• Involving PRIs for a meaningful role
Different Levels of Interventions
• Clinical level
• Quality improvements
• Operationalising FRUs for Comprehensive EmOC
Different Levels of Interventions
• Availing Basic EmOC at CHCs and PHCs
• Skill based trainings for health providers
• Public Private Partnership: Need based out sourcing
Different Levels of Interventions
• Outreach
• Field Visit
• RCH Camps
• Immunisation Sessions on fix days
• Mobile Health Units for inaccessible areas
Broad Strategies to reduce IMR
• FOCUS is on URBAN SLUMS and NEWBORN CARE.
Strategic Interventions
• Neonatal Care: At community, household level as well as hospital for prevention of hypothermia and infection & to go for breast-feeding exclusively.
• Immunization, Diarrhoea, Treatment of ARI
• Dealing with Malnutrition
Strategic Interventions
• Community Campaigns for nutritional goals including change in dietary behavior of community
• Birth spacing as an IMR reducing strategy
• Intersectoral coordination
• Monitoring and supervision
Broad Strategies to reduce MMR
• Identifying Risk Causing Complications (like Bleeding, Eclampsia, Obstructed labour, Anemia, Sepsis):
• Delay level 1: • Community identifies
complications- family decides for Emergency Obstetric Care- IEC Issues
Broad Strategies to reduce MMR
• Delay level 2:• Availability of emergency
transport-mobilization of community resources
• Delay level 3: • Starting the Emergency care at
hospital level and make all FRUs functional
Areas of Strategic Intervention
Two Major thrust areas:
• Essential Obstetric Care
• Emergency Obstetric care
Essential Obstetric Care
• Comprehensive Antenatal care
• Replacing Trained Birth Attendance by Skilled Birth Attendance
• Quality obstetric services at primary Health Center
• Effective Supply management of DDKs
Essential Obstetric Care
• Creating the right Infrastructure• Training for early recognition of
bleeding /prolonged labor / Infection /Abnormal presentation/Convulsions
• Incentive based approach for trained TBAs and early referral for EmOC
• Mobility support- Interest free moped loans to ANMs
Emergency Obstetric Care
• Effective Emergency Obstetric care management
• Strengthening FRUs for effective service delivery with Blood transfusion facilities
• BEmOC to be made available at CHCs and PHCs.
• Skill development at all required stages
Emergency Obstetric Care
• Promoting timely referral by TBAs through training
• Expertise of Gynae and Anesthetists to be made available on panel and promote telemedicine for emergency.
• Emergency transport for cases with complications and needing referral.
Broad strategy for population stabilization
• CNA approach and focusing on unmet needs
• Volunteerism and informed choices as basis of population policy
• Community behavioral change through IEC
Broad strategy for population stabilization
• Community based contraceptive availability
• Skill based training for doctors and paramedics
• Monitoring and supervision: Ensuring filling up all posts of ADHOs, DIECOs and strengthening MIS
Overarching Issues
• Emphasizing Adolescent Health
• Harnessing Technology
• Increasing the Involvement of Stakeholders
• Mainstreaming Gender
• Meaningful role of PRIs
Overarching Issues
• Enhancing Performance of Health Delivery Systems
• Promoting Indian Systems of Medicine & Homeopathy
• Qualitative Improvements in Family Planning
• Establishing Effective Monitoring Mechanisms
• Increasing Awareness among Women
Harnessing Technology
• Harnessing opportunities created by IT revolution for health services through networking of district health offices with the health directorate
• The establishment of GIS• Implementation of the
telemedicine application
Increasing the Increasing the Involvement of Involvement of StakeholdersStakeholders
Type of Organization Role in Health Activities
Academic Institutions Basic and applied researchOperationsTrainingMonitoring and evaluationPolicy guidance/advice
NGOs Providing servicesIEC and Community mobilisationProviding community inputs in planningProviding feedback of government servicesTraining
Professional Bodies (e.g. IMA, Nurses Associations)
Providing support to national health programmesGiving input in planning and policy makingHelping in staff recruitmentPutting forward view of the professionals
Women’s organizations Supporting the programmePutting forward women’s issues and gender issuesHelping monitor programmeHelp in IEC and services delivery
Youth organizations (e.g. NSS, NCC NYK etc.)
Support programme implementationIEC and community mobilizationYouth involvement
Community based organization
IEC and mobilizing communityHelping in service delivery Advice and referralTransport
Religious organizations Helping in promoting healthy lifestylePromoting health by inculcating religious and cultural valuesHelping in services delivery and community mobilisation
Press and Media Projecting the correct and balance image of the health servicesProviding feedback on health service functioningGiving voice to people’s needs and feelingsIEC and mass mobilisation
Voluntary and philanthropic organizations
Providing volunteer time and money for health work
Services Clubs (e.g. Rotary, Lions, JC)
Supporting health awareness and services by volunteer time and money
Corporate Support health activities for employees and families and neighboring villages and help IECProvide funds and help in management development in health department
Judiciary Provide balanced judgments where public interest is developed with individual interestsProvide effective and quick resolution of public grievances
Consumer organizations Protect consumer interests in health with long term view
Enhancing Performance of Health Delivery Systems • Enhancing productivity and
accountability within the department through training programme and systemic changes
• Developing capacity among senior personnel for strategic planning and health systems management
Enhancing Performance of Health Delivery Systems • Improving logistics and
supplies including improvements in the Central Medical Stores Organization
• Optimum utilization of equipments and maintenance of infrastructure
Budget for Human Resource
• Specialists at 100 Comprehensive BEmOC centers (Obstetrician/Pediatrician/Anesthetist on contractual basis)
• Contractual Staff Nurse at All PHCs
• State and district level consultants and support staff
• Village level link couples• Community based health
volunteers in urban areas
Budget for facility improvement
• Civil works
• Repair/renovation at CHCs / PHCs / SCs
• Equipment / Instrument based on facility survey for Comprehensive and basic BEmOC
• Capacity building
Budget for Service provision
• Drugs/ Consumables for EmOC/STI/RTI
• Iron supplement for Adolescent population
• Institutional deliveries
Budget for IEC activities
• Mass Media
• Family and self care-Educational material
• Mahila Swasthya Sangh
• Print media
Budget for Human Resource• Specialists at 100 Comprehensive
BEmOC centers (Obstetrician/Pediatrician/Anesthetist on contractual basis)
• Contractual Staff Nurse at All PHCs• State and district level consultants and
support staff• Village level link couples• Community based health volunteers in
urban areas
Budget for facility improvement
• Civil works
repair/renovation at CHCs /PHCs / SCs
• Equipment/Instrument based on facility survey for Comprehensive and basic BEmOC
• Capacity building
Budget for Service provision
• Drugs/ Consumables for EmOC/STI/RTI
• Iron supplement for Adolescent population
• Institutional deliveries
Budget for IEC activities
• Mass Media
• Family and self care-Educational material
• Mahila Swasrthya Sangh
• Print media
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