Short Programme Review - South-East Asia Regional...

Short Programme Review

Child Health Programme in Rajasthan

2010

Presentations during inaugural session

Shri BN Sharma, Principal Secretary

Health and Family Welfare, addressing

the workshop on the closing day.

Preliminary Facilitator Meeting

Dr ML Jain lighting the lamp to formally inaugurate the proceedings on 21 Sep 2010

Plenary Sessions

REPORT

ON

SHORT PROGRAMME REVIEW ON CHILD HEALTH

IN

RAJASTHAN

Directorate of Health & Medical Services, Government of Rajasthan

Institute of Health Management Research (IIHMR), Jaipur

Norway India Partnership Initiative (NIPI)

World Health Organization, Country Office for India

2010

Contents

Abbreviations ................................................................................................................................................. i

Executive summary ...................................................................................................................................... iii

1. BACKGROUND .................................................................................................................................. 1

1.1 Background information of Rajasthan State ....................................................................................... 1

1.2 Child health situation in Rajasthan ..................................................................................................... 2

1.3 Child health programmes in Rajasthan ............................................................................................... 2

2. The Short Programme Review .................................................................................................................. 3

2.1 Objectives ......................................................................................................................................... 3

2.2 Proposed Participants ....................................................................................................................... 4

2.3 Methods Used ................................................................................................................................. 4

2.3.1 Preliminary data collection and adaptation of Worksheets .......................................................... 4

2.3.2 Data Sources: ............................................................................................................................... 4

2.3.4 Period of Review .......................................................................................................................... 5

2.3.5 Formation of review team ............................................................................................................ 5

2.3.6 Preliminary Workshop ................................................................................................................. 6

2.4 Steps of SPR ..................................................................................................................................... 6

2.5 Inaugural Session .............................................................................................................................. 7

3. Goals and Objectives of the Child Health Programme ............................................................................. 7

4. Neonatal and Child Health Status ............................................................................................................. 8

5. Intervention Coverage ............................................................................................................................... 9

5.1 Interventions and delivery of packages ............................................................................................... 9

5.1 Coverage Indicators .......................................................................................................................... 10

6. Summary of status of the child health programme ................................................................................. 12

6.1 Summary of technical areas along the continuum of care: ............................................................... 12

6.1.1 Status of Implementation ............................................................................................................... 13

6.2 Summary of Strengths and Weaknesses ........................................................................................... 20

6.2.1 Maternal Group .............................................................................................................................. 20

6.2.2 Newborn Group ............................................................................................................................. 21

6.2.3 Child Group ................................................................................................................................... 22

6.3. Identifying the main problems ............................................................................................................. 24

7. Core problems, Solutions and Recommendations .................................................................................. 24

7.1 Listing the Core Problems ................................................................................................................ 24

7.2 Reorganization of Small groups ........................................................................................................ 24

7.3 Group Activity: Completing Worksheet 7 ........................................................................................ 25

7.4 Decide on next steps ......................................................................................................................... 25

7.5 Presentation of findings and finalization of recommendations ......................................................... 25

7.6 Final Recommendations .................................................................................................................... 26

7.6.1 Group I. Policy, Planning and Management / Monitoring and Evaluation .................................... 26

7.6.2 Group II. Human Resources, Training and Strengthening Health Systems ................................... 29

7.6.3 Group III. Health Communication / IEC and Development of Community Supports ................... 32

7.6.4 Core Group: Scaling up of existing interventions for Child Health ............................................... 35

Annexure I: Day wise summary of Steps completed

Annexure II: Worksheet 1

Annexure III : Worksheet 2

Annexure IV: Worksheet 3

Annexure V : Worksheet 4

Annexure VI : Worksheet 5

Annexure VII: Worksheet 6 (Consolidated)

Annexure VIII: Worksheet 7

Annexure IX : List of Participants

Annexure X : List of Documents Reviewed

Annexure XI : Timetable

References

Acknowledgement

It was indeed a great pleasure to host the Short Programme Review on Child Health in Rajasthan, the first

workshop on the SPR CH package in India.

On behalf of the entire organizing team, I express my sincere thanks to Shri BN Sharma, Principal Secretary Health

and Family Welfare, Government of Rajasthan for his keen interest, support and involvement in the programme

which got the entire process rolling.

I wish to thank the World Health Organization for taking the initiative to organize the Short Programme Review in

Rajasthan. Special thanks are due to Dr Samira Aboubaker, Dr Mikael Ostergren, Dr Harish Kumar,

Dr Rajesh Mehta and Dr Paul Francis, for their expert role and guidance throughout the programme. My special

thanks to Dr Subodh S Gupta for his excellent efforts in coordinating the programme on behalf of WHO.

I acknowledge the active participation and contribution of Dr Kaliprasad Pappu, National Coordinator, NIPI and

overall support provided by UNOPS-NIPI for organizing this workshop.

I thank Dr ML Jain, Director RCH, Directorate of Medical and Health Services, Government of Rajasthan for his

unflinching support, active participation and valuable inputs. The success of this workshop owes much to his pivotal

role in constituting the team participants representing the state government in this review. I also acknowledge the

efforts of Dr Anuradha Aswal, Nodal Officer Training and Child Health, Directorate of Medical and Health

Services, Government of Rajasthan for coordinating the state team of participants and helping in data review. I wish

to thank Dr Avatar Singh Dua, UNICEF State Office, Jaipur, Dr Karanveer Singh, Programme Officer Child

Health, NIPI; Dr SP Yadav, Senior Programme Officer, NIPI , Rajasthan; Dr Shiv Chandra Mathur, Executive

Director, RHSRC and Dr Akhilesh Bhargava, Director SIHFW, Jaipur, for sparing time to provide key information

on State programmes during interviews before this workshop.

Much of the success of this workshop goes to the active involvement and participation shown by all the participants.

Inputs given by the state programme managers and the field experience brought in by the district level officials and

programme coordinators were vital to this review. Inputs and active participation by faculty from departments of

Preventive and Social Medicine and Paediatrics, SMS Medical College, Jaipur and representatives from NIHFW

(New Delhi), UNICEF India (New Delhi), , CARE India (Rajasthan), Save the Children (Rajasthan) and Vatsalya

(Jaipur), IIHMR Bangaluru, is gratefully acknowledged.

I must specially mention the contribution of Dr Suresh Joshi, Professor, and IIHMR Jaipur, whose overall guidance,

expertise and lead facilitation were crucial for the success of this workshop.

I take this opportunity to compliment the local organizing team from IIHMR led by Dr Vinod Kumar SV,

Assistant Professor IIHMR for their flawless conduct of the event. I acknowledge the efforts of Mr Gowtham Ghosh

Research Officer, IIHMR Jaipur whose efforts and dedication were evident in the data review. I appreciate the

efforts of Dr Vivek Lal, Assistant Professor, IIHMR Jaipur in the preparations and conduct of the workshop. The

Institute’s administration, finance and computer department deserve special thanks for extending valuable logistic

and other support in facilitating the programme.

Shiv Dutt Gupta, MD,FAMS,Ph.D [Johns Hopkins University]

Director

Institute of Health Management Research

Jaipur

i

Abbreviations

AIDS Acquired Immunodeficiency Syndrome

ANC Ante Natal Care

ANM Auxiliary Nurse Midwife

ARI Acute Respiratory Infection

ASHA Accredited Social Health Activist

AWC Anganwadi Centre

AWW Anganwadi Worker

AYUSH Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homeopathy

BEmOC Basic Emergency Obstetric Care

CEmOC Comprehensive Emergency Obstetric Care

CHC Community Health Centre

CHW Community Health Worker

DLHS District Level Household Survey

DMHS Directorate of Medical and Health Services

EmOC Emergency Obstetric Care

F-IMNCI Facility based Integrated Management of Neonatal and Childhood Illness

FRU First Referral Unit

FWS Family Welfare Statistics

HBPNC Home Based Post natal Care

HIV Human Immunodeficiency Virus

HMIS Health Management Information System

HW Health Worker

ICDS Integrated Child Development Services Scheme

IEC Information, Education and Communication

IIHMR Institute of Health Management Research

IMNCI Integrated Management of Neonatal and Childhood Illness

IMR Infant Mortality Rate

IVR Interactive voice response

JSY Janani Suraksha Yojana

LHV Lady Health Visitor

LSAS Life Saving Anesthesia Skills

MCHN Maternal Child health and Nutrition Day

MD Mission Director

MDG Millennium Development Goals

ii

MMR Maternal Mortality Rate

MNCH Maternal Newborn and Child Health

MO Medical Officer

MoHFW Ministry of Health and Family Welfare

MTC Malnutrition Treatment Centre

NFHS National Family Health Survey

NGO Non-governmental Organization

NIHFW National Institute of Health and Family Welfare

NIPI Norway India Partnership Initiative

NMR Neonatal Mortality Rate

NRHM National Rural Health Mission

NSSK Navjat Shishu Suraksha Karyakram

PCTS Pregnancy and Child Health Tracking System

PHC Primary Health Centre

PHS Principal Health Secretary

PIP Program Implementation Plan

PNC Post Natal Care

PPTCT Prevention of Parent to Child Transmission

RCH Reproductive and Child Health

RHS Rapid Household Survey

RHSDP Rajasthan Health Systems Development Project

RI Routine Immunization

ROP Record of Proceedings

SBA Skilled Birth Attendant

SC Sub Centre

SEARO South East Asia Regional Office

SHSRC State Health Systems Resource Centre

SIHFW State Institute of Health and Family Welfare

SPR Short Program Review

SPR-CH Short Program Review- Child Health

SRS Sample Registration System

UBR Universal Birth Registration

UNICEF United Nations Children Fund

VHND Village Health and Nutrition Day

VHSC Village Health and Sanitation Committee

WCD Women and Child Health Department

WHO World Health Organization

Short programme Review

iii

Executive summary

India is a signatory to Millennium Development Goals. However, as per the Countdown report

2010, India is unlikely to achieve MDG 4 of reducing the under-five mortality rate (U5MR) by

two-third.

As health is a state subject in India, strategic directions for health programs are mostly decided at

this level. Moreover, there are lots of variations between different states in India. Therefore, it

was decided to conduct Short Program Review for Child Health (SPR – CH) at state level in

India. Rajasthan, being one of the focus states for Norway India Partnership Initiative and having

supportive environment for new initiatives in health sector, was chosen for the first Short

Program Review in India.

Consequent to massive investments in the health sector targeting child health through the RCH

II(under NRHM) and ICDS programmes, there have been visible improvements in health status

of children in Rajasthan, being reflected in the decline in the IMR and improvements in various

other morbidity and mortality indicators, but the improvements have not been adequate.

According to SRS 2009, Rajasthan has an infant mortality rate of 63 per 1000 live births and

Under5 Mortality rate of 80 per 1000 live births which is 10 points higher than the national

figure. Decline in IMR has been much less than what would be required to reach the XIth plan

goals of reducing IMR to 32/1000 live births by the year 2012.Furthermore, the Newborn

mortality in the state has remained almost static for past seven years. This is highlighted by the

fact that Rajasthan alone contributes to around 8.4% of country‟s total new born mortality even

though it has just 6% of the national population.

SPR-CH is a review package developed at global level to help decision- making at national or

state level. The package helps programme managers to identify which areas need strengthening –

based on previous experiences and to set new priorities if necessary. As a process, SPR-CH

reviews all the interventions for child health at various levels (facility based, community level or

outreach) directed anywhere along the continuum of care for the mother and child- pregnancy,

delivery, the post-natal period, infancy and older childhood. It also reviews activities in all the

areas which are part of process of implementation of child health programs; including policy,

planning and financing, human resources and training, systems supports (drug, delivery,

supervision, referral etc.), communication, community supports and monitoring and evaluation.

For conducting SPR-CH, a review team of close to 50 members was conceived and included

State level programme managers and consultants, District Programme Managers, Divisional

MCH Coordinators and block level service delivery personnel. In addition, Academic and

Research Institutions (IIHMR Jaipur, SIHFW, SMS Medical College), local and international

Child Health in Rajasthan

iv

NGOs (Save the Children , Vatsalya, CARE) and UN Agencies (WHO, UNICEF and UNOPS)

also participated in the review process.

A one day workshop was held on 20th September, 2010 for reviewing overall preparations,

finalizing the worksheets ( filled in by reviewing and gathering information from different

published documents & other sources) and training of facilitators. The workshop on „Short

program review of Child health in Rajasthan‟ was held from 21st September to 25

th September,

2010 at IIHMR, Rajasthan – India.

SPR-CH adopted a systematic participatory approach consisting of 7 sequential steps which the

team completed in a week. Participants reviewed the available data on maternal and child health

and decided the implementation status of the child health interventions. The review team was

divided into three smaller groups viz Maternal Health, Newborn Health and Child Health

Groups. Participants worked on sequential worksheets of the SPR review process, discussing and

reviewing available data gathered from data review as well as from the policy/programme

documents. Lists of documents used in the data review as well as during the SPR is appended

vide Annexure X.

In addition group discussions enabled sharing of views, experiences and individual discussion

with selected individuals provided more insights. Findings from group discussions were later

presented in the plenary for finalization. Based on the findings, participants defined the main

problems for further analysis. The participants were then regrouped into three thematic groups

policy/planning, management and monitoring & evaluation; Human Resources and Training;

Community supports and IEC, based on the activity areas forming part of the implementation.

Thematic groups discussed and reviewed the problems and identified possible solutions, which

were used as the basis for developing detailed recommendations about what the program should

do in major activity areas.

The recommendations developed by thematic groups were presented before the officials of the

state government and various stakeholders. The feedbacks were recorded and the

recommendations were forwarded to a core team for finalization and prioritization. The core

team had representation from all the stakeholders including the state government, UN agencies

(WHO, UNOPS-NIPI, UNICEF). Representatives from IIHMR were also part of the core team.

The final recommendations were prioritized into two categories - immediate and successive,

taking into consideration their relative importance and feasibility of incorporation in the next or

successive PIPs. The core team also decided to organize a meeting to formally disseminate the

findings of the report to all key stakeholders. The recommendations which merit immediate

priority are enumerated below:


v

Policy Planning, Management, Monitoring and Evaluation

State to ensure that result based monitoring of performance is operational along the

monitoring cascade whereby the state officials monitor the performance of districts,

district officials monitor the performance of the blocks and so on till the sub centre level.

State Health Department to organize capacity building workshops on ‘Programme

Planning and Management’ for block, district and state level officials to promote data

based and need based planning.

Health Directorate to ensure that specific and appropriate plans for improving access to

services are developed by the desert/ tribal districts and other districts for their difficult

to reach areas and support provided for implementation

State government to develop joint planning and joint review mechanisms for ICDS and

Child Health Programmes at district and sub-district level to address Malnutrition,

anaemia and child development in under 3 children.

Joint Supervision by supervisors of Health and ICDS should be done.

HMIS department to develop a plan for orientation of frontline workers and managers to

improve data quality.

State Demographic Cell and HMIS department to plan and conduct

orientation/training of block and district level officials to improve data analysis and

provision of appropriate feedback

State to introduce Neonatal and PNC indicators in the monitoring system

State to assign responsibility to individual officials and programme managers of SPMU

at State level for specific areas of child health programmes with regard to monitoring of

progress, data collections, analysis and feedback.

Departments of Maternal and Child health and ICDS to periodically evaluate quality of

care at health facilities and community level

Human Resources, training and strengthening health systems

Principal Health Secretary (PHS) to lead strengthening of Human Resource

Development Strategy/policy (with adequate reflection of requirement forecasting skills/ set

mix required for MNCH, including policy for induction training development and transfers )

Director RCH to develop a procedure to get quality assurance of trainings conducted.

MD NRHM to lead Review of existing drug supply management to identify specific gaps

and develop state specific solutions

MD NRHM to issue directives for urgent prioritization and integration of supportive

supervision for MNCH services

Director RCH to explore implementation of mechanisms similar to those followed by

immunization division for maintenance of equipments and apply lessons learnt.


vi

Health communication, IEC and development of community supports

Ensure provision of IEC materials as well as AV aids at facility level (CHC and 24X7

PHC level)

Strengthen relevant section on health communication in the state PIP with an activity

plan including R and D with budget allocations.

IEC Activities for child health focusing on the Key Messages

Complete the ongoing training of VHSCs within one year followed by hand holding

support through allocation of a set of villages to PHC level supervisors

Capacity building of supervisors to be completed in the next six months.

Expedite the process of training of ASHA on module 5.

Core Group: Scaling up of existing interventions for Child Health

Scale-up of IMNCI in all districts; Ensure supplies for IMNCI drugs at all levels

Rapid scale-up of F-IMNCI in high-focus districts on priority basis

Strengthening of community-based management of newborn and childhood illnesses

through ASHA and Anganwadi Workers

Strengthening of infra-structure and services for Facility-based Newborn Care in high-

focus districts (includes Special Care Newborn Unit, Neonatal Stabilization Unit and

Newborn Care Corners)


1

1. BACKGROUND

India is a signatory to Millennium Development Goals. However, as per the Countdown report

2010, India is unlikely to achieve MDG 4 of reducing the under-five mortality rate by two-third.

According to SRS 2009, Rajasthan has an infant mortality rate of 63 per 1000 live births which is

10 points higher than the national figure. There is thus an urgent need to improve intervention

coverage and reduce child deaths to come on track towards achieving MDG 4.

SPR-CH has been developed at global level to help decision- making at national or state level.

SPR-CH package helps programme managers to identify which areas need strengthening – based

on previous experiences and to set new priorities if necessary. SPR-CH reviews all the

interventions for child health directed anywhere along the continuum of care for the mother and

child- pregnancy, delivery, the post-natal period, infancy and older childhood. Interventions may

be facility- based (first-level or referral facilities); outreach; or related to behavior change

communication or community mobilization directed at the level of home or community. It also

reviews activities in all the areas which are part of process of implementation of child health

programmes; including policy, planning and financing, human resources and training, systems

supports (drug, delivery, supervision, referral etc.), communication, community supports and

monitoring and evaluation.

As health is a state subject in India, strategic directions for health programs are mostly decided at

this level. Moreover, there are lots of variations between different states in India. Therefore, it

was decided to conduct Short Program Review for Child Health at state level in India. Rajasthan,

being one of the focus states for Norway India Partnership Initiatives and having supportive

environment for new initiatives in health sector, was chosen for the first Short Program Review

in India.

1.1 Background information of Rajasthan State

Covering an area of 342,239 sq km (132,150 sq mi) Rajasthan is the largest state in the Republic

of India. Jaipur is the capital of the State. The population of the state is 56.5 million according to

2001 census, which is 5.49 percent of the national population. The ratio of the rural and urban

population is 77:23. The growth rate of population in the state at 28.41 % was higher than that of

the country 21.34 %. Rajasthan has one of the largest concentrations of SC (17.15%) and ST

(12.56%) population in the country. Socio-economic indicators are, in general lower than the

country average. 60.41% and 43.85% of its total urban and rural female population respectively

is literate, the corresponding figures for India being 64.8% and 53.7% respectively. The sex ratio

is 921 (per thousand males) compared to the country average of 933. The health indicators

particularly IMR and MMR have shown downward trends in the recent surveys (18, 25). Moreover

the Crude Birth Rate is also steadily coming down. This is a positive indication that state is moving in the

direction to achieve goals set for health sector.


2

1.2 Child health situation in Rajasthan

Out of about 26.1 million children born every year in India, 9.38 lakh newborns die before one month of

life. Rajasthan alone contributes to 8.4% of country‟s total new born mortality even though it has just 6%

of country‟s population. In Rajasthan nearly 1.6 million children are born every year while a hundred

thousand die before they are one year old (1)

.

NFHS surveys showed a decreasing trend in IMR, declining from 80 (infants deaths per thousand live

births) in 1998 – 99(20)

to 65 in 2005 -06(18).

Registrar general of India has released the latest estimates of

Infant Mortality Rate (IMR), Crude birth rate (CBR), Crude Death Rate(CDR) for India and all

States/Union Territories, according to which IMR of Rajasthan has declined from 65 to 63/1000 live

births in 2008(25)

. IMR in rural areas has declined from 72/1000 in 2007 to 69/1000 in 2008 and in urban

areas it has declined from 40/1000 in 2007 to 38/1000 in 2008(25)

. Neonatal mortality rate in Rajasthan is

44/ 1000 live births (India -- 36/1000 live births), contributing to about 50% of all deaths in childhood.

Despite massive investments under RCH-II Programme and NRHM, and visible improvements in health

system, the decline in IMR has been inadequate: much less than what would be required to reach the XIth

plan goals of reducing IMR to 32/1000 live births by the year 2012. While there has been some decline in

the mortality among infants from one month to one year of life, the Newborn mortality has remained

almost static for past seven years.

The nutritional status of children in Rajasthan has improved substantially since NFHS-2(20)

, but 44% of its

children under age five years are still underweight (NFHS-3) (18)

. The problem of anemia requires radical

changes in prophylactic measures as 79.6% of the children under-3 years in rural Rajasthan are still

anaemic (NFHS-3) (18)

. According to DLHS-3(14)

(2007-08) 69.8% of children of ARI/fever and 59.7% of

children with diarrhoea had access to treatment. The usage of ORS among children suffering from

Diarrhoea was 30.6% in 2007-8 (DLHS-3) (14)

.

Access to health care and care seeking for sickness among children has definitely improved. Latest data

on care seeking for ARI in any health facility among children <2 years of age was 89.9 percent for the

state. More needs to be done to improve routine immunization coverage. The coverage of complete

immunization in Rajasthan was 53.8% (CES-2009) (28)

1.3 Child health programmes in Rajasthan

As in most of the states of the country Reproductive and Child Health Programme (RCH II) and

Integrated Child Development Services Scheme (ICDS) constitute the two major programmes of the state

directed at child health and nutrition.

RCH II under the NRHM is the state government‟s flagship programme for maternal and child health.

Conceived with a broad perspective the programme caters for the health of mothers and children bundling

the child health interventions across the prenatal to 5 year continuum and has been in action since 2005.

Integrated Child Development Services Scheme (ICDS) by Department of Women and Child (WCD) is

another major programme in the state catering to the health and nutrition interventions for children under

six years.


3

Although the two programmes are under separate departments, there are activities where coordination and

joint efforts are being done to execute the services. ASHA Sahyogini, a common community level worker

who is responsible for delivery of services through both RCH and ICDS is one of the examples of such

coordination.

Based on the fact that three main preventable causes viz, Birth Asphyxia, Prematurity and Infections,

contribute to more than 80% of the newborn deaths, State Plan had envisaged a set of interventions to be

delivered at home, community and Facility levels(4)

. Accordingly the concept of having a network of

Facility Based Newborn Care Centers (FBNCs) was planned to be established at District Hospitals &

Medical college hospitals and linkages with IMNCI and JSY were also conceived thus connecting home,

community and institutional level interventions. Navjat Shishu Suraksha Karyakram (NSSK) was also

launched with the aim of reducing NMR by providing immediate essential newborn care and resuscitation

at birth to every newborn in the institutional setup.

