STATE PROGRAMME IMPLEMENTATION PLAN

Transcription

1 STATE PROGRAMME IMPLEMENTATION PLAN Government of Bihar NATIONAL RURAL HEALTH MISSION February 2009

2 State PIP, Bihar National Rural Health Mission Abbreviations ANM ASHA AWC AWW BCC BPL BEmOC CBO CDR CEO CEmOC CMR DHS DPT GO GoB GoI HIV ICDS IEC IMR MMR NFHS I NFHS II NFHS III NGO O & M OP OPD RCH PHC PPP PIP PRI RKS SHC SIHFW TB TFR Auxiliary Nurse Midwife Accredited Social Health Activist Aaganwadi Centre Aaganwadi Worker Behaviour Change Communication Population Below Poverty Line Basic Emergency Obstetric Care Community Based Organization Crude Death Rate Chief Executive Officer Comprehensive Emergency Obstetric Care Crude Mortality Rate Directorate of Health Services Diphtheria, Pertusis and Tetanus vaccine Government Order Government of Bihar The Government of India Human Immunodeficiency Virus Integrated Child Development Services Information Education Communication Infant Mortality Rate Maternal Mortality Rate National Family Health Survey I National Family Health Survey II National Family Health Survey III Non-Governmental Organizations Operation and Maintenance Out-Patient (section or department of a hospital) Out-Patient Department Reproductive and Child Health Primary Health Centre Public Private Partnership Program Implementation Plan Panchayati Raj Institutions Rogi Kalyan Samiti Sub Health Centre State Institute of Health & Family Welfare Tuberculosis Total Fertility Rate 2

3 State PIP, Bihar National Rural Health Mission Preface National Rural Health Mission offers unprecedented opportunity to improve the health of the people of Bihar. The Public Health System of Bihar, through its more than ANMs, of ASHAs, of Aaganwadi Workers and thousands of doctors reaches out to the people living in more than villages. The Public Health infrastructure, particularly PHCs/CHCs and other Government hospitals ought to be the institutions where people can put their trust for good and affordable quality health services as per needs. Though the role of Public Health system is primarily important, NRHM heralds a new beginning where the health of the people will be placed in their own hands and government will play a role of facilitator providing all round support and ensuring access to health services. The PIP has been prepared through consultation with block and district level functionaries. The plans have been prepared on the needs identified and has addressed lots of critical issues to implement the programme. The plan is aimed at improving the access to comprehensive quality health care by improving the public health infrastructure to desired standards and placing the health of the people in their hands. Government will play the role of a facilitator and undertake new initiatives. As planned here the capacity to manage the programme in the state is going to be significantly strengthened. The Programme Management Support Units at the block level, HMIS and the support systems shall also be strengthened. This year also a number of PPP initiatives is taken to reach out services to the people through varied channels. It is expected that for the state of Bihar, this will be the turning point for accelerated improvement in health. 3

4 State PIP, Bihar National Rural Health Mission Table of Contents Chapter Content Page No. Preface 3 1 Executive Summary Process of Plan Preparation Background and Current Status 3.1 Demographic and Socio-Economic Features at State and District Levels 3.2 Administrative Divisions RCH Outcome and Service Utilization Public Health Infrastructure Private and NGO Health Service Donor Assisted Programme in the State Institutional Arrangements and Organizational Development Program Finance 27 Part A Reproductive & Child Health-II 4 Situation Analysis 4.1 Maternal Health Child Health Family Planning Adolescent Health District/Sub District Variations Health Infrastructure and Facilities Human Resource Development including Training Inequity/ Gender; Vulnerable Groups Including Urban Slums & Tribal Inequity and Gender Urban Slums Logistics HMIS and Monitoring & Evaluation Behaviour Change Communication Convergence/Coordination Finance 50 5 Progress and Lessons learnt from RCH II Implementation of 05-4

5 State PIP, Bihar National Rural Health Mission Major achievement during Programme Management RCH II PROGRAMME OBJECTIVES AND STRATEGIES 6.1 Vision Statement Technical Objectives, Strategies and Activities 1 Maternal Health Child Health Family Planning Adolescent Reproductive and Sexual Health Urban Health Vulnerable Groups (Health Camps in Maha Dalit Tola) 84 7 Tribal Health 84 8 Innovations 8.1 PNDT Act Muskaan Programme Strengthening of SIHFW Fast Track Training Cell in SIHFW Filling Vacant Position at SIHFW/Hiring Consultant at SIHFW Infrastructure and Human Resource Institutional Strengthening Training IEC/BCC Procurement of Equipments/ Instruments and Drugs/Supplies Programme Management Convergence and Coordination Role of State, District & Blocks Monitoring and Evaluation Synergie with NRHM Additionalities Sustainability Extra inclusions in RCH Work Plan (Annexure - 3d) Budget (Annexure- 3c & 3e) 131 Part B NRHM Additionalities 1. Decentralisation 133 5

6 State PIP, Bihar National Rural Health Mission 1.0 ASHA Untied Funds for Health Sub-Centre, APHC & PHCs Village Health & Sanitation Committee Seed Money for Rogi Kalyan Samiti Infrastructure Development 2.1 Construction or establishment of Health Sub-Centre Construction of PHC Upgradation of Community Health Centre (CHC) Infrastructure & Service Improvement as per IPHS in 48 (District 152 & Sub-Divisional) Hospitals for accreditation/iso 9000 Certification of Health facilities 2.5 Upgradation of Infrastructure of ANM Training Schools Annual Maintenance Grant Contractual Manpower 3.1 Incentive, Contractual Salaries and Bonus Block Programme Management Unit Additional Manpower for State Health Society Bihar Additional Manpower under NRHM PPP Initiative in State Ambulance Service Dial Doctor on Call & Samadhan Additional PHCs Management by NGOs AAPIO State Health Resource Centre Services of Hospital waste treatment and Disposal in all Government Health facilities upto PHCs in Bihar (IMEP) 4.7 Dialysis Unit in Government Hospital of Bihar Setting up of Ultra Modern Diagnostic Centre in RDCs and all Government Medical College Hospitals 4.9 Providing Telemedicine Services in Government Health facilities Outsourcing Pathology & Radiology Services from PHCs to District Hospital 4.11 Operationalising Mobile Medical Unit

7 State PIP, Bihar National Rural Health Mission 4.14 Monitoring and Evaluation Generic Drug Shop Nutrition Rehabilitation Centres (NRCs) for Treatment of sever and acute malnutrition 4.17 Hospital Maintenance Providing Ward Management Services in Govt. Hospitals Provision of HR Consultancy Services Advanced Life Saving Ambulances (ALS) Mobilisation and Management support for Disaster Management Health Management Information System (HIMS) Strengthening of Cold Chain Main streaming AYUSH under NRHM Summary Budget of NRHM Part- B Part C Immunization 1 Routine Immunization Part D National Disease Control Programmes 1 IDSP IDD NPCB NLEP TB NVBDCP 5 Kalazar Malaria Dengu & Chikungunya JE Filaria Part E Intersectoral Convergence 1 Intersectoral Convergence BUDGET 1 NRHM Part A RCH II NRHM Part B - Additionalities NRHM Part C - Immunization NRHM Part D NDCP NRHM Part E - Convergence 397 7

8 State PIP, Bihar National Rural Health Mission 6 Summary of Budget 398 Annexures Annexure 3a Self Appraisal of State PIP against Appraisal Criteria Annexure 3b Targets for goals, outcomes, outputs and inputs Annexure 3d Work plan RCH Annexure 3e Details of Budget of RCH- II (Part-A) Annexure 4 IMNCI Annexure 5 IFA Annexure 6 IUD Training Annexure 7 MTP Training Annexure 8 CTP (Comprehensive Training Programme) Annexure 9 Annexure 10 Annexure 11 Annexure 12 Annexure 13 Annexure 14 Annexure 15 Annexure 16 Annexure 17 Annexure 18 Annexure 19 Annexure 20 Annexure 21 Pilot Health Financing Scheme for Safe Maternity to BPL/SC/ST beneficiaries in accredited private facilities Incentive for Cesarean Section, Pregnancy testing, Safe Abortion & IUCD in Bihar Procurement School Health List of 27x7 Pregency Kit MAPEDIR Training Details Mahadalit Tola Report IEC Budget Breakup NSV Kit Minilap Set FRU Report 8

9 State PIP, Bihar National Rural Health Mission Executive Summary Chapter 1 Executive Summary Introduction The State Health Society, Government of Bihar is committed towards promoting the right of every woman, man and child to enjoy a life of health and equal opportunity and is making all round efforts in this direction. SHSB under the aegis of Department has taken steps to bring about outcomes as envisioned in the Millennium Development goals, RCH II / NRHM programme and Vision 2010 Bihar. It aims at minimizing regional variations in the areas of Reproductive and Child Health including population stabilization through an integrated, focused and participatory programme. Meeting unmet demands of the target population, and provision of assured, equitable, responsive quality services are central to the programme strategies. Based on experience gained during the implementation of RCH II, the Department anticipates that current RCH programme implementation would produce equitable reproductive and child health outcomes and contribute to raising the status of the girl child. The Goal The goal is to improve quality of life of the people by: (Goals mentioned below are for the period of RCH-II i.e. to be achieved by 2010) reducing Maternal Mortality Ratio (MMR) from 371 to 100 per 1,00,000 live births, reducing Infant Mortality Rate (IMR) from 61 to 30 per 1000 live births, Reducing Total Fertility Rate (TFR) 1 from 4.3 to 2.1 for population stabilization with enhanced satisfaction of clients with medical services. The Department is making all out efforts to reduce the IMR and has initiated an innovative program MUSKAAN for the same cause and so as to also reach the poorest of the poor with effective, quality and equitable health services. Simultaneously taking steps to effectively implement national health programme while creating synergy and convergence with RCH II. 1 NFHS-3 9

10 State PIP, Bihar National Rural Health Mission Status and Situation Important RCH indicators such as MMR, IMR and TFR are showing declining trends whereas institutional deliveries, complete ANC, contraceptive use in the state has increased. The state has mapped poorly performing districts and is now extensively focusing on them. Status of Important RCH indicators in the state are as follows: Declined MMR has declined from 389 (1998) to 371 (SRS ) IMR has declined from 63 (Census 2001) to 61 per 1000 live births (SRS ) Total Fertility Rate (TFR) has decreased from 4.3 to 4.0 (NFHS III ) to 3.9 (SRS 8) Percentage of children under age 3 who are underweight has marginally declined from 48 percent to 47 percent. Increased Institutional deliveries have increased from 12.1 (NFHS-I ) percent to 22 percent (NFHS-III ) to 27.7 percent (DLHS-III ) Antenatal Care has increased from 15.9 percent (NFHS-II ) to 16.9 percent (NFHS- III) to 45% (DLHS-III ) % Full Immunization coverage has increased from 10.7 (NFHS-I ) percent to 41.4 percent (DLHS-III ) Contraceptive use has increased from 23.1 percent (NFHS-I ) to 34.1 percent (NFHS- III) Sex ratio from 825 to 871 (CRS ) Strategic Direction The entire State Health Society Bihar team is working in a mission mode to achieve goals set-in for the state and is effectively dealing with the challenges. The Department has set the strategic direction that encompasses year wise objectives, technical strategies; interventions include program and services for improving maternal health, child health, family planning, adolescents' health etc. The complete programme has been bifurcated into institutional and cross cutting programme strategies as well as specific core programmatic strategies for taking effective actions. These institutional and cross cutting strategies have impact on all the components of RCH viz. maternal health, child health, family planning, adolescent health etc whereas specific core programme strategies have wider impact on the specific programme component. It has been recognized that all these strategies should converge and go hand-in-hand to achieve the programme outcome. The state considers that strengthening institutional mechanisms, infrastructural development, ensuring adequately trained human resources etc. are fundamental requirements for getting better programme outcomes. Accordingly, the document is presented with backward linkages from core programme strategies to institutional framework. Convergence of strategies and progress is as described below: i) Core Programme Strategies Special schemes such as Muskaan, MAMTA addressing child health, incentives to health staff. ii) Cross Cutting Programmatic Strategies Capacity building, PPP, quality assurance, gender mainstreaming, community participation, serving vulnerable community through mobile units etc. Resource planning for all the sectors will be also done. iii) Strengthening Institutional Framework and Governance Mechanisms Recruitment and placement of qualified human resource Structures: Functional, accountable State/District Health Mission with Governing and Executive Board; Integrated Organizational Structure of Department of Health; Functional 10

11 State PIP, Bihar National Rural Health Mission SPMU, DPMU, BPMU; Constitution of RKS and Village Health and Sanitation Committee for bringing in transparency and accountability by involving the community. Infrastructure Development and ensuring consistent logistics support. Strategies RCH Components Goals Maternal Health Reduction in MMR Institutional framework and Governance mechanism Cross Cutting Strategies Core Programme Strategies Child Health Family Planning Adolescent Health Vulnerable Community Reduction in IMR Reduction in TFR Services to each adolescent Ensuring equitable healthcare delivery SUMMARY of BUDGET PART HEAD BUDGET (Rs. In lakhs) In Cr. % A RCH II B NRHM Additionalities C Immunization D NDCP 7, E Intersectoral Convergence TOTAL PPI Operational Cost Infrastructure Maintenance (Treasury Fund) GRANT TOTAL

12 State PIP, Bihar National Rural Health Mission Process of Plan Preparation Chapter 2 Information collected from the District and Block level is the key in preparing the State PIP. At the block level, consultation was done which was further sent to the District. With the information gathered from the block, district has further held consultations and prepared their priorities and requirements, which are being reflected in the District Health Action Plans, still being prepared in the districts. The method of data collection is both primary and secondary in the preparation of the Plan. The secondary data were collected by reviewing records, registers and annual reports. The data were also collected from DLHS, SRS and NFHS surveys to support the background information. For primary data, the procedure involved focus group discussions, interactions and meetings in different districts. This was done to have opinion of all the programme officers, health staff, grass root workers and private partners. Based on the feedback received from the districts state programme officers have discussed and finalized the SPIP requirements. The state has considered the requirement of the district thoroughly and provision has been made in the PIP as per their need. The SPMU team was thoroughly involved in the process and their critical inputs were incorporated to make this plan more holistic, realistic and achievable. The Plan was further reviewed by the Executive Director, SHSB and the CEO-cum-Secretary, Health, Deptt.of Health, Govt. of Bihar. It should be mentioned that the plan has been prepared keeping in mind that private party can simultaneously complement the role of the Government machinery in delivering the health care services in the state. 12

13 State PIP, Bihar National Rural Health Mission Background & Current Status Chapter Demographic and Socio-Economic Features at State and District Levels Bihar with a population of 82.9 million is the second most populous state in India, next only to Uttar Pradesh. Despite efforts in the last few decades to stabilise population growth, the state s population continues to grow at a much faster rate (28.43%) than the national population (21.34%). The state is densely populated with 880 persons per square kilometre as against the country average of 324.The sex ratio of the state at 919 is also less favourable than the national average of 933. Table 3.1.1: Bihar: Demographic, Socio-Economic and Health Indices Characteristics Bihar India Area 94,163 Sq. Km Demographic Indicators Population Million Million Population Density (Population / km2) Sex Ratio % decadal growth rate 28.43% 21.34% Socio-Economic Indicators Per Capita Income (Rs.) for year At constant prices At current prices % decadal growth in Per capita Income ~ zero ~ 45% Proportion of population below poverty line 42% 26% Level of Urbanization 10.5% 27.8% Literacy 47.5% 65.4% Source: Census 2001, Ministry of Statistics and Program Implementation Among the 38 districts of the state, West Champaran is the largest in terms of area ( sq. km) while the smallest is Sheikhpura ( sq. km). In terms of population, Patna is the largest at 4.72 millions followed by East Champaran that has a population of 3.94 millions. Sheohar and Sheikhpura have the smallest population of 0.52 millions and 0.53 millions respectively. In terms of Sex Ratio, while districts such as Siwan (1031) and Gopalganj (1001) have a favourable ratio, other districts like Munger (872), Patna (873) and Bhagalpur (876) have a less favourable ratio. 13