Setting up 38 Malnutrition Treatment Centers was planned and is being implemented in a phased manner

to tackle the problem of underweight and malnourished children.

Expansion of IMNCI from the current status of 9 districts to cover all districts and launch of Facility

based IMNCI (F-IMNCI) is under process. The State Plan focuses on the quality of district level IMNCI

trainings and strengthening and improvement of the supervision activity for IMNCI trained workers by

engaging the supervisory cadre.

Yashoda scheme being implemented by NIPI in its 3 focus districts was adopted for implementation in all

districts of State.

Maternal and Child Health Nutrition (MCHN) Days held at village level under joint collaborative effort

of RCH II and ICDS aims to address the issue of improving routine immunization coverage and level of

Vitamin A supplementation among under 5 children.

2. The Short Programme Review

2.1 Objectives

The overall objective of this review was to identify priorities and to formulate strategic directions

for child health interventions to be implemented in the state of Rajasthan.

Specific Objectives

To review the status of the child health programme being implemented in the state;

Assess progress towards programme goals and objectives and identify the data gaps;

Assess how well the programme implemented its plans in to deliver child health interventions;

Identify the problems programme has faced and to suggest solutions;

Develop recommendations about what the programme needs to do;

Decide on next steps for incorporating recommendations into the work plan.


4

2.2 Proposed Participants

For conducting SPR, a review team of close to 50 members was conceived and was proposed to include

State level programme managers and consultants, District Programme Managers, Divisional MCH

coordinators and block level service delivery personnel. In addition, Academic and Research Institutions

(IIHMR, NIHFW, SIHFW, SMS Medical College), Local and international NGOs (VATSALYA, Save

the Children and CARE India) and UN Agencies (WHO, UNICEF and UNOPS) also participated in the

review process.

2.3 Methods Used

2.3.1 Preliminary data collection and adaptation of Worksheets

The Data Review Team from IIHMR, Jaipur did the preliminary data collection and interview of key

personnel to gather background data on child health situation in Rajasthan.

Worksheets of SPR-CH package were used for the purpose. Some of the items/indicators which were not

found relevant in context of India were removed and new ones were incorporated wherever found

necessary.

Worksheets were filled in by reviewing and collecting information from published documents of various

health surveys as well as state programme implementation plans of the past three years.

Apart from reviewing the documents, some key officials and experts were interviewed to assess the

coverage of various intervention packages and their implementation and performance. Information about

relevant programmes from the experience and views of experts who had been associated with the

programmes for a long time was also incorporated in the worksheets. Various child health programmes

delivered by the Department of Medical and Health services at the state level, were covered in the

worksheets.

2.3.2 Data Sources:

In India health services and morbidity data are derived from three main sources:

(a) The National Family Health Survey (NFHS)

It is a large scale nationwide multiround household survey conducted on a representative sample

of households throughout India. The survey provides state wise as well as national information on

Fertility, Infant and Child Mortality, Maternal and Child Health, Reproductive Health, Nutrition

Anaemia, practice of Family Planning, Utilization and quality of health and family planning

services. Three rounds of NFHS have been conducted since 1992– NFHS I (1992 – 93) , NFHS II

(1998 – 99 ), NFHS III (2005 – 06)

(b) District Level Household Survey (DLHS)

It is a nationwide district level survey designed to provide information on health care and

utilization indicators on Maternal and child health, reproductive health and family planning.

Three rounds of DLHS have been conducted since 1998 – DLHS I (1998 – 99), DLHS II (2002 –

04) and DLHS III (2007 – 2008)


5

(c) The report of the Registrar General of India (RGI):

Office of the Registrar General, India, initiated the scheme of sample registration of births and

deaths in India popularly known as Sample Registration System (SRS) in 1964 65 on a pilot basis

and on full scale from 1969 70. The SRS since then has been providing data on regular basis.

Based on a dual record system the SRS System in India consists of continuous enumeration of

births and deaths in a sample of villages/urban blocks by a resident part time enumerator, and an

independent six monthly retrospective survey by a full time supervisor. The data obtained through

these two sources are matched. SRS bulletins published annually provide up-to-date data on

Birth Rate, Death Rate, Growth Rate and Infant Mortality Rates at National and State Levels.

Apart from above sources, the team also incorporated findings from recent coverage evaluation

survey (28)

and state HMIS. Family Welfare Statistics of India(22)

(2009) published by the

Ministry of Health and Family Welfare , GoI and relevant research papers pertaining to Maternal

and Child Health in Rajasthan were also reviewed for reference and data collection. The complete

list of documents reviewed is appended vide Annexure X.

2.3.4 Period of Review

Since the last set of comprehensive data on various indicators relevant to this review is provided by

NFHS III (2005 – 06), it was decided to keep NFHS-III as the baseline and any data on corresponding

indicators obtained subsequently (including SRS, DLHS-III,CES-2009, HMIS, other sources) was

included in the most recent data.

2.3.5 Formation of review team

In accordance with the composition of the proposed review team mentioned earlier , representatives from

various stakeholders including State Government, International Organizations, NGOs working in the field

of maternal and child health, academic institutions were included to make the 51 member review team.

Representatives from the state Government were finalized in consultation with the Department of Medical

& Health services, Government of Rajasthan, and included state level programme managers and

consultants, district programme managers, divisional MCH coordinators and block level service delivery

personnel.

The team members comprised of nodal persons, experts working in the area of child health and

programme managers concerned with child health interventions and had the following affiliations:

Department of Medical & Health Services , Government of Rajasthan

State Programme Managers and consultants including

- Maternal Health

- IMNCI

- Immunization

- Nutrition

- Health Communication

- HMIS/ Statistics

Health Professionals including Medical Officers/Programme Managers/Coordinators

form District/Block and PHC levels


6

International Organizations :

WHO (Headquarters / SEARO/India Country Office)

NIPI ( India and State Offices)

UNICEF (India and State Offices)

Academic / Research / Training Institutions :

IIHMR (Jaipur and Bengaluru)

NIHFW, New Delhi

SMS Medical College and Hospital, Jaipur

SIHFW, Jaipur

RSHRC

NGOs working in the field of Maternal and Child Health

CARE India State Office

Save the Children State Office

Vatsalya, Jaipur

2.3.6 Preliminary Workshop

A one day preliminary workshop was held on 20th September, 2010 for reviewing overall preparations,

finalizing the worksheets and training of facilitators. Representatives from the Department of Medical &

Health services - Govt. Rajasthan, Institute of Health Management Research (IIHMR), Norway India

Partnership Initiative (NIPI), WHO and UNICEF participated.

2.4 Steps of SPR


7

2.5 Inaugural Session

The workshop was formally inaugurated on 20 Sep 2010 by Dr ML Jain, Director RCH, Directorate of

Medical and Health Services, GoR amidst the presence all the participants of the 5 day programme. The

inaugural session comprised of a presentation on the status of child health in Rajasthan by Dr ML Jain.

Dr Paul F Francis, National Professional Officer and Cluster Focal Point, FHR, WHO SEARO, briefed

the participants on the objectives of SPR. Dr Kaliprasad Pappu, National Coordinator NIPI and Dr SD

Gupta, Director IIHMR, Jaipur also spoke on the occasion.

3. Goals and Objectives of the Child Health Programme

As part of Step 1 of the SPR, goals and objectives of the child health programme were discussed in the

first technical session on Day 1. Working in a plenary the group discussed the programme goals and

objectives as per filled Worksheet 1 which included the programme goals and objectives from the two

major programmes on child health – RCH II and ICDS. In addition goals / objectives of relevance to child

health from disease control and other programmes were also included. Participants discussed whether

goals and objectives were written clearly and whether they were realistic and measurable. It was agreed

upon that though most of the child health related goals and objectives are clearly laid out, some of them

were either too general or were not measurable.

Goals:

The participants concluded that the Goals laid out under various programmes were satisfactory except the

one for “Reducing Newborn Deaths” which was felt to be too general and lacking clarity as to what

reduction to achieve.

Objectives :

The review team concluded that program implementation plans of the state as described in Worksheet 1,

does have many objectives which are clear and measurable but there were certain others which were

either not measurable or were not really framed as objectives. The objectives like “strengthening IEC

activities”, and “strengthening of newborn facilities at tertiary level hospitals” were not measurable while

some activities like “setting up of level II neonatal ICUs” were put under program objectives.


8

4. Neonatal and Child Health Status

Continuing in the afternoon session on Day 1, the group worked in plenary to review and discus the

indicators for maternal, newborn and child health status. In the facilitator guided discussion, the group

reviewed worksheet 2 (which was prefilled). Each indicator was reviewed by asking the following

questions:

Are data available?

Has the target been met? (if a target has previously been established)

How has it changed over time? Is it going up or going down?

Does it differ between different regions or groups?

Are there any problems with the validity or reliability of the data – are new or different methods

needed?

Consensus was arrived at for each indicator and the status was marked by: (a) Ticking for indicators with

positive results; (b) crossing those with negative results and (c) shading those with need for more data.

Summary of Key Findings :

The group reviewed available data and discussed trends to identify areas where the programme has been

doing well and those where the programme is off track and needs to do more. In addition the discussion

also focussed on finding data gaps and identified indicators with need for data collection.

The program has been doing well for improving coverage of delivery by skilled birth attendants mainly

by the marked increase in institutional delivery under Janani Suraksha Yojana. This is likely to reduce

maternal mortality.

There were a number of indicators where the progressive trends were either not on track, static or had no

set targets. Neonatal Mortality rate was identified as a key area where significant efforts would be

required. Moreover, there was no set target in the state plan for this indicator. Infant Mortality and under

five mortality rates had shown decline but the group concluded that going by the present trends,

achievement of MDG targets was unlikely. Review of data on childhood morbidity showed that

comparable data was available only for the prevalence of ARI/Pneumonia and Diarrhoea. It was found

that there was a declining trend in childhood morbidity represented by these conditions. Decline in

prevalence of anaemia among children had been insufficient and prevalence of low birth weight babies

had been relatively static.

Data on causes of death in infants and mothers were limited to few research papers and there was no

available data on causes on child mortality. It was concluded that there was a definite need to have more

data on state specific causes of death among these groups. More data was required on the prevalence of

micronutrient deficiencies, especially Vitamin A.


9

5. Intervention Coverage

Step 2 of the SPR aimed at assessing the interventions included in the child health programme, delivery

mechanisms and review of the intervention coverage indicators. The participants were divided in three

smaller groups – maternal, newborn and child. Each group had a facilitator and rapporteur for the session.

In accordance with the SPR guidelines (29)

, worksheets were first discussed within the small groups, each

group covering its respective area. Updates and conclusions were finalized by the rapporteur in consensus

with members of the group. Updates were then shared in a plenary with the rapporteurs of each group

making their presentations followed by discussion and further update of the worksheets. This process was

done in sequence for worksheets 3 and 4.

5.1 Interventions and delivery of packages

The group reviewed and discussed worksheet 3 considering the following aspects

Interventions that are currently delivered

Levels at which the interventions are currently delivered

Description of packages under which the interventions are delivered

Extent of implementation : whether complete or partial

Accordingly the findings were discussed and summarized under the three heads:

(a) Availability and levels of delivery of interventions.

Interventions available were appropriate in terms of requirement and the levels at which they are being

delivered. The groups did not identify any such intervention which is lacking and needs to be introduced

afresh except IYCF, which is already being planned to be implemented.

(b) Description of packages under which the interventions are delivered :

Maternal: ANC, BEmOC, CEmOC, PPTCT, Safe Delivery Package, PNC/HBPNC

Newborn: NSSK, FBNC, IMNCI, Yashoda, PNC/HBPNC, RI, Control of Malnutrition, PPTCT

Child: IMNCI, RI, ICDS, IYCF (under planning),

(c) Extent of Implementation:

There was considerable variation in the extent of implementation of various intervention packages.

Packages which have been implemented throughout the state include ANC, PNC, BEmOC, CEmOC,

NSSK, RI, Control of Malnutrition, Supplementary Nutrition (Under ICDS), Control of ARI / Diarrhoea.

Packages with limited implementation include:

IMNCI : Currently implemented in 9 districts. Being expanded to all districts.

Yashoda : Implemented in 3 NIPI focus districts. Taken up for implementation in all districts.

HBPNC : Only in 3 NIPI action districts.

PPTCT : Currently implemented in 10 districts.


10

5.1 Coverage Indicators

Participants split again into the small groups to review worksheet 4 (Prefilled) to review the coverage

indicators. Each indicator was reviewed by asking the following questions:

Are data available?

Has the target been met? (if a target has previously been established)

How has it changed over time? Is it going up or going down?

Does it differ between different regions or groups?

Are there any problems with the validity or reliability of the data – are new or different methods

needed?

Consensus was arrived at for each indicator and the status was recorded by rapporteur by : (a) Ticking

for indicators with positive results; (b) crossing those with negative results and (c) shading those with

need for more data.

Summary of Key Findings:

The groups reviewed available coverage data and discussed trends to identify areas where the programme

has been doing well; those where the programme is off track and needs to do more and areas where there

were major issues. In addition the discussion also focussed on data gaps and identified indicators with

need for data collection.

(a) Coverage indicators with positive trends and realistic targets

Programme was found to be doing well with regards to the intranatal and immediate post natal care, being

reflected in positive trends in the data on Appropriate Cord care and Hygiene for Deliveries at Home and

Immediate Postnatal Visit. NFHS III data showed that 89.5% of babies delivered at home had the cord

cut with a clean instrument. Similarly the proportion of mothers/ newborns receiving a care contact

within first two days of delivery increased from 7.7% in 1998 – 99(20);

to 37.3 % in 2007 – 08 (14)

. With

the current rise of institutional deliveries to above 70% (28)

and universal PNC visit in case of institutional

deliveries; the target of achieving 80% immediate PNC visit mentioned in the State PIP appears realistic .

Micronutrient supplementation (except in case of Vitamin A) was another area where the indicators have

shown a healthy trend. Proportion of mothers who received iron supplementation during pregnancy has

gone up steadily from 29.2 % in 1992 – 93 to 39.3% in 1998 – 99 (20)

and was 57.7% in 2005 – 06(18)

.

Proportion of children living in household using iodized salt has also increased from 35.1% in 2005 – 06 (18)

to 58% in 2009.(28)

Care seeking for pneumonia has also risen promisingly. Proportion of children with suspected pneumonia

taken to appropriate provider has increased from 64.7% in 2005 – 06 (18)

to 89.9% in 2009 (28)

which is

sync with the set target of 90% access in the State PIP for 2010 – 11(4)

.


11

(b) Coverage indicators with positive trends but programme needs to do more

Proportion of institutional deliveries has increased steadily from 22.5% in 1998 – 99 (9)

to being 31.4% in

2002 – 04 (11)

to 45.4% in 2007 – 08 (14)

. The impact of JSY was visible in significant further increase in

the proportion of institutional deliveries shown to be close to 70% as per the CES by UNICEF in 2009(28)

.

But the figure is still far from the desired target of 90% by 2011 kept under the state PIP 2010 – 11(4)

.

There are disparities in terms of rural urban differences and inter-district variations and although the

trends are good, achievement of target is unlikely.

Appropriate complimentary feeding for children in the age group of 6 -9 months has been quite low and

the proportion of infants aged 6-9 months who received appropriate breast feed and complimentary

feeding stood at 43.7% in 2007 – 08 (14)

.

Management of diarrhoeal diseases in children has also shown a positive trend. Proportion of children

with diarrhea who received ORT rose from 4.7% in 1998 – 99 (14)

to 30.6% in 2007 – 08 (14)

and the latest

data puts the figure at 45% (28)

. Though has been a progress in improving access of such children to ORT

but it falls short of the target of increasing it to 60% by 2010(4)

.

(c) Coverage indicators with negative results – major issues; programme needs to do more

The review team identified a number of coverage indicators for priority interventions showing negative

results, ie, with downward or static trends. Additionally, there were some which have fallen short of

achieving the targets or with widespread disparity in coverage among sub-groups.

Considering the intervention of adequate antenatal care, coverage measure reviewed was the proportion

of mothers who received at least 3 antenatal visits. The latest coverage figure stood at 55.2% in 2009(28)

which is far short of the target of 80% by 2010-11(4)

Moreover there were wide regional and subgroup

differences.

Proportion of mothers who received 2 doses of Tetanus Toxoid had risen from 28.3% in 1998 – 99(9)

to

59.1% in 2002 – 04(11)

and then declined to 50.9% in 2007 – 08(14)

. There were significant rural urban and

subgroup variations too.

Identification and treatment of maternal emergencies such as eclampsia and obstructed labour was

reviewed by looking at the proportion of rural pregnancies having a caesarian; which was 2.2% in 2005

– 06 (18)

. This is less than one fourth of the corresponding figure of 9.9 % in urban areas.

Prevention of hypothermia as assessed by reviewing the data on babies delivered at home; who were

dried, wrapped (and not bathed) immediately after birth shows that the proportion was 34.2%(18)

of the

total babies born at home.

Immediate initiation of breastfeeding as seen from the trends in proportion of mothers who initiated

breast feeding within one hour of birth did show an increase from 14.5 % in 2002 – 04(11)

to 41.4 % in

2007 – 08(14)

but the findings from the Coverage Evaluation Survey 2009 show an alarmingly low figure

of 27.7%(28)

. Moreover, there are widespread regional differences in the practice. The proportion of

babies who received a prelacteal feed was 71.6 % in 2005 – 06(18)

.

Proportion of infants under 6 months exclusively breastfed continues to be relatively low at 65.4 % .(18)


12

Routine Immunization coverage is another area of major concern. Coverage of 0 dose OPV has dipped

from 33.8% in 2002 – 04 (11)

to 33.1% in 2007 – 08. (14)

Most recent HMIS data also reports coverage of

40% for 0 OPV. Percentage of children aged 12 – 23 months who received measles vaccine increased

from 35.9% in 2002 – 04(11)

to 67.3% in 2007 – 08(14)

. CES 2009 however, revealed coverage of

65.6 %( 28)

. State target of achieving coverage of 80% by 2010(4)

thus seems unlikely.

Vitamin A supplementation has not kept pace with the laid down targets. Proportion of children who

received a dose of Vitamin A increased from 22.4% in 2002 – 04(11)

to 52.5% in 2007 – 08(14)

and 60.5%

in 2009(28)

which falls short of the target of 90% by 2009 -10 as laid down under the XI Five Year Plan

Goals for Rajasthan.

Considering the proportion of children who received appropriate antimalarials, the figure of 9.0 % for

2005 – 06(18)

is in fact less than that of 13.9 % in 1998 – 99.(20)

6. Summary of status of the child health programme

Step 3 of the SPR was to critically review the activity areas in the field of child health Programme along

the continuum of care, find the status of implementation, reasons for the observed performance and

identify the strengths and weaknesses of the programme using worksheet 5. The Worksheet had 6 cross

cutting areas as heads under which the review was to be undertaken – namely (a) Policy, Planning and

Management; (b) Human Resources and Training (further divided into In-service and Pre Service

Training);(c) Health Communication/IEC; (d) Development of Community Supports; (e) Strengthening

Health Systems and (f) Monitoring and Evaluation. Day 3 was fully dedicated to discussion and review of

worksheet 5. The participants continued in smaller groups i.e, maternal, newborn and child health groups.

Customized worksheets for each small groups were used. Each group had a facilitator and rapporteur for

the session. As in Step 2, the worksheet was first discussed within the small groups, each group covering

its respective area. Some supporting data filled in the worksheets along with the plan documents were

utilized for assistance. In addition, field experience of the participants helped to guide the discussion.

Updates and conclusions were finalized by the rapporteur in consensus with members of the group.

Updates were then shared in a plenary with the rapporteurs of each group making their presentations

followed by discussion and further update of the worksheets.

6.1 Summary of technical areas along the continuum of care:

Each group started by reviewing the activity areas in their respective areas as applicable in the continuum

of care. Discussion initially sought to identify the activity areas delivering the intervention packages and

then proceeded to decide the status of implementation.


13

6.1.1 Status of Implementation

Policy, Planning and Management

Status of implementation was complete in most of the activity areas under this head for all the three

groups (Table 6.1). Maternal group had all activity areas being fully implemented except No 5 (Annual

budget adequate to complete all activities in the last plan). Activity area No 4 (Planning done

collaboratively with other divisions and with donors) was considered to be partially implemented with

regards to the packages under the New Born group . For the child group, activity area No1 (Practice

standards and guidelines updated and being used) was in a partial state of implementation for F-IMNCI

excepting which all others were considered to have a full status of implementation.

Table 6.1 GroupWise summary of activity areas and status of implementation

(Activity Head: Policy, Planning and Management)

S

No Activity Area

Groups

(Intervention Packages)

Maternal

(ANC, SBA, EmOC,

PNC)

Newborn

(PNC, FBNC)

Child

(IMNCI, UIP,

Facility based

interventions)

Status of Implementation

(Fully, Partially or not at all)

1 Practice standards and guidelines

updated and being used Fully Fully

Fully (Partially for

F – IMNCI)

2 Essential drug list available Fully Fully Fully

3 Budgeted plans developed annually

– at the state and district levels Fully Fully Fully

4 Planning done collaboratively with

other divisions and with donors Fully Partially Fully

5 Annual budget adequate to complete

all activities in the last plan Partially Fully Fully


14

Human Resources / Training (In Service)

Status of implementation was mostly inadequate in majority of the activity areas under this head and all

the three groups marked them as partially implemented.(Table 6.2)

Table 6.2 Groupwise summary of activity areas and status of implementation

(Activity Head : Human Resources / Training (In Service))

S

No Activity Area

Groups


Maternal

(ANC, SBA, EmOC,

PNC)

Newborn

(PNC, FBNC)

Child

(IMNCI, UIP,

Facility based

interventions)



1

Plan to ensure adequate staffing at

each level, which includes

incentives

Partially

Partially (Not

adequate for

FBNC)

Partially

2 In-service training strategy available Fully

Partially (Not

adequate for

FBNC)

Partially

3 In-service training conducted for

health staff Partially Partially Partially

4 In-service facilitators trained Partially Partially Partially

5 Follow-up after in-service training

conducted Partially Partially Partially

6

Quality of in-service training – are:

types of staff trained, materials

used, time allocated, amount of

clinical practice adequate?

Partially Partially No information

available


15

Human Resources / Training (Pre Service)

Status of implementation was inadequate or not at all implemented in most of the activity areas under this

head and all the three groups marked them as partially implemented or not implemented. (Table 6.3)


(Activity Head: Human Resources / Training -Pre Service)

S

No Activity Area

Groups


Maternal

(ANC, SBA, EmOC,

PNC)

Newborn

(PNC, FBNC)

Child

(IMNCI, UIP,

Facility based

interventions)



1 Pre-service training strategy

available No Partially

Fully (Partially

for F – IMNCI)

2

Pre-service training incorporated

into curricula of medical and other

schools

Partially Partially (only

IMNCI)

Partially (Only

IMNCI)

3 Pre-service trainers trained No Partially Partially

4

Quality of pre-service training –

materials used (including

textbooks), time allocated, amount

of clinical practice adequate?

No information Inadequate No Information


16

Health Communication / IEC

In case of the Maternal health Group, most of the activity areas were in a state of partial implementation

(Table 6.4) although the status of development and distribution of messages and materials seemed to be

adequate. It was heartening to note that under this head, barring few; most of the activity areas were

considered fully implemented by the newborn and child health groups. Newborn health group concluded

that focus on reaching low level populations was an area of partial implementation. Child health group

felt that implementation status of development and distribution of messages and materials as well as the

quality of the messages in terms of adaptation to local context and pretesting remains inadequate.


(Activity Head: Health Communication/IEC )

S

No Activity Area

Groups


Maternal

(ANC, SBA, EmOC,

PNC)

Newborn

(PNC, FBNC)

Child

(IMNCI, UIP,

Facility based

interventions)



1

Maternal / Child health

communication strategy or plan

available

Partially Fully Fully

2 Focus on reaching low level

populations Partially

Partially (Separate

plan from Desert &

tribal areas)

Fully

3

Communication activities

conducted: mass media, printed

materials, training for local

groups/volunteers in inter-personal

communication; training for health

workers


4 Messages and materials developed

and distributed Fully Fully Partially

5

Quality: Key Maternal / Child

health messages used; messages and

materials pre-tested and adapted for

local context

Partially Fully Partially (no

field testing)


17

Development of Community Supports

This activity head again had many activity areas which were considered to be partially implemented by all

the groups. Availability of trained community volunteers and the quality were two such areas where all

the three groups felt that more need to be done to achieve full implementation. In comparison,

Availability of implementation plan for community level activities as well as that of trained community

health workers were better implemented (Table 6.5).


(Activity Head: Development of Community Supports )

S

No Activity Area

Groups


Maternal

(ANC, SBA, EmOC,

PNC)

Newborn

(PNC, FBNC)

Child

(IMNCI, UIP,

Facility based

interventions)



1

Implementation plan for

community-level activities

available

Fully Fully Partially

2 Community health workers trained

and available

Fully (ASHA,

AWWA) Partially

Fully (ANMs,

LHV, AWW)

3 Community groups or volunteers

trained and available Partially Partially Partially

4

Quality: Developed collaboratively;

use local staff and volunteers;

supervision or oversight plan

Included

Partially Partially Partially


18

Strengthening Health Systems

This activity head is an area of concern as almost all the activity areas under it were thought to be in a

partial state of implementation by all the three groups. Availability of essential drugs and equipment at

first and referral levels in respect of the child health group was the only activity area considered to be

adequate.


(Activity Head: Strengthening Health Systems )

S

No Activity Area

Groups


Maternal

(ANC, SBA, EmOC,

PNC)

Newborn

(PNC, FBNC)

Child

(IMNCI, UIP,

Facility based

interventions)



1 Quality of case-management No Partially Partially

2

Services available

Partially (EmOC

partially available,

remaining fully

available)

Partially Partially

3 Essential drugs and equipment

available at first and referral levels Partially Partially Fully

4

Routine supervision conducted

using checklists, and observation of

practice


5 Systems for timely referral for

maternal complications in place Partially Partially Partially


19

Monitoring and Evaluation

Activity areas under this head are in a mixed state of implementation, with GroupWise differences. (Table

6.7). Functional status of vital registration systems and use of monitoring data for routine planning at

various levels was considered to be incomplete by all the three groups. In contrast, availability of

population and health facility data for monitoring and evaluation was considered adequate by all groups.

Remaining activity areas had varied implementation status across the three groups, being partial with

regard to some while being full in the others.


(Activity Head : Monitoring and Evaluation )

S

No Activity Area

Groups


Maternal

(ANC, SBA,

EmOC, PNC)

Newborn

(PNC, FBNC)

Child

(IMNCI, UIP,

Facility based

interventions)



1

Plan for routine monitoring and

periodic evaluation of the maternal

health programme included in

strategic plan and work plans

Fully for

Monitoring ,

Partially for

evaluation

Fully Partially

2 Standard international indicators used


3 Short and long term targets set

Fully Partially Fully

4

Population- and health facility-based

data available for monitoring and

evaluation

Fully Fully Fully

5

Monitoring data used for routine

planning by all levels


6 Vital registration systems working



20

6.2 Summary of Strengths and Weaknesses

After identifying the Activity areas for each of the activity heads each group discussed the strengths and

weaknesses for every activity area. Policy and plan documents as well as field experience of the

participants yielded the necessary inputs to required making the consensus. The strengths and weaknesses

identified by the groups are summarized under the sequentially below:

6.2.1 Maternal Group

Maternal group considered ANC, SBA, EmOC and PNC packages and identified the following strengths

and weaknesses:

Strengths:

Systems and mechanisms are in place to enable updating of practice standards and guidelines

District plans contribute to making of State level Budgeted Plans

Essential drug lists uploaded on website

Email connectivity up to block level HMIS availability online block level and upwards

Provision of contractual hiring and rural health cadre

Presence of autonomous training institutes

Availability of adequate number of trained in service facilitators

Provision of supervisory checks for in service training

Availability of adequate budget for Health communication / IEC activities along with special budget

for low level areas.

Support from donor partners in development of IEC/communication materials and use of standard set

of materials across the state.

Budget for community level activities and creation of Village Health and Sanitation committees in

all villages

Concurrent monitoring system

Trained Health workers and ambulance attendants for managing and transferring emergencies

Weaknesses:

Limited awareness of policies at field level

Essential Drug lists not displayed at facility level

District plans not developed in time

State proposed budget is usually slashed by the center.

Non availability of specialists

Attrition among contractual staff

In service training : Non compliance by candidates identified for training; Inadequate capacity and

frequent transfers of training staff ; limited training sites ; limited capacity to follow up in service

training; Injudicious utilization of facilitators

Lack of orientation of medical / nursing education according to the need of medical programmes

IEC weak for EmOC and PNC


21

Lack of coordination between NRHM and RHSDP for IEC/Health Communication

All relevant messages are not covered under IEC

VHSCs : Formation of VHSCs took longer than planned; all VHSCs are not active; only 30 – 40%

VHSC members are trained

Shortage of medicines

Emergency transport and referral mechanisms available in some blocks only

6.2.2 Newborn Group

Newborn group considered PNC and FBNC packages and identified the following strengths and

weaknesses:

Strengths:

Commitment from Government

Partnerships with collaborating agencies / donors

Availability of resources

Adequate funds for maintaining essential drugs

Development of plans done in participatory manner with involvement of important stakeholders

Strong partnership for FBNC training

Adequate facilitators available for NSSK

Plan for monitoring FBNC through State Level Newborn cell

ICDS involved for supportive supervision of community based newborn care

Systems for timely referral : Refrral card/availability of funds/Ambulance services

HMIS – Online system

Pregnancy and Child Health tracking system (PCTS) established

Indicator based monitoring

Vital Registration System : Maternal and Infant Death Inquiry and being scaled up

Weaknesses :

Essential drug list not updated regularly

Template based planning – lack of flexibility

Less involvement of ICDS

Underutilization of Budget and complicated financial processes

Vacancy of ASHA

Inservice training :Handholding supervision after training is poor; Inadequate number of facilitators

for IMNCI/FBNC; Training protocols not followed in training institution; Less number of facilities

for conducting training; Lack of quality assurance mechanism for training

Pre Service training : not started in all medical colleges; New Born component is inadequate

IEC : Distribution and dissemination of IEC materials is inadequate; Content and impact evaluation

is not done; weak monitoring; operational and managerial issues

Post training support and handholding of community health workers is not adequate.

All community workers not covered in training


22

Training of ASHA completed only for a few modules

Quality issues in ASHA training

Poor training and follow up

Lack of infrastructure and supportive supervision

Lack of awareness and acceptance of services

Lack of feedback and accountability for community based services

Poor referrals despite having referral system and services

Poor quality of data

Lack of proper system for analysis of data and feedback to providers

No system for monitoring quality of care

Targets not available for all indicators

Exact data required for planning is not always available

Training of managers in planning process is weak

Vital Registration System : Home deliveries and deaths at home not being registered

6.2.3 Child Group

Child Group considered IMNCI, UIP/RI and FBI packages and identified the following strengths and

weaknesses:

Strengths:

Good policies, guidelines updated regularly

Existence of implementation plans; availability of multi level plans for monitoring and supervision

of child health services

Participation of districts through District action plans(Bottom up Approach)

Joint Planning undertaken at State Level. Increasing involvement of Medical Colleges and training

Institutions

Hiring of contractual staff

Mainstreaming of AYUSH personnel

In Service Training : Specific training packages for each intervention group; Training plan/calendar ;

Two Designated Sites for providing trainings; Entry in service book of candidate

IEC : Special directorate at State level; District IEC coordinators; Adequate budget for IEC

activities; Inclusion of IEC in all major training packages; development of variety of materials

pertaining to major interventions; presence of technical committee to ensure correctness and local

adaptation of messages.

Placement of ASHA; trainings of ASHA; availability of funds at community level; dedicated training

packages for various community groups

Mechanism of providing services through village health and nutrition days (VHND)

Regular supplies of drugs and equipment through partner support

Availability of Ambulance services

Online system of sending and receiving reports; Facility level surveys and HMIS to monitor facilities

and services


23

Use of standard indicators for planning; Targets based on community surveys and determined bottom

up and validated by demography cell

Availability of disaggregated data even at peripheral levels

Monthly review meetings for progress in implementation

Weaknesses:

Lack of some critical operational elements like supportive supervision mechanisms

Most plans and policies are either centrally determined or adopted from National guidelines .

Frequent change of directives and circulars

Matching of drug list with the intervention packages has not been done

IMNCI planning confined to training plan only

Convergence with ICDS inadequate. Collaboration with other divisions and donors not uniform at all

levels

Underutilization of funds

Delays in filling vacancies

In service Trainings: Lack of coordination and integration of trainings; Frequent disruptions in

trainings; Multiplicity of trainings; Training calendar not adhered to; Frequent transfers and lack of

reorientation training of facilitators

Pre Service Training : National strategy not endorsed at state level; No set plan for pre service

training; IMNCI training not present in Nursing colleges

IEC : Strategy does not have a comprehensive plan on using appropriate media mix; Implementation

and reach are suboptimal; Loss of materials developed in the past; Slow pace of trainings of

IPC/BCC packages; Field testing aspect often ignored; Evaluation of materials not undertaken

Community Supports : Involvement of community not as per desire, non formal leaders are not

involved; . Timeliness of training and quality of training is variable especially those given through

NGOs; Weak supportive supervision

Manpower not appropriately trained to use equipment

Maintenance of equipment not streamlined

Inadequate supervisory manpower for field level supportive supervision

Inadequate monitoring at lower levels

Analysis of computerized data at block level is inadequate

Review mechanisms are more administration oriented rather than programme oriented.

Use of HMIS data and triangulation is limited

Standard international indicators are not internalized by system on regular basis

Lack of techno managerial skills to set realistic targets; Unrealistic targets

Proper analysis and use of available data on population and health facilities is limited

Lack of demand of astute data by decision makers; Very limited data is used in planning

Vital registration not yet universalized


24

6.3. Identifying the main problems

Worksheet 5 provided specific set of strengths and weaknesses for various cross cutting activity areas of

intervention packages for all the three levels along the continuum of care. (Pregnancy, Newborn and

Child groups ). Next logical step was to identify the main problems by reviewing and summarizing the

weakness listed in Worksheet 5 which was done by completing Worksheet 6 .

Continuing to work in small groups through the second half of Day 3, participants picked up the

important weaknesses from worksheet 5 and summarized them as the most important problems, picking

4-5 from each activity area.

The problems were then presented and discussed in the large group.

7. Core problems, Solutions and Recommendations

7.1 Listing the Core Problems

A final list of the most important problems from each activity area across the continuum of care was

discussed in the large group in the first session of Day 4. Common problems across the groups were

clubbed together and the most critical ones were selected for inclusion in the final list. The main problems

were summarized as per the six activity areas – (a) Policy, planning and Management; (b) Human

Resources and Training; (c) Communication/IEC ;(d) Development of Community Supports; (e)

Strengthening Health Systems and (f) Monitoring and Evaluation . The final list of problems formed the

basic input for Step 5 which was conducted on Day 4, to develop solutions and recommendations by

completing worksheet 7.

7.2 Reorganization of Small groups

The small groups were reorganized in accordance with the activity areas :

Group I : Policy, Planning, Financing and Management; Monitoring and evaluation.

Group II : Health Communication/IEC; Development of Community Supports

Group III : Strengthening Health Systems; Human Resources and Training

Each group had its facilitator and a rapporteur. The groups were given copies of adapted Worksheet 7 and

the final list of problems identified. Each group then discussed the main problems faced in their

respective thematic areas.


25

7.3 Group Activity: Completing Worksheet 7

The groups started by taking each problem in turn. The selected problem was entered in the first column

of the worksheet. In the facilitator guided discussion the groups then identified and discussed the possible

causes to the problem. Consensus was taken and the causes were listed in the second column on the

worksheet. Possible solutions were explored keeping in view the main categories of programme activities

and by reasoning how these could be strengthened to overcome the causes of the problem. The possible

solutions were written down in the column succeeding the listed causes. Based on the solutions the groups

formulated recommendations. Groups aimed at developing clear and concise recommendations which

would be action oriented and practically feasible.

Each group developed its set of recommendations in respective thematic areas. Completed worksheet 7

was then presented in plenary session.

7.4 Decide on next steps

Immediately after completion of the worksheet 7, the core group consisting of the representatives from

the state health department, UN organizations (WHO, UNOPS-NIPI, UNICEF) and IIHMR met to

decide on the future steps on ensuring the incorporation of recommendations into the state PIP. It was

decided that the recommendations would be formally presented to the Principal Secretary Health,

Government of Rajasthan on day 5 and subsequently finalized by incorporation of important feedback. It

was also decided that the finalized set of recommendations would then be prioritized in consultation with

the members of the core group for incorporation in the next and subsequent PIPs.

7.5 Presentation of findings and finalization of recommendations

The groupwise findings of SPR were formally presented to Shri BN Sharma, Principal Secretary Health,

Department of Health and Family Welfare, Government of Rajasthan in the closing meeting on 25

September 2010. He assured full support from the Health department with regards to the incorporation of

the recommendations in the upcoming PIP. The feedback on the presentation was recorded for

subsequent prioritization and finalizing of the recommendations. The findings were then forwarded to the

members of the core team for prioritization. Final recommendations are presented in the subsequent

section below.


26

7.6 Final Recommendations

7.6.1 Group I. Policy, Planning and Management / Monitoring and Evaluation

Core problems and recommendations:

(a) There is a gap in communication, uniform interpretation and follow up of directives from State HQ to

grass root level.

Recommendations:

Priority for Action

Immediate

1. To ensure that result based monitoring of performance is operational along the

monitoring cascade whereby the state officials monitor the performance of districts,

district officials monitor the performance of the blocks and so on till the sub centre level.

Successive

2. (a) A Checklist for ensuring clarity, consistency and completeness of directives and

operational guidelines, and their follow-up to be developed by Health Directorate

2. (b) Originating units/ departments use the checklist to ensure that the directives and

guidelines are clear, comprehensive and self explanatory

2. (c) The district and block units to ensure that the guidelines reach the intended user

in time and an action taken report is sought

3. Explore the use of E-mails, Video-conferencing, Gramsat and other alternative means

of communication to improve interactions .

(b) Planning not need based but driven by template and budget

Recommendations:

Priority for Action

Immediate

1. State Health Department to organize Capacity Building workshops on ‘Programme

Planning and Management’ for block, district and state level officials to promote data

based and need based planning.

2. Health Directorate to ensure that specific and appropriate plans for improving access

to services are developed by the desert/ tribal districts and other districts for their

difficult to reach areas and support provided for implementation


27

(c) Underutilization of AYUSH practitioners in MNCH services

Recommendations:

Priority for Action

Successive

1. State government to utilize AYUSH practitioners for monitoring of MNCH services

2. State government to take a policy decision to enable AYUSH practitioners to deliver

IMNCI through training and ensuring health system support for practicing IMNCI

(d) Lack of coordinated and inadequate attention to address Nutrition and Development in Children

Recommendations:

Priority for Action

Immediate

1. State government to develop joint planning and joint review mechanisms for ICDS

and Child Health Programmes at district and sub-district level to address Malnutrition,

anaemia and child development in under 3 children.

2. Joint Supervision by supervisors of Health and ICDS should be done.

(e) Lack of quality in data capture at field level

Recommendations:

Priority for Action

Immediate 1. HMIS department to develop a plan for orientation of frontline workers and

managers to improve data quality.

Successive

2. HMIS department should also develop a ward wise reporting system in urban areas

for PCTS.

3. Sensitization of private practitioners for reporting morbidity,mortality and service

utilization data.


28

(f) Inadequate data analysis, feedback and reviews at district and sub-district level

Recommendations:

Priority for Action

Immediate

1. State Demographic Cell and HMIS department to plan and conduct

orientation/training of block and district level officials to improve data analysis and

provision of appropriate feedback

Successive

2. Conduct short programme reviews at district level annually before development of

District PIPs

3. Reinstate statisticians at block level

(g) Difficulty in monitoring neonatal care and PNC interventions

Recommendations:

Priority for Action

Immediate 1. State to introduce Neonatal and PNC indicators in the monitoring system

(h) No systematic evaluation plan for MNCH services in place

Recommendations:

Priority for Action

Immediate 1. State to develop a systematic plan to periodically evaluate implementation of IMNCI,

New born care and PNC interventions


29

(i) Limited data on Quality of care of MNCH services

Recommendations:

Priority for Action

Immediate

1. State to assign responsibility to individual officials and programme managers of

SPMU at State level for specific areas of child health programmes with regard to

monitoring of progress, data collections, analysis and feedback.

2. Departments of Maternal and Child health and ICDS to periodically evaluate quality

of care at health facilities and community level

Successive 3. Develop/adapt tools to assess key elements of quality of care (facility infrastructure,

case management process, satisfaction of beneficiaries)

7.6.2 Group II. Human Resources, Training and Strengthening Health Systems


(a) There is inadequate number of staff and expertise for maternal, newborn and child health

Recommendations:

Priority for Action

Immediate

1. PHS to lead strengthening of Human Resource Development Strategy/policy (with

adequate reflection of requirement forecasting, skills set mix required for MNCH,

including policy for induction training development and transfers )

Successive 2. MD NRHM to get evaluation done of focus district approach and based on experience

decide next steps.


30

(b) Quality of training is not optimal

Recommendations:

Priority for Action

Immediate 1. Director RCH to develop a procedure to get quality assurance of trainings

conducted

Successive

2. Director RCH to lead development of comprehensive need based training strategy for

MNCH and implementation plans by adopting the following approaches :

Develop and maintain adequate pool of trainers. May have to look beyond

traditional trainers and sharing trainers across programmes

Innovative training approaches such as distance learning, technology based

trainings to be explored. Develop and maintain adequate number of appropriate

training site for competency based trainings like IMNCI, SBA ,EmOC etc.

Innovative training approaches such as distance learning, information

technology based trainings

Ensure the prescribed clinical hands-on training

(c) Pre-service training

Recommendations:

Priority for Action

Successive

1. Principal Secretary Medical Education to formulate a policy to strengthen pre-service

education in medical and nursing institutions.

2. Health Directorate to organize training of teaching staff in MNCH packages and

develop implementation plans for teaching of the same in medical and nursing

institutions

3. Develop a plan for introducing and implementing pre-service IMNCI.


31

(d) Shortage of drugs ; Mismatch between requirements and supply of drugs and consumables as per

intervention packages

Recommendations:

Priority for Action

Immediate 1. MD NRHM to lead Review of existing drug supply management to identify specific

gaps and state specific solutions

Successive 2. Develop and circulate guidelines on rational use of drugs

(e) Poor supportive Supervision of MNCH services

Recommendations:

Priority for Action

Immediate 1. MD NRHM to issue directives for urgent prioritization and integration of supportive

supervision for MNCH services

Successive 2. Director RCH to identify and train pool of supervisors in each block for integrated

supportive supervision

(f) Poor Maintenance of equipment

Recommendations:

Priority for Action

Immediate 1. Director RCH to explore implementation of similar mechanisms as it is followed by

immunization division for maintenance of equipments and apply lessons learned


32

7.6.3 Group III. Health Communication / IEC and Development of Community

Supports


(a) No Comprehensive Communication Plan

Recommendations:

Priority for Action

Successive

1. MD/ Director IEC to create a Task Force at the State level headed by a health

communication professional (involving technical persons) to develop MNCH

communication strategy and implementation plan

2. Identify a resource pool of health communication professionals at State and District

Level to support and monitor implementation of plan

(b) Improper media mix

Recommendations:

Priority for Action

Immediate

1. Ensure provision of IEC materials as well as AV aids at facility level (CHC and 24X7

PHC level)

2. Strengthen relevant section on health communication in the state PIP with an activity

plan including R and D with budget allocations.

Successive

3. Explore and expand use of latest technologies, e.g. Mobile phones, Interactive voice

response (IVR) system, rejuvenate use of Gramsat system; Video conferencing etc.

4. Ensure provision of operational guidelines for implementing and monitoring IEC

activities.


33

(c) Poor quality of IEC materials

Recommendations:

Priority for Action

Immediate 1. IEC Activities for child health focusing on the Key Messages

Successive

2. Strengthen Skill up-gradation of State and District IEC coordinators on development

of IEC materials

3. Consider outsourcing for IEC materials and skills development of staff

(d) Poor communication skills of health and nutrition service providers

Recommendations:

Priority for Action

Successive 1. Organize communication skills training programme for service providers in low

coverage areas

(e) Lack of monitoring and evaluation

Recommendations:

Priority for Action

Successive 1. State Directorate to develop a plan of monitoring and evaluation for IEC.

2. State Directorate to develop a system of concurrent evaluation (may be outsourced)


34

(f) Limited capacity of Village Health Sanitation Committee (VHSC)

Recommendations:

Priority for Action

Immediate 1. Complete the ongoing training of VHSCs within one year followed by hand holding

support through allocation of a set of villages to PHC level supervisors

Successive

2. Develop five model VHSCs per block. Explore role of NGOs to establish model

VHSCs

3. Develop a recognition mechanism and reward good performance for VHSC

4. Plan a Quarterly newsletter for VHSC with success stories from the field

(g) VHSC not able to perform its functions like community monitoring and thematic community

meetings

Recommendations:

Priority for Action

Immediate 1. Capacity building of supervisors to be completed in the next six months

Successive 2. The best practices of community monitoring to be explored and adopted for the state

(h) Inadequate quality of training for ASHA and Jan Mangal Couple on MNCH issues

Recommendations:

Priority for Action

Immediate 1. Expedite the process of training of ASHA on module 5

Successive 2. Develop database of Jan Mangal couples and complete trainings within an year

3. Develop a mechanism for QA of trainings


35

7.6.4 Core Group: Scaling up of existing interventions for Child Health

Based on the discussion held within groups, the Core Review Group added the following

recommendations regarding technical interventions for newborn and child health. The technical

interventions were not covered in the theme-based group work.