14 State PIP, Bihar National Rural Health Mission Bihar has a total SC population of around 15.07%. However, SC population in certain districts like Gaya (29.6%) and Nawada (24.1%) is much higher than the state average. On the other hand, districts such as Kishanganj (6.6%) and Arwal (8.9%) have a relatively low proportion of SC population. After the bifurcation of the state in 2002, most of the areas with large ST population have been included in the state of Jharkhand. Therefore, the state has less than 1% ST population. In terms of key health indicators, Bihar is among the low performing states. Though the state fares reasonably well in terms of its Infant Mortality Rate (61) as against the national average (58), it continues to be among the poorer performing states in terms of other indicators such as TFR, MMR and NMR. In terms of socio-economic indices too the district level variation is obvious. For literacy rates, districts such as Arwal (26%), Jehanabad (29.3%), Kishanganj (31.1%), Araria (35%) and Katihar (35.1%) are much below the even state average of 46.4%. However, there are districts - Aurangabad (57%), Bhojpur (59%), Munger (59.5%), Patna (62.9%) and Rohtas (61.3%) -that have performed better than the state average with literacy rates close to 60%. Similarly performance of districts on percentage of people living below the poverty line is varied with districts such as Araria faring the worst at 80.3%. Other poor performing districts are Bhagalpur, Madhubani, Purnea, Sitamarhi, Supaul and Sheohar, where close to 70% of the population continues to live below the poverty line. Despite such a large number of districts having a significant proportion of their population living below poverty line, the state average of 46.2% (among the lowest in the country) is largely due to the fact that there are some districts such as Kaimur, Saharsa, Samastipur, Arwal, Jehanabad and Gopalganj where close to 80% of the population are living above the poverty line. (See table for district-wise detailed data). 14

15 State PIP, Bihar National Rural Health Mission Table 2.1.2: Bihar: Key Demographic and Socio-economic Indicators of Districts Sl No Districts Area in Sq. Population BPL SC ST Sex Literacy Km Rural Urban Total (%) (%) (%) Ratio Rates Araria Aurangabad Arwal Banka Begusarai Bhagalpur Bhojpur Buxar Champaran (E) Champaran (W) Darbhanga Gaya Gopalganj Jehanabad Jamui Kaimur Katihar Khagaria Kishanganj Lakhisarai

16 State PIP, Bihar National Rural Health Mission Sl.No. Districts Area sq.k.m in Population Rural Urban Total BPL (%) SC (%) ST (%) Sex Ratio Literacy Rate Madhepura Madhubani Munger Muzaffarpur Nalanda Nawada Patna Purnia Rohtas Saharsa Samastipur Saran Sheikhpura Sheohar Sitamarhi Siwan Supaul Vaishali State Total

17 3.2 Administrative Divisions Bound by Uttar Pradesh in the west, West Bengal on the east, Nepal on the north and Jharkhand on the south, Bihar covers an area of 94,363 square kilometers. The state has 38 districts divided into 9 administrative divisions. The number of districts in each division is detailed below - Table 3.2.1: Administrative Divisions Sl. Divisions Districts 1 Patna Patna, Nalanda, Bhojpur, Rohtas, Kaimur, Buxar 2 Magadh Gaya, Jehanabad, Arwal, Aurangabad, Nawada 3 Tirhut Muzaffarpur, Sitamarhi, Vaishali, Champaran East, Champaran West, Sheohar 4 Saran Saran, Siwan, Gopalganj 5 Darbhanga Darbhanga, Madhubani, Samastipur 6 Munger Begusarai, Jamui, Khagaria, Lakhisarai,Munger, Sheikhpura 7 Kosi Saharsa, Madhepura, Supaul 8 Bhagalpur Bhagalpur, Banka 9 Purnea Purnia, Araria, Kishanganj, Katihar In addition, the state has 101 sub-divisions, 534 community development blocks, 9 urban agglomerations, 130 towns (125 statutory towns and 5 non-statutory census towns) and 37,741 villages. Table 3.2.2: Community Development Blocks Sl. Districts Community Development Blocks Total Block Name 1 Araria 9 Narpatganj, Forbesganj, Bhargama, Raniganj, Araria, Kursakatta, Sikti, Palasi, Jokihat 2 Arwal 3 Karpi, Kurtha, Makhdumpur 3 Aurangabad 11 Daudnagar, Haspura, Goh, Rafiganj, Obra, Aurangabad, Barun, Nabinagar, Kutumba, Deo, Madanpur 4 Banka 11 Shambhuganj, Amarpur, Rajaun, Dhuraiya, Barahat, Banka, Phulidumar, Belhar, Chanan, Katoria, Bausi 5 Begusarai 18 Khudabandpur, Chhorahi, Garhpura, Cheria Bariarpur, Bhagwanpur, Mansurchak, Bachhwara, Teghra, Barauni, Birpur, Begusarai, Naokothi, Bakhri, Dandari, Sahebpur Kamal, Balia, Matihani, Shamho Akha Kurha 6 Bhagalpur 16 Narayanpur, Bihpur, Kharik, Naugachhia, Rangra Chowk, Gopalpur, Pirpainti, Colgong, Ismailpur, Sabour, Nathnagar, Sultanganj, Shahkund, Goradih, Jagdishpur, Sonhaula

18 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Bhojpur 14 Shahpur, Arrah, Barhara, Koilwar, Sandesh, Udwant Nagar, Behea, Jagdishpur, Piro, Charpokhari, Garhani, Agiaon, Tarari, Sahar 8 Buxar 11 Simri, Chakki, Barhampur, Chaugain, Kesath, Dumraon, Buxar, Chausa, Rajpur, Itarhi, Nawanagar 9 E. Champaran 27 Raxaul, Adapur, Ramgarhwa, Sugauli, Banjaria, Narkatia, Bankatwa, Ghorasahan, Dhaka, Chiraia, Motihari, Turkaulia, Harsidhi, Paharpur, Areraj, Sangrampur, Kesaria, Kalyanpur, Kotwa, Piprakothi, Chakia(Pipra), Pakri Dayal, Patahi, Phenhara, Madhuban, Tetaria, Mehsi 10 Champaran W 18 Sidhaw, Ramnagar, Gaunaha, Mainatanr, Narkatiaganj, Lauriya, Bagaha, Piprasi, Madhubani, Bhitaha, Thakrahan, Jogapatti, Chanpatia, Sikta, Majhaulia, Bettiah, Bairia, Nautan 11 Dharbhanga 18 Jale, Singhwara, Keotiranway, Darbhanga, Manigachhi, Tardih, Alinagar, Benipur, Bahadurpur, Hanumannagar, Hayaghat, Baheri, Biraul, Ghanshyampur, Kiratpur, Gora Bauram, Kusheshwar Asthan, Kusheshwar Asthan Purbi 12 Gaya 24 Konch, Tikari, Belaganj, Khizirsarai, Neem Chak Bathani, Muhra, Atri, Manpur, Gaya Town CD Block, Paraiya, Guraru, Gurua, Amas, Banke Bazar, Imamganj, Dumaria, Sherghati, Dobhi, Bodh Gaya, Tan Kuppa, Wazirganj, Fatehpur, Mohanpur, Barachatti 13 Gopalganj 14 Katiya, Bijaipur, Bhorey, Pach Deuri, Kuchaikote, phulwaria, Hathua, Uchkagaon, Thawe, Gopalganj, Manjha, Barauli, Sidhwalia, Baikunthpur 14 Jahanabad 12 Arwal, Kaler, Sonbhadra Banshi Suryapur, Ratni Faridpur, Jehanabad, Kako, Modanganj, Ghoshi, Hulasganj 15 Jamui 10 Islamnagar Aliganj, Sikandra, Jamui, Barhat, Lakshmipur, Jhajha, Gidhaur, Khaira, Sono, Chakai 16 Kaimur 11 Ramgarh, Nuaon, Kudra, Mohania, Durgawati, Chand, Chainpur, Bhabua, Rampur, Bhagwanpur, Adhaura 17 Katihar 16 Falka, Korha, Hasanganj, Kadwa, Balrampur, Barsoi, Azamnagar, 18 Khagaria Pranpur, Dandkhora, katihar, Mansahi, Barari, Sameli, Kursela, Manihari, Amdabad 7 Alauli, Khagaria, Mansi, Chautham, Beldaur, Gogri, Parbatta 18

19 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Kishanganj 7 Terhagachh, Dighalbank, Thakurganj, Pothia, Bahadurganj, Kochadhamin, Kishanganj 20 Lakhisarai 6 Barahiya, Pipariya, Surajgarha, Lakhisarai, Ramgarh Chowk, Halsi 21 Madhubani 21 Madhwapur, Harlakhi, Basopatti, Jainagar, Ladania, Laukaha, Laukahi, Phulparas, Babubarhi, Khajauli, Kaluahi, Benipatti, Bisfi, Madhubani, Pandaul, Rajnagar, Andhratharhi, Jhanjharpur, Ghoghardiha, Lakhnaur, Madhepur 22 Madhepura 13 Gamharia, Singheshwar, Ghailarh, Madhepura, Shankarpur, Kumarkhand, Murliganj, Gwalpara, Bihariganj, Kishanganj, Puraini, Alamnagar, Chausa 23 Munger 9 Munger, Bariarpur, Jamalpur, Dharhara, Kharagpur, Asarganj, Tarapur, Tetiha Bambor, Sangrampur 24 Muzaffarpur 17 Sahebganj, Baruraj (Motipur), Paroo, Saraiya, Marwan, Kanti, Minapur, Bochaha, Aurai, Katra, Gaighat, Bandra, Dholi (Moraul), Musahari, Kurhani, Sakra 25 Nalanda 20 Karai Parsurai, Nagar Nausa, Harnaut, Chandi, Rahui, Bind, Sarmera, Asthawan, Bihar, Noorsarai, Tharthari, Parbalpur, Hilsa, Ekangarsarai, Islampur, Ben, Rajgir, Silao, Giriak, Katrisarai 26 Nawada 14 Nardiganj, Nawada, Warisaliganj, Kashi Chak, Pakribarawan, Kawakol, Roh, Gobindpur, Akbarpur, Hisua, Narhat, Meskaur, Sirdala, Rajauli 27 Patna 23 Maner, Dinapur-Cum-Khagaul, Patna Rural, Sampatchak, Phulwari, Bihta, Naubatpur, Bikram, Dulhin Bazar, Paliganj, Masaurhi, Dhanarua, Punpun, Fatwah, Daniawan, Khusrupur, Bakhtiarpur, Athmalgola, Belchhi, Barh, Pandarak, Ghoswari, Mokameh 28 Purnia 14 Banmankhi, Barhara, Bhawanipur, Rupauli, Dhamdaha, Krityanand Nagar, Purnia East, Kasba, Srinagar, Jalalgarh, Amour, Baisa, Baisi, Dagarua 29 Rohtas 19 Kochas, Dinara, Dawath, Suryapura, Bikramganj, Karakat, Nasriganj, Rajpur, Sanjhauli, Nokha, Kargahar, Chenari, Nauhatta, Sheosagar, Sasaram, Akorhi Gola, Dehri, Tilouthu, Rohtas 30 Saharsa 10 Nauhatta, Satar Kataiya, Mahishi, Kahara, Saur Bazar, Patarghat, Sonbarsa, Simri Bakhtiarpur, Salkhua, Banma Itahri 19

20 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Samastipur 20 Kalyanpur, Warisnagar, Shivaji Nagar, Khanpur, Samastipur, Pusa, Tajpur, Morwa, Patori, Mohanpur, Mohiuddinagar, Sarairanjan, Vidyapati Nagar, Dalsinghsarai, Ujiarpur, Bibhutpur, Rosera, Singhia, Hasanpur, Bithan 32 Saran 21 Mashrakh, Panapur, Taraiya, Ishupur, Baniapur, Lahladpur, Ekma, Manjhi, Jalalpur, Revelganj, Chapra, Nagra, Marhaura, Amnour, Maker, Parsa, Dariapur, Garkha, Dighwara, Sonepur 33 Sheikhpura 6 Barbigha, Shekhopur Sarai, Sheikhpura, Ghat Kusumbha, Chewara, Ariari 34 Sitamarhi 17 Bairgania, Suppi, Majorganj, Sonbarsa, Parihar, Sursand, Bathnaha, Riga, Parsauni, Belsand, Runisaidpur, Dumra, Bajpatti, Charaut, Pupri, Nanpur, Bokhara 35 Sheohar 5 Purnahiya, Piprarhi, Sheohar, Dumri Katsari, Tariani Chowk 36 Siwan 19 Nautan, Siwan, Barharia, Goriakothi, Lakri Nabiganj, Basantpur, Bhagwanpur Hat, Maharajganj, Pachrukhi, Hussainganj, Ziradei, Mairwa, Guthani, Darauli, Andar, Raghunathpur, Hasanpura, Daraundha, Siswan 37 Supaul 11 Nirmali, Basantpur, Chhatapur, Pratapganj, Raghopur, Saraigarh, Bhaptiyahi, Kishanpur, Marauna, Supaul, Pipra, Tribeniganj 38 Vaishali 16 Vaishali, Paterhi Belsar, Lalganj, Bhagwanpur, Goraul, Chehra Kalan, Patepur, Mahua, Jandaha, Raja Pakar, Hajipur, Raghopur, Bidupur, Desri, Sahdai Buzurg, Mahnar 3.3 RCH Outcome and Service Utilization The government and its concerned agencies have initiated various programmes to address the health related issues of the state. However, there is considerable scope of improvement. One of the reasons for limited achievements of the programs has been the lack of quality of services. The State Health Society has paid special attention to the quality of services and aims at meeting the needs of the population leading to widespread acceptance of the services. The goal is to provide integrated reproductive health care services, including addressing the unmet need for contraception in order to improve the situation by the year The program has made positive impact on the indicators in the state but there is still a long way to go. The current situation of the selected indictors based on NFHS-3 shows that overall the state is moving towards achieving the goals. The recent NFHS-3 has shown the improvements in health indicators in the State. IMR has reduced from 78 to 62, MMR from 389 to 371. However TFR has risen from 3.7 to 4. 20

21 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Important indicators reviewed during NFHS-3: Total Fertility Rate (TFR) has increased from 3.7 to 4 Contraceptive use has increased from 24 % to 34 % Antenatal Care has not improved at all Institutional deliveries have increased from 15 % to 22% IMR has declined from 78 to 62 per 1000 live births Percentage of children under age 3 who are underweight has increased 54.3 to 58.4% Though the State has achieved some progress in terms of output indicators, the maternal mortality, child mortality and population growth continues to be a cause of serious concern to the state's development efforts. Moreover, floods in some parts of the state make the State vulnerable to communicable diseases. Besides, the health infrastructure is inadequate to cater to the needs of the people and the upkeep of the already existing facilities is quite challenging. Human resource is another major issue where the State health system is struggling. The paucity of medical professionals especially the specialists limits the public health facilities in providing much required higher level of care to the needy. A mismatch exists in the State between the available medical and Para medical professionals and the demand for their services. More medical graduates and Para medical professionals are required to fill up this gap. Moreover despite number of trainings held, rationalization of manpower is yet to take place. To overcome this, the State has initiated public private partnerships, out sourcing health facilities and programmes to private sector and NGOs, contracting specialists for specialized care, etc. There is also dearth of well-trained public health professionals and managers to effectively steer the public health and family welfare programs. Another issue which the state is encountering is a declining sex ratio. Several initiatives like advocacy, intensive IEC programs and enforcement of PNDT aimed at reversing the existing sex ratio will be initiated this year. In the coming years, the state envisions a system, which provides all the individuals specially the BPL population the ability to access health care at an affordable price by tackling the existing problems and build on its strengths and address its weaknesses. 21

22 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Public Health Infrastructure District wise Availability of Health Centres of Bihar State Sl. Name of Districts No. of DH New Constr uction Total DH No. of Sub Divl Hospitals exist New Constr uction No. of Referral Hospital upgraded in Sub Div Hospitals Total Sub Div Hospi tals No. of Referral Hospitals exist previousl y No. of Referral Hospitals exist Presently No. of PHCs exist New Constr uction No. of APHCs upgrade d into PHCs Total No. of PHCs No. of APHCs exist previosly No. of APHCs exist presently No. of HSCs 1 Araria Arwal Aurangabad Banka Begusrai Bhagalpur Bhojpur Buxar Champaran 9 (E) Champaran 10 (w) Darbhanga Gaya Gopalganj Jamuai Jhanabad Kaimur Katihar Khagaria Kishanganj Lakhisarai Madhapura Madhubani

23 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Munger Muzaffarpur Nalanda Nawada Patna Purniea Rohtas Saharsa Samastipur Saran Sheikhpura Sheohar Sitamarhi Siwan Supaul Vaishali Total

24 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Table : Bihar: Public Health Infrastructure Personnel Sl. No Districts MO ANM LHV MHW Staff Nurse AWW Sanct. Working Sanct. Working Sanct Working Sanct. Working Sanct. Working Sanct. Working 1 Araria Aurangabad Arwal Banka Begusarai Bhagalpur Bhojpur Buxar Champaran (E) Champaran (W) Darbhanga Gaya Gopalganj Jehanabad Jamui Kaimur Katihar Khagaria Kishanganj Lakhisarai Madhepura Madhubani Munger Muzaffarpur Nalanda Nawada Patna Purnia Rohtas Saharsa Samastipur

25 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Saran Sheikhpura Sheohar Sitamarhi Siwan Supaul Vaishali

26 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Private and NGO Health Service The State has a wide network of private health facilities in the urban areas providing Health services. In general, these private health facilities are run either by individuals/organizations for profit or by Non-profit Charitable organization/ngos. However, exact data on the number of these health facilities are not available with the State as in the State, the registration of private clinics and nursing homes has not yet started although the Clinical Establishment Act has been passed last year. Presently these health facilities are also not regulated by the DoH & F.W. However under PNDT Act, the private clinics and nursing homes undertaking ultra sonography have been regulated and these facilities are being monitored. There is an urgent need to create a comprehensive database for private health service providers and develop appropriate regulatory mechanism for them. NGOs The state has only 12 Mother NGOs (MNGOs) covering 22 of the 38 districts of Bihar. However the state does not have a structured procedure to assess the working of MNGOs. There is a need to improve coordination between the NGOs and the Government at all levels i.e. state, districts and sub-district levels in order to make them effective. Further analysis of information related to NGOs in the state revealed that there are many NGOs that are engaged in the health service delivery. Although no attempts have been made to assess the functioning of these NGOs, it is important to take initiative to develop efficient NGO network in the State. 3.6 Donor Assisted Programmes in the State UNICEF Unicef is supporting the state for immunization, maternal health, nutrition and trainings. Unicef has already initiated the implementation of IMNCI programme and is supporting the operationalization of Nutritional Rehabiltization Centres. Extensive support is provided by them in the health sector especially during flood seasons. Unicef is providing technical support in operationlising ANM training centres, procurement of equipments related to child health etc. NIPI - Norwegian India Partnership Initiative Under NIPI s Child Health Initiatives, a voluntary health worker called Mamta has been engaged at all the District Hospitals and Sub Divisional Hospitals. A District Training Resource Centre wil be set up in Nalanda district. In three NIPI focus districts namely Jehanabad, Nalanda and Sheikhpura for operationzation of SNCUs, technical support and training of doctors and paramedical staffs are 26

27 NRHM STATE PROGRAMME IMPLEMENTATION PLAN being provided. Home Based Newborn Care is being implemented in three NIPI focus districts through ASHAs. SPMU, DPMU and Block Programme Management Units shall be supported by provision of consultants. At the State level Child Health Consultant, Finance Analyst and Data Assistant, at the district level District Child Health Managers, at District Hospitals and Sub divisional level Child Health Supervisors and Dy. Child Health Supervisors and at the block level Junior Child Health Managers shall be placed. The detailed fund allocation has been annexed. WHO-NPSP WHO is supporting the state in Pulse Polio Immunization Programme. UNFPA UNFPA is collaborating with SHSB from financial year and is providing technical support in Maternal Health. 3.7 Institutional Arrangements and Organizational Development Along with Health department the ICDS, PHED and Panchayat are helping in implementing the NRHM Programme. The coordination has been placed at State level, District Level and Block Level. At the Grassroot level linkage between ASHA, ANM with AWW has been strengthened. PHED department has taken up the training of ASHA. Trainings are being regularly conducted under different programmes in the state. The state has already started the trainings of IMNCIs. With the Unicef support the State has initiated to operationlise 22 ANM schools in Repair and renovation of these schools are already in progress and are expected to be operationalised in this year. Most of the districts have their own warehouse. The state has a unique system of collecting data from each PHC level. The state has established a data centre in the state and has centres in District and at PHC. These data centres collect data from each PHC through mobile phone and feed in the computer. The computerized data is later given to the respective Programme Officers. 3.8 Program Finance Governments Of India s funds are released to the state through two separate channels, i.e; through the state budget and directly through the State Health Society. Further the Department s outlay for the procurement of vaccines, drugs, equipments etc; is spent centrally and assistance to the state has been in the form of kind. 27

28 NRHM STATE PROGRAMME IMPLEMENTATION PLAN PART- A RCH Flexible Pool

29 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Situational Analysis Chapter Maternal Health Improving the maternal health scenario by strengthening availability, accessibility and utilization of maternal health services in the state is one of the major objectives of RCH. However, the current status of maternal health in the state clearly shows that the programme has not been able to significantly improve the health status of women. There are a host of issues that affect maternal health services in Bihar. The important ones are listed below: Shortage of skilled frontline health personnel (ANM, LHV) to provide timely and quality ANC and PNC services. The public health facilities providing obstetric and gynecological care at district and sub-district levels are inadequate. Mismatch in supply of essential items such as BP machines, weighing scales, safe delivery kits, Kit A and Kit B, etc and their demand. Shortage of gynecologists and obstetricians to provide maternal health services in peripheral areas. Inadequate skilled birth attendants to assist in home-based deliveries Weak referral network for emergency medical and obstetric care services Lack of knowledge about antenatal, perinatal and post natal care among the community especially in rural areas Low mean age of marriage resulted in pregnancy and difficult deliveries. Low levels of female literacy resulted unawareness on maternal health services. High levels of prevalence of malnutrition (anemia) among women in the reproductive age group Poor communication because of bad roads and a law and order situation. One of the very good things happen to maternal health is introduction JBSY. In , 16 MOs trained in CEmOC and 59 MOs in Life Saving Anesthetic Skills who are now managing complicated cases at their respective place of postings. Bihar is the first state to have formally evaluated the LSAS examinees and issued certificates of practice for the obstetric anesthesia. 29

30 NRHM STATE PROGRAMME IMPLEMENTATION PLAN A quality monitoring cell at the state level housed in State Institute of Health & Family Welfare is monitoring all the trainings. The cell has members drawn from SIHFW faculty, medical colleges, retired faculty members, officials from State Health Society and officials from partner agencies as its members. Their initial focus is to monitor the quality of various trainings being undertaken under NRHM like IMNCI, SBA, Minilap etc. In the year , the role shall be expanded to include the monitoring of quality of critical care services. (details in annexure) 4.2 Child Health The child health indicators of the state reveal that the state's IMR is lower than the national average but the NMR is disproportionately high. Morbidity and mortality due to vaccine-preventable diseases still continues to be significantly high. Similarly, child health care seeking practices in the case of common childhood diseases such as ARI and Diarrhoea are not satisfactory. The child health scenario is worse for specific groups of children, such as those who live in rural areas, whose mothers are illiterate, who belong to Scheduled Castes, and who are from poor households is particularly appalling. Issues affecting child health are not only confined to mere provision of health services for children, but other important factors such as maternal health and educational status, family planning practices and environmental sanitation and hygiene have enormous bearing on child health. This is more than evident in the case of Bihar where child health continues to suffer not only because of poor health services for children but due to issues such as significantly high maternal malnutrition, low levels of female literacy, early and continuous childbearing, etc. The specific issues affecting child health in the state are listed below. Maternal Factors High levels of maternal malnutrition leading to increased risk pre-term and low -birth weight babies that in turn increase risk of child mortality. Low levels of female literacy, particularly in rural areas. Family Planning Services The Family Planning programme has partially succeeded in delaying first birth and spacing births leading to significantly high mortality among children born to mothers under 20 years of age and to children born less than 24 months after a previous birth. Child Health Services The programme has not succeeded fully in effectively promoting colostrum feeding immediately after birth and exclusive breastfeeding despite almost universal breastfeeding practice in the state. In the State majority of mother breast feed children beyond six months. However both State and Unicef have taken initiative to generate awareness among mothers for exclusive breast feeding. 30

31 NRHM STATE PROGRAMME IMPLEMENTATION PLAN High levels of child malnutrition, particularly in rural areas and in children belonging to disadvantaged socio-economic groups leading to a disproportionate increase in under five mortality. Persistently low levels of child immunisation primarily due to non-availability of timely and quality immunisation services. Lack of child health facilities, both infrastructure and human resource, to provide curative services for common childhood ailments such as ARI, Diarrhea, etc. Inadequate supply of drugs, ORS packets, weighing scales, etc. Lack of knowledge of basic child health care practices among the community. Failure to generate community awareness regarding essential sanitation and hygiene practices that impact on the health of children. Since these factors are inter-linked and synergistic, any effort to improve the health of the children in the state needs to address child health issues in a holistic manner. IMNCI Training: IMNCI training has successfully started in the State. The Pilot project has also successfully completed in the district of Vaishali. The project is being monitored and managed by Unicef. In IMNCI Training is being scaled up in thirteen districts. In phase wise rest of districts will be completed. In , a pilot project done through SHSB on Nutritional Rehabilitation Centre. In this project special nutritious food provided to the severely malnutrition children. 4.3 Family Planning RCH emphasizes on the target-free promotion of contraceptive use among eligible couples, the provision to couples a choice of various contraceptive methods (including condoms, oral pills, IUDs and male and female sterilization), and the assurance of high quality care. It also encourages the spacing of births with at least three years between births. Despite RCH and previous programmes vigorously pursuing family planning objectives, fertility in Bihar continues to decline at much lower rates than the national average. Although the total fertility rate has declined by about half a child in the six-year period between NFHS-1 and NFHS-2, it has increased in NFHS-3 and is far from the replacement level. Furthermore, certain groups such as rural, illiterate, poor, and Muslim women within the population have even higher fertility than the average. The persistently high fertility levels point to the inherent weakness of the state's family planning programme as well as existing sociodemographic issues. High TFR is reflected by a dismal picture of women in Bihar 31

32 NRHM STATE PROGRAMME IMPLEMENTATION PLAN marrying early, having their first child soon after marriage, and having two or three more children in close succession by the time they reach their late-20s. At that point, about one-third of women get sterilized. Very few women use modern spacing methods that could help them delay their first births and increase intervals between pregnancies. The major issues affecting the implementation of the Family Planning programme in Bihar are as follows. Lack of integration of the Family Planning programmes with other RCH components, resulting in dilution of roles, responsibilities and accountability of programme managers both at state and district levels. Failure of the programme to effectively undertake measures to increase median age at marriage and first childbirth. Inability of the programme to alter fertility preferences of eligible couples through effective behavior change communication (BCC). Over emphasis on permanent family planning methods such as, sterilization ignoring other reversible birth spacing methods that may be more acceptable to certain communities and age groups. (Overall, sterilization accounts for 82 percent of total contraceptive use. Use rates for the pill, IUD, and condoms remain very low, each at 1 percent or less). Due to high prevalence of RTI/STD, IUDs are not being used by majority of women. Continued use of mass media to promote family planning practices despite evidently low exposure to mass media in Bihar, leading to lower exposure of family planning messages in the community, particularly among rural and socio-economically disadvantaged groups. Weak public-private partnerships, social marketing to promote and deliver family planning services.(public Private Partnership is improved since Nursing homes in 20 districts are accredited to conduct Family planning operations. In accredited private Nursing homes are expected to conduct more than thousand family planning operations in the state. From April, 2008, sterilization conducted till Jan, 2009 of which 40,000 are conducted by the accredited private Nursing Homes. Details in Annexure) The issues mentioned above are closely interlinked with the existing sociodemographic conditions of the women, specially rural, poor and illiterate. Comprehensive targeted family planning programme as well as intersectoral co-ordination on an overall female empowerment drive is needed to address the factors responsible for persistently high fertility levels in Bihar. 32

33 NRHM STATE PROGRAMME IMPLEMENTATION PLAN The state has quality assurance committee for family planning both at State and District level. The committee sits quarterly and report is sent to state. Also, 102 private hospitals and Clinics are accredited by the District Quality Assurance Committees for conducting sterilization in 20 districts.these private facilities are monitored by the QAC on sterilization conducted in the facilities. Family planning Insurance scheme is also being implemented in the state with ICICI Lombard. Most of the Sterilizations are conducted in the last two quarters due to existing sociodemographic and programmatic reasons as evident from the graph- Month wise comparison of Sterilization & , Apr May June July Aug Sep Oct Nov Dec Jan Feb Mar Efforts are being made to offer fixed day family planning services at District hospitals, Sub divisional hospitals, FRUs and accredited private facilities. Later on this will be extended to the PHCs. 4.4 Adolescent Reproductive & Sexual Health The World Health Organization (WHO) defines adolescence as the period between 10 and 19 years of age, which broadly corresponds to the onset of puberty and the legal age for adulthood. 33

34 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Commencement of puberty is usually associated with the beginning of adolescence. In some societies, adolescents are expected to shoulder adult responsibilities well before they are adults; in others, such responsibilities come later in life. Although it is a transitional phase from childhood to adulthood, it is the time that the adolescents experience critical and defining life events first sexual relations, first marriage, first childbearing and parenthood. It is a critical period which lays the foundation for reproductive health of the individual s lifetime. Therefore, adolescent reproductive and sexual health involves a specific set of needs distinct from adult needs. The reproductive health needs of adolescents as a group has been largely ignored to date by existing reproductive health services. Many adolescents in India face reproductive and other health risks. Poor nutrition and lack of information about proper diets increase the risk of iron-deficiency anemia for adolescent girls. Young women and men commonly have reproductive tract infections (RTIs) and sexually transmitted infections (STIs), but do not regularly seek treatment despite concerns about how these infections may affect their fertility. India also has one of the highest rates of early marriage and childbearing, and a very high rate of irondeficiency anemia. The prevalence of early marriage in India poses serious health problems for girls, including a significant increase of maternal or infant mortality and morbidities during childbirth. The following facts will help understand the situation objectively. The median age of marriage among women (aged 20 to 24) in India is 16 years. In rural India, 40 percent of girls, ages 15 to 19, are married, compared to only 8 percent of boys the same age. Among women in their reproductive years (ages 20 to 49), the median age at which they first gave birth is 19. Nearly half of married girls, ages 15 to 19, have had a least one child. India has the world s highest prevalence of iron-deficiency anemia among women, with 60 percent to 70 percent of adolescent girls being anemic. Underlying each of these health concerns are gender and social norms that constrain young people especially young women s access to reproductive health information and services. Motherhood at a very young age entails a risk of maternal death that is much greater than average, and the children of young mothers have higher levels of morbidity and mortality. Early child bearing continues to be an impediment to improvements in the educational, economic and social status of women in India. Overall for young women, early marriage and early motherhood can severely curtail educational and employment opportunities and are likely to have a long-term, adverse impact on their and their children s quality of life. In many societies, adolescents face pressures to engage in sexual activity. Young women, particularly lowincome adolescents are especially vulnerable. Sexually active adolescents of both sexes are increasingly at high risk of contracting and transmitting sexually transmitted diseases, including HIV/AIDS; and they are typically poorly informed about how to protect themselves. To meet the reproductive and sexual health needs of adolescents, information and education should be provided to them to help them attain a certain level of maturity required to make responsible decisions. In particular, information and education should be made available to adolescents to help them understand their sexuality and protect them from unwanted pregnancies, sexually transmitted diseases and subsequent risk of 34