Recommendations:

Priority for Action

Immediate

1. Scale-up of IMNCI in all districts; Ensure supplies for IMNCI drugs at all levels

2. Rapid scale-up of F-IMNCI in high-focus districts on priority basis

3. Strengthening of community-based management of newborn and childhood illnesses

through ASHA and Anganwadi Workers

4. Strengthening of infra-structure and services for Facility-based Newborn Care in

high-focus districts (includes Special Care Newborn Unit, Neonatal Stabilization Unit

and Newborn Care Corners)

ANNEXURES

Annexures

Annexure I: Day wise summary of Steps completed

Day Steps Summary of Activities

1 -

Formal Inauguration

1 1

2 Plenary sessions were held.

Prefilled worksheets 1 & 2 were discussed

Goals and Objectives were reviewed with regard to Clarity, measurability and realism.

Trend of Neonatal and Child Health Indicators of the State were reviewed to identify areas of

poor performance, adequate / good performance and data gaps.

Preparatory activity for Step 2 was completed – Participants were allocated into three smaller

groups – Maternal, Newborn and Child.

Worksheets 3 & 4 were customized.

2 2

Participants were divided into three smaller groups: maternal, newborn and Child.

Each group had its own facilitator and rapporteur.

Worksheets 3 and 4 were discussed and reviewed.

Small group discussions were followed by presentation of findings by respective rapporteurs

in plenary sessions.

3 3,4

Worksheet 5 was reviewed and discussed

Participants continued in the three smaller groups : maternal, newborn and Child.


Each group identified respective Activity areas for intervention packages of relevance

followed by assessing their status of implementation.

The groups discussed and identified specific strengths and weaknesses for each activity area.

Small group discussions were followed by presentation of findings by respective rapporteurs

in plenary session to finalize the worksheet 5. This completed Step 3

Step 4 consisted of filling up the Worksheet 6 – identifying the main problems faced by the

program.

Worksheet 6 was again completed working in small groups, and presented and discussed in

the large group

4 5

Reorganization of small groups.

Worksheet 7 was completed based on the final list of problems.


Each group went sequentially taking one problem at a time, to identify the causes, suggest

solutions and make action oriented feasible recommendations.

GroupWise Worksheet 7 was presented in plenary and recommendations were finalized

5 6,7

Discussion with key stakeholders on future steps for ensuring the incorporation of

recommendations into the State PIP

Presentation of findings before the representatives of the State Health Department

Recording of feedback.

5 - Formal Thanksgiving and conclusion

Annexures

Annexure II: Worksheet 1

Goals and Objectives of the Child Health Program

Program Goal Program Objectives

Maternal Health

RCH II

- Reduce Maternal mortality to

213 by 2010 (State PIP RCH II)

- Reduce Maternal mortality to

148 by 2012 (State PIP RCH II

& 11th Five-year Plan)

ICDS

- To bring down anemia among

women from current level to 40%

by 2010 and 27% by 2012

State Program Implementation Plan

To increase coverage with Antenatal Care to 80% in 2010 – 11

from the level of 60% in 2009-10 (State PIP 2010-11) (ICDS

targets 100%)

Increase coverage of administering 2 TT injections during

Ante natal period from 80%(2009-10) to 100% in 2010-11

Increase the proportion of pregnant women receiving IFA

tablets from 30% (2009-10)to 50% by 2011

Strengthening of IEC to increase awareness on these issues

Increase delivery by skilled birth attendant (doctor, ANM,

Nurse) from 80% (2009-10) to 100% by 2011 (State PIP 2010-

11).

Increasing institutional deliveries from 65% (2009-10) to 90%

by 2011 through Janani Suraksha Yojana.

(ICDS targets 100%)

Increasing access to CEmOC by operationalizing FRUs

Increasing access to postnatal care to 60% in 2009 – 10 to

80% in 2010-11

Urban RCH Program (brief note on urban RCH 2008-09)

Achieving 80% ANCs for pregnant.

Achieving 80% institutional deliveries

Annexures

Newborn Health

RCH II

- Reduce Newborn Deaths

- To reduce the percent of low

birth weight babies by 10% by

2012 (from ICDS)


Strengthening of tertiary level newborn care facilities at

Medical Colleges

Setting up 36 Level II Neonatal ICUs (FBNC – Facility Based

Newborn Care Centers) across the state at District Hospitals

and all Medical Colleges.

Setting up the level I care units called Newborn Stabilizing

Units (NSUs) at each FRU to link & strengthen the referral

from Home Based (IMNCI) / PHC to tertiary level

Phased training of all Medical Officers at PHC/CHCs on

basic newborn care and resuscitation under Navjat Shishu

Suraksha Karyakram (NSSK)

Reducing NMR by providing immediate care at birth to every

newborn through NSSK

Child Health

RCH II

- Reduce Infant Mortality Rate

to 37 by 2011 (State PIP RCH II

2010-11)

- Reduce Infant Mortality Rate

to 32 by 2012 (State PIP RCH II

& 11th Five Year Plan)

- Reduce the prevalence of

malnutrition among children

under 3 years to 25.3% by 2011

(11th 5-year Plan)

NVBDCP

- Proportionate reduction in

Malaria Mortality among under

-five children by 50%. (State

PIP NVDBCP 2010-11)


To increase coverage with complete immunization to 85 % by

2010 (State PIP 2010 -2011)

(ICDS targets 90%)

Complete coverage of IMNCI across the state with

implementation in all districts except Chittorgarh as it is the

control district (State PIP 2010-11)

Improving access to clinical care among children with

diarrhea, ARI and Childhood illness (90% by 2010)

Increasing the proportion of ORS use among children with

Diarrhoea (60% by 2010)

Increasing the proportion of Children getting Vitamin A

Supplementation (90% by 2010)

To Increase IFA administration among children to at least

50% by 2010(State PIP 2010 – 2011)

Urban RCH Program (brief note on urban RCH 2008-09)

Increase in the coverage of fully immunized children by 25%

in 6 months of start of program and 50% by one year of start

of service in the selected slum

100% immunization in the slum.

Annexures

ICDS

- To bring down percentage of

severe and moderate

malnutrition among 0 – 6 years

of age to 10% and 15 %

respectively by 2012

- To reduce the prevalence of

mild malnutrition among

children 0 – 6 years to 20% by

2012

- To bring down anemia among

children from current status to

60% by 2010 and 39% by 2012

ICDS

To promote exclusive breastfeeding and increase the number

of mothers initiating early breastfeeding to 50% by 2010 and

75% by 2012

To increase the quality complementary feeding rate and

feeding care to 45% by 2010 and to 75% by 2012

To ensure 100% coverage of children aged 6 months to 6

years for availing age appropriate supplementary nutrition

To expand the availability of age appropriate micronutrient

enriched – RTE foods to the beneficiaries by up-scaling

successful and cost effective interventions

Annexures

Annexure III : Worksheet 2

Indicators of maternal, newborn and child health status

Data

Required Measures

Back ground data

(Year and source)

Baseline data

(year and source)

Most recent data

(year and source) Target

Differences

by region or

group

(highest/low

est)

Neonatal

deaths

Neonatal death rate

37.2

(P.136 NFHS-1 Rajasthan state

report)* 43.9

(P.56 NFHS-3,(2005-06)

Rajasthan state)

43

(SRS Statistical

Report -2008, P.79)

Urban: 23

Rural: 48

(SRS Statistical

Report -2008,

P.79)

X

- Need to

work

signif -

icantly

Difference

in rural and

urban

49.5

(P. 122 NFHS-2 Rajasthan state

report)**

Neonatal mortality

as a proportion of

IMR and U5MR

Neonatal mortality as a proportion of

IMR :51.2%

(Neonatal death rate-37.2/IMR-72.6)


UMR: 36.3%

(Neonatal death rate-37.2/U5MR-

102.6)*

** Neonatal mortality as a proportion

of IMR : 61.6%

(Neonatal death rate-49.5/IMR-80.4)


UMR: 43.1%

(Neonatal death rate-49.5/U5MR-

114.9)

Neonatal mortality as a

proportion of IMR : 67.2%

(Neonatal death rate-

43.9/IMR-65.3)

Neonatal mortality as a

proportion of UMR: 51.4%

(Neonatal death rate-

43.9/U5MR-85.4)

Causes of death No data No data No data

-Data

needed

-Need to

work

significant-

ly

Annexures

Data

Required Measures

Back ground data

(Year and source)

Baseline data

(year and source)

Most recent data


Differences

by region or

group

(highest/low

est)

Maternal

deaths

Maternal

mortality ratio

670 /1,00,000 live births

P. A-68 FWS-2009

(Data represents for the

year1997-98)

501/1,00,000 live

births

P. A-68 FWS-2009

(Data represents for

the year 1999-2001)

388/1,00,000 live

births

P. A-68 FWS-

2009

(Data represents

for the year 2004-

06

( By 2010

– 213

(State PIP

RCH II)

(By 2012

– 148

(State PIP

RCH II in

accordanc

e with XI

FYP)

Trends

are

down-

wards,

sustain

efforts

Causes of death

Hemorrhage

:37.0%

Sepsis:11.0%

Abortion: 10.0%

Obstructed labour

& Hypertensive

disorder: 9.0%

(SRS, 2009)

Low birth

weight

Prevalence of

low birth weight

21.9 %

(RCH-RHS,1998-99

P. 54,India report)

(Data represents Rajasthan)

28.3%

ICDS-state PIP IV,2008-

12,P.81

(Data represents Base line

survey-2000)

27.5%

(NFHS-3,2005-

06,P.226, India report)

(Data represents

Rajasthan state)

X

Static

Annexures

Data

Required Measures

Back ground data

(Year and source)

Baseline data

(year and source)

Most recent data


Differences

by region or

group

(highest/low

est)

Infant

deaths

Infant mortality

rate

72.6

(NFHS-1, 1992-93,P. 136,

Rajasthan report)*

65.3

(NFHS-3,2005-06,

P. 56 ,Rajasthan report)

63 - (SRS- 2009)

By 2011 –

37

(State PIP

RCH II

2010-11)

By 2012 –

32

(State PIP

RCH II in

accordance

with XI

FYP)

Urban: 66.0

Rural: 65.1

SRS

Urban – 39

Rural 68

Differences

across

different

regions

Decline

not

sufficient

to reach

goals

80.4

(NFHS-2 , 1998-99, P. 122,

Rajasthan report)**

Infant mortality as

a proportion of all

child mortality

70.8 %

(Infant deaths-72.6/U5MR-102.6)* 76.5%

(Infant deaths-

65.3/U5MR-85.4)

70%

(Infant deaths-80.4/U5MR-114.9)**

Causes of death

Pneumonia: 25.8% Diarrhoea: 14.5%

Severe Malnutrition: 19.4%

Rashes/Fever: 16.1% Prematurely/LBW:12.9%

Asphyxia: 9.7%

Birth injury: 1.6% Congenital anomalies:0.0

(Data represents for the year of 1980)

(Health and Population: Perspectives and Issues

Vol. 32 (2), 105-111, 2009- Changes in

IMR in Rajasthan over 25 years-2009)

Perinatal conditions:42.9%

Respiratory infections:24.5%

Diarrheal diseases: 10.4% Other infectious and parasitic

diseases: 10.3%

Malaria: 1.3% Nutritional deficiencies: 2.3%

Symptoms signs and ill-

defined conditions: 2.7% Unintentional injuries-

Other:1.2%

Congenital anomalies:1.9% Fever of unknown origin: 0.7%

(Report on Causes of death in

India,2001-03,P.26) (Data of EAG states)

Pneumonia: 27.8%

Diarrhoea: 8.3%

Severe Malnutrition: 8.3%

Rashes/Fever: 5.6%

Prematurely/LBW: 19.4%

Asphyxia: 19.4%

Birth injury: 5.6% Congenital anomalies:

5.6%

(Health and Population: Perspectives and Issues

Vol. 32 (2), 105-111,

2009- Changes in IMR in

Rajasthan over 25 years-

2009)

Annexures

Data

Required Measures Back Ground

Baseline data (year

and source)

Most recent data (year and source)

Target

Differences

by region or

group

(highest/lowe

st)

Child deaths

Under 5

mortality

rate

102.6

(NFHS-1,1992-93, P. 136

Rajasthan report)

85.4

(NFHS-3,2005-06

P. 56 ,Rajasthan

report)

80

(SRS-Statistical

Report 2008,P.84)

34.2

MDG

Goal

Urban: 49

Rural: 88

Male: 72

Female:88

(SRS-

Statistical

Report

2008,P.84)

Decline

not

sufficient

to

achieve

MDG 114.9

(NFHS-2,1998-99

P. 120, Rajasthan report)

Causes of

death

Perinatal conditions: 29.9%

Respiratory

infections:24.4%

Diarrheal diseases:14.8%

Other infectious and

parasitic diseases:12.3%

Malaria: 3.3%

Nutritional

deficiencies:3.1%

Ill-defined conditions:2.6%

Unintentional injuries:2.6%

Congenital anomalies:1.6%

Fever of unknown

origin:1.3%

(Report on Causes of death

in India,2001-03,P.26)

(Data of EAG states)

Annexures

Data

Required Measures

Back

ground data

(Year and

source)

Baseline data

(year and source)

Most recent

data

(year and

source)

Target Differences by region or group

(highest/lowest)

Child

morbidity

Prevalence

of childhood

illnesses:

pneumonia,

diarrhea,

malaria

(fever),

measles (2

week

prevalence)

Pneumonia/A

RI: 21.2%

Diarrhea:

33.1%

(RCH-RHS-

1998-

99,P.52,Rajast

han report)

Fever: 10.7%

(NFHS-

1,1992-

93,P.168,Rajas

than report)

Fever: 11.9%

(NFHS-3,2005-

06,P.68,Rajasthan

report)

Pneumonia/AR

I: 7.7%

Diarrhea: 8.4%

(DLHS-

3,2007-

08,P.92,Rajast

han report)

ARI Diarrhea

No targets

available.

Rural: 7.9%

Urban: 6.6%

8.5%

7.7%

Lowest: 0.8%

(Barmer)

Highest:

18.9%(Bharatp

ur)

(DLHS-3,2007-

08,P.92,Rajasth

an report)

Lowest: 0.5%

(Hanuman

garh)

Highest: 25.3%

(Bharatpur)

(DLHS-3,2007-

08,P.92,Rajasth

an report)

Pneumonia/A

RI: 13.2%

Diarrhea:

15.9%

(DLHS-

2,2002-

04,P.106,Rajas

than report)

Fever: --

25.8%

(NFHS-

2,1998-

99,P.140,Rajas

than report)

Prevalence

of HIV –

among

children who

are tested

No data No data No data

Annexures

Data

Required Measures

Back

ground data

(Year and

source)

Baseline data

(year and source)

Most recent

data

(year and

source)


(highest/lowest)

Under

nutrition

Prevalence of

low weight

for height (z-

score -2 or

less)

19.5%

(NFHS-

1,1992-

93,P.186,

Rajasthan

report) 22.5%

(NFHS-3,2005-

06,P.76, Rajasthan

report)

Urban: 20.8%

Rural: 20.3%

Shows

increase in

wasting

Male: 20.8%

Female: 20.1%

SC: 22.0%

ST: 27.8%

OBC: 16.0%

Others: 23.8%

(NFHS-3,2005-06,P.75, Rajasthan)

16.2%

(NFHS-

3,2005-

06,P.76,

Rajasthan

report)

Data

represents

NFHS-2

Prevalence of

low height for

age (z-score -

2 or less)

43.1%

(NFHS-

1,1992-

93,P.186,

Rajasthan

report) 40.1%

(NFHS-3,2005-

06,P.76, Rajasthan

report)

Urban: 33.9%

Rural: 46.3%

Marginal

decline in

Stunting

Male: 44.3%

Female:43.1%

SC: 48.2%

ST:48.8%

OBC:42.5%

Others:37.3%

(NFHS-3,2005-06,P.75, Rajasthan

report)

59.0%

(NFHS-

3,2005-

06,P.76,

Rajasthan

report)Data

represents

NFHS-2

Annexures

Data

Required Measures

Back

ground data

(Year and

source)

Baseline data

(year and source)

Most recent

data

(year and

source)


(highest/lowest)

Under

nutrition

Prevalence of

low weight for

age (z-score -2

or less)

41.6%

(NFHS-1,1992-

93, P.186,

Rajasthan

report) 36.8%

(NFHS-3,2005-06,P.76,

Rajasthan report)

20%

(ICDS)

– find

out the

source

Urban: 30.1%

Rural:42.5%

Marginal

decline in

underweight

Male: 40.3%

Female:39.5%

SC: 44.5%

ST:46.8%

OBC:36.7%

Others:37.1%

(NFHS-3,2005-06,P.75, Rajasthan

report)

46.7%

(NFHS-3,2005-

06,P.76,

Rajasthan

report)

Data represents

NFHS-2

Micronutrient

deficiencies

Prevalence

of

xerophthalm

ia

No data No data No data Need to

collect

informa-

tion Prevalence

of low serum

retinol


Prevalence

of anemia

(Hb 10g/dl)

82.3%

(NFHS-

2,1998-

99,P.175,

Rajasthan

report)

79.9%

(NFHS-3,2005-

06,P.82,Rajasthan

report)

27%

(2012)

Urban: 62.9 %

Rural: 71.4%

Insufficient

decline Male: 69.9%

Female:69.3%

(NFHS-3,2005-06,P.81,

Rajasthan)

Annexures

Summary of Worksheet 2 – Health impact indicators

Health status indicators - program is doing enough now

Maternal Mortality: Trends are downwards, sustain efforts

Under nutrition: Marginal decline in Stunting and Underweight

Health status indicators - program needs to do more

Neonatal Mortality: Need to work significantly. Difference in rural and urban

Infant Mortality Rate: The declining rate is not sufficient to reach the MD Goals

U5 Mortality: Declining rate is not sufficient to reach the MD Goals.

Child Morbidity: There are no targets

Under nutrition: Shows increase in wasting

Prevalence of Anaemia: Insufficient decline.

Annexures

Annexure IV: Worksheet 3

Child health interventions and how they are delivered

PREGNANCY

Interventions

Included

in

program?

Tick if yes

Level at which intervention is

delivered

Tick levels

Implemented in a

training package

with 1 or more

other

interventions?

specify package

(s)

Implemented

in all areas or

selected areas

- specify

Home and

Communit

y

First

level

facility

Referral

facility

Tetanus toxoid

immunization ANC All

Birth and emergency

planning ANC All

Detection of problems

complicating pregnancy

(e.g. hypertensive

disorders, bleeding,

anaemia)

ANC

Management of problems

complicating pregnancy

(e.g. hypertensive

disorders, bleeding,

malpresentations, multiple

pregnancy, anaemia)

24X7

PHC

BEmOC,

CEmOC All

Detection and treatment of

syphilis (RTI/STI)

RTI/STI All

Intermittent prophylactic

treatment for malaria - - - - - -

Information and counseling

on self-care, nutrition, safer

sex, breastfeeding, family

planning

ASHA

All

Insecticide treated bed nets - - - - - -

Prevention of mother to

child transmission of HIV

PPTCT

(RSACS) Selected

Other : (specify) Blood

Storage CEmOC

All DH and

Functional

FRU

Other : (specify)

Anemia Prophylaxis ANC All

Other: (specify) ________

Annexures

BIRTH AND IMMEDIATE POST-NATAL PERIOD

Interventions Included in

program?

Tick if yes

Implemented at which levels?

Tick levels

Implemented in a

training package

with 1 or more

other

interventions? –

specify package (s)

Implemented

in all areas or

selected areas?

- specify

Home and

Community

First level

facility

Referra

l

facility

Monitoring progress of

labour, maternal and

foetal well being with

partograph

Safe delivery

package All

Active management of

the third stage of labour

Safe delivery

package All

Social support

(companion) during birth

24X7

Safe delivery

package

Yashoda

All

YASHODA

Being

expanded to

all districts

Immediate newborn care

(Resuscitation if required,

Thermal care, Hygienic

cord care, Early initiation

of breastfeeding)

ENC

NSSK

All

Emergency obstetric and

neonatal care for

complications

BEmOC

NSSK All

Antibiotics for preterm

premature rupture of

membranes

BEmOC All

Antenatal corticosteroids

for preterm labour

- - - - - -


child transmission of HIV PPTCT

Selected

districts (10)

MC Colleges

and DH

Other : (specify) Blood

transfusion

CEmOC

DH,

Functional

FRU

Other : (specify) _______

Other : (specify) ______

Annexures

NEWBORN PERIOD

Interventions Included

in

program?

Tick if

yes


delivered

Tick levels

Implemented in a

training package with

1 or more other

interventions? –

specify package (s)

Implemented

in all areas or

selected areas

– specify

Home and

Community

First level

facility

Referra

l

facility

Exclusive breastfeeding

IMNCI*

Yashoda*

HBPNC*

ICDS

All (IMNCI/

Yashoda)

HBPNC :

NIPI focus

districts

Thermal care

NSSK

Yashoda*

IMNCI*

HBPNC*

*

Hygienic cord care

NSSK

Yashoda*

IMNCI*

HBPNC*

*

Prompt care seeking for

illness

IMNCI*

ASHA

HBPNC*

Yashoda*

*

Extra care of LBW

infants

FBNC*

Yashoda*

IMNCI*

HBPNC*

*

Management of newborn

illness

IMNCI*

NSSK

FBNC*

*


child transmission of

HIV

PPTCT* *

Other : (specify) Early

initiation of breast

feeding

IMNCI*

Yashoda*

HBPNC*

ASHA

*

Other : (specify)

Referral transport

Untied Funds

HBPNC *

Other : (specify)

Immunization

Routine

Immunization

IMNCI/ASHA

*

Annexures

INFANTS AND CHILDREN

Interventions Name of

Package


delivered

Tick levels

Implemented

in package

with 1 or

more other

interventions

? – specify

package (s)

Implemented in all

areas or selected

areas - specify

Home and

Community

First level

facility

Referral

facility

Preventive interventions

Exclusive breastfeeding

(<6 months)

IMNCI

9 districts almost

saturated; 24

districts have 30-50

% coverage

Facility Based

Care

Counseling

(Yashoda,

IMNCI)

Yashoda (27 DH +

42 CHCs) and

IMNCI-9 Districts;

40% coverage

PNC

Rolled out in 3

districts with

almost saturation;

9 districts

(IMNCI) ; One

third districts

covered

ICDS

(Health

Education/MC

HN Sessions)

Universal

Coverage

Safe and appropriate

complementary feeding

with continued

breastfeeding (at least

up to 2 years)

ICDS

(Health

Education/MC

HN Sessions)

Universal

Coverage

IMNCI

9 districts almost

saturated; 24

districts have 30-50

% coverage

IYCF

IYCF not yet

implemented

Insecticide treated nets

- - - - - -

Immunization (BCG,

Hepatitis B, DPT, OPV,

Measles, Hib)

Routine

Immunizatio

n (BCG,

DPT, OPV,

RI All Districts

Annexures


Package


delivered

Tick levels

Implemented

in package

with 1 or

more other

interventions

? – specify

package (s)

Implemented in all

areas or selected

areas - specify

Measles)

Hepatitis B

Hepatitis B only in

Jaipur Urban

Hib

Hib not in the RI

package

Vitamin A

supplementation

Routine

Immunizatio

n

Up to 9

months All

ICDS

Monthly drive

twice a year All

Water, sanitation,

hygiene

VHSC

VHSC All

Primary

Health Care

(Water

Chlorination)

All

Safe Water

(PHED)

All

Total

Sanitation

Campaign

Limited

coordination

between Health

and TSC

Birth spacing by > 24

months

Family

Planning

Package

(Jan

Mangal

Scheme)

Other : (specify)

_________

Annexures

INFANTS AND CHILDREN


Package


delivered

Tick levels

Implemented in a

training package

with 1 or more

other interventions?