35 NRHM STATE PROGRAMME IMPLEMENTATION PLAN infertility. This should be combined with the education of young men to respect women s self-determination and to share responsibility with women in matters of sexuality and reproduction. Information and education programs should not only be targeted at the youth but also at all those who are in a position to provide guidance and counseling to them, particularly, parents and families, service providers, schools, religious institutions, mass media and peer groups. These programs should also involve the adolescents in their planning, implementation and evaluation. Being a sensitive and often, controversial area, adolescent reproductive and sexual health issues and information are very often difficult to handle and disseminate. Furthermore, the contents do not only deal with factual and knowledge-based information but more importantly, need to deal with attitudinal and behavioral components of the educational process. Thus it can be conclusively stated that adolescents are a diverse group, and their diversity must be considered when planning programs. Adolescents, the segment of the population in the age group of years, constitute about 23% of the population of the state. This group is critical to the success of any reproductive and sexual health programme, as it would remain in the reproductive age group for more than two decades. Early marriages seem to be still a key problem. Percentage of boys who are married before attaining 21 years in consistently high in most districts. The mean age of marriage for girls is % pregnant mothers in the state are in the age group of years. This is due to the reason that most of the girl s married before 18 years. The various anecdotal evidences emerging from the community level participatory planning exercises and opinions voiced by the various levels of health officials during consultation exercise indicate that there is lack of a cohesive ARSH strategy at the state level. Possibility of bifurcating the total target into school going and out of school going adolescents have not been examined as a strategy option. Hence the current school health program by and large lacks any adolescent oriented interventions. In the consultations with the Bihar State AIDS Control Society, it had emerged that they have several adolescent targeted intervention including using special adolescent counselors currently going actively implemented. The possibility of convergence between the RCH II program priorities and NACP priorities require to be integrated. Specific capacity building initiatives to orient the health providers at various levels to specific necessities of the ARSH program like adolescent vulnerability to RTI/STI/HIV /AIDS, communication with adolescents, gender related issues, designing adolescent friendly health services, body and fertility awareness, 35

36 NRHM STATE PROGRAMME IMPLEMENTATION PLAN contraceptive needs etc have not been actively taken up the state health department to prepare itself to tackle the problems / issues of this important segment. 4.5 District/Sub District Variations Key indicators related to Maternal and Child Health (MCH) and Family Planning clearly show the poor status of RCH in Bihar. However, close examination of data reveals that there exist wide inter-district variations for almost all the key indicators. 36

37 NRHM STATE PROGRAMME IMPLEMENTATION PLAN DLHS-3 Data for Bihar S.no. State/district % of households with low standard of living % girls marrying below legal 18 age at marriage Birth order 3 and above Any Method Any Modern Method Female Sterilization Male Sterilization Unmet need for family planning % women received at least three visits for ANC Institutional Birth Delivery at home assisted by a doctor/nurse/lhv/anm % of children (age12-23 months) received full immunization Children breastfed within one hour of birth % women aware of HIV/AIDS 1 Banka Aurangabad Araria Bhagalpur Muzaffarpur Nalanda Nawada Champaran W Patna Champaran E Buxar Begusarai Munger Madhubani Madhepura

38 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Lakhisarai Darbhanga Gaya Gopalganj Jamui Jehanabad Kaimur Katihar Khagaria Kishanganj Purnia Bhojpur Saharsa Samastipur Saran Sheikhpura Sheohar Sitamarhi Siwan Vaishali Supaul

39 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Focus Districts: As per the guidelines issued by the Ministry of Minority Affairs, GoI regarding districts with higher percentage of the minority population, the SPIP for NRHM, attempts to provide adequate resources. Bihar has got seven districts Araria, Kishanganj, Purnia, Katihar, Sitamarhi, West Champaran, Darbhanga in category-a which have both socio-economic and basic amenities parameters below national average while allocating available resources to the districts, we've tried to give priority to these Category-A districts. The District Magistrates of 3 (three) of these districts i.e. Araria, Purnea and Katihar have been made members of State Health Mission headed by CM. This year the rest 4 will also be included, so that the specific problems of these districts may be brought into fore. 39

40 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Health Infrastructure and Facilities The delivery of services could only be improved if facilities are within reach and have minimum basic physical infrastructure to provide the basic services. There seemed a major challenge in construction of the health care facilities. Lack of clear guidelines sometimes delayed the process. To make the BEmOCs and CEmOCs functional, adequate staff, essential equipments and infrastructure (OT, Labour rooms, new born care area, blood storage and blood storage units) are to be taken up as a priority area. District wise Availability of Health Centres of Bihar State No. of No. of No. of Referral Referra Referra No. of New Total No. No. of Total No. of No. of Hospital l l No. No. New Tota Sub Const Sub of New APHCs No. APHCs APHCs Sl Name of upgrade Hospit Hospit of of Constr l Divl r Div PHC Constr upgrad of exist exist. Districts d in Sub als als HSC DH uction DH Hospital uctio Hosp s uction ed into PHC previos present Div exist exist s s exist n itals exist PHCs s ly ly Hospital previou Present s sly ly 1 Araria Arwal Aurangaba 3 d Banka Begusrai Bhagalpur Bhojpur

41 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Buxar Champaran 9 (E) Champaran 0 (w) Darbhanga Gaya Gopalganj Jamuai Jhanabad Kaimur Katihar Khagaria Kishanganj Lakhisarai

42 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Madhapura Madhubani Munger Muzaffarp 4 ur Nalanda Nawada Patna Purniea Rohtas Saharsa Samastipur Saran

43 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Sheikhpura Sheohar Sitamarhi Siwan Supaul Vaishali Total Table : Bihar: Public Health Infrastructure Personnel Sl. No Districts MO ANM LHV MHW Staff Nurse AWW Sanct. Working Sanct. Working Sanct Working Sanct. Working Sanct. Working Sanct. Working 1 Araria Aurangabad Arwal Banka Begusarai Bhagalpur Bhojpur Buxar Champaran (E)

44 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Champaran (W) Darbhanga Gaya Gopalganj Jehanabad Jamui Kaimur Katihar Khagaria Kishanganj Lakhisarai Madhepura Madhubani Munger Muzaffarpur Nalanda Nawada Patna Purnia Rohtas Saharsa Samastipur Saran Sheikhpura Sheohar Sitamarhi Siwan Supaul Vaishali

45 NRHM STATE PROGRAMME IMPLEMENTATION PLAN District Hospitals: Out of 38 Districts 25 have district hospitals. Most of the district hospitals are not functioning up to the level due shortage of specialties and Staff Nurses. Construction of 11 District Hospitals are on full swing and expected to be completed by Sub District Hospitals: At present there are 23 Sub District Hospital, 20 new SDH are under construction and 15 Referral Hospital are in the process of up gradation to SDH. Referral Hospitals: There are 55 referral Hospitals. These referral hospitals get patient from PHCs, APHCs and are covered by specialised services. Block PHCs: At present there are 398 PHCs, 135 new PHCs are under construction and will be operationalised by this year. 73 Adll PHCs will also be upgraded to PHCs. These PHCs require to be upgraded at CHC level for specialised Services. Adll PHCs: The total no. of Adll PHC is These adll PHCs only provide OPD services. All these PHCs require to functionalise the inpatient for providing deliver services and reduce the load of Block PHCs. HSCs: At present there are 8858 HSCs in the state. Half of the HSCs are running from the rented place or Panchayat office. Mostly these HSCs are manned by one ANM only. Infection Management and Environmental Plan: Bio medical waste management has emerged as a critical and important function within the ambit of providing quality healthcare in the country. It is now considered an important issue of environment and occupational safety. As per the Bio-Medical Waste (Management & Handling) Rules, 1998, all the waste generated in the hospital has to be managed by the occupier in a proper scientific manner. The GoI has also issued the IMEP guidelines for SCs, PHCs and CHCs. The state is in the process of outsourcing the Biomedical Waste Management system for all the hospitals. 4.7 Human Resource Development including Training Human Resource Development forms one of the key components of the overall architectural corrections envisaged by both the RCH II and NRHM programs. The Government of Bihar also has spelt out the same as the number one priority. However the implementation of this vision has been fraught with various obstacles. Though the state has reasonable number of MBBS doctors, there is an acute shortage of specialized medical manpower. The shortage of specialists like obstetricians and Anesthetists are obstructing the state plans to operationalise all district hospitals as First Referral Units. The available specialists in the state cadre is 45

46 NRHM STATE PROGRAMME IMPLEMENTATION PLAN concentrated at the state Referral Hospital and hence the same handle bulk of the institutional deliveries state wide and is the only center capable of providing comprehensive emergency obstetric care services. In , there has been a continuous focus on the capacity building of the existing manpower in the state. Trainings as per GoI guidelines on Immunization, IMNCI, EmOC, LSAS, SBA and Minilap/MVA etc have been taken up with full vigour. It is proposed to continue these trainings in In addition, the state wide training on Immunization for Medical Officers, IPC skills for Breast feeding and basic training of neonatal resuscitation-shall also be taken up for various levels. (Details of training plan and Budget is given in the annexure) 4.8 Inequity/ Gender; Vulnerable Groups Including Urban Slums & Tribal Inequity and Gender Ensuring Gender Equity One of the broad indicators for measuring gender disparity is the sex ratio. The sex ratio in Bihar is unfavorable to women. Analysis of other indicators on the basis of gender reveals widening gaps between the sexes. While NMR for females is marginally higher than that of males, it widens further for the IMR, and even further for the under-five Mortality Rate. In conditions of absolute poverty, where resources to food and health care are severely limited, preference is given to the male child, resulting in higher female malnutrition, morbidity and mortality. Gender discrimination continues throughout the life cycle, as well. Women are denied access to education, health care and nutrition. While the state's literacy rate is 47.5%, that for women in rural areas is as low as 30.03%. Abysmally low literacy levels, particularly among women in the marginalised sections of society have a major impact on the health and well being of families. Low literacy rate impacts on the age of marriage. The demand pattern for health services is also low in the poor and less literate sections of society. Women in the reproductive age group, have little control over their fertility, for want of knowledge of family planning methods, lack of access to contraceptive services and male control over decisions to limit family size. According to NFHS data, for 13% of the births, the mothers did not want the pregnancy at all. Even where family planning methods are adopted, these remain primarily the concern of women, and female sterilization accounts for 19% of FP methods used as against male sterilization, which is as low as 1%. In terms of nutritional status too, a large proportion of women in Bihar suffers from moderate to severe malnutrition. Anemia is a serious problem among women in every population group in the state, with prevalence ranging from 50% to 87% and is more acute for pregnant women. 46

47 NRHM STATE PROGRAMME IMPLEMENTATION PLAN In all the programmes efforts will be made to meet the needs of vulnerable groups and ensure equity. Gender sensitization shall be made part of each training. The monitoring system too will be geared for this so that we may get disaggregated data. The state of Bihar is implementing the PC- PNDT Act at right earnest. The MOs are being trained by the State Health and Family Welfare Institute. The Civil Surgeons are the nodal person in the district in this regard. However monitoring of the activity still a big problem and require to improve. The state has procedures for registering the diagnostic centres and hospitals which comply these institutes to follow the PC-PNDT Act Urban Slums Urban health care has been found wanting for quite a number of years in view of the fast of urbanization leading to growth of slums and population as more emphasis is given in rural areas. Most of the Cities and Towns of Bihar have suffered due to lack of adequate primary health care delivery especially in the field of family planning and child health services. At present, there are 12 Urban Health Centres (UHC) in the state. However, as per the GoI guidelines, there should be one UHC for 50,000 population (outpatient). The Urban Health Centres should provide services of Maternal Health, Child Health and Family Planning and especially cater to the Urban slums. The infrastructure condition of the existing Urban Health Centres is not up to the mark and requires some major renovation work. The staff at each UHC should comprise of 1 Medical Officer (MO), 1 PHN/LHV, 2 ANMs, 1 Lab Assistant and 1 Staff clerk with computer skills. 4.9 Logistics Validation of equipments and drugs procurement is within the domain of state level decision making. The Districts generally purchase the requirements and distributed to the other Health institutes mostly Block PHCs. However stock out of drugs still a problem for concern and require insurability of drug availability in the health institutes. There is provision of contingency funds for emergency drugs at the district level and health facilities. Whenever PHCs/PHSCs run out of drugs, medicines are purchased through contingency fund and supplied to the PHCs/PHSCs. The general impression is supplies arrive too late and too little. However under NRHM there is scope for huge and rapid flow of materials from the MOHFW, GOI and the State level. Also under the decentralization process the CHC, PHCs and HSCs will have larger autonomy to purchase drugs and 47

48 NRHM STATE PROGRAMME IMPLEMENTATION PLAN supplies locally as per procurement guidelines to be developed by the State Government under the NRHM. District and the peripheral institutions need to be strengthened through capacity building for enhancing their capabilities of indenting, procurement, inventory management and distribution of drugs and supplies and maintenance of medical equipment and transport. Cold Chain Vans are available in the districts for distribution of Vaccines to PHCs/ HSCs during vaccination programs and camps. Generally PHC vehicles are used to collect the drugs and supplies from the district store. Currently local purchase of drugs and supplies are not approved. Drugs, consumables, and vaccines are directly supplied by the state to districts for HSCs, PHCs and other facilities very irregularly. There is need to streamline the process for estimation and indenting of vaccines, drugs and supply of consumables. The supply system would ensure smooth flow of indented materials as per guidelines from state to all levels of utilization. A big leap has been taken in in the field of Procurement concerning Maternal and Child Health equipments and drugs. One of the key achievements has been the finalization of rate contracting for the state owned 26 Sick Newborn Care Unit, 533 Neonatal Stabilization Units and essential equipment for strengthening the labour rooms of the state hospitals. In addition, rate contracting of some important drugs like Misoprostol has also been ensured HMIS and Monitoring & Evaluation The National Rural Health Mission has been launched with the aim to provide effective health care to rural population. The programme seeks to decentralize with adequate devolution of powers and delegation of responsibilities has to have an appropriate implementation mechanism that is accountable. In order to facilitate this process the NRHM has proposed a structure right from the village to the national levels with details on key functions and financial powers. To capacitate the effective delivery of the programme there is a need proper a proper HMIS system Regular monitoring, timely review of the NRHM activities should be carried out. The quality of MIES in State HQ and in districts is very poor. Reporting and recording of RCH formats (Plan and monthly reporting) are irregular, incomplete, and inconsistent and few districts are not reporting at all. Formats are not filled up completely at the sub center level. There information is not properly reviewed at the PHC level. No feedback is provided upon that information. For overall management of the programme, there is a Mission Directorate and a State Programme Management Unit in the state. The Unit is responsible for overall monitoring and evaluation of the 48

49 NRHM STATE PROGRAMME IMPLEMENTATION PLAN programme in the state and the districts. The data gathering is being facilitated by the State, District and PHC Data Centres. The numerous formats being used have been reviewed and it is found that data needs to be compiled only as per RCH, NRHM programme and State needs. Hence the new MIES formats have been shared with all the health functionaries and it is expected that they shall be reporting in the new formats from the 3 rd quarter. At district level, there is a District Health Society who will be responsible for the data dissemination from the sub-district level to the district level. Data Manager/HMIS expert at the State level and Data Assistant at the district level will be responsible for management of HMIS. As such, there is a Monitoring Team constituted each at state and district level to monitor the implementation of the NRHM activities. The Team comprises of representatives from the Mission Directorate and Programme Committee for various health programmes. The Team also comprises of representatives from Govt. of India. There is a Hospital Management Committee/Rogi Kalyan Samiti at all PHCs and CHCs. The PHC / CHC Health Committee will monitor the performance of HSC under their jurisdiction and will submit the report and evaluate the HSC performance, and will be submitted to the District, which will compile and sent it to the State Behaviour Change Communication The state does not have any comprehensive BCC strategy. All the programme officers implement the BCC activity as per their respective programmes. The IEC logistic is designed, developed and procured at the district level and distributed to the PHC in an ad hoc manner. However some activity is done at the state level. There is no credible study available to identify the areas / region specific knowledge, attitudes and practices pertaining to various focus areas of interventions like breast feeding, community & family practice regarding handling of infants, ARSH issues etc. At present there is no impact assessment of the IEC and BCC activities. It s very important to assess the impact of IEC/BCC activities, resources and methods to undertake mid way corrective measures Convergence/Coordination Convergence with ICDS has been taken care of to cover immunization and ANC Service. ASHA, AWW and ANMs together hold monthly meetings with Mahila Mandals under MUSKAAN Programme. Government of Bihar has decided to merge Village Health and Sanitation Committee with Lok Swasthya Pariwar Kalyan and Gramin Swaschata Samiti constituted by Department of Panchayat Raj in Bihar. The PHED has 49