– specify package (s)

Implemented

in all areas or

selected areas

– specify

Home and

Community

First

level

facility

Referral

facility

Treatment interventions

Oral rehydration therapy

for diarrhea

IMNCI

9 districts

almost

saturated; 24

districts have

30-50 %

coverage

Zinc for diarrhea

IMNCI

9 districts

almost

saturated; 24

districts have

30-50 %

coverage

Antibiotics for dysentery

IMNCI - - 9 districts

almost

saturated; 24

districts have

30-50 %

coverage -

Antibiotics for pneumonia

IMNCI

9 districts

almost

saturated; 24

districts have

30-50 %

coverage

Antimalarials

National

Anti Malaria

Program

Management of severe

malnutrition

MTC

ICDS

Management of HIV-

exposed/infected children

PPTCT

All

Other : Anaemia

Primary

Health Care

Other : De-worming

Primary

Health

Care

Annexures

Annexure V : Worksheet 4

Period Intervention Coverage

measure

Back ground

(year and source)

Baseline data

(year and source)

Most recent data

(year and source)

Target Differences by region or

group (highest/lowest)

Pregnancy Adequate

antenatal care

Proportion of

mothers who

received at least 4

ANC visits

Available data is

for 3 visits

28.3%

(RCH- RHS-

1998-99,

Rajasthan report

P.32)

(>3 visits)

20.5 %

(DLHS-2, 2002-

04, P.61,Rajasthan

report)

27.6%

(DLHS-3, 2007-08,

P.65 Rajasthan

report)

55.2 %

(UNICEF-

Coverage

Evaluation Survey-

2009, National fact

sheet)

80% in

2010 – 11

(State PIP

2010-11)

Rural: 23.3 %

Urban: 48.0%

(DLHS-3, P.65 Rajasthan

report)

X

SC: 22.4%

ST :19.4%

OBC: 27.8%

Others: 40.8%


report)

Highest: 48.4% (Ajmer)

Lowest: 7.7% (Dhaulpur)


report)

Tetanus Toxoid

to all pregnant

women

Proportion of

mothers who

received TT2+

during pregnancy

28.3 %

(NFHS-1 1992-

93,P.154

,Rajasthan report)

59.1 %

(DLHS-2 ,2002-

04, P.61,

Rajasthan report)

50.9 %

(DLHS-3, 2007-08,

P. 66, Rajasthan

report)

100% Rural: 47.2%

Urban: 68.1%

(DLHS-3, 2007-08, P. 66,

Rajasthan report)

X

SC: 45.0%

ST : 43.0%

OBC: 51.6%

Others: 63.0%

(DLHS-3, 2007-08, P. 66,

Rajasthan report)

Highest: 76.8 % (wealth

index)

Lowest: 38.2%

DLHS-3, 2007-08, P. 66,

Rajasthan report)

Proportion of

newborns

protected at birth


Annexures


measure

Back ground

(year and source)

Baseline data

(year and source)

Most recent data

(year and source)



Iron

supplementatio

n

Proportion of

mothers women

who received iron

during pregnancy

29.2 %

(NFHS-1 1992-

93, P.154

Rajasthan report)

39.3 %

(NFHS-2, 1998-

99,P.190,

Rajasthan report)

57.7%

(NFHS -3,2005-06,

P.61,

Rajasthan report )

53.7%

(DLHS-3,2007-

08,P.67, Rajasthan

report)

Rural: 53.1%

Urban: 73.9%

(NFHS -3,2005-06,

P.61,Rajasthan report)

+

Trends are

good with

Disparities SC: 56.8%

ST : 54.6%

OBC: 56.9%

Others: 63.0%

Highest: 77.7 % (Bharatpur)

Lowest: 32.0% (Pali)

(DLHS-3,2007-08,P.67,

Rajasthan report)

Malaria

prevention

Proportion of

pregnant women

who slept under

an ITN the

previous night

No data No data No data Not

introduced

in

Rajasthan

Voluntary

counselling and

testing for HIV

and PMTCT

Proportion of HIV

+ mothers who

received ART

prophylaxis

No data No data No data RSACS to

be

contacted

Labour and

delivery

All deliveries

by a skilled

birth attendant

Proportion of

deliveries by

skilled birth

attendants

22.6%

(NFHS-1, 1992-

93, P.65,

Rajasthan report)

35.8 %

(NFHS-2,1998-99,

P.196, Rajasthan

report)

43.2%

(NFHS-3,2005-

06,P.65, Rajasthan

report)

80%

(2009-10)

to

100% by

2011 (State

PIP 2010-

11).

Rural: 32.5%

Urban: 74.2%

(NFHS-3,2005-06,P.64,

Rajasthan report)

+

Trends

are good

Not likely

to meet

targets

Disparities

SC: 34.2%

ST : 29.6%

OBC: 43.5%

Others: 52.9%

(NFHS-3,2005-06,P.64,

Rajasthan report)

Annexures


measure

Back ground

(year and source)

Baseline data

(year and source)

Most recent data

(year and source)



Labour and

delivery

All deliveries by

a skilled birth

attendant

Percentage of

safe deliveries

33.5%

(RCH-RHS-

1998-99 , P.

30,Rajasthan

report

44.4%

(DLHS-2 ,2002-

04, P.72,

Rajasthan report)

52.6 %

(DLHS-3,2007-08,

P.68, Rajasthan

report)

Rural: 48.1%

Urban: 73.5%

(DLHS-3,2007-08, P.68,

Rajasthan report)

SC: 47.0%

ST :44.3%

OBC: 52.8%

Others: 66.2%

Highest: 69.4% (Sikar)

Lowest: 30.6 %(Barmer )

(DLHS-3,2007-08, P.68, Raj

report)

Proportion of

home births/

proportion of

institutional

births

Home births:

77.2%

Inst. Births:

22.5%

(RCH-RHS-

1998-99 ,P. 30,

Rajasthan report)

Home Births:

68.0%

Inst. Births:

31.4%

(DLHS-2, 2002-

04, P.70,

Rajasthan report)

Home births: 53.8%

Institutional Births:

45.4%

(DLHS-3,2007-08

P. 68,Rajasthan

report)

70%

institutional delivery

(UNICEF-Coverage

evaluation survey-

2009)

90% by

2011

through

Janani

Suraksha

Yojana.

Home Institution +

Trends

are good

Not likely

to meet

targets

Disparities

Rural:58.5%

Urban: 32.0%

40.6%

67.5%

SC: 59.5%

ST : 59.3%

OBC: 54.3%

Others:40.9%

39.6%

39.9%

44.8%

58.5%

Highest: 78.7

%(Barmer)

Lowest : 34.1%

( Kota)

(DLHS-3,2007-

08 P. 70, Raj

report)

65.0%

(Kota)

21.3 %

(Barmer)

(DLHS-

3,2007-08

P. 70, Raj

report) Identification and

treatment of

maternal

emergencies such

as eclampsia and

obstructed labour

Proportion of

rural pregnancies

having a C-

section

0.3% (Rural)

(NFHS-1,1992-

93, P.159,

Rajasthan report)

2.1% (Rural)

(NFHS-2,1998-99,

P.197,Rajasthan

report)

2.2% (Rural)

(NFHS-3,2005-06,

P.63, Rajasthan

report)

Total: 3.8%

Urban :9.9%

Rural : 2.2%

(NFHS-3,2005-06, P.63,

Rajasthan report)

X

Annexures


measure

Back ground

(Year and

Source)

Baseline data

(year and source)

Most recent data

(year and source)



Immediately

after birth

Prevention of

hypothermia Proportion of

babies who were

dried, wrapped

(and not bathed)

immediately

after birth

Data not available Data not available 34.2 %


deliveries held at

Home)

(NFHS-3,2005-06,

P.63 ,Rajasthan

report)

Urban : 40.5%

Rural : 33.4 %

(NFHS-3,2005-06, P.63,

Rajasthan report)

Appropriate cord

care and hygiene Proportion of

babies who had

the cord cut with

a clean

instrument

Data not available Data not available 89.5%


deliveries held at

Home)

(NFHS-3,2005-06,

P.63 ,Rajasthan

report)

Urban : 93.7%

Rural : 89.0%

(NFHS-3,2005-06, P.63,

Rajasthan report)

Annexures

Period Intervention Coverage measure Back ground

(Year and

Source)

Baseline data

(year and

source)

Most recent data

(year and source)


(highest/lowest)

Immediate

initiation of

breastfeeding

Proportion of

mothers who

initiated BF within

1 hour of birth

15.8% (within

two hours)

(RCH-RHS-1998-

99, P. 43,

Rajasthan

report)

7.9%

(NFHS-1, 1992-

93,

P.178, Rajasthan

report

14.5 %

(within two

hours)

(DLHS-2, 2002-

04,P.88,

Rajasthan report)

14.1%

NFHS 3

Rajasthan report

41.4 %

(DLHS-3,2007-08

P.82, Rajasthan

report)

27.7%

(UNICEF-Coverage

evaluation survey-

2009)

60% by

2010-11

SPIP

Rural: 39.6%

Urban: 49.5%

(DLHS-3,2007-08

P.82, Rajasthan report)

SC: 38.7%

ST: 39.2%

OBC: 41.6%

Other: 45.6%

(DLHS-3,2007-08

P.82, Rajasthan report

Lowest: 24.2 % (Jaisalmer)

Highest: 54.8% ( Bundi)

(DLHS-3,2007-08

P.84, Rajasthan report)

Proportion of

babies who

received a pre-

lacteal feed

Data not available Data not available 71.6%

(NFHS-3,2005-06,P.

77, Rajasthan report)

Rural: 74.7%

Urban: 60.5%

(NFHS-3,2005-06,P. 77,

Rajasthan report)

SC: 71.6%

ST:78.3%

OBC:70.9%

Other: 67.5%

(NFHS-3,2005-06,P. 77,

Rajasthan report)

Annexures


(Year and

Source)

Baseline data

(year and

source)

Most recent data

(year and source)


(highest/lowest)

Postnatal /

neonatal

period

Postnatal care

visit

Proportion of

mothers/newborns

who had a care

contact in the first 2

days after delivery

7.7%

(NFHS-2,1998-

99,P.199,

Rajasthan report

32%

(NFHS 3, 2005-

06, Rajasthan

report, P. 63)

37.3%

(DLHS-3,2007-08,P.

74, Rajasthan report )

80% in

2010-11

SPIP-2010-

11

Rural: 33.1%

Urban: 56.9%

SC: 31.0%

ST: 33.0%

OBC: 36.4%

Other: 50.7%

(DLHS-3,2007-08,P. 74,

Rajasthan report )

Immuni-zation 0 dose OPV/BCG No data 0 dose OPV

33.8% (DLHS-2)

0 dose- OPV

33.1%

(DLHS -3,2007-08,

P.85)

0 dose OPV 40%

(HMIS 2009-10)

Exclusive

breastfeeding Proportion of

mothers who did

not give anything

other than breast

milk in the first 3

days after birth


Proportion of

infants 0-28 days

who are exclusively

breastfed


Annexures


(Year and

Source)

Baseline data (year

and source)

Most recent data

(year and source)


(highest/lowest)

Infants and

children

Exclusive

breastfeeding Proportion of

infants under 6

months exclusively

BF

57 %

(Computed based

on NFHS-1

data Rajasthan

report (P.180,Table

10.2)

33.2%

(NFHS-3,2004-06,

P.78, Rajasthan

report )

65.4%

(DLHS-3,2007-

08,P.83, Rajasthan

report)

34.9%

(UNICEF-CES-

2009)

Rural: 65.0%

Urban: 67.1%

SC: 63.4%

ST: 67.3%

OBC: 66.1%

Other: 63.3% (DLHS-3,2007-08,P.83, Raj report)

Appro-priate

compli-

mentary

feeding

Proportion of

infants 6-9 months

who receive

appropriate BF and

complimentary

feeding

47.8%

NFHS-1

Computed based

on NFHS-1 data,

Rajasthan report (pg.180,Table 10.2)

17.5%

(NFHS-2,1998-

99,P.265,India

report)

(Data represents

Rajasthan state)

43.7%

(DLHS-3,2007-08,

P. 83,Rajasthan

report)

49%

(UNICEF-CES 2009)

Micro-nutrient

supple-

mentation

Proportion of

children who

received a dose of

vitamin A in the

previous 6 m

No data No data 57.2 %

(UNICEF-Coverage

evaluation survey-

2009)

Proportion of

children who

received a dose of

vitamin A

22.2%

(RCH-RHS-1998-

99,P.47,

Rajasthan report)

22.4%

(DLHS-2,2002-

04,P.99, Rajasthan

report)

52.5%

(DLHS-3,2007-

08,P.88, Rajasthan

report)

60.5 %

(UNICEF-Coverage

evaluation survey-

2009)

90% by

2009 – 10

(Chapter 23

XI Five

Year Plan

Rajasthan p

23.3)

Rural: 50.5%

Urban: 61.7%

Male: 54.3%

Female: 50.4%

(DLHS-3,2007-08,P.88,

Rajasthan report)

Lowest: 20.1% (Bharatpur)

Highest: 93.3%

( Dungarpur)

Proportion of

children living in

HH that use iodised

salt (>15 ppm)

No data 35.1%

( NFHS-3,2004-06,P.

83 Rajasthan report)

58%

(UNICEF-Coverage

evaluation survey-

2009)

Urban: 65.1%

Rural: 27.3%

SC: 28.0%

ST: 31.7%

OBC:32.7%

Other: 52.9%

( NFHS-3,2004-06,P. 83

Rajasthan report)

Annexures


(Year and

Source)

Baseline data (year

and source)

Most recent data

(year and source)


(highest/lowest)

Immunization

against

vaccine

prevent-able

diseases

Proportion of children 12-23 months of age

vaccinated against

measles before 12 months


Percentage of

children aged 12- 23

months who received

Measles vaccine

42.3%

(RCH-RHS-1998-

99,P.47, Rajasthan

report )

35.9%

(DLHS-2,2002-

04,P.99,Rajasthan

report)

67.3%

(DLHS-3,2007-08,P.85

Rajasthan report)

65.6%

(UNICEF-Coverage

evaluation survey-

2009)

80 %

by 2010

(State PIP

2010 -2011)

Rural: 65.5%

Urban: 75.7% (DLHS-3,2007-08,P.85 Rajasthan report)

SC: 64.2% ST: 64.6%

OBC: 66.5% Other:76.8% (DLHS-3,2007-08,P.85 Rajasthan report)

Male: 70.0%

Female : 64.3% (DLHS-3,2007-08,P.85 Rajasthan report)

Lowest: 39.9%( Bharatpur)

Highest: 93.6%(Dungarpur) (DLHS-3,2007-08,P.86 Rajasthan report)

Prevention of

malaria

Proportion of children

who slept under an

ITN the previous

night


Antimalarial

treatment for

malaria


with fever who

received appropriate

antimalarials

13.9%

(NFHS-1,1992-93,

P.171, Rajasthan

report )

No data

9.0%

(NFHS-3,2004-06,P. 68

Rajasthan report)

Urban: 7.4%

Rural: 9.5%

SC: 6.5% ST: 11.2%

OBC: 10.4% Other: 5.4%

Male: 8.8%

Female : 9.2% (NFHS-3,2004-06,P. 68 Rajasthan report)

Care seeking

for pneumonia


with suspected

pneumonia taken to

appropriate provider

No data

64.7%

(NFHS-3,2005-

06,P.68,Rajasthan

report)

89.9%

(UNICEF-Coverage

evaluation survey-

2009)

90% access

by 2010 (

State PIP

2010-11)

Urban: 71.9%

Rural: 62.9%

Male: 66.6%

Female :61.8% (NFHS-3,2005-06,P. 68 Rajasthan report)


suffered from /

symptoms of ARI

21.2%

(RCH-RHS-1998-

99,P.52, Rajasthan

report )

13.4%

(DLHS-2,2002-

04,P.105, Rajasthan

report)

7.7 %

( DLHS-3,2007-

08,P.91,

Rajasthan report)

Rural: 7.9%

Urban: 6.6%

SC: 7.9%

ST: 7.4%

OBC: 7.8%

Other: 7.5%

Lowest: 0.8% ( Barmer)

Highest: 18.9% (Bharatpur)


measure

Back ground

(Year and

Source)

Baseline data

(year and source)

Most recent data

(year and source)



Proportion of

children sought

advice /

treatment

35.2%

(RCH-RHS-1998-

99,P.52,Rajasthan

report)

70.5%

(DLHS-2,2002-

04,P.105,Rajasthan

report)

75.7%

(DLHS-3,2007-

08,P.91,Rajasthan

report)

Rural: 73.7%

Urban: 86.5%

SC: 70.1 %

ST: 72.6%

OBC: 77.2%

Other: 80.8% (DLHS-3,2007-

08,P.91,Rajasthan report)

Lowest: 62.2% (Dhaulpur)

Highest:

100%(Hanumangarh) (DLHS-3,2007-


Antibiotic

treatment for

suspected

pneumonia

Proportion of

children with

suspected

pneumonia who

received

appropriate

antibiotics

No data No data 18.2% (NFHS-3,2005-

06,P.68,Rajasthan

report)

Urban: 12.5%

Rural: 19.6% (NFHS-3,2005-


Male:20.6 %

Female: 14.3% (NFHS-3,2005-


Oral rehydration

for diarrhea

Proportion of

children with

diarrhea who

received ORT

4.7% (RCH-RHS-1998-

99,P.52,Rajasthan

report)

29.4% (DLHS-2, 2002-

04,P.102,Rajasthan

report)

30.6% (DLHS-3,2007-

08,P.90,Rajasthan

report)

45%

(UNICEF-Coverage

evaluation survey-

2009)

increase to

60% by

2010,ensuri

ng 100%

availability

of ORS at

sub centre

level.(SPIP-

2010-11)

Urban: 52.7%

Rural: 26.5%

SC: 25.9%

ST: 26.7%

OBC: 31.0%

Other: 40.3% (DLHS-3,2007-


Use of zinc for

the treatment of

diarrhea

Proportion of

children with

diarrhea who

received ORT and

a course of zinc


Annexures

Summary of Worksheet 4 – Coverage Indicators

Coverage indicators - programme is doing enough now

Iron supplementation: Proportion of mothers women who received iron during pregnancy

Appropriate cord care and hygiene: Proportion of babies who had the cord cut with a clean instrument

Postnatal care visit: Proportion of mothers/newborns who had a care contact in the first 2 days after

delivery

Proportion of children living in HH that use iodised salt (>15 ppm)

Case seeking for pneumonia: Proportion of children with suspected pneumonia taken to appropriate

provider

Coverage indicators – trends are positive, but programme needs to do more

Proportion of Institution deliveries.

Proportion of babies who were dried, wrapped (and not bathed) immediately after birth

Appropriate complimentary feeding: Proportion of infants 6-9 months who receive appropriate BF and

complimentary feeding

Proportion of mothers who initiated BF within 1 hour of birth

Proportion of babies who received a pre-lacteal feed

Proportion of mothers who did not give anything other than breast milk in the first 3 days after birth

Proportion of infants 0-28 days who are exclusively breastfed

Oral rehydration for diarrhea: Proportion of children with diarrhea who received ORT

Coverage indicators – major issues; programme needs to do more

Adequate antenatal care: Proportion of mothers who received at least 4 ANC visits

Tetanus Toxoid to all pregnant women: Proportion of mothers who received TT2+ during pregnancy

Identification and treatment of maternal emergencies such as eclampsia and obstructed labour:

Proportion of rural pregnancies having a C-section

Prevention of hypothermia: Proportion of babies who were dried, wrapped (and not bathed)

immediately after birth

Immediate initiation of breastfeeding: Proportion of mothers who initiated BF within 1 hour of birth;

Proportion of babies who received a pre-lacteal feed

Exclusive breastfeeding: Proportion of infants under 6 months exclusively BF

Immunization – „0‟ dose OPV; Percentage of children aged 12- 23 months who received Measles

vaccine

Micronutrient supplementation: Proportion of children who received a dose of vitamin A

Antimalarial treatment: Proportion of children with fever who received appropriate antimalarials

Coverage indicators - Adequate data not available

Malaria prevention: Proportion of pregnant women who slept under an ITN the previous night

Voluntary counseling and testing for HIV and PMTCT: Proportion of HIV + mothers who received

ART prophylaxis

Annexures

Annexure VI : Worksheet 5

Review how well the programme implemented activities

Pregnancy __Birth and Immediate Post-natal period__ Neonatal period __Infants and children 1-59 months

INTERVENTION PACKAGES BEING DELIVERED: ANC, SBA, EmOC, PNC

Activity area

Status of

implementation

(fully, partly or

not at all)

Reasons for observed

implementation

Performance

Strengths Weaknesses

Policies, planning and management

Practice

standards and

guidelines

updated and

being used

Fully met -Disseminated through

regular mechanisms

-Monitored whether

put into practice

System and

mechanisms in place

-Email up to block level

-Monthly meetings of

staff

Awareness at field level is

limited

Essential drug

list available

Fully met -Disseminated through

regular mechanisms

-EDL gets revised with

the revision of

guidelines

-Posted on website

-Supplied with

regularly provided kits

-No individual memory

among staff

-Not displayed in health

facilities

Budgeted plans

developed

annually – at

the state and

district levels

Partly met Planning units exist at

district and state level

District plans are

supposed to contribute

to state plan

District plans are not

developed in time

Planning done

collaboratively

with other

divisions and

with donors

Fully Technical support from

the donor partners

Exec Committees exist

and meet

The final call is taken by

the state, so some

suggestions from donors

not

Annual budget

adequate to

complete all

activities in the

last plan

Partly Inadequate funds for

civil works and

medicine procurement

-Proposed state budget is

slashed down by the

National government

- State is not able to

generate funds to cover the

shortfall

Annexures

Supporting data: policy and planning

Indicator Current status

Policies for exemption of pregnant women, newborns and

children from health charges available and implemented

Y N Rs 2 for

registration

CRC reporting mechanism established and working Y N (Rajasthan third draft report on

convention on rights of child suggests focused

attention on needs of children at policy and

programme level- Source: p.8 Child Policy Rajasthan

2009)

Costed national plan for ensuring universal access to

newborn and child survival interventions available

Y N

Mechanism for monitoring the International Code for

Marketing of Breast milk substitutes working

Y N

Laws and policies on vital registration adopted

Y N

National child health strategy endorsed and costed

Y N

% of districts implementing intervention package

100%

% of proposed child health budget received on time in the

previous year

Info to be collected

Annexures




Activity area

Status of

implementa

tion

(fully,

partly or

not at all)

Reasons for

observed

implementation

Performance


Human resources/training – in-service

Plan to ensure adequate

staffing at each level,

which includes

incentives

Partly Inadequate financial

resources to hire

Contractual hiring

Rural health cadre

Non availability of

specialists

Attrition rates among

contractual staff

In-service training

strategy available

Fully met Training cell in the

ministry

Training institute is

autonomous

State health

resource centre

Postponements

Non compliance by

identified candidates

(MOs)

In-service training

conducted for health

staff

Partly met

LSAS: 28 /

72

completed

Targets partly met -Trainer capacity is limited

-Training sites not

adequate

Trained staff is transferred

In-service facilitators

trained

Partly Adequate numbers

available

Utilization of facilitators

needs to be rationalized

Follow-up after in-

service training

conducted

Partly Policy and

mechanism for SBA

and BEmOC exists

Clear guidelines for

SBA F-up training

Capacity is limited

Quality of in-service

training – are: types of

staff trained, materials

used, time allocated,

amount of clinical

practice adequate?

Partly State monitoring cell

monitoring quality of

training created

-SIHFW provides

supervisory checks

CEmOC: certification

delayed

Annexures

Worksheet 5: Review how well the programme implemented activities



Activity area

Status of

implementation

(fully, partly or

not at all)


implementation

Performance


Human resources/training – pre-service

Pre-service

training

strategy

available

No Need to reorient medical

nursing education to the

needs of national

programmes

Pre-service

training

incorporated

into curriculae

of medical and

other schools

Knowledge and

skills are

covered in

normal

curriculum

Pre-service

trainers trained

No

Quality of pre-

service training

– materials

used (including

textbooks),

time allocated,

amount of

clinical practice

adequate?

N/A

Supporting data: human resources/ training

Indicator Baseline data (year

and source)

Most recent data

(year and source)

Target Differences by

region or

group

(highest/lowest)

% of health staff who have

received training in intervention

package

SBA 53 MO

136(PHN/NT/SN)* up

to 2006-07

(P.7, PIP 2009-10)

1236ANM/SN/LV

up to

2007-08

% ANMs trained in SBA 36.07 % up to

2009-10 (P.20, ROP 2010-11)

57.9 % for

2010-2011 (P.20 ROP

2010-11)

Annexures

Indicator Baseline data (year and

source)

Most recent data

(year and source)


region or group

(highest/lowest)

Doctors trained in EmOC (numbers) 49 up to 2009-10

(P.20, ROP 2010-11)

89 for 2010-

2011 (P.20

ROP 2010-

11)

Doctors trained in LSAS 117 up to 2009-10

(P.20 ROP 2010-11)

189 for 2010-

2011 (P.20

ROP 10-11)

% of planned trainings completed in

the previous year

% of health facilities with at least 60%

of health workers caring for children,

newborns or pregnant women trained

in training package

% of all trained staff who receive

follow-up visit within 3 months of

training

% of medical/nursing/midwifery

training schools that have incorporated

focus intervention or package=

% of mothers who receive ANC/PNC

from a skilled provider

3 or more ANC Checkups 28.8% (DLHS-2 ,2002-

04)

P.4 DLHS-3 Rajasthan

Fact sheet)

41.2 % (NFHS-3,

2005-06)

27.7%

(DLHS-3 ,2007-08)

P.4 DLHS-3

Rajasthan Fact sheet)

80%

(P.4

RCH chapter

PIP 2009-10)

Rural: 23.3 %

Urban: 48.1%

(P.4 DLHS-3,

2007-08

Rajasthan Fact

sheet)

At least 1 TT injection administration 61.4% (DLHS-2 ,2002-

04)


Fact sheet)

55 %

( DLHS-3 ,2007-08)

P.4 Rajasthan Fact

sheet)

80% ( P.4

RCH chapter

PIP 2009-10)

Intervention

Target:

RCH

outreach

camps- 2436

(No.) in

2010-2011

Rural: 51.4%

Urban: 72.4%

(DLHS-3,2007-

08, P.4, Rajasthan

Fact sheet)

Institutional deliveries 32.2%

(DLHS-2, 2002-04)


Fact sheet)

32.2%

(NFHS-3, 2005-06)

45.5%

( DLHS-3, 2007-08)

P.4 DLHS-3

Rajasthan Fact sheet)

70% in 2009 (p.4 RCH chapter PIP 09-10)

80% was the

target for

2009-10( P.4

RCH chapter

PIP 2009-10)

Rural: 40.7%

Urban: 67.7%

(DLHS-3

,2007-08

P.4, Rajasthan

Fact sheet)

Access to PNC -

38.2%

( DLHS-3 ,2007-08)

P.4 Rajasthan Fact

sheet)

60% was the

target for

2009-10( P.4

RCH chapter

PIP 2009-10)

Rural: 34.1%

Urban: 57.8%

(DLHS-3,2007-

08,P.4 Rajasthan

Fact sheet)

% of achievement of need assessed-

Institutional Deliveries

52.1%

(Performance

Statistics Table B.4-

Maternal Health –

Institutional

deliveries, July 2010)

Annexures


__Pregnancy __Birth and Immediate Post-natal period__ Neonatal period __Infants and children 1-59

months


Activity area

Status of

implementation

(fully, partly or

not at all)


implementation

performance


Health communication/IEC

Maternal health

communication

strategy or plan

available

Partly Delay in marriage, ANC

registration, institutional

delivery, emergency

transport

Adequate budget EMOC, PNC component is

weak

Focus on reaching

low level

populations

Partly Special drives and camps Special budget

RHSDP

Lack of coordination

between NRHM and RHDSP

Communication

activities

conducted: mass

media, printed

materials, training

for local

groups/volunteers

in inter-personal

communication;

training for health

workers

Partly Variable in different

districts

Folk groups empanelled

and used

All messages not covered

Messages and

materials

developed and

distributed

Fully Independent state and

district units

Donor partners provide

support for developing

materials


Quality: key

maternal health

messages used;

messages and

materials pre-tested

and adapted for

local context

Partly Standard set used across

the state, Local contexts

not used


Annexures




Activity area

Status of

implementation

(fully, partly or

not at all)


implementation

performance


Development of community supports

Implementation

plan for

community-level

activities

available

Fully Village committees

formed(VHSC)

Funds transferred Took longer than planned

30-40% VHSC members

trained

Community

health workers

trained and

available

AWW,

ASHA Sahayogini

90% villages have

appointed ASHA

Budgets ensured Motivation not sustained

Community

groups or

volunteers trained

and available

Partly Jan-Mangal couples

being revived

VHSC created in all

villages

All VHSC have not been

active

Quality:

Developed

collaboratively;

use local staff and

volunteers;

supervision or

oversight plan

Included

Partly 80% PHCs have ASHA

supervisors

ASHA, VHSC selected by

local community

Difficult to sustain

motivation

Supporting data: health communication/ community

Indicator Baseline

data (year

and

source)

Most recent

data (year

and source)


region or

group

(highest/lowest)

% of mothers receiving at least one mass media communication

activity (radio, TV, groups etc) which includes the key

interventions in the he last 3 months =

% of caregivers who know 2 danger signs for seeking care

during pregnancy/for their sick child

% of villages with trained CHWs for promoting key family and

community practices =

% of CHWs trained in intervention package =

% of caretakers of children 0-59 months who received a home

visit and counseling from a community health provider in the

previous 3 months =

% of villages with trained volunteers for promoting key family

and community practices =

Annexures



months


Activity area

Status of

implementation

(fully, partly or

not at all)


implementation

performance


Strengthening health systems

Quality of case-

management

No system for

assessment or

assuring quality of

care for SBA,

EMOC, PNC

Services

available

ANC, SBA, PNC

are fully available

EMOC is partly

available

FRUs and 24X7 PHCs

not functional

Lack of specialists

Essential drugs

and equipment

available at first

and referral

levels

Partly Equipment available Medicine shortage

Routine

supervision

conducted using

checklists, and

observation of

practice

Partly Checklists are not

adequate to address

Concurrent monitoring

system

Systems for

timely referral

for maternal

complications in

place

Partly Emergency transport HW and ambulance

attendants trained

available at some blocks only

Annexures

Supporting data: systems

Indicator Baseline data

(year and

source)

Most recent

data (year

and source)


region or group

(highest/lowest)

Quality of case-management

% of children who received integrated

assessment (10 assessment tasks) - IMNCI

% of children attending facilities who need an

antibiotic and/or an antimalarial who are

prescribed the medicine correctly - IMNCI

Data on quality of antenatal care, delivery or

newborn care

Services available

% of hospitals providing comprehensive

emergency obstetric and newborn care (24

hours/day, 7 days/week) =

% of hospitals or maternity facilities accredited

as baby-friendly in the previous 2 years =

% of facilities with immunization services

available daily =

% of facilities providing ANC, delivery, ANC,

IMNCI services =

% of caretakers receiving PNC/ANC from a

skilled provider

Essential drugs, equipment and supplies

% of health facilities with all essential

medicines for managing common newborn

childhood illnesses or obstetric emergencies =

% of health facilities with all equipment and

supplies for vaccination =

% of facilities with all equipment and supplies

for managing sick newborns and children

% of facilities that manage severely ill children

with oxygen/delivery systems available in the

paediatric ward =

Supervision and referral

% of health facilities receiving at least one

supervisory visit with observation of case-

management in the previous 6 months =

Annexures




Activity area

Status of

implementation

(fully, partly or

not at all)


implementation

performance


Monitoring and evaluation

Plan for routine

monitoring and

periodic

evaluation of the

maternal health

programme

included in

strategic plan and

work plans

Fully for

monitoring

Partly, for

evaluation

Monthly reporting

system

Some components are

evaluated each year

HMIS online at block

level and upwards

Power and internet

connectivity

Training on data entry

required

No integrated evaluation

plan

Standard

international

indicators used

Partly, But All

nationally

decided

indicators are

captured

Short and long

term targets set

Fully at state

level

Five year and annual

programme cycles

have targets

District specific targets

not fixed

Population- and

health facility-

based data

available for

monitoring and

evaluation

Yes Facility based data at

state level

Population based data

available from

national surveys

Quality of data needs to

be improved

No data on quality of case

management collected

Monitoring data

used for routine

planning by all

levels

Partly Data is used at state

level

Data based planning not

done at district level and

sub-district level

Vital registration

systems working

Partly

About 80 %

births registered

Maternal death

registration are

very low

Awareness

programme on birth

registration in parts of

state

Supporting data: monitoring and evaluation


(year and

source)

Most recent

data (year

and source)


region or group

(highest/lowest)

% of births registered at birth =

61.43%

(UBR 2005)

75.27%

(UBR-2009)

118.51% (Urban)

63.49% (Rural)

(UBR -2009)

% of child deaths registered =

% of routine reports from districts received on time

Annexures



months

INTERVENTION PACKAGES BEING DELIVERED: PNC & Newborn Care

Activity area

Status of

implementation

(fully, partly or

not at all)


implementation

Performance


Policies, planning and management

Practice

standards and

guidelines

updated and

being used

Facility-based

Newborn Care -

NNF guidelines

being utilized

- Interest of the state

government in FBNC

- Resources available

through NRHM

Strong partnership –

NNF, UNICEF, NIPI

Commitment from

government

Partnerships

Resources

Home-based

Newborn Care -

Available

- Activity not covered in

PIP 2010-11

- Although guidelines are

available, implementation

poor

Essential drug

list available

Available;

Drugs are being

purchased based

on the list

- Adequate funds

available

- Was done in

participatory manner

- Not updated regularly

Budgeted plans

developed

annually – at

the national and

sub-national

levels

Yes; available at

state and district

level

- Commitment of the

government

- Done in participatory

manner with

involvement of

important stakeholders

- Template based planning

– lack of flexibility

-

Planning done

collaboratively

with other

divisions and

with donors

Yes; but not all

partners

adequately

involved

- Involvement of ICDS is

less

Annual budget

adequate to

complete all

activities in the

last plan

- Available - Approximately 20%

budget not utilized

- Complicated processes

Annexures

Supporting data: policy and planning

Indicator Current status

Policies for exemption of pregnant women, newborns and

children from health charges available and implemented

Y N

CRC reporting mechanism established and working Y N (Rajasthan third draft report on

convention on rights of child suggests focused

attention on needs of children at policy and

programme level- Source: p.8 Child Policy Rajasthan

2009)

Costed national plan for ensuring universal access to

newborn and child survival interventions available

Y N

Mechanism for monitoring the International Code for

Marketing of Breastmilk substitutes working

Y N

Laws and policies on vital registration adopted

Y N

National child health strategy endorsed and costed

Y N

% of districts implementing intervention package

26 functional FBNC out of 36 planned (source: p.67

NRHM PIP 2010-2011)

% of proposed child health budget received on time in the

previous year

Annexures



months


Activity area

Status of

implementation

(fully, partly or

not at all)


implementation

Performance


Human resources/training – in-service

Plan to ensure

adequate

staffing at each

level, which

includes

incentives

- Adequate

staffing at

FBNC not

planned

-

- Shortage of trained

manpower

- Vacancy of ASHA (15%)

- Lack of staff nurses at

FBNC

In-service

training

strategy

available

Yes; not

adequate

(FBNC &

HBNC)

- Strong partnership for

FBNC training

- Handholding supervision

after training is also poor

In-service

training

conducted for

health staff

Yes; not

adequate

(FBNC &

HBNC)

- Strong partnership for

FBNC training

- Handholding supervision

after training is also poor

In-service

facilitators

trained

Yes - Adequate facilitators

available for NSSK

- Inadequate facilitators

for IMNCI, FBNC

- Protocols not being

followed in training

institutions

Follow-up after

in-service

training

conducted

Not adequate - No mechanism

Quality of in-

service training

– are: types of

staff trained,

materials used,

time allocated,

amount of

clinical practice

adequate?

Need

improvement

- not adequate clinical

practice during training

Quality assurance

mechanism for training not

available

- Less number of facilities

for conducting training

Annexures




Activity area

Status of

implementation

(fully, partly or not

at all)

Reasons for

observed

implementation

Performance


Human resources/training – pre-service

Pre-service training

strategy available

- IMNCI – MBBS,

ANM; Not available

for nursing schools

- Training on

newborn care not a

priority

- Not started in all

medical colleges

-

Pre-service training

incorporated into

curriculum of

medical and other

schools

- Only IMNCI

included

- Newborn component

not adequate

Pre-service trainers

trained

Partly - Not perceived as

priority

Quality of pre-

service training –

materials used

(including

textbooks), time

allocated, amount of

clinical practice

adequate?

Inadequate

Supporting data: human resources/ training

Indicator Baseline

data (year

and

source)

Most recent

data (year and

source)


region or group

(highest/lowest)

% of health staff who have received training in

intervention package =

% of planned trainings completed in the previous year

=

% of health facilities with at least 60% of health

workers caring for children, newborns or pregnant

women trained in training package =

% of all trained staff who receive follow-up visit

within 3 months of training =

% of medical/nursing/midwifery training schools that

have incorporated focus intervention or package =

% of mothers who receive ANC/PNC from a skilled

provider =

-

38.2%

( DLHS-3

,2007-08)

P.4,

Rajasthan

Fact sheet)

60% 2009-

10( P.4

RCH

chapter PIP

2009-10)

Rural: 34.1%

Urban :57.8%

(DLHS-3 2007-

08,

P.4, Rajasthan

Fact sheet)

Access to PNC

Annexures


__Pregnancy __Birth and Immediate Post-natal period__ Neonatal period __Infants and children 1-59 months


Activity area

Status of

implementation

(fully, partly or

not at all)


implementation

Performance


Health communication/IEC

Child health

communication

strategy or plan

available

- Part of the

state health and

ICDS PIP

Focus on reaching

low level

populations

- Separate plan

for tribal and

dessert areas

both in RCH

and ICDS PIP

Communication

activities conducted:

mass media, printed

materials, training

for local

groups/volunteers in

inter-personal

communication;

training for health

workers

- Available (IPC

and Print media)

Messages and

materials

developed and

distributed

Yes

Quality: key child

health messages

used; messages

and materials pre-

tested and adapted

for local context

Yes - Distribution and

dissemination of the IEC

materials

- Evaluation of the

content and impact not

done

- Operational and

managerial issues

- Monitoring of IEC

Annexures



months


Activity area

Status of

implementati

on

(fully, partly

or not at all)

Reasons for

observed

implementation

Performance


Development of community supports

Implementation plan

for community-level

activities available

Available

Community health

workers trained and

available

Partly

- Mechanism for

monitoring by

independent agency

available

- Post-training follow-up

and handholding is not

adequate

- All Community Health

Workers not covered

- Training of ASHA

completed only for a few

modules

- Quality issues in training

of ASHA

Community groups or

volunteers trained and

available

Partly - Jan Mangal Couple

available for 24 hours

Quality: developed

collaboratively; use

local staff and

volunteers;

supervision or

oversight plan

Included

Annexures

Supporting data: health communication/ community


(year and

source)

Most recent

data (year

and source)


region or group

(highest/lowest)

% of mothers receiving at least one mass media

communication activity (radio, TV, groups etc)

which includes the key interventions in the he last 3

months =

% of caregivers who know 2 danger signs for

seeking care during pregnancy/for their sick child =

Awareness among women about danger signs of

ARI

71.7%

(DLHS-

2,2002-04)

P.5 DLHS-3

Rajasthan Fact

sheet)

98.6%

( DLHS-

3,2007-08)

P.5,

Rajasthan

Fact sheet)

Rural:98.6%

Urban: 98.8%

(DLHS-3 ,2007-

08)

P.5, Rajasthan

Fact sheet)

% of villages with trained CHWs for promoting key

family and community practices =

% of CHWs trained in intervention package =

% of caretakers of children 0-59 months who

received a home visit and counseling from a

community health provider in the previous 3 months

=

% of villages with trained volunteers for promoting

key family and community practices =

Annexures




Activity area

Status of

implementation

(fully, partly or

not at all)


implementation

Performance


Strengthening health systems

Quality of case-

management

Unsatisfactory

- Training and follow-

up after training

- Lack of Quality

Assurance system

- Poor monitoring

- Lack of skilled

manpower

- Lack of infrastructure

-

- Plan for monitoring of

FBNC through State

level Newborn cell

- Training and follow-up

after training

- Lack of Quality

Assurance system

- Poor monitoring

- Lack of skilled

manpower

- Lack of infrastructure

- Lack of awareness and

acceptance of services

(community-

based/facility-based)

- Gender bias in care

Services

available

Inadequate

- Services

available only at

District hospital

- Unsatisfactory

for Community

level

- Lack of skilled

manpower

- Lack of well-

established

infrastructure

- Lack of supportive

supervision

- Lack of awareness and

acceptance of services

(community-

based/facility-based)

- Lack of accountability

Essential drugs

and equipment

available at

first and

referral levels

- For first level,

units to be

established

- For referrals,

equipments and

drugs available - The list of

essential drugs

need to be

updated for

newborns

- Although equipments

available at referral level,

maintenance is a problem

Routine

supervision

conducted

using

checklists, and

observation of

practice

Not at all for

FBNC

Partly for

Community-

based

-Still in the

preliminary stage of

planning for FBNC

- For community-

based, we have

checklists available for

supervisors

- ICDS involved for


of Community-based

Newborn Care

-

Community-based care

- Lack of feedback

- Lack of accountability

Systems for

timely referral

of sick

newborns and

children in place

Available - Acceptance of the

public health system

- Training of the

workers

- Follow-up of referral

- Referral card

- Funds are available

- Ambulance services

- Although system is

available, referrals remain

poor

Annexures

Supporting data: Health systems

Indicator Baseline

data (year

and source)

Most recent data

(year and source)


region or group

(highest/lowest)

Quality of case-management

% of children who received integrated

assessment (10 assessment tasks) –

IMNCI

IMNCI (Integrated Management of

Neonatal

& Childhood Illnesses)

To

implement

IMNCI in

33 districts

in next two

years. (P.8 NRHM PIP 2010-11)

Personnel Trained in IMNCI 17000 by 2009-10

(No.)

(P.21

ROP 2010-11)

25250 up

to 2010-11 (P.21 ROP 10-11)

% of children attending facilities who

need an antibiotic and/or an

antimalarial who are prescribed the

medicine correctly - IMNCI

Data on quality of antenatal care,

delivery or newborn care

Please note : All data on T/t of diarrhea and ARI is for two weeks before the concerned survey.