50 NRHM STATE PROGRAMME IMPLEMENTATION PLAN been entrusted to train ASHAs as per GoI norm. Adolescent councilors are placed in each district from State AIDS Control Society. The Health department is looking to cooperate with them by giving training to these councilors for implementing ARSH programme. The State PWD Department has taken care of the construction of Health Department. All the construction activity for Health Institutions under NRHM has already been handed over to the PWD department Finance In the GoI had approved an amount of Rs Crores under RCH II. 50

51 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Progress and Lessons learnt from RCH II Implementation of Major achievements during SHSB at State level and District Health Societies (in all 38 districts) formed & registered. 2. ASHA: A total of ASHAs selected against the total revised target of 87, SPMU & DPM: The State Level consultants in SHSB and DPMU staff (3 in each district) have been recruited in 34 out of 38 districts. The orientation training for all has been completed. 4. Free drug distribution of essential drugs started from 1st July 2006 and 24 hours presence of doctors ensured in all facilities up to PHC level resulting in unprecedented increase in OPD patients times increase has been reported. Free drug list has been expanded to incorporate 33 OPD and 75 IPD at MCH, 33 OPD and 107 IPD drugs at DH and 33 OPD and 37 drugs IPD at PHC. 5. Routine Immunization: Full immunization percentage increased to 41.4% (DLHS). Use of AD Syringe increased to 95%. 6. Against a total figure of posts of ANM (R), appointment of ANM (R) posts of ANM(R) have been filled up.5200 new appointments have to be made. 7. Rogi Kalyan Samitis formed in all health facilities till PHC level, registration of RKS completed rest in progress, so far 470 RKS have been registered. 8. Training Programmes: Training of EmOC, Life Saving Anesthesia Training, IMNCI, ASHA, DPMUs, SBA training, Immunization and Neonatal resuscitation started. This includes the regular monitoring and corrective actions taken. 9. ANM/GNM training Schools-Out of 22 ANM schools and 6 GNM schools, 20 ANM schools were restarted after a period of more than a decade. Currently approx. 600 students enrolled. In year 2009, it is being ensured that ANM and GNM schools train students up to their optimum capacity. Besides, efforts have been made to strengthen the overall structure of these schools in the state. 10. Institutional delivery has increased manifold as evident from the bar diagram below (till -Dec 08) Series1 51

52 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Additionally in the year , rate contracting of equipments for Child (SNCU & NSU) and Maternal Health (Labour room) for District, Sub-Divisional, CHC and PHC hospitals has been achieved, which will pave the way for procurement and availability of the same in the Districts. The State Programme Implementation Plan has been framed on the basis of strategies and activities which worked in last three years. The major bottlenecks have been identified and an attempt has been made to overcome them through alternative strategies. 5.2 Programme Management Some of the things which didn't work in last three years are:- i. Construction & Renovation- Slow progress in Infrastructure ii. BCC strategy formulation. iii. High turnover of personnel in programmes. iv. The quality of training. v. Keeping up the motivational level of health staff at all levels. vi. Utilization of trained staff (It is sub optimal now). vii. Mismatch of personnel and equipment. viii. Lack of Proper monitoring and evaluation framework. ix. Quality issues in critical care services (timely use of referral transport by pregnant women, utilization of EmOC trained doctors ) x. Acceptance of Private Partners t the district level Following strategies have been adopted to overcome the problem Slow progress in infrastructure - To overcome the problem of slow progress in infrastructure, a separate infrastructure cell has been created in State Health Society, Bihar. This year, it is proposed that two more personnel may be added to this wing to strengthen it. Moreover all the DMs have been requested to designate an agency for their district that would carry out all infrastructure-related tasks. Procurement of Equipment- Though essential drugs have been rate contracted so far, the rate contract of various equipments needed for carrying out RCH activities are still to be completed. Idea of a TNMSC model of Corporation is also taking shape in the Department to solve the logistic and procurement problem. BCC strategy formulation- Even after two and half years of NRHM, Bihar lacks a consolidated BCC strategy in health due to lack of technical know how. Besides, some other initiatives are planned this year in areas like promotion of Breast feeding, PNDT and ARSH among others. 52

53 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Quality Assurance committees in State and Districts- Quality assurance committees formed in 80 % of the districts as per Quality Assurance Manual of GoI and in rest of the districts, it will be formed by 2009 March end. State Quality Assurance Cell has been formed. Quarterly monitoring visits are planned at the state level and the divisional level to monitor quality of trainings and critical services including family planning. Recruitment of Medical officers and paramedics- The process of recruitment is lengthy and takes about months. The number of applicants is quite limited because of dearth of doctors and paramedics in the state. Moreover the consolidate remuneration is not lucrative enough. Hence from the previous year incentive for rural postings and specialist services have been provided in the SPIP. Similarly for ANMs, mobile phone facilities for all ANMs are being provided. High turnover of Personnel- It is felt that the state needs to restrict the turnover of doctors on contract and also programme managers. It is proposed that a study may be undertaken to assess the situation and recommend remedies, however it is assumed that rural and specialist bonus will help to curb the turnover to same extent. Quality of training - Monitoring cell has been constituted at the state level in State Institute of Health & Family Welfare. The trainings are being monitored at regular intervals. Low motivational level of health staff - The motivational level of health staff at all levels is low. Continuous communication and feedback by state level programme officers is being done. Sub optimal utilization of trained staff Regular evaluation and monitoring is being done and corrective steps are being taken. Placement of trained people at such facilities where infrastructure is in place. E.g. The government has taken up on priority the placement of the trained EMoC and LSAS doctors to the FRUs where there is no such facility. Poor monitoring and evaluation framework Regular monitoring visits by programme officers. Pilot initiatives in two districts In Maternal and perinatal death enquiry and response is being initiated in two districts (Kishanganj and Jehanabad). In these districts referral transport money for JBSY is being linked for payment of referral transport arranged by the pregnant woman through PHC staff. as a pilot initiative. EmOc services, MTP services, Maternity complex, Newborn corner are also being strengthened in these two districts in intensive manner. Data collection on maternal and perinatal death will be done before and after the intervention. If the data collected after the intervention shows decline in MMR and IMR then the model will be replicated throughout the State. 53

54 NRHM STATE PROGRAMME IMPLEMENTATION PLAN RCH II Programme Objectives and Strategies 6.1 Vision Statement: The NRHM seeks to provide universal access to equitable, affordable and quality health care which is uncountable at the same time responsive to the needs of the people, reduction of child and maternal deaths as well as population stabilisation, gender and demographic balance in this process. The mission would help achieve goals set under the National Rural Health Policy and the Millennium Development Goals. To achieve these goals NRHM will: Facilitate increased access and utilization of quality health services by all. Forge a partnership between the Central, state and the local governments. Set up a platform for involving the Panchayati Raj institutions and community in the management of primary health programmes and infrastructure. Provide an opportunity for promoting equity and social justice. Establish a mechanism to provide flexibility to the states and the community to promote local initiatives. Develop a framework for promoting inter-sectoral convergence for promotive and preventive health care. 54

55 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Technical Objectives, Strategies and Activities 1 Maternal Health Goals: Reduce MMR from present level 371 (SRS ) to less than 100 Objectives: 1. To increase 3 ANC coverage from 26.4% to 45% by and to 75% by (DLHS3) 2. To increase the consumption of IFA tablets for 90 days from present level of 9.7% to 20% by and to 35% by (DLHS-3) 3. To reduce anemia among pregnant mothers from 60.2% to 52% by and to 40% by To increase institutional delivery from 70% to 76% by and to 85% by (MIS data) 5. To increase birth assisted by trained health personnel from 31.9% to 45%. (DLHS-3). 6. To increase the coverage of Post Natal Care from 26% to 40% by and to 55% by (DLHS-3). 7. To reduce incidence of RTI/STI cases 8. To reduce the no of unsafe abortions Source of data: DLHS 3, NFHS 3 and MIS Data Objective No. 1: To increase 3 ANC coverage from 26.4% to 45% by and to 75% by Strategies and Activities: 1.1. Institutionalization of Village Health and Nutrition Days (VHND) In collaboration with ICDS, such that the Take Home Ration (THR) distribution and ANC Happens on the same day This will require minor changes in the microplans of Health and ICDS Policy decision and appropriate guideline under convergence between Health and ICDS need to happen as a priority 1.2 Improved Access of ANC Care Provision for Additional ANMs in each Sub Centres (Refresher Training to ANMs on Full ANC to improve the quality of ANC) Setting up of New Sub Centres to cover more areas 55

56 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Micro planning: Identifying vulnerable groups, left out areas and communities having high percentages of BPL under each block and incorporating the same into the block micro plans to focus attention on them for providing Community and Home based ANC to them Organizing Monthly Village Health and Nutrition Days in each Aaganwadi Centres Organizing RCH camp in Each Block PHC areas Tracking of Pregnant mothers by ASHAs 1.3 Ensure quality service and Monitoring of ANC Care Strengthen the monitoring system by checking of ANMs duty rooster and visits of LHVs and MOs Involvement of PRIs in monitoring the ANMs service through convergence Refresher training of ANMs on ANC care Proper maintenance of ANC Register and Eligible couple register 1.4 Strengthening of Health Sub Centres Repair and Renovation of Sub Centres Provide equipments like BP Apparatus, Weighing machines, Heamoglobinometer etc to the Sub Centers Timely supply of Drug Kit A and Kit B 1.5 Generate Awareness for ANC Service Convergences meeting with AWWs, ASHAs, PRI Members, NGOs at the Gram Panchayat level by ANMs. These meetings will also attended by MOs from Adll PHCs Tracking of Pregnant mothers by ASHA, ANM and AWWs though organizing Mahila Mandals meeting. Incentive for ASHAs and ANMs to give for the initiative. This initiative is under MUSKAAN Programme. Incentive for ASHA will be taken care under Intersectoral Convergence Counseling by ASHAs and ANMs to the pregnant mothers, mothers and Mother in Laws. Objective No. 2: To increase the consumption of IFA tablets for 90 days from present level of 9.7% to 20% by and to 35% by (DLHS-3) Strategies and Activities: 2.1 Purchase and Supply of IFA Tablets 2.1.1To include IFA under essential drug list Timely supply of IFA Tablets to the Health Institutions ( Ensuring no stock out of IFA at every level down to Sub-Centre Level) District to purchase IFA tablets in the case of stock out Convergence with ICDS and Education for regular supply of IFA tablets through AWWCs And Schools for the pregnant and lactating women, children 1-3 years and adolescent girls 2.2 Awareness generation for consumption of IFA Tablets 56

57 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Pregnant mothers will be made aware for consumption of IFA tablets for 90 days ASHA and AWWs will generate awareness along with ANMs at the Village level Ensure utilizing the platform of Mahila Mandal meetings being held every third Wednesday Objective No.3: To reduce anemia among pregnant mothers from 60.2% to 52% by and to 40% by Supplementing IFA tablets consumption with other clinical strategies Half yearly de-worming of all adolescent girls Training of ANM, AWW and ASHA on module on EDPT (Early Diagnosis and Prompt Treatment) of anemia Activities for consumption of IFA tablets as per Objective No Other strategies Refer severely Anemic Pregnant Mothers to referral centers IPC based IEC campaigns emphasizing on consumption of locally available iron rich foodstuff. Details given under Special Scheme on Anemia Control in Part B Objective No. 4: To increase institutional delivery from 70% to 76% by and to 85% by (MIS data) and to increase facilities for Emergency Obstetric Care (EmOC) Strategies and Activities: The strategies will lead to up gradation and operationalization of the facilities to increase institutional deliveries along with providing EmOC and emergency care of sick children. These facilities will also provide entire range of Family Planning Services, safe MTPs, and RTI/STI Services. 4.1 Upgrading Block PHCs/CHCs in to FRUs Provision of OT and lab facility by upgrading 76 FRUs Blood Bank and or Provision of Blood storage, OT and lab facility by upgrading 76 FRUs 1. All district hospitals must have either its own Blood Bank, operational round the clock, or must have access to one that can be accessed in less than 30 minutes 2. All CHC / PHCs have blood storage facility Training of MOs on Obs & Gynae and Anesthesia week Life Saving Anesthetic Skills (LSAS) training for MBBS Doctors week -Emergency Obstetric Skill training for MBBS doctors 3. 3 days training of doctors and nurses posted at FRUs for the neonatal stabilization unit Repair and renovations of FRUs Appointment of Anesthetist, O&G specialist, Staff Nurses at the FRUs 57

58 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Incentivise the conduct of C section at Rs 1500 per C section for the staff involved at the FRUs Accreditation of FRUs 4.2 Operationalization of 24x7 facilities at the PHC level Training of MOs and Staff Nurses of PHCs in BEmOC Appointment of at least 3 Staff Nurse in each PHCs Repair and renovation of PHCs Availability of and timely supply of medical supplies and DDK & SBA kits Training of MOs, Staff Nurses on SBA 4.3 Increase beneficiary choice for institutional delivery through IEC campaign complimented by network of link workers working on incentive basis for each institutional delivery achieved Strengthening JBSY Scheme 1. Improving quality: Infrastructural support to high burden facilities to avoid early discharge following institutional deliveries 2. Mapping of high burden facilities and proving them support for matching infrastructural up gradation to increase the hospital stay following delivery 3. Identifying districts and blocks and communities within them, where the awareness and reach of JBSY scheme is poor and to ensure increased service utilization in these areas Design and implement an IEC campaign focusing on communicating the benefits of institutional delivery and benefits under JBSY scheme Equip the ASHA network to reinforce the IEC messages through IPC interventions at village / community level Provide incentives to ASHA for every institutional delivery achieved in her village / designated area Involvement of PRIs for JBSY scheme to monitor and generate awareness for institutional delivery. 4.4 Provision of Referral Support system Provision of a dedicated referral transport system for the newborns and pregnant women to refer them from home/hscs/phcs to referral centers Monitoring of referral transport system Development of proper referral system between Health Institutions Operationalising of Blood Storage Units in 76 FRUs 58

59 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Lack of Blood Storage Units in the state make things complicated during emergency hence in 76 FRUs blood storage units has been proposed. Operationalising of at least one Blood Storage Units in 76 FRUs is proposed as per IPHS guidelines. Particulars Qty. Rate (Rs.) Months Amount Sl. (3x4x5=6) Salary of One Medical Officer 76 20,000/- pm 12 1,82,40,000/- 2 Salary of 3 Lab Rs. 6500/ ,500/- pm 1,77,84,000/- 12 pm 3 Diesel 76 5,000/- pm 12 45,60,000/- 4 Service and Maintenance Charge 76 5,000/- pm 12 45,60,000/- 5 Misc. and Others 76 2,000/-pm 12 18,24,000/- Total Operational Cost 4,69,68,000/- Objective No.5: To increase birth assisted by trained health personnel from 31.9% to 45%. (DLHS-3). Strategies and Activities: 5.1 Ensure safe delivery at Home Provision of Disposable delivery kits with ANMs and LHVs - Establishing full proof Supply Chain of the DD Kits Training of ANMs on SBA 1. Providing SBA with approved drug kits, in order to deal with emergencies, like post-partum hemorrhage, eclempsia, and puerperal sepsis 2. Ensuring regular supply of these drugs to the SBA Supply of adequate DD Kits to ANMs, LHVs. 5.2 Provision of delivery at HSC level Supply of DDkits to HSCs Delivery tables to be provided to the HSCs Objective No.6: To increase the coverage of Post Natal Care from 26% to 40% by and to 55% by (DLHS-3). Strategies and Activities 59

60 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Ensuring proper practice of PNC services and follows ups at the health facility level Refresher sessions for all ANMs on uniform guidelines to be followed for PNC care all delivery cases to remain at facility for minimum 6 hours after normal delivery and to be recalled to facility for check up with 4 days and after 42 days Ensuring follow up PNC care through out reach services (ANM) for delivery cases where the patient does not return to facility for follow up check ups Referral of all complicated PNC cases to FRU level LHV and MO to monitor and report on PNC coverage during their field visits 6.2 Utilizing the ASHA network to strengthen the follow up of PNC services through tracking of cases, mobilization to facilities and providing IPC based education / counseling Utilize ASHA to ensure 3 PNC visits by the ANM for home delivery cases (1 st within 2 days, 2 nd within 4 days and 3 rd within 42 days of delivery) and 2 follow up visits for institutional delivery cases Counseling of all pregnant women on ANC and PNC during monthly meetings of MSS and during VHND Linking of ASHA s incentives on institutional deliveries to completion of the PNC follow-ups. 6.3 Basis Orientation of AWWs on identifying Post-partum and neonatal danger signs during her scheduled visits following delivery Basic orientation on IMNCI in order to be able to alert the beneficiary and coordinate with ASHA and ANM (to avoid undue delay) Basic orientation on identifying post-partum danger signs, specially, for home based deliveries, such that the she can alert ASHA, ANM or the local PHC towards avoiding undue delay Objective No. 7: Reduce incidence of RTI/STI Strategies and Activities 7.1 Ensuring early detection through regular screenings and contact surveillance strategies Early diagnosis of RTI / STI through early detection of potential cases through syndromic approach and referral by ANM and ASHA Conducting VDRL test for all pregnant women as a part of ANC services Implementing contact surveillance of at risk groups in convergence with Bihar AIDS Control Society. 7.2 Strengthening the infrastructure, service delivery mechanism and capacity of field level staff for handling of RTI / STI cases Conducting community level RTI / STI clinics at PHCs 60

61 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Training to all MOs at PHC / DH level in Management of RTI / STI cases in coordination with Bihar AIDS control Society Training of frontline staff, LHV, ANM and ASHA in identifying suspected cases of RTI / STI in coordination with Bihar AIDS Control Society Strengthening RTI / STI clinic of the District Hospitals Objective No. 8 Reduce incidence of unsafe abortion Strategies and activities 8.1 Early diagnosis of pregnancy using Nischay pregnancy testing kits 8.2 Counselling and proper referral for termination of pregnancy in 1st trimester if the woman wishes so Training of MOs and Nurses/LHV in MTP (MVA) Procurement and availability of MVA at the designated facilities. 61

62 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Child Health Goal: Reduce IMR from 61 (SRS 2005) to less than 30 Objectives: 1. To reduce low birth weight baby s by supplementing nutritional support to pregnant mothers 2. To increase exclusive breast feeding from 38.4% to 50% by and to 75% by To reduce incidence of underweight children (up to 3 years age) from 58.4% to 50% by and to 40% by To strengthen neonatal care services in all PHCs/CHCs/SDHs by setting newborn care centers & having trained manpower therein. 5. To reduce the prevalence of anaemia among children from 87.6% to 77% by and to 60% by To increase full immunization of Children from 41.4%% to 60% by and then to 70% by To reduce morbidity and mortality among infants due to diarrheoa and ARI Objective No.1: To reduce low birth weight baby s by supplementing nutritional support to pregnant mothers Strategies and Activities: 1.1 Convergence with ICDS, supplementary diet which is being given by AWW to pregnant mothers may be improved A supplementary diet comprising of rice, dal and ghee will be provided to all pregnant women. This will be given for the last 3 months to all underweight pregnant BPL mothers. The Scheme will be implemented in convergence with ICDS Joint Monitoring by Block MO i/cs with CDPO for implementation of the scheme. Objective No. 2: To increase exclusive breast feeding from 27.9% to 35% by and to 50% by Strategies and Activities: 2.1 Use mass media (particularly radio) to promote breastfeeding immediately after birth (colostrum feeding) and exclusively till 6 months of age Production and broadcast of radio spots, jingles, folk songs and plays promoting importance of correct breastfeeding practices Production and broadcast of TV advertisements and plays on correct breastfeeding practices 62

63 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Publication of newspaper advertisements, booklets and stories on correct breastfeeding practices 2.2 Increase community awareness about correct breastfeeding practices through traditional media Involve frontline Health workers, Aaganwadi Workers, PRIs, TBAs, local NGOs and CBOs in promoting correct breastfeeding and complementary feeding through IPC, group meetings, folk media and wall writing Educate adolescent girls about correct breastfeeding and complementary feeding practices through school -based awareness campaign. 3. To reduce incidence of underweight children (up to 3 years age) from 58.4% to 50% by and to 40% by Strategies and Activities: 3.1. Growth monitoring of each child Supply of spring type weighing machine and growth recording charts to all ASHAs, AWWs. All ASHAs, Aaganwadi centers and sub centers will have a weighing machine and enough supply of growth recording charts for monitoring the weight of all children through Untied fund of S/Cs Weighing and filling up monitoring chart for each child (0-6 years) every month during VHNDs Each child in the village will be monitored by weight and height and records will be maintained 3.2 Referral for supplementary nutrition and medical care Training for indications of growth faltering and SOPs for referral to AWWC for nutrition supplementation and to PHC for medical care Establishment of 10 Nutrition Rehabilitation Centres in Districts having severe problems of malnutrition and continue of 8 existing Centres (A Special Scheme taken up and put under NRHM B) Objective No.4: To strengthen neonatal care services in all PHCs/CHCs/SDHs by setting newborn care centers & having trained manpower therein. Strategies and Activities: 4.1. Strengthen institutional facilities for provision of new born care It is planned to develop a model for comprehensive care of the newborn at all levels, from state to the community level. 63

64 NRHM STATE PROGRAMME IMPLEMENTATION PLAN MODEL FOR COMPREHENSIVE CARE OF NEWBORN District Level Neonatal Stabilization Unit PHC Level Sick Newborn Care Unit (level 2) Village Level IMNCI trained worker, community initiatives (BCC approaches, involving PRI, Self Help groups etc.) Level Facility Services/Activities Training required Equipment 1. District Level Near Level II Sick Newborn Care Unit ( (SNCU) to provide specialized care services to sick newborns 2. PHC level Neonatal Stabilization Unit with basic care services in health facilities Special care of neonates 4 days training Equipment for SNCU and refurbishment. Delivery services Neonatal Resuscitation Warmth 1 day training in essential newborn care Neonatal warmer Oxygen supply Ambu bag and Mask 3. Village level IMNCI Trained workers in each village to provide essential child care and counseling services to community Post natal Visits, Counseling for breastfeeding and newborn care practices, immunization Timely identification, classification and treatment and referral, if needed 8 days training in IMNCI IMNCI module Drug Kit training Plan of action: DISTRICT LEVEL: NEAR LEVEL II SICK NEWBORN CARE UNIT Neonatal mortality accounts for over 60% of Infant mortality. Further reduction in Infant and Child mortality is critically dependant upon significant decline in Newborn deaths. Although on average 41% of deliveries are conducted in the institutions, i.e., at P.H.C and district hospitals, there are no separate facilities to manage sick Neonates in the hospital and health centers, Even at district hospital, the sick Neonates (Home delivered and Institutional delivered) are generally treated along with the older sick children. 64

65 NRHM STATE PROGRAMME IMPLEMENTATION PLAN It has been observed that near level II Neonatal care is Needed for 15-20% of all the neonates 5000 neonates need special care per million population per year Need for 150 special care beds per million population Establishment of near levei SNCU (sick newborn care unit) in 13 districts is proposed. REQUIREMENTS FOR ACCREDITATION 1. Location of the SNCU: Should be easily accessible from entrance of the hospital Should not be located on top floor For units catering both inborn and out born neonates: next to labor ward & delivery room For units catering out born neonates only: near children ward 2. Space Requirement: 1200 sq ft area for a 12 bed near Level II 100 sq ft per patient of which: a. 50 sq ft would be patient care area and b. 50 sq ft would be added up for ancillary areas 3. Equipments for individual patient care in the Sick Newborn Care Unit: Item Requirement for the unit 1. Servo controlled radiant warmer 1 for each bed (essential) +2 Total=14 2. Low reading digital thermometer (centigrade scale) 1 for each bed (essential) Total=14 3. Neonatal stethoscope 1 for each bed (essential) Total=14 4. Neonatal resuscitation kit: 1 set for each bed (essential) Total=14 5. Electrically operated pressure controlled slow suction machine 1 for 2 beds (essential) Total=7 (5 electrical, 2 foot operated) 6. Oxygen hood (neonatal or infant size, unbreakable) 1 for each bed (essential) Total=14 7. Non stretchable measuring tape (mm scale) 1 for each bed (essential) Total=14 9. Infusion pump or syringe pump 1 for 2 beds (essential) Total=7 10. Pulse oxymeter 1 for every two beds Total=7 11. Double outlet oxygen concentrator 1 for every two beds Total=7 65

66 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Double sided blue light phototherapy 1 for every three beds Total=2 13. Single side blue light phototherapy Total=3 13. AC (1.5 ton) split Generator (15 KVA) 1 4. Side Laboratory Equipments: Item Requirement for the unit Microscope with gram and Leishman staining facility 1 (essential) Microhematocrit centrifuge, capillary tubes and reader 1 (essential) Billirubinometer 1 Multistix strips (in container) 1 Glucometer with Dextrostix 3 5. STAFF Manpower 12 bed SNCU 1. Pediatricians 2 2. Medical Officer 4 3. Sister-in-charge / PHN 1 4. Staff Nurse 6 5. ANMs 8 6. Class IV 6 6. Life Saving drugs for Emergency: This list is not exhaustive for an Emergency situation in any Sick Newborn Care Unit Item Injection adrenaline, naloxone, sodium bicarbonate, aminophylline, phenobarbitone, hydrocortisone, Requirement for the unit A stock of 1 set per bed per month should always be maintained in the unit 10% dextrose, normal saline, ampicillin with cloxacillin, ampicillin and cefotaxime and gentamycin etc 66

67 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Support establishment of Neonatal Stabilization Units in select 100 high-mortality blocks with personnel and equipment for neonatal resuscitation, Postnatal Care, Healthy Newborn Care, weeks gestation, Stabilize neonates < 35 weeks FACILITIES FOR PHC LEVEL: NEONATAL STABLIZATION UNIT NEONATAL STABILIZATION Adequate warming through radiant heat source. Facilities for Resuscitation with self inflating resuscitation bag and well fitting neonatal face masks (at least two sizes). Medicines of essential newborn care 1. Supply of bucket type / spring type weighing machines to all sub centres and Anganwadi centres Many times new borns and infants are not weighed or incorrectly weighed using adult type weighing machines which are usually available at sub centres and Anganwadi centres. Provision of bucket type or spring type weighing instruments will improve weight monitoring. 2. Pediatrician will be appointed on contract Rs pm. 3. Training of MOs on Paediatrics 4. Training of MOs, Staff Nurses on Facility Based New Born care Training and operationalization cost will be borne by the UNICEF. GRASSROOT LEVEL IMNCI TRAINING Details as per Annexure 4.2 Generation of awareness on new born and infant care (home-based) in community through MSS Community Awareness on home-based care of new born (skin-to-skin contact, bathing after a week, not removing vermix, etc.); early recognition of danger signs - ARI, diarrhoea; proper weaning practice The ASHAs / MPWs / AWWs at every point of contact for ANC and PNC will reinforce tenets of homebased care of new born as per IMNCI guidelines. The training will be part of IMNCI. 5. To reduce the prevalence of Aneamia among children from 87.6% to 77% by and to 60% by Strategies and Activities Details in special programme for Controlling Iron Deficiency Anemia in Bihar under Part B NRHM Additionalities. 67

68 NRHM STATE PROGRAMME IMPLEMENTATION PLAN To increase full immunization of Children from 32.8% to 40% by and then to 60% by Strategies and Activities 6.1 Conduct fixed day and fixed-site immunization sessions according to district micro plans Fill vacant ANM posts and appoint additional ANMs in a phased manner to achieve GoI norm of one ANM for 5000 population by the year Update district micro plan for conducting routine immunization sessions Ensure timely and adequate supply of vaccines and essential consumables such as syringes, equipment for sterilization, Jaccha-Baccha immunization cards, and reporting formats at all levels Supply AD Syringes to conduct outreach sessions in select areas Enlist help of AWW/ASHA in identification of new-borne and follow-up with children to ensure full immunization during sessions. New born tracking system to be implemented Replace all Cold Chain equipment, which is condemned, or more than five years old in a phased manner by the year and supply new Cold Chain equipment based on analysis of actual need of the health facilities Facilitate maintenance of Cold Chain equipment through Comprehensive annual maintenance contract with a private agency with adequate technical capacity. Tender already floated and decided Provide POL support to State and Regional WIC/WIF Rs per month Rs per PHC per month to each PHCs for running of Gensets and minor repair Issue necessary departmental instructions to re-emphasize provision of ANC services in the job description of Aaganwadi Workers and ANMs. 6.2 Build capacity of immunization service providers to ensure quality of immunization services Provide comprehensive skill up gradation training to immunization service providers (LHVs/ANMs), particularly in injection safety, safe disposal of wastes and management of adverse effects Conduct training to build capacity of Medical Officers, MOICs and DIOs for effective management, supervision and monitoring of immunization services Train Cold Chain handlers for proper maintenance and upkeep of Cold Chain equipment 6.3 Form inter-sectoral collaboration to increase awareness, reach and utilization of immunization services Develop working arrangements with ICDS and PRIs to ensure coordination at all levels Involve Aaganwadi Workers and PRIs to identify children eligible for immunization, motivate caregivers to avail immunization services and follow-up with dropouts. 68

69 NRHM STATE PROGRAMME IMPLEMENTATION PLAN ASHA, AWW and ANM will hold meeting with Mahila Mandals at each village monthly for increasing the coverage of Immunization. Incentive to be provided to ASHA and ANM under RCH and AWW under intersectoral convergence Involve ICDS and PRI networks in behavior change communication for immunization. 6.4 Strengthen Supervision and monitoring of immunization services Build capacity of Medical Officers, MOICs and DIOs in supervision and monitoring of implementation of immunization services as per the micro-plan Provide mobility support to MOICs and DIOs for supervision and monitoring of implementation of immunization services Develop effective HMIS to support supervision and monitoring of implementation of immunization services Coordinate with representatives of PRI to strengthen supervision and monitoring of immunization services Details of Immunization have been incorporated in part- C of PIP. 7. To reduce morbidity and mortality among infants due to Diarrhea and ARI Strategies and Activities: 7.1 Increase acceptance of ORS Supply of ORS and ensure availability in all depots and supply of cotrimoxazole tablets. The ASHA drug kit will have ORS and cotrimoxazole tablets which should be replenished as per need. Aaganwadi centers should also be given ORS. In the absence of ORS, the use of home-based sugar and salt solution will be encouraged Orientation of ASHA for diarrhea and ARI symptoms and treatment ASHAs will be specifically trained to identify symptoms of diarrhea and ARI and to provide home-based care. Danger signs prompting transportation to seek medical care will also be taught to ASHAs Organize meetings for ASHAs/AWWs for dissemination of guidelines for Home based care ASHA and AWW will be trained and provide guidelines for Home based care. The meeting will be held at Block PHC level. A detail Action Plan for ORS submitted under Part B of NRHM Additionalities 7.2 Strengthening of referral services for infants seeking care for life threatening diarrhoea and ARI Availability of referral Rs.500 available for transporting of sick infants to the health institute Blood slide examination of all febrile children with presumptive treatment 69

70 NRHM STATE PROGRAMME IMPLEMENTATION PLAN In endemic areas, most children are anemic due to repeated bouts of malaria. Any febrile child needs to be checked for malaria compulsorily Strengthening of PHCs/ referral centers School Health Programmes Counseling sessions will be organized in Govt. Schools in collaboration with BSACS. Story lines and slogans will be published in text books of schools in collaboration with the Education Deptt. Reference Books on Health Issues and Healthy Life-Style will be published for School libraries. Health Camps will be organized for health check-ups for school children. Innovative strategies will be adopted to orient school children about healthy practices. Details annexed 70