Children with Diarrhea who sought

advice or treatment

61.7%

(DLHS-2

,2002-04)

P.5 DLHS-3

Rajasthan

Fact sheet)

59.7%

( DLHS-3 ,2007-08)

P.5 Rajasthan Fact

sheet)

Rural: 58.7%

Urban: 64.9%

(DLHS-3 ,2007-08)

P.5 DLHS-3

Rajasthan Fact

sheet)

Children with Diarrhea who received

treatment with ORS

28.9%

(DLHS-2

,2002-04)

P.5 DLHS-3

Rajasthan

Fact sheet)

30.6%

( DLHS-3 ,2007-08)

P.5 Rajasthan Fact

sheet)

Rural: 26.4%(

Urban: 53.0%

(DLHS-3,2007-08)

P.5 Rajasthan Fact

sheet)

Children who had Diarrhoea

% Children taken to Health Provider

Treated with ORT

No Treatment

10.3% (

NFHS-3,2005-2006

P.69 State report )

56.7%

21.4%(including16.5%

ORS)

28.7%

(NFHS-3,2005-2006

P.69 State report)

Annexures

Children with Diarrhea who were

treated with ORS

16.5%(2005-06)

50% (2006-07)

60%(2007-08)

80%(2009-10)

P.31 NRHM PIP 2010-2011

Children under 5 who had symptoms of

ARI

Out of these who were taken to the

health facility

Out of these who received antibiotics

7%

(NFHS-3,2005-2006

P. 24 State report)

65%

18%

% children with ARI and fever who

sought advice or treatment

70.1%

(DLHS-2

,2002-04

P.5 DLHS-3

Rajasthan

Fact sheet)

75.6%

( DLHS-3,2007-08


Fact sheet)

Rural: 73.6%

Urban: 86.3%

(2007-08

P.5 DLHS-3

Rajasthan Fact

sheet)

% Of Sick children (with

Diarrhea/ARI/childhood illnesses)

having access to care

90% by

2010-11

(P.67

NRHM

PIP 2010-

11)

Services available

% of hospitals providing

comprehensive emergency obstetric

and newborn care (24 hours/day, 7

days/week) =

FBNC(facility based new born care) at

district hospitals

11 FBNC

functional

out of 35

planned in

2009-10

(P.14 RCH

chapter PIP

2009-10)

26 functional FBNC

out of 36 planned

(P.67 NRHM PIP

2010-2011)

36 by March

2010

(P.67

NRHM PIP

2010-11)

36 in

number (A.2.2 excel sheet PIP

budget sheet

2010-11)

NBSU(newborn stabilizing units) at

FRUs

100 in

number (A.2.2 excel

sheet PIP budget sheet

2010-11)

New born care services Since April 2009 a

total 18452 Newborns

were admitted till Nov

09 (p.68 NRHM PIP

2010-2011)

85% of 19971 of

neonates cured and

treated

( State PIP 2010-2011)

Estimates :

50000 new

born will

receive

quality care

every year(

State PIP

2010-2011)

Annexures

% of hospitals or maternity facilities

accredited as baby-friendly in the

previous 2 years =

% of facilities with immunization

services available daily =

% of facilities providing ANC,

delivery, ANC, IMNCI services =

FRUs Operational 100 FRUs by 2008-09

were functional

(P.4 PIP 2009-10)

237 in

number in

2010-11 (P.134 NRHM PIP 2010-11)

% of caretakers receiving PNC/ANC

from a skilled provider

Essential drugs, equipment and supplies

% of health facilities with all essential

medicines for managing common

newborn childhood illnesses or

obstetric emergencies =

% of health facilities with all

equipment and supplies for vaccination

% of facilities with all equipment and

supplies for managing sick newborns

and children

% of facilities that manage severely ill

children with oxygen/delivery systems

available in the paediatric ward =

Supervision and referral

% of health facilities receiving at least

one supervisory visit with observation

of case-management in the previous 6

months =

Annexures



INTERVENTION PACKAGES BEING DELIVERED: IMNCI,UIP/RI, MTC

Activity area

Status of

implementation

(fully, partly or

not at all)


implementation

performance


MONITORING AND EVALUATION

Plan for routine

monitoring and

periodic

evaluation of the

child health

programme

included in

strategic plan and

work plans

Yes - Online

- Pregnancy and child

tracking system

established

- Indicator based

monitoring

- Quality of data needs

improvement

- Proper system for analysis

of data and feedback to the

providers not available

-Monitoring for quality of

care

- System of verification of

data

Standard

international

indicators used

Yes

Short and long

term targets set Partly - Targets not available for

all indicators (impact and

coverage

Population- and

health facility-

based data

available for

monitoring and

evaluation

Yes - Use of data for decision-

making needs

improvement

Monitoring data

used for routine

planning by all

levels

Partly - Planning process

- Training of managers in

planning process

- Exact data needed for

planning may not be

available

Vital registration

systems working

Partly

- - Maternal death

enquiry initiated and

being scaled up

- Birth registration has

improved with increase

in institutional delivery

- home delivery and death

at home not being

registered

-

Supporting data: monitoring and evaluation

Indicator Baseline data (year

and source)

Most recent data

(year and source)


region or group

(highest/lowest)

% of births registered at birth =

61.43%

(UBR 2005)

75.27%

(UBR 2009)

118.51% (Urban)

63.49% (Rural)

( UBR 2009)

% of child deaths registered =

% of routine reports from districts

received on time

Annexures



INTERVENTION PACKAGES BEING DELIVERED: IMNCI, UIP, MTC FBI

Activity

area

Status of implementation Reasons for

observed

implementation

Performance


POLICIES, PLANNING AND MANAGEMENT

Practice

standards

and

guidelines

updated

and being

used

IMNCI –Full Good Policies

Guidelines, updated

regularly,

Implementation Plans

Some critical

operational elements

are lacking e.g


mechanisms.

UIP - Full Comprehensive

guidelines available

encompassing several

components of program

management

Centrally determined

plans and policies,

local needs for certain

vaccines may not be

met as per

requirement.(e.g need

for HepB and HiB)

Elements of demand

side is missing;

tackled separately in

IEC section

Facility based Interventions

(MTC,Yashoda,F-IMNCI)=Yes

except for F-IMNCI; policy

decision has been taken,

details being worked out

Most policies are

adoption of National

level guidelines;

sometimes even the

translation in the local

language is not

undertaken.

Frequent change of

circulars and

directives.

Dissemination of the

guidelines are not

timely: there is also

variation in

interpretation.

Essential

drug list

available

IMNCI -Yes as part of the

State Essential Drug List

One comprehensive drug

list for each level of

facility has been

prepared.

Provision to buy

materials outside the list

if required.

Matching of the drug

list with the

intervention packages

has not been done.

UIP: All vaccines available Vaccines available but

supply chain

management issues

Facility based Interventions:

part of essential drug list

Matching of essential

drug list required

specially for newer

programs such as F

IMNCI and MTC.

Annexures

Activity

area


observed

implementation

Performance


Budgeted

plans

developed

annually –

at the

national

and sub-

national

levels

Yes, for all as a part of the

PIP

Participation of districts

which are preparing dist

action plans/ sub plans:

bottom up approach

IMNCI Planning

confined to Planning

for Training

Planning

done

collaborativ

ely with

other

divisions

and with

donors

IMNCI-Yes,

UIP; Yes

FBI: Yes

Joint planning

undertaken at state level

Medical college/ training

institutions involvement

is increasing

Collaboration not

uniform at all levels

Convergence with

ICDS not adequate.

Annual

budget

adequate to

complete all

activities in

the last

plan

IMNCI-Yes

UIP: Yes

FBI: yes

Most of the budgeted

money remains

underutilized.

Annexures




Activity area Status of implementation Reasons for

observed

implementa

tion

Performanc

e


HUMAN RESOURCES/TRAINING – IN-SERVICE

Plan to ensure

adequate staffing

at each level,

which includes

incentives

Partial. plan is available,

positions are identified

where vacancies are.

Hiring of contractual

staff where needed.

Main streaming of

AYUSH personnel

DP also providing

/supporting techno-

managerial personnel.

Delays in filling

vacancies.

In-service

training strategy

available

Yes there are a variety of

training packages available

(21)!!

specific training

packages for each

intervention group

Lack of coordination

and integration of

trainings.

Frequent disruptions

in trainings.

In-service

training

conducted for

health staff

Yes Training plan/calendar

made

Flexibility in training;

can change calendar if

necessary

multiple trainings in

process a burden to

time and personnel.

Training calendar not

adhered to:

synchronization of

trainings not always

evident.

budget sometimes not

available in time

leading , external

exigencies prolong

duration of trainings.

Contingency plans not

made.

Annexures


observed

implementat

ion

Performance


In-service

facilitators

trained

Yes lack of reorientation

leads to loss of skills

Transfer of facilitators

leading to loss in

manpower.

Follow-up after

in-service

training

conducted

Partial Each candidate's service

book would contain the

trainings he has

undertaken.

post training

deployment is not

appropriate

Quality of in-

service training –

are: types of staff

trained, materials

used, time

allocated, amount

of clinical practice

adequate?

mixed; trainings at block

level tend to be of poor

quality, at govt venue tend

to have other distractions

Two sites designated at

training sits to assure

quality (for state level

trainings)

the appropriate

persons are not sent

for the trainings;

tendency for the same

person to be sent for

several trainings.

Annexures


observed

implementat

ion

Performance


HUMAN RESOURCES/TRAINING – PRE-SERVICE

Pre-service

training strategy

available

Partial; Formal strategy in

place for IMNCI, not for all

National strategy not

endorsed at state level

dissemination not

done to all levels.

No set plan for in

service training.

Pre-service

training

incorporated

into curriculae

of medical and

other schools

Partial Material not

incorporated

yet in all

relevant text

books.(only

select;OP

Ghai)

At present , IMNCI

training is for medical

colleges and not for

nursing schools.

Pre-service

trainers trained

Partial: only from medical

colleges e.g for IMNCI

Quality of pre-

service training

– materials used

(including

textbooks), time

allocated,

amount of

clinical practice

adequate?

No information available

Annexures




Activity area Status of

implementation

Reasons for

observed

implementation

Performance


HEALTH COMMUNICATION/IEC

Child health

communication

strategy or plan

available

Yes, as a part of the the

overall IEC plan

Special directorate at

state and IEC

coordinators at districts

in place

Budget available for IEC

activity

Strategy does not have

comprehensive plan

using appropriate

media mix: more

emphasis written

messages and not

always appropriate

Focus on

reaching low

level populations

Yes Despite availability of

plans , implementation

and reach are less than

optimum.

Communication

activities

conducted:

mass media,

printed

materials,

training for local

groups/volunteer

s in inter-

personal

communication;

training for

health workers

Yes Local religious leaders

have been used, puppet

shows have been

organised, video CD

materials have been

developed, posters and

LCD screens with 7 CD

sets of IEC materials are

being displayed in

maternity wards,

claender for IMNCI.

BCC trainings for HW

by RHSDP, IEC training

a part of all major

training packages.

Loss of materials

developed in the past,

Slow pace of trainings

of IPC/BCC packages,

often not practiced by

HW.

Messages and

materials

developed and

distributed

Yes(developed); partial

dissemination

Variety of materials

developed pertaining to

major interventions.

materials not always

available where

required; often not

displayed despite

availability

Quality: key child

health messages

used; messages and

materials pre-

tested and adapted

for local context

Partial: field testing part

not undertaken

Technical committee

ensures correct

messages, local context

adapted

field testing aspect

often ignored

Evaluation (output) of

material not

undertaken

Annexures





observed

implementation

Performance


DEVELOPMENT OF COMMUNITY SUPPORTS

Implementati

on plan for

community-

level activities

available

Partial; ASHAs recruited,

VHSC made; plan for

training PRI members

lack of

coordination

between health

functionaries and

community

persons to

develop concrete

plan

ASHA placed; trained,

funds available at

community level

Involvement of

community is not as

per desired, non-

formal leaders are not

involved.

Community

health

workers

trained and

available

Full: ANMs , LHV, and

AWW

different training

packages for each group

timeliness of training,

quality of training

variable(through

NGOs)

Conflicting messages

in different trainings

as understood by

trainees.

Community

groups or

volunteers

trained and

available

Almost complete (ASHA)

Partial (VHSC)

Quality:

developed

collaborativel

y; use local

staff and

volunteers;

supervision or

oversight plan

included

Partial. Models of supportive

supervision has been

created and tested in

Rajasthan(e.g

director=district, nursing

schools)


weak

multiplicity of

packages; no

integration of


mechanism

Annexures




Activity area Status of

implementation

Reasons for

observed

implementation

Performance


STRENGTHENING HEALTH SYSTEMS

Quality of

case-

management

Partial (from given data

of diarrhea, pneumonia,

mal nutrition)

Logistics issues,

training issues

Gradual improvement

is evident

irrational use of antibiotics,

IV fluids, feeding

counseling weak

Services

available

Partial IPHS standards

available to be

followed.

Facility level survey

carried out periodically

HMIS also monitors

facilities and services.

Mechanism for

providing services

through VHND

facilities and services not

uniformly available as per

IPHS standards

Essential drugs

and equipment

available at

first and

referral levels

Full Equipment are being

supplied by regular

and partner support

Drug supplies are

mostly regular

manpower not appropriately

trained to use equipment

Maintenance of the

equipment not streamlined

Routine

supervision

conducted using

checklists, and

observation of

practice

Partial Senior personnel

from directorate

allotted districts for

direct supervision

(has a comprehensive

common checklist)

Inadequate supervisory

manpower for field level

supportive supervision.

Available supervisors need

appropriate training for use

of checklists.

Systems for

timely referral

of sick

newborns and

children in

place

Partial, 108 mechanism for

referral

funds available at

VHSC for referral

when needed

Awareness for need

for referral

increasing.

Recent problems with 108

company PPP arrangement;

introduced phase-wise at

Rajasthan.

Timely referral being

hindered due delays in

identification and decision

making ( also information

on where to refer)

Referral slips not honoured.

Availability of doctors at

facility level.

Need for training processes

at facility level.

Annexures




Activity

area


observed

implementation

Performance


MONITORING AND EVALUATION

Plan for

routine

monitoring

and

periodic

evaluation

of the child

health

programm

e included

in strategic

plan and

work plans

Partial State has made multi

level plans for

monitoring and

supervision of child

health activities.

State has tool for

validation of monitoring

data.

Has an online system for

receiving reports from

the lowest levels; also

pregnancy child tracking

system in place.

CRMs and JRMs also

include review of child

health packages.

Stock taking of CRM

and JRM

recommendations are

undertaken through

action taken report.

Monthly review meeting

for progress in

implementation

undertaken at the state

UIP has a monitoring

system including

periodic reviews.

Monitoring at lower

levels inadequate (lack

of time, variety of

tasks including non-

health tasks)

Analysis of

computerized data at

block level

inadequate, now

started at district level.

Teams involved in

JRMs and CRMs are

not apprised of the

action and are not

involved in the

corrective planning

process. central

initiative rather than

the state.

Review mechanisms

have more focus on

administrative

processes than

program indicators.

use of HMIS data and

data triangulation

limited.

UIP reviews are

mostly undertaken

where DP support is

strong.

Annexures

Activity

area


observed

implementation

Performance


Standard

international

indicators

used

Yes Yearly periodic

reports have to be

submitted based on

the indicators.

In the PIP the standard

indicators have been

mentioned each year and

have been used for planning

purposes.

Not internalized by the

system on a regular basis

Not used to drive the

programs systematically.

Short and

long term

targets set

Yes Need to provide

reports with

targets.

Targets determined

following community

surveys and determined

bottom up.

Demography cell validates

and finalises these targets.

Targets for each

intervention related to

child health not

available.

Sometimes targets are

unrealistically set due to

ambitious requirements

of decision makers.

Lack of techno

managerial skills to set

realistic targets.

Population-

and health

facility-

based data

available for

monitoring

and

evaluation

Yes, through HMIS data and

through surveys

Disaggregated data (e.g sex

wise, rural urban) now

available even at peripheral

levels

Sometimes validation of

data carried out by

independent agencies.

Proper analysis and use

is limited.

Lack of demand for

astute data by decision

makers and not

appropriately used in

planning and review

processes.

Data of private services

not available.

Monitoring

data used

for routine

planning by

all levels

Partial Indicators and information

are available.

Only limited data (key

indicators information)

used for planning

processes e.g

immunization

Feedback of data is not

usually shared at lower

levels, the block review

mechanisms vary from

block-to-block

Vital

registration

systems

working

Partial

(85%)

Being done at

village by gram

sachivs (85%

registration)

Maternal death

audits started in 14

districts

Incentives for reporting

maternal and infant death.

Computerization of data/

support by DPs e.g

maternal death audits.

Not yet universal

Annexures

Annexure VII: Worksheet 6 (Consolidated)

Identify the main problems

Activity Area Problems

Policy, planning

and

management

Communication from HQ to grass root level:

a. Clarity and completeness

b. Timeliness

c. F/U on action

Lack of Operational Guidelines/ SOPs

a. Clarity on program incentives

Need based Planning

a. Limited Program Planning and Management capacities especially at

district level

b. Constraints of templates and budget, flexibility not there

c. Data not used, equity not considered (RBP)

d. Special plans for desert and tribal areas

Stronger HR policy and Training strategy to be developed

a. Deployment

b. Recognitions and incentives

c. Involvement of AYUSH practitioners in IMNCI

Lack of Convergence with health related departments like ICDS, Water,

Sanitation, PRIs

Program Implementation challenges

a. Feedback system

b. Weak supervisory mechanisms

c. Logistics management

1. Transmission loss of stated guidelines resulting into ambiguity in understanding

guidelines- (Language, Individual interpretation) (M)

2. Frequent changes, time lag in issue to implementation, lack of reference (M)

3. Policies do not explicitly state the operational element /implementation plan e.g.

post training programmatic support (needs detailing). (C)

4. The local level adaptation and dissemination of National level guidelines of the

guidelines are weak. (C)

5. Delink between the district plans & section plans and hence lack of consistency in

district plans and state plans. (M)

6. Facility-based newborn care – availability of SCNU beds not decided on the

number of deliveries conducted (N)

7. Budget allocation does not often match with plan needs. (M)

8. Procedural delays resulting in poor budget utilization (N)

9. Lack of linkages between program activities planned coverage of key interventions

& achieving impact and set goals. (M)

10. Posting of staff far away from their native district. (N)

11. Comprehensive training strategy does not exist. (C)

12. Weak coordination between ICDS and Health Department related with defining

the role of ASHA. (N)

Annexures

Human

resources and

training

Lack of Systematic policy of human resource development. (M)

- Selection of proper person for trainings. (M)

- Delink between available data of PIS (personal information system) and its

use. (M)

- Proper Utilization of training skills. (M)

Weak supportive supervision system, lack of follow-up after training and

programmatic support. (M)

Pre service education programme does not incorporate training packages of

medical & paramedical staff. (M)

Vacancies of critical staff at facility and community level (N)

Post training Supportive supervision and handholding is weak. (N)

Pre service training on IMNCI not being done. (N)

Not adequate training of trainers for pre-service courses. (N)

Newly recruited field staff (ASHA coordinator) not provided adequate training

and mobility support. (C)

Attrition of junior doctors high for PG seats. (C)

Delays in filling vacancies, recruitment slow. (C)

The appropriate participants and facilitators not selected for trainings. (C)

Communication

No well designed BCC strategy for MCH. (M)

Messages do not match with the all services packages. (M)

Inappropriate Media mix. (M)

Lack of impact assessment of communication materials. (M)

Communication skills of health workers. (M)

Absence of Integrated communication plan for newborn health, no focus on

gender either. (N)

Interpersonal communication weak (N)

Monitoring and evaluation of IEC activities weak (N)

Intensity of IEC is not sustained throughout the year. (C)

Slow pace of trainings of IPC/BCC packages (C)

Field testing aspect and content analysis often ignored (C)

Impact evaluation of material not undertaken (C)

Development of

community

supports

Inadequate quality of VHSC, ASHA, Janmangal couple trainings. (M)

Un-sustained motivation of support groups. (M)

Handholding of Village Health and Sanitation Committee is weak (N)

Community Monitoring not being done by Village Health and Sanitation

Committee (N)

Thematic community meetings involving right community members (on

Immunization, breastfeeding: for role in community mobilization, behavior

change, community monitoring of activities) not happening. (C)

Weak linkages with different community groups and health systems. (C)

Lack of timeliness of training for community members, quality of training

variable (through NGOs). Conflicting messages in different trainings as

understood by trainees. (C)

Annexures

Strengthening

health systems

No system for assessment or assuring quality of care for SBA, EMOC, PNC.

(M)

Lack of specialists (CEmOC), nursing staff, ANMs. (M)

Shortage of medicines. (M)

Inadequate emergency transport. (M)

Lack of skilled manpower; extra positions not created to keep pace with the

new facilities; e.g. FBNC (N)

Supportive supervision (N)

Maintenance of equipments (N)

Maintenance of the equipment and training for their appropriate use not

streamlined (C)

Weak supportive supervision. (C)

Referral related delays are a problem. (C)

Poor case management (C)

Monitoring and

evaluation

Lack of comprehensive analysis of data at district and sub-district level

o Some issues in data quality (e.g. morbidity, mortality)

o Denominators not considered

o In individual tracking, Urban data not covered

o Some Private sector data missing e.g. Newborn and Child health data

Weak Review and feedback mechanisms at district and sub-district level- more

administrative- less programmatic, targets- results should be discussed, need to

be more structured, Joint director of respective zones should attend the reviews

o Joint reviews with related departments like ICDS, Water, Sanitation

and PRIs

Need to update monitoring indicators related to MNCH

Targets not realistic

No systematic evaluation plan

Assessment of Quality of care of MNCH services

1. System for analysis of data at district and sub-district level and feedback to the

providers not available. (N)

2. No analysis and feedback on HMIS data. (M)

3. Monitoring and feedback at all levels inadequate (lack of time, variety of tasks

including non-health tasks) (C)

4. Standard newborn care indicators and targets not included in monitoring

system (N)

5. Inadequate Quality of HMIS data. (M)

6. Analysis of computerized data at block level inadequate. (C)

7. Data of private sector services not available. (C)

8. Realistic targets for each intervention related to child health not available. (C)

9. Review mechanisms have more focus on administrative processes than

program indicators. (C)

10. No integrated evaluation plan. (M)

11. Quality assurance system of facility based and community based newborn care

not included in PIP. (N)

12. Inadequate Use of data for planning. (M)

M: Maternal Group, C: Child Health Group, N: New born group

Annexures

Annexure VIII: Worksheet 7

Develop solutions and recommendations: Activity area: Policy, planning and management

The Problems are… Causes Solutions Recommendations

There is a gap in communication,,

uniform interpretation and

follow-up of directives from State

HQ to grass root level.

a. Lack of clarity, consistency and

completeness

b. Delay in communication

c. There is no follow up on

communication and action taken

Checklist to be developed to

ensure clarity and completeness

and all communications to go

through this checklist

Action taken report should be

obtained and Periodic Follow

ups should be done

Should be shared verbally and in

written during monthly/

quarterly reviews

Apart from verbal and written

communication, video

conferencing and Gramsat

platform can be utilized to bring

clarity in communication

Along with long guidelines, gist

in bullets to be included

CMHOs & BCMHOs to be

made more accountable

In the area of addressing „Gaps in

Communication‟ of guidelines from

state HQ to grass root level it is

recommended that:

1. Checklist for ensuring clarity,

consistency and completeness of

guidelines, follow-up is

developed by Health Directorate

2. Originating units/ departments

use the checklist to ensure that

the guidelines are clear,

comprehensive and self

explanatory

3. The district and block units

ensure that the guidelines

reaches the intended user in time

and an action taken report is

sought

Annexures

Activity area: Policy, planning and management


Planning not need based but

driven by template and budget

a. Limited Program Planning and

Management capacities

especially at district level

b. Constraints because of template

planning and budget restraints

c. Data not used, equity not

considered (RBP)

d. Desert and tribal areas not given

adequate priority

e. Targets unrealistic or missing

for some interventions

Building capacities for „Program

Planning and Management‟ at

state and district and block level

Decentralized planning based on

data and local needs as

recommended in NRHM

Alternate approaches to be

developed for difficult areas

In the area of „Need based Planning‟

it is recommended that:

1. Organize Capacity building

workshops on „Program

Planning and Management‟ for

block, district and state level

officials to promote data and

need based planning

2. Health Directorate to ensure that

specific and appropriate plans

for improving access to services

are developed by desert/ tribal

districts and other districts for

their difficult areas

Underutilization of AYUSH

practitioners in MNCH services

a. No clear policy for utilization of

services of AYUSH

practitioners in MNCH

Utilization of AYUSH

practitioners for IMNCI

implementation

Monitoring of other MNCH

services

State government to take a

policy decision to enable

AYUSH practitioners to deliver

IMNCI through training and

monitoring of other health

services

Lack of coordinated and

inadequate attention to address

Nutrition and Development in

Children

a. Lack of coordination between

ICDS and Health departments Better coordination between

AWW, ASHA and ANM

Joint planning and reviews of

ICDS and Child Health

programme at district and sub-

district level to address

Malnutrition, anaemia and

development in under 3 children

Joint training

Annexures

Activity area: Monitoring and Evaluation


Lack of quality in data capture at

field level

o Some issues in data quality like

under-reporting, misreporting,

definitions not clear (e.g.

morbidity, mortality), fear factor

high

o In individual tracking, Urban

data not covered

o Some Private sector data

missing e.g. Newborn and Child

health data

1. Orientations on importance of

data for frontline workers to

improve data quality

2. Sensitization and Orientation of

block and district level officials

to address apprehension to

report morbidity and mortality

data

3. Ward wise reporting system in

urban areas to be developed for

PCTS

4. Sensitization of private

practitioners

State to develop :

A plan for orientations of

frontline workers and managers

to improve data quality

Ward wise reporting system in

urban areas for PCTS

Sensitization of private

practitioners for reporting

morbidity, mortality and service

utilization data

Inadequate data analysis,

feedback and reviews at district

and sub-district level

o Mechanism for analysis and

feedback exists but is

inadequate and not target

oriented

o Review is more administrative

rather than programmatic

o Some MNCH targets not

realistic

1. Orientations of block district

and state level officials to

improve data analysis and

provide appropriate feedback

2. Monthly sector & block

meetings to be used for review

and data analysis

3. Reviews need to be made more

structured, Joint director of

respective zones should attend

the reviews

4. PHC sector meeting is the most

important point where adequacy

and quality of data can be

discussed at length with the

grass root workers. The meeting

at PHC level should be

organized regularly and a block

level officer should attend it

State to plan:

Orientations/training of block

and district level officials to

improve data analysis and

provide appropriate feedback

Conduct short program reviews

at district level annually before

development of District PIPs

Provision of statistician at Block

level

Annexures


Difficulty in monitoring neonatal

care and PNC interventions

Indicators related to neonatal

care and PNC are not available

Need to update monitoring

indicators related to neonatal care

and PNC

State to introduce Neonatal and

PNC indicators in the

monitoring system

No systematic evaluation plan in

place

Evaluation for priority interventions

to be more systematic

State to develop a systematic

plan to periodically evaluate

implementation of IMNCI, New

born care and PNC interventions

Limited data on Quality of care of

MNCH services

No system for „Assessment of

Quality of Care for MNCH services

Periodic assessment of „Quality of

care for sick newborns and children‟

State to:

Develop/adapt tools to assess

quality of care (facility, case

management, satisfaction of

beneficiaries)

Periodically evaluate quality of

care at health facilities and

community level

Annexures

Activity area: Human resources/training


Human resource

1) There is in-adequate number

of staff and expertise for

maternal, newborn and child

health

Lack of Systematic policy

of human resource

placement & development.

Vacancies not filled

(administrative process)

and as a result inadequate

number of critical staff at

facility and community

level

Attrition of junior doctors

high for PG seats. (C)

Mismatch between personal

information (health worker

profile) and posting

Mismatch between patient

load (services) and number

of staff needed

Short term

Use data generated from

Personal information system

(PIS) appropriately for

placement of critical HR

Acknowledge development of

Focus District Approach that

has just been started and

document experiences and

lessons learnt for scaling up

for improving quality of

services.

Long term

Have in place a human

resource development

policy/strategy

Rationalization of existing HR

available in the system at

different levels by appropriate

authority

Fast track recruitment for

vacant posts through online,

walk-in-interviews

Accessing HR services

through PPP model

HR policy/ strategy to address

HR issues systematically

Include succession planning

Mapping of facilities of various

levels to be done and as per

requirement, right HR to be

posted.

Evaluation of focus district

approach and based on

experience decide next steps

Synchronization of HR as per

intervention package wherever

possible

PHS to lead strengthening of

Human Resource Development

Strategy/policy (with adequate

reflection of number, skills

including induction training,

transfers )

Annexures


Training

2 Quality of training is not

optimal

A Comprehensive training

calendar not made

Information regarding

training status of personnel

not available

Same message delivered in

various training (integration

of training modules on same

issues)

Lesser no of trainers as

compared to no of training

programs in place

Increase pool of trainers by going

beyond traditional trainers and

sharing trainers across

programmes

Innovative training approaches

such as distance learning,

technology based trainings to be

explored

All clinical trainings to have

adequate hands on components

Post training programmatic

support to be put in place

External agency support for on

job/follow up training and


Collection of information for

impact analysis to be explored

Strengthen district training

capacity

Director RCH to lead

development of comprehensive

training strategy and

implementation plans

Increase pool of trainers

by going beyond

traditional trainers and

sharing trainers across

programmes

Innovative training

approaches such as

distance learning,

technology based

trainings to be explored

Ensure hands on clinical

training and these training

sites need to be

strengthened further.

Supervision/ evaluation of

training programmes on

routine basis

Specialist services to be

increased through

targeted training

Directive need to be

issued by appropriate

authority to include

training like IMNCI in

MBBS, nursing and ANM

education

Annexures


3) Pre-service training

Teaching staff are not fully

informed on need to

incorporate MNCH

guidelines in pre-service

Orientation of teaching staff

(medical and paramedical

schools)

Orient and conduct

training for teaching staff

on MNCH guidelines

With teaching staff

develop a plan for

introducing and

implementing MNCH

pre-service

IMNCI

Annexures

Activity area: Strengthening Health Systems


Shortage of drugs

Mismatch between requirements

and supply of drugs and

consumables as per intervention

package

Kit base supply also it‟s a

push system

Need base supply system

not in place

Irrational drug usage

Poor Awareness among

personnel for resources

available for drug

procurement at local level

Kit supply to match need

Essential drug list should

include all drugs required

for newborn and child

health

Better quality of training on

usage of drugs (as per

principles of rational drug

use)

Create awareness

Review and identify gap in

drug supply management

and utilization of alternative

available funds (Untied

fund, RKS fund etc.)

MD NRHM to lead Review existing

drug supply management to identify

specific gaps and solutions

Strengthen teaching on

rational use of drugs

At district level, all the

supplies received through

kits and supply of essential

drugs used to be reviewed.

Drugs and consumables that

are missing to be procured

through untied funds and

RKS. A clear-cut guidelines

and financial directive in

this regard need to be issued

to all concerned facilities.

Poor supportive Supervision

Micro planning of


action plan is not evident

Not getting adequate

attention/importance


Shortage of adequate human

resource, inadequate skills

of supervisory cadre

Supportive supervision to

be given adequate priority

Integration of supportive

supervision for related

activities

Urgent prioritization and

integration of supportive

supervision for various activities

Dir.RCH to identify and train pool

of supervisors in each block for

integrated supportive supervision

Checklist and clear guidelines for

planning implementation, analysis

& feedback for supervision

Annexures

Activity area: Strengthening Health Systems


Poor Maintenance of equipment

Training of staff on

handling and maintenance

not uniform

Mechanism for maintenance

of equipments not in place

Annual maintenance

contract

Training of staff

Mechanism for repair

maintenance

Dir. RCH to explore implementation

of similar mechanisms as it is

followed by immunization division

for maintenance of equipments and

apply lessons learned

Weak referral linkages Ensure availability of

transport

Referral facilities not

prepared adequately to

receive patients

Triaging not done properly

Transport mechanism to be

streamlined.

Written protocols need to be

made available at all

referral facilities

Link the existing transport

mechanism with F-IMNCI. Further

strengthening wherever required

Community based services not

optimally utilized for increasing

coverage of key MNCH services

Annexures

Activity area: Communication/IEC

The problems are … Causes Solutions Recommendations

No Comprehensive

Communication Plan

- Weak linkage between technical

and IEC section

- IEC for Maternal and Child

health is not a priority

- Lack of professional approach

Develop a comprehensive

communication plan with

professional input and in

participatory manner (involving

technical and IEC

professionals)

Ensure availability of IEC

professionals at different levels

Director IEC to create a Task Force at

the State level headed by a health

communication professional (involving

technical persons) to develop the

communication strategy and

implementation plan

Identify a resource pool of health

communication professional at State and

District Level to support and monitor

implementation of plan

Improper media mix


- Poor coordination of technical

personnel with media (e.g. song

and drama division, folk media,

TV, radio)

- No comprehensive workplan

with defined responsibilities and

accountabilities

Results of R & D to identify

media mix

Well defined workplan with

defined responsibility and

accountability

Prior planning for campaigns;

e.g. Swasthya Chetna Yatra;

immunization week

Members of VHSC to be

utilized for disseminating

messages and changing

community norms

Explore approaches to be used

to disseminate health messages

during mother‟s stay in facility

after delivery

Strengthen relevant section on health

communication in the PIP with an

activity plan including R and D with

budget allocations

Explore and expand use of latest

technologies, e.g. Mobile, Interactive

voice response (IVR) system, rejuvenate

use of Gramsat system; Video

conferencing (after proper R &D)

Provisions of IEC materials as well as

AV aids at facility level (CHC and

24X7 PHC level)

Provide guidelines

Monitor IEC activities

Annexures


Poor quality of IEC materials - Research and development is

weak


- Receiver is not in focus rather

message is focus

- Inter-region disparities never

addressed

- Results of R& D to be used to

develop IEC materials, to

disseminate the materials etc.

(for interventions with poor

coverage and on new knowledge

in maternal and child health)

- Professional training

Skill up-gradation of State and District

IEC coordinators on development of

IEC materials

Outsourcing for materials and skills

development

Poor communication skills of

health and nutrition service

providers

- All packages have component of

communication, but given the

least priority; Skill-based training

lacking

- Inadequate of facilitators

- Weak supportive supervision

- improper utilization of mobility

support

- Improper use of available

communication materials at all

levels

- Dedicated training on

communication skills (existing

training packages to be explored

for this purpose)

- Revisit existing IEC materials

and prepare proper job aids for

frontline workers; train them on

use of materials

Organize communication skills

training program for service

providers in low coverage areas

Lack of monitoring and

evaluation

- Indicators, tools and mechanism

not available for monitoring

- System of concurrent evaluation

is lacking

-

Develop a plan of monitoring and

evaluation for IEC

Develop a system of concurrent

evaluation (may be outsourced)

Annexures

Activity area: Community Support

The problems are … Causes Solutions Recommendations

Limited capacity of VHSC - Training of VHSC not completed

- Support mechanism weak

- Motivation related issues both

for trainees and trainers

- Accelerate training and assure

quality

- Regular support from PHC MO,

block and district level authorities

- (may be outsourced to NGOs)

- Extending role of NGOs for

follow-up after training

Complete the training within

one year followed by hand

holding support through

allocation of a set of villages

to PHC level supervisors

Develop five model VHSCs

per block. Explore role of

NGOs to establish model

VHSCs

Quarterly newsletter for

VHSC with success stories

from the field

Develop a recognition

mechanism and reward good

performance for VHSC

VHSC not involved in

community monitoring

- VHSCs are in development stage - Inclusion of community

monitoring in VHSC

The best practices of community

monitoring to be explored and

adopted for the state

Thematic community meetings

involving community members

not happening

- Capacity of convener is limited

- Weak support from ASHA

supervisors

- Capacity building of PHC level

supervisors for monthly thematic

meetings

Capacity building of

supervisors to be completed in

the next six months

Inadequate quality of training

for ASHA and Jan Mangal

Couple on MNCH issues

- Jan Mangal Couples revived

recently

- Accelerate update of listing of

Jan Mangal Couple and training Develop database of Jan

Mangal couples and complete

trainings within an year

Expedite the process of

training of ASHA on module

Develop a mechanism for QA

of trainings

Annexures

Annexure IX : List of Participants Dr. Samira Aboubaker

Coordinator country Implementation and support

WHO/ HQ

Geneva

Mr.Pradeep Choudhary

State Program Officer

UNOPS-Norway India Partnership Initiative

Rajasthan

Dr. Mikael Ostergren

Medical Officer

WHO/HQ

Geneva

Dr. M. P. Sharma

Professor & Head

Dept. of Community Medicine

SMS Medical college

Dr. Rajesh Mehta

MO- CAH

WHO-SEARO

Dr. S Sitaraman

Professor of Paediatrics

SMS Medical College

Dr. Harish Kumar

M O-CAH

WHO/Dhaka

Bangladesh

Dr. Jayanta K Das

Professor & Head (Dept. of Epidemiology)

National Institute of Health and Family

Welfare- New Delhi

Dr. Paul P Francis

National Professional Officer and Cluster Focal Point, FHR

WHO Country Office for India

New Delhi

Dr. Suresh Joshi

Professor


Jaipur

Dr. Subodh Sharan Gupta

National Professional Officer - Child Health & Development

WHO Country office for India

New Delhi

Dr. Anoop Khanna

Associate Professor


Jaipur

Dr. Dhananjoy Gupta

Health Specialist - Policy & Planning

UNICEF

New Delhi

Dr. Vinod Kumar SV

Assistant Professor


Jaipur

Dr. Avtar Singh Dua

Health Specialist

UNICEF

Rajasthan

Dr. Vivek Lal

Assistant Professor


Jaipur

Dr. Kaliprasad Pappu

National Co-coordinator


New Delhi

Ms. Preety Sharma

Assistant Professor


Bengaluru

Dr. Karanveer Singh

Programme Officer- Child Health


New Delhi

Dr.Manisha Chawala

State Health & Nutrition Coordinator

Save the Children

Rajasthan

Dr.Narottam Pradhan

Immunization Officer


New Delhi

Dr.Vandana Mishra

State program Representative

CARE-India

Rajasthan

Dr. Satya Pal Yadav

Senior Program Officer


Rajasthan

Dr. Hitesh Gupta

CEO

VATSALYA- Rajasthan

Annexures

Dr.ML. Jain

Director - RCH

Directorate of Medical & Health Services[DMHS]

Govt. of Rajasthan

Dr. Sheetal Joshi

Consultant

DMHS - Govt. of Rajasthan

Dr. J P Dhamija

Add. Director - RCH


Dr. Madhu Dhamija

S.M.O., Govt. Hospital -Sri Ganganagar


Dr.Rajendra Singh Rathore

Deputy Director Immunization


Dr. Ragini Agrawal

S.M.O. Udaipur


Mr. J.P. Jat

State Demographer


Dr. R.K. Vijayvargiya

S.M.O, Govt. Dispensary – Ajmer


Mr. N.L. Paliwal

Social Scientist


Dr. Dinesh Kharadi

Medical Officer, Udaipur

DMHS- Govt. of Rajasthan

Dr. Jal Singh

C.O. F.R.U


Mr. Kaushal Kumar

District Programme Manager - Churu


Dr. Shiv Chandra Mathur

Executive Director

State Health Systems Resource Centre

Rajasthan

Dr. Manoj Vijay

Rural Medical Officer

CHC- Bhopalsagar- Chittorgarh


Dr. Anuradha Aswal

Nodal Officer – Training & Child Health


Mr. Abid Siraj

Divisional Maternal & Child Health Coordinator - Ajmer


Dr. Indra Gupta

Nodal Officer SBA


Mr. Akhilesh Gupta

Divisional Maternal & Child Health Coordinator - Bikaner


Ms. Vaidehi Agnihotri

Coordinator-VHSC

DMHS

Govt. of Rajasthan

Mr. Pawan Kumar

District Maternal & Child Health Coordinator

Barmer

DMHS – Govt. of Rajasthan

Mr.Lalit Kumar Tripathi

Consultant-HRHH

DMHS

Govt. of Rajasthan

Ms. Renu Yadav

District Maternal &Child Health Coordinator

Dausa

DMHS – Govt. of Rajasthan

Dr. Laxman Singh Jadoun

Medical Officer- Kanwatia Hospital

DMHS

Govt. of Rajasthan

Dr. Sandeep Kumar Aggarwal

RCH Medical Consultant

State Institute of Health & Family Welfare

Rajasthan

Dr. Kishor Kumar

Medical Officer- CHC- Chomu

DMHS- Govt. of Rajasthan

Dr. Richa Chaturvedy

RCH Medical Consultant

SIHFW- Rajasthan

Ms. Poonam Srivastava

District Maternal &Child Health Coordinator

Bharatpur

Annexures

Annexure X : List of Documents Reviewed

1 Baseline survey on Child Health and related maternal Health Care, 2009, NIPI.

2 Coverage Evaluation Survey- 2009, National Fact sheet- UNICEF.

3 District level House Hold and Facility Survey-III, 2007-08; Rajasthan

4 Family Welfare statistics in India- 2009, Ministry of Health & Family Welfare, Govt. of India.

5 Family Welfare statistics in India- 2006, Ministry of Health & Family Welfare, Govt. of India.

6 Fact Sheet of Rajasthan-National Family Health Survey-III, 2005-06.

7 Five Year plan – IX, Rajasthan- Chapter 18

8 ICDS: Programme implementation plan- Rajasthan 2009-10

9 National Family Health Survey-I Rajasthan & India-1992-93

10 National Family Health Survey-II Rajasthan & India 1998-99

11 National Family Health Survey-III Rajasthan & India 2005-06

12 Report on Causes of Death in India- 2001-2003; Office of the Registrar general, Ministry of Home

affairs, Govt. of India.

13 Reproductive and Child Health- District level Household Survey-II , 2002-04; Rajasthan

14 Reproductive and Child Health Project- Rapid Household survey -1998-99,Rajasthan; by IIPS

15 Rajasthan State Program implementation Plan – 2008-09



18 Rajasthan State Report on National Rural Health Mission-2009-10

19 Sample Registration System -Statistical Report -2008, Office of the Registrar general, Ministry of

Home affairs, Govt. of India.

20 Sample Registration System –Maternal Mortality in India-1997-2003: Trends, Causes & Risk

Factors, Office of the Registrar general, Ministry of Home affairs, Govt. of India.

21 Sample Registration System- Special Bulletin (April 2009) on Maternal Mortality in India 2004-06;

Office of the Registrar general, Ministry of Home affairs, Govt. of India.

22 Shiv D Gupta et.al ; Maternal mortality ratio and predictors of maternal deaths in selected desert

districts in Rajasthan - A community-based survey and case control study; Women‟s Health Issues

20 (2010) 80–85

23 S.D.Gupta et al. Changes In IMR in Rajasthan over 25 Years; Health and Population: Perspectives

and Issues Vol. 32 (2), 105-111, 2009

Annexures

Annexure XI : Timetable

Short Program Review - Child Health

Government of Rajasthan Indian Institute of Health Management and Research, Jaipur

Sep 20 – 25, 2010

Supported by: WHO Country Office for India and Norway India Partnership Initiative

Agenda: Day 1

Day 1 Tuesday; Sep 21, 2010

With all SPR review participants

0900- 1000 Registration

1000-1100

Inaugural session Welcoming remarks Inaugural ceremony Objectives of Short Program Review Round of introduction Opening Remarks and Presentation on Child Health Program

in Rajasthan 1100-1130 Tea break

1130-1200 Overview: how the short programme review will be conducted and

background concepts that will be used (from handouts 1 and 2) –

facilitator

1200-1300

Step 1: Where are we going? Work in plenary session to review: goals and objectives; status of maternal and child health. Key data presented and discussed.

Review and discuss Worksheets 1 and 2

1300-1400 Lunch break

1400-1530 Plenary discussion: review of child health data: summary of findings

1530-1545 Tea break

1545-1730

Step 2: Are interventions reaching women and children? Introduction to small group work Definition of terms Introduction to use of Worksheets 3 and 4 Small group work: worksheet 3: Groups work through the worksheet.

Each group has a different point along the continuum of care–

pregnancy, delivery, neonatal, infants and children.

The First session for Day 2 (Wednesday; Sep 22, 2010) will start at 0900h

Annexures

Short Program Review - Child Health

Government of Rajasthan Indian Institute of Health Management and Research, Jaipur

Sep 20 – 25, 2010

Supported by: WHO Country Office for India and Norway India Partnership Initiative

Agenda Day 2 – 5

Day 2 Wednesday; Sep 22, 2010

0900-1030

Step 2: Are interventions reaching women and children (continued) Small group work: review of coverage indicators. Complete worksheets 3 and 4. Summarize findings on computer template. Present, discuss and summarize findings in plenary session.

1030-1045 Tea break 1045-1230

Step 3: How well are programme activities being implemented? Introduction to small group work Definition of terms Introduction to use of Worksheet 5 Group work: worksheet 5. Groups work through the worksheet.

Each group has a different point along the continuum of care–

pregnancy, delivery, neonatal, infants and children.

1230-1330 Lunch break 1330-1500 Group work Step 3: continue review and complete worksheet 5.

1500-1515 Tea break 1515-1630 Group work Step 3: continue review and complete worksheet 5.

Summarize findings on computer template.

1630-1730 Plenary session Step 3: each group summarizes findings from their

level of the continuum of care: how well the programme implemented

maternal and child health interventions.

Annexures

Day 3 Thursday; Sep 23, 2010

0900 -1030 Step 4: Identify the main problems the programme has faced Review of previous steps and introduction to worksheet 6 Small group work: identify the main problems identified for each of

the main activity areas. Summarize findings on flip charts.

1030-1045 Tea break 1045-1230 Small group work (continued): summarize problems for each activity

area 1230-1330 Lunch break break 1330-1500 Plenary session Step 4: summarize problems identified by all groups

into a single list of common problems.

1500-1515 Tea break 1515-1730 Complete plenary session Step 4: summary of problems

Day 4 Friday; Sep 24, 2010

0900-1030 Step 5: Identify solutions and recommendations to the main problems Introduction to group work and begin group work Summarize findings using standard template.

1030 - 1045 Tea Break 1030-1230 Small group work (continued) 1230-1330 Lunch break 1330-1500 Plenary session Step 5: summary and discussion of solutions and

possible recommendations

1500-1515 Tea break 1515-1700 Summary of next steps

Feedback from participants

Day 5 Saturday ;Sep 25, 2010

0900-1230 Step 6: decide on next steps for taking action on recommendations Step 7: Present SPR findings

1230-1330 Formal Closing Ceremony 1330-1430 Lunch break

Annexures

References

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BPNI , New Delhi

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Mission(NRHM) State Program Implementation Plan 2009 -10 : Volume II


Mission(NRHM) State Program Implementation Plan 2010 -11

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GoR

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Annexures


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of maternal, newborn and child survival.

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