71 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Family Planning Goal: Reduce TFR by 2.1 from present level of 4.3 Objectives: 1. To reduce total unmet need for contraception from 23.1 % to 15% 2. To increase Contraceptive Prevalence Rate (Any Modern Method) from 28.8% to 35% by and to 45% by To increase male participation in family planning 4. To increase proportion of male sterilizations from 0.6% to 1.5%. 5. Monitor the quality of service as per GoI guidelines for Sterilization Objective No.1: To reduce total unmet need for contraception from 23.1 % to 15% Strategies and Activities 1.1 Plan to organize RCH camp in each PHC/CHC once in two months Creating dedicated cadre of skilled manpower 1. Training of MBBS doctors on Minilap and NSV 2. Training of MBBS doctors on Anesthesia 3. Training on IUCD: MOs, ANMs etc One RCH camp will be organize in each PHC/CHC where Laparoscopic Ligation/Mini Lap will be done Incentive to acceptors Incentive for LL operations Training on LL operation, MTP and IUD Insertion ASHA and MPWs will publicize about the RCH in their area and motivate the eligible women to go for spacing & terminal methods of family planning. 1.2 Motivate eligible couples who have had their first child for spacing for condoms, OCPs or IUDs Update EC register with help of ASHAs and AWW The eligible couple register is presently being updated once a year (usually in April) in a survey mode. It is done in a hurry and may not have complete information in many cases. With the involvement of ASHAs and AWWs, updates should be done each month preferably during VHNDs. This will result in less wastage of time and resources and better recording of information Availability of FP services: IUCDs, OCPs, Emergency Pills, Condoms 71

72 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Each SDH/CHC/PHC should have static FP cell / corner, with earmarked ANM / LHV responsible, for providing these services daily as OPD services to clients Community Based Distribution (CBD) of Condoms and Pills: The OCPs and condoms can be provided to community based motivated volunteers, like members of Self Help Groups (for Pills) and Husbands of motivated ASHA, Satisfied NSV client, active PRI members etc. (for condoms) for community based distribution (CBD) of these. The availability of condoms and OCPs with the volunteers and their geographical responsibilities should be widely known to the potential clients / beneficiaries. Before they are made the community based distributors, they should be properly trained and mechanism developed to regularly monitor them and review their performance Public Private Partnership (Social marketing): This can be taken up on an experimental basis in a couple of districts, or a few blocks in these districts to pilot selling through entrusted community based institutions, volunteers, market mechanisms (like the popular pharmacist of the village, or grocery shop owner or the like) condoms and OCPs at normal or subsidized rates. This should be properly preceded by adequate awareness generation of the availability of these for price in the community itself and that the clients or the community members could buy these from specified vendors (volunteers etc.). The research has shown that the services, drugs, supplies etc. bought for fee are valued more by the user and they use them more Organize monthly IUD Camps in PHCs/CHCs/SDHs IUD camps will be organize in each PHC/CHC/SDH every month. ANM and ASHA will be informed the dates on which the camp will be held in the concern HIs Ensure follow up after IUD and OCP for side effects and treatment Many of the drop outs for IUD and OCP occur due to side effects and lack of proper attention to take care of these. Follow-ups after IUD insertion and starting of OCPs and provision of medical care to mitigate side effects will help in continuing with the service and also create further demand Organize Contraceptive update seminars at the district level twice in a year. The seminar for contraceptive updates will be organized at the district level twice in a year. All the healthcare providers from the district will attend the seminar. 1.3 Motivate eligible couples for permanent methods in post partum period specifically after second and third child Efforts will be made by the service providers to motivate parents to adopt permanent methods after the birth of the second or third child Update EC register with help of ASHAs and AWW Every event will be recorded in the EC register and thus the register will be updated. This can be done after every event has occurred or reported to have occurred or during the VHNDs visit each month to a village Motivate couple after second child in Post Partum period to go in for tubectomy / NSV 72

73 NRHM STATE PROGRAMME IMPLEMENTATION PLAN After the second child is born, the couple will be motivated to adopt a permanent method of family planning preferably NSV. For this communication materials will be prepared and distributed Follow up after tubectomy /NSV for side effects and treatment Each tubectomy / NSV will be followed up for side effects and their treatment. This will provide positive reinforcement and motivate others to adopt family planning. 1.4 Making available MTP Services in all Health Institutions. Since 8% of maternal mortality continues to be attributed to unsafe abortion, therefore, availability of and accessibility to quality abortion services / MTP services acquire greater importance. There is a need to identify, map and train the providers, both in public and private sectors on abortions / MTP services. There is also a need to ensure availability of medical abortion drugs; this can be done by including these drugs into the state procurement list. The latest guidelines on this can be had from GoI. Revisions in MTP Act are underway; once done, systematic orientation of entire cadre of health personnel on this is required MTP Services in the state is not fully operational in all the hospitals of the state. Training of MOs have been under taken during RCH-1. To further strengthen the skill of the doctors for MTP training, training shall be taken up during the year. 100 MOs will be trained in Plastic MVAs will utilize and state will made purchase for availability in health institutions. Objective No.2: To increase Couple Protection Rate Strategies and Activities 2.1 Awareness generation in community for small family norm Preparation of communication material for radio, newspapers, posters Communication materials highlighting the benefits of a small family will be prepared for radio, TV and newspapers Meetings with MSS, CBOs Communication materials to be used for monthly MSS/CBO meetings will be prepared and distributed for use. These meetings will be scheduled during or preceding the month family planning camps are scheduled to be held. 2.2 Regularise supply of contraceptives in adequate amounts Indent and supply contraceptives for all depots and subcentre/ AWCs and social outlets: Each AWC and ASHA will have at least one month s requirement of condoms and OCPs. Sub centres will have adequate supplies of IUDs also. 73

74 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Objective No.3: To increase male participation in family planning Strategies and Activities 3.1 Promote the use of condoms Counseling men in villages to demonstrate ease of use of condoms and for prevention of STDs Male workers will assist the MPWs in addressing the meetings of men in villages to demonstrate the use of condoms and its benefits in family planning and prevention of STDs. It should be stressed that condoms are easy to use and is a temporary method. Current methods of family planning which target women are not very easy to adopt while condoms can be very easily used Regular supply of condoms and setting up depots which are socially accessible to all men It is very essential to supply condoms through depots which can be easily accessible to men and confidentiality will also be ensured. During the meetings, the sources of condoms in the village will be made known to all. It will be ensured that the client s identity will not be disclosed. The depot holder will be set up only on condition that he shall not reveal the identity of clients. 3.2 Promote adopting NSV: as simple and convenient method of hassle free FP methods (however, it must be told that it doesn t protect from STI/RTI of HIV / AIDS) Objective No.4: To increase proportion of male sterilizations from 0.6% to 1.5%. 4.1 Increase demand for NSVs (develop a cadre of satisfied NSV Client, who could be the advocates for NSV in their designated geographical areas. Orient and train them and give them specific geographical responsibility to give roster based talks etc to identified groups of probable clients. During these talks the probable clients can be registered and they could be escorted to the nearest static facility or the camp on designated days for NSV. Once completed the procedures, then these new clients can become advocates for the same. This entire process must be fully facilitated by respective PHCs and be provided with all logistics support along with some incentives for the work or activities undertaken by them) Village level meetings in which men who already underwent NSV share experiences to motivate men to undergo NSV All the GP/ADC Villages will be chosen in the district to hold meetings in which men who have undergone NSV will tell male members of the community about their experience and the benefits of NSV. These meetings will be repeated each month in the same batch of Gram Panchayat or ADC Villages. NSV will be conducted on the motivated men. The same men will then be requested to share their experiences in the next batch of five villages for the next three months. 4.2 Increase capacity for NSV services Training of doctors for NSV While demand is being generated, a team of doctors should be trained at all the FRU level to conduct NSVs Organize NSV camps at the Sub District Level 74

75 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Objective No. 5: Monitor the quality of service as per GoI guidelines for Sterilization 5.1 A quality assurance committee initiated in every district for monitoring the quality of sterilization in the respective district. The Civil Surgeon is the chairman of the committee with at least one Gynecologist. 5.2 Streamline the contraceptive supply chain & Monitoring 1. Identifications &Renovation of Warehouse State /District/ PHC 2. Budget allocation for transportation at every level 3. Provision for report format printing and their availability at every level Action Plan for Strengthening Sterilization Services The activities are segregated into short-term and long-term. They are separately spelled out for the state and the district. Short Term Activities State Level Activities: 1. Service Availability STATIC SERVICES i. Ensure that district level facilities are fully equipped with manpower and equipments ii.availability of Sterilization services everyday at district hospitals, separately for, Males and Females iii.availability of Sterilization services at PHC level on at-least 3 fixed-days a week (these days could be fixed for the entire state, like the Immunization Days, which are Wednesday and Saturdays) iv. Demand generation activities: wide dissemination of information on the regular (daily and on fixed days) availability of the services 1. prominent display 2. workshop of key department functionaries, who in turn would disseminate the same to their line staff, who in turn will directly inform the public about the availability of services CAMPS v. The number of camps needs to be planned and based on the ELA of the districts a. Districts must plan camps in various PHCs and locations based on the need, in the beginning of the year; this should be based on the past years records etc., and these must be shared in the beginning of the year with the state b. These camps must be planned round the year, they must be evenly distributed through out the year and wide publicity on the venue and dates of the camps, well in advance must be disseminated through out the respective catchment areas 75

76 NRHM STATE PROGRAMME IMPLEMENTATION PLAN c. Availability of Providers d. Line listing of available Providers by Geographical Areas (DHQ, PHCs, SDH etc.) Gynecologist, Surgeon Anesthetist Nursing Staff e. Roster for year long Static Services Providers: Based on the above line listing form Surgical Teams for male and female sterilization separately, the teams then must be provided with earmarked days of the week at static centres, like the rotation duties in Medical Colleges and big private Nursing Homes. For example Team 1 will perform on Mondays and Wednesdays; Team 2 on Tuesdays and Fridays; and Team 3 on Thursdays and Saturdays etc. and on rotation one Team can be on call for emergencies on holidays etc. f. Roster for year long Camp Services Providers Similarly, by camps the teams should be identified in the beginning of the year and their year-long roster be prepared and informed so to them in advance. The evenness in providers work load should be ensured such that it is not the situation that a few providers are doing all the surgeries while the remaining are doing none. g. Identification of Providers for Training: Line Listing of Providers for the same. It must be prepared for every district and every PHC in the district. Before the training begins for the identified future providers, their choice must sought as to the posting to the facility they would be interested in; as far as possible this should be respected. Based on this they should be trained and posted to the pre-identified facility in a time bound fashion. This exercise should be done in advance and proper notification regarding the same should be widely publicised and disseminated. This activity should be very closely monitored by the State Health Society, in order to ensure its full operationalization. Once done, the training in phased manner should happen in a time bound fashion. h. Equipping the facilities and keeping the sets of equipments ready for the camps i. This needs to be ensured as per the guidelines for the facilities: As per the guidelines, minimum numbers of sets must be available at district and sub-divisional hospitals ii. The same needs to be ensured for every camp in advance, such that the quality and hygiene are not compromised in the camps i. Monitoring System: Both for Static Services and Camps: To monitor provider out put and progress in static facilities and camps i. A check list needs to be developed at State Health Society to monitor the above ii. A mechanism needs to be developed on this and how the information so gathered could be used to improve the services and provider output 76

77 NRHM STATE PROGRAMME IMPLEMENTATION PLAN j. Monthly Review of sterilization progress and performance by district and sub-district levels, specially focusing on high-burdened areas hard to reach areas i. A fixed agenda and points to be reviewed need to developed in order to make there review meetings focused and result oriented District Level Activities: 1. Undertake block-wise analysis of service utilization and work out detailed service provisions: fixed day roster based static services, camps and their schedules 2. Prepare block wise demand generation activities, separately for static services and camps 3. Prepare a list of providers not providing sterilization services and orient and reorient them and place/post them as per defined roster to the services: static services and camps 4. Finalize work plan with state to get specific need-based inputs 5. Conduct monthly review of sterilization activities at district level Long Term Actions State Level Actions 1. increased trained manpower 2. create dedicated pool of providers exclusively for sterilization, develop a mechanism of incentives for the high achievers 3. provide appropriate mix of services male and female sterilization at static facilities 4. undertake state level NSV campaign 5. gradually increase static facilities and popularize the availability of the same and similarly gradually reduce the number of camps proportionately 6. organize state and regional level experience sharing District Level Actions 1. saturate training of all available providers 2. ensure presence of providers in all static facilities 3. institutionalize sterilization services 4. public private partnership a. line listing of the same b. dedicated pool of the same, MBBS doctors (ask them to perform surgeries at government facilities) 5. orient block level MOs in using data for monthly review and stocktaking 77

78 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Adolescent Reproductive and Sexual Health Objective: 1. To reduce incidence of teenage pregnancies from present 25% to 22% by and to 15% by To ensure the access to information on Adolescent Reproductive & Sexual Health (ARSH) through services at District Hospitals, SDH, CHCs, PHCs & HSC level. 3. To increase awareness levels on adolescent health issues Objective No.1: To reduce incidences of teenage pregnancies from present 25% to 22% by and to 15% by Strategies and Activities: 1.1 Improve access to safe abortions MTP services made available at all the FRUs initially & at all SDHs in subsequent years, through training of select medical officers at DH/MC. MOs will be trained in MTPs Manpower (Training) & logistic support to private hospital doctors and will also be trained in conducting safe abortions. 1.2 Ensure availability of condoms/ocps/emergency contraceptives Depot holders among adolescent groups/youth organizations In addition to the ASHA and the AWW, youth organizations such as football clubs and others will have depot holders who will provide condoms/ocps and Emergency contraceptive pills and maintain confidentiality. Objective No.2: To ensure the access to information on Adolescent Reproductive & Sexual Health (ARSH) through services at District Hospitals, SDH, CHCs, PHCs & HSC level. Strategies and Activities 2.1. Organize regular adolescent clinics/counseling camps at SC/PHC/CHC/SDH/DH Appointment of 5 nos. Adolescent Counselor for districts setting up Adolescent clinics Adolescent health sessions/clinics will be held in each Sub Centre/ PHC / CHC/SDH and DH with service delivery & referral support Risk reduction counseling for STI/RTI 78

79 NRHM STATE PROGRAMME IMPLEMENTATION PLAN During the monthly or weekly interactions through health sessions and clinics, counseling for preventing STI/RTI will be also be done. This will include single partner sex and use of condoms for safe sex. 2.2 ASHA/AWW to act as nodal persons at village level for identifying & referring adolescents in need of such services Training of AWW/ASHA in adolescent health issues All ASHAs and AWWs will be oriented on problems faced by adolescents, signs and symptoms of the problems and where to refer these cases. 2.3 Referrals to de-addiction centers for treating alcoholism/drug addiction Identification of de-addiction centers in the state/district The state / district will identify NGOs or other de-addiction centres in the state and through the health workers will refer the cases in need to these centres for treatment Circulate information on services provided at these centres and setup referral system The state/district will have an understanding with the de addiction centre on the process for referring patients to the de-addiction centres. Objective No.3: To increase awareness levels on adolescent health issues Strategies and Activities 3.1 Organizing Behavioral Change Communication campaigns on specific problems of adolescents IEC activities along with take-home print material to be organized in coordination with MSS, Youth club One of the monthly theme meetings with the MSS / CBOs will be related to adolescent health problems, signs and symptoms, treatment and referrals monthly health checkups under School Health Programme through PHC medical and paramedical staff School Health Programmes (Health Check up under MDM) As part of the School Health Programme, adolescents in schools will undergo health check ups thrice in a year. Some counseling related to common adolescent problems will also be given during these check ups. Children are the asset and future of the Nation. The progress of any country and state depends upon them for which they must remain healthy. In Bihar there are about 1.5 crore children of 6-14 years age reading in government primary & middle schools. The health check-up of these children are must atleast once in a year to detect any serious disease in the early stage, so that preventive and curative measures may be taken at the 79

80 NRHM STATE PROGRAMME IMPLEMENTATION PLAN earliest. For this objective in mind government has decided to do medical health check-up of children reading in government primary and middle schools. OBJECTIVE : Regular annual health check-up of Children registered in government primary and middle school. To detect any defect in progress of health and nutritional deficiencies. Early detection of serious illnesses and to refer them in the nearest specialized government health facilities. To develop good habit for better health and hygiene to remain healthy. To inculcate through the children habit to remain healthy among Family members and community. To improve quality of food supplied to children by adding micronutrients. Additionally Counseling sessions will be organized in Govt. Schools in collaboration with BSACS. Story lines and slogans will be published in text books of schools in collaboration with the Education Deptt. Reference Books on Health Issues and Healthy Life-Style will be published for School libraries. Health Camps will be organized for health check-ups for school children. Innovative strategies will be adopted to orient school children about healthy practices. Details annexed Orientation of VHSC on adolescent issues The MPWs will during their routine interactions with the VHSC members apprise them of the problems and issues related to adolescents and what to do for treatment and referrals. (Budgeted in RCH Training along with maternal health, Child health and Family Planning) Premarital counseling of adolescent girls on reproductive health issues at PHC/RH/SDH/DH This will be part of the adolescent health session/clinics which will be regularly conducted at sub centres, PHCs and also at youth clubs. 3.2 Dissemination of ARSH Guidelines and Trainings Organize dissemination of ARSH guidelines at State level Training of TOTs on ARSH Training of MOs, ANMs on ARSH Proposed Strategies and Activities for Operationalization of ARSH 1. ARSH service delivery through the public health system: 80

81 NRHM STATE PROGRAMME IMPLEMENTATION PLAN a. Actions are proposed at the level of sub-centre, PHC, CHC, district hospitals through routine OPDs. Separate arrangements should be done for male and female adolescents. b. Fixed day, fixed time approach could be adopted to deliver dedicated services to adolescents and newly married couples. A fixed day across the state, either once a month or twice a month can be declared for ARSH, and the information regarding the same should be properly disseminated in the community and properly displayed at the facilities. c. A separate ARSH Cell, comprising of ANM, LHV, Health Educators etc. (perhaps on a rotatory basis) can be established at these Cells. d. A separate ARSH Cell can be constituted at every CHCs and Referral Units, with one MO as its nodal officer (on call, sort of) and two counselors. 2. Interventions to operationalise ARSH a. Orientation of the service providers: Equipping the service providers with knowledge and skills is important. The core content of the orientation should be vulnerabilities of adolescents, need for services, and how to make existing services adolescent friendly. b. Environment building activities: this should include orienting broad range of gatekeepers, like district officials, panchayat members, women s group and civil society. Proper communication messages should be prepared for the same exercise. District, block and subblock level functionaries should be responsible for this. c. The MIS should at least capture information on teenage pregnancy, teenage institutional delivery and teenage prevention of STI. 5 Urban Health Urban health care has been found wanting for quite a number of years in view of fast urbanization leading to growth of slums and population as more emphasis is given in rural areas. Most of the Cities and Towns of Bihar have suffered due to lack of adequate primary health care delivery especially in the field of family planning and child health services. Objectives: 1. Improve delivery of timely and quality RCH services in urban areas of Bihar 2. Increase awareness about Maternal, Child health and Family Planning services in urban areas of the state At present, there are 12 Urban Health Centres (UHC) in the state which are non-functional. However, as per the GoI guidelines, there should be one UHC for 50,000 population (outpatient). The Urban Health Centres are required to provide services of Maternal Health, Child Health and Family Planning. The infrastructure condition of the Urban Health Centres is not up to the mark and requires some major renovation work. The 81

82 NRHM STATE PROGRAMME IMPLEMENTATION PLAN staff at each UHC should comprise of 1 Medical Officer (MO), 1 PHN/LHV, 2 ANMs, 1 Lab Assistant and 1 Staff clerk with computer skills. Objectives No. 1: Improve delivery of timely and quality RCH services in urban areas of Bihar Strategies and Activities 1.1 Identify health service providers of both public and private sectors (including NGOs) in urban areas and plan delivery of RCH services through them Mapping of Urban Slums and existing providers of RCH services of both public and private sectors has been completed Develop Micro-plans for each urban area for delivery of RCH services, both outreach and facility based. 1.2 Strengthen facilities of both public and private sectors in urban areas Establish partnerships with select private health clinics for delivery of facility-based RCH services e.g. institutional delivery, permanent methods of FP, curative MCH service, etc Collaborate with health facilities managed by large public sector undertakings such as Railways, ESIS, CGHS and Military to provide RCH services to general population from identified urban areas. 1.3 Strengthen outreach RCH services in urban areas through involvement of both public and private sector service providers Deliver outreach services planned under RCH through reinforced network of frontline health service providers (ANMs, LHVs) Expand outreach of RCH services by adoption of identified under-served or un-served urban areas by facility-based providers (e.g. adoption of a particular slum by a medical college or private health institute) Establish 20 Urban Health Centres on a rental basis under PPP in this financial year especially in districts with DHs having heavy patient load Objective No. 2: Increase awareness about Maternal, Child health and Family Planning services in urban areas of the state Strategies and Activities 2.1 Use Multiple channels for delivery of key RCH messages in urban areas Utililise various channels of mass media with extensive reach in urban areas such as TV, local cable networks, radio (particularly Vividh Bharti channels), cinema halls, billboards at strategic locations, etc to propagate messages related to key programme components of RCH Extensive use of print media such as newspapers (particularly local newspapers), journals and magazines for dissemination of key RCH messages. 82

83 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Broad inter-sectoral coordination to increase awareness and knowledge of key messages under the RCH programme Involve representatives from Urban Local Bodies (municipal corporations and municipalities), commercial associations, sports bodies, voluntary and religious organisations for intensive inter-personal communication and community-based awareness campaigns Use various channels of mass media for ensuring utilization of services of Urban Health Centres, private or Government 83

84 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Vulnerable Groups Health Camps in Maha-Dalit Tola Two camps shall be held in each Maha-Dalit tola where health check-up and counseling shall be done, followed by distribution of spectacles to reach out to the vulnerable sections of the Society Projected cost for larger districts Rs.500 x 30 districts x 100 tolas=15.00 lakhs Projected cost for smaller districts Rs.500 x 8 districts x 50 tolas=02.00 lakhs Projected cost for spectacles Rs.200 spectacles x 30 people x no. of villages 7. Tribal Health - Deleted 84

85 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Innovations 8.1 PNDT Act Implementation of Medical Termination of Pregnancy Act, 1971 and Pre-natal Diagnostic Techniques (prohibition) Act, In order to arrest the abhorrent & growing menace of illegal termination of pregnancies as well that of prenatal diagnostic test ascertaining sex-selection, the Medical Termination of Pregnancy Act, 1971 read with Regulations & Rules 2003 and the pre-natal Diagnostic Techniques (Prohibition of sex selection)act were formulated. The misuse of modern science & technology by preventing the birth of girl child by sex determination before birth & thereafter abortion is evident also from the fact that, there has been a decline in sex ratio despite the existing laws. The Apex court has observed that:- We may state that there is total slackness by the Administration in implementing the Act. Some learned counsel pointed out that even though the Genetic Counselling Centre, Genetic Laboratories or Genetic Clinics are not registered, no action is taken as provided under Section 23 of the Act, but only a warning issued. In our view, those Centres which are not registered are required to be prosecuted by the Authorities under the provision of the Act and there is no question of issue of warning and to permit them to continue their illegal activities.the apex court accordingly directed the central as well as state Governments to implement the PNDT Act. In Bihar too the concerned authorities have been directed to implement the provisions of the both the Acts forcefully. Following actions have been taken and planned in this regard. A. State, District and block level workshops on PNDT has been planned. B. Create public awareness against the practice of prenatal determination of sex and female foeticide through advertisement in the print and electronic media by hoarding and other appropriate means C. A district wise task force to carry out surveys of clinics and take appropriate action in case of non registration or non compliance of the statutory provisions. Appropriate authorities are not only empowered to take criminal action but to search and sieze documents, records, objects etc. D. Beti Bachao Abhiyaan As female foeticide is a concern both in rural and urban areas, this year, Beti Bachao Abhiyan will be launched to sensitize people against this heinous practice. Massive awareness drive with the support of College students, women s organizations and other voluntary associations is planned this year. Human Chain, rallies, seminars, workshops and press conferences will be organized for the same. 85

86 NRHM STATE PROGRAMME IMPLEMENTATION PLAN MUSKAAN Programme The state has started a New Programme called MUSKAAN Programme to track pregnant women and New Born Child. Under this programme ASHA, AWW and ANMs jointly track the pregnant mothers and New Born Child. This programme launch in October Under this programme ASHA, AWW and ANM will hold meeting with Mahila Mandals in AWWCs. The main objective is to cover ANC coverage and Immunization. A Data Centre also placed in all the 533 PHCs to monitor this programme. After the introduction of this programme it has been seen that the coverage of ANC and Immunization increased. The State wants to continue this programme and requested the GoI to fund the programme.infrastructure is one of the important components for upgradation of facility to deliver the quality service. In the PIP it has been proposed a number of infrastructural corrections for upgrading the facilities. These are 1. As per RCH Programme operationalisation of 76 First Referral Unit to provide emergency obstetric and newborn care 24 hrs. a day / 7 days a week. The aim is to ensure atleast two operational FRUs per district. There are 76 hospitals in the State which have been identified to be upgraded as FRUs. The main focus initially to provide remedial measures absolutely required to ensure proper functioning of the facility. Another important aims to provide appropriate specialist in each of these 76 Hospitals. It is proposed to upgrade 76 Health facilities to FRUs in Unit cost of construction at the rate of average of 2 Crores as per RCH norm. The above hospital will be well equipped with OT, electric supply, water supply, toilet, telephone services, sewerage system and disposal system for hospital infectious waste. 2. Anesthetist will be Rs.1000 per case for EmOC. A provision for cases included in the PIP. 3. Neonatal Intensive care unit will be setup in 13 districts at the district hospitals. Each Neonatal unit will cost Rs. 39,36,000/- 1 Civil & Electrical Works: Rs. 6,86,000/- 2 Equipments for individual patient Care: Rs. 25,00,000/- 3 General Equipments: Rs. 2,50,000/- 4 Side Lab Equipments: Rs. 2,00,000/- 5 Equipments for disinfection Rs. 1,50,000/- 6 Data Collection & Recording Rs. 1,50,000/- Total Rs. 39,36,000/- 86

87 NRHM STATE PROGRAMME IMPLEMENTATION PLAN The costs also include provision of equipments at these hospitals either as per IPHS or as required. 4. Newborn Care Unit will be set up in all the 533 Rs. 1,57,400/-. This includes minor civil work and purchase of Equipments. 87

88 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Strengthening of SIHFW 9.1 Fast-Track Training Cell in SIHFW It is also proposed in this budget to have a full time training experts/coordinator to spearhead various trainings under NRHM. Unless a dedicated Fast-Track Training cell is constituted at state level (at SIHFW), it will be very difficult to improve the quality of trainings and linkage training with performance. As training constitutes one of the largest single components of NRHM Budget allocation, this investment in creating the Fast-Track Training cell at the State level will be very cost effective intervention. Looking at the magnitude of the work under trainings, it is being proposed that under the training co-coordinator, there should be two training sub-coordinators, looking after 50% districts each. Additionally, one clerical staff is suggested. This training cell should be at the SIHFW and will eventually further strengthening SIHFW. Budget: (1.) One Training expert/coordinator = Monthly salary Rs. 30,000/- x 12 months = Rs. 3,60,000/- per annum (2.) Two Training sub-coordinators = Monthly salary Rs. 25,000/- x 2 individuals x 12 months = Rs. 6,00,000/- per annum (3.) One Clerk = Monthly salary Rs. 10,000/- x 12 months =Rs. 1,20,000/- per annum (4.) Office expenses = Monthly Rs. 5000/- x 12 months =Rs. 60,000/- per annum Total Annual Budget = Rs. 3,60,000/- + Rs. 6,00,000/- + Rs. 1,20,000/- + 60,000/- = Rs. 11,40,000/- 9.2 Filling Vacant Position at SIHFW/Hiring Consultant at SIHFW AT the same time, the remaining vacancies of SIHFW can be filled. In order to fast-track the appointments of these faculties and support staff, the appointments can happen on a contractual basis such that trainings can be better organized and their quality improved. As part of strengthening SIHFW, a monitoring section needs to be created at SIHFW to use data on various aspects of training and to improve the quality of training, to make them need based, to assess if skill enhancement is happening, if program efficiency and effectiveness are increasing or if the trained staff are being rationally posted etc. Budget (1.) 10 consultant/faculties = Monthly Rs. 30,000/- x 10 individuals x 12 months = Rs. 36,00,000/- per annum (2.) 4 Clerical Staff = Monthly salary Rs. 10,000/- x 4 individuals x 12 months = Rs.4,80,000/- per annum (3.) Office expenses = Monthly expenses Rs. 15,000/- x 12 months = Rs. 1,80,000/- per annum (4.) Monitoring Cell (additional expenses for regular reporting within the system = Rs. 5,000,00/- per annum Total annual budget= Rs. 47,60,000/- per annum 88

89 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Infrastructure and Human Resource Infrastructure is one of the important components for upgradation of facility to deliver the quality service. In the PIP it has been proposed a number of infrastructural corrections for upgrading the facilities. These are 1. As per RCH Programme operationalisation of 76 First Referral Unit to provide emergency obstetric and newborn care 24 hrs. a day / 7 days a week. The aim is to ensure atleast two operational FRUs per district. There are 76 hospitals in the State which have been identified to be upgraded as FRUs. The main focus initially to provide remedial measures absolutely required to ensure proper functioning of the facility. Another important aims to provide appropriate specialist in each of these 76 Hospitals. It is proposed to upgrade 76 Health facilities to FRUs in Unit cost of construction at the rate of average of 2 crores as per RCH norm. The above hospital will be well equipped with OT, electric supply, water supply, toilet, telephone services, sewerage system and disposal system for hospital infectious waste. 2. Anesthetist will be Rs.1000 per case for EmOC. A provision for cases included in the PIP. Similarly Gynecologists and Pediatrician will also be hired as per requirement. 3. For follow up and monitoring RCH Coordinators will be hired at Commissionaire level and at SIHFW. 4. Newborn Care Unit will be set up in all the 533 PHCs and DH. This includes minor civil work and purchase of Equipments. 5. Setting up of Intensive Care Unit in all the District Hospitals An Intensive Care Unit (ICU) is a specialized department in a hospital that provides intensive care medicine. Many hospitals also have designated intensive care areas for certain specialties of medicine, as dictated by the needs and available resources of each hospital. The naming is not rigidly standardized. In most of the districts do not have Intensive Care Unit in any set up whether it is Private or Public. The patients have to shift either to the nearest medical colleges or to Patna for Intensive Care. In the process of transfer most of time it has been seen that patient die on transportation. The distance to the nearest ICU set up is long and most precious time waste for treatment of the patient. Setting up of Intensive Care Unit will help to avail patient the facility in all districts so that accessibility for intensive care can be addressed. The state has proposed to establish 4 bedded ICU in all the 36 District Hospitals. 89

90 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Institutional Strengthening For HRD, training of 10 regular Government doctors is being proposed in Public Health for improving their administrative skills. Multi - Skilled Specialist DNB (Family Physician) 3 years course for 20 service doctors from CHCs SHSB proposes to initiate DNB (Family Physician) 3 years course in select district hospitals. 20 Service doctors preferably from CHCs who want to undergo DNB courses run by National Board of Examinations shall be selected based on competitive examination. The course will run via distance education mode for one and half years followed by another 18 months for hands on experience. There is an option to complete the course in two parts. After 3 years training, these doctors shall be posted in the CHCs and referral hospitals to provide caesarean and anesthetist services. The permission of National Board of examination to commence the DNB Family Medicine course may have to be obtained. To select the suitable young doctors for the course who will give an undertaking to work in the government health system for 10 years in CHC upwards. Further more it is proposed that for Multi skilling of Doctors they can be sent to hospitals like Safdarjung etc in New Delhi for continuing medical education. Sub-centre rent shall be provided for 20% of the HSCs operational. Quality Assurance The state has Quality Assurance Committee for Sterilisation, Birth Control, Maternity Services, Child Survival Services, Immunization, and Case Management of Diseases in the district Quality of health care and reproductive health services consists of the proper performance (according to standards) of interventions that are known to be safe, that are affordable to the society in question and have the ability to produce an impact on client attraction & satisfaction, belief, population stabilization, inclination towards the continuation of method(s) etc. As per the guidelines lay down by the Honorable Supreme Court of India. The State Government is in the process of constituting Quality Assurance Committees (QACs) at the State and District levels to ensure that the standards for female and male sterilization and other health services are being 90

91 NRHM STATE PROGRAMME IMPLEMENTATION PLAN followed in respect of preoperative measures, operational facilities and post-operative follow-ups and other ethical diagnostic and treatment protocols. The terms of reference for the State / District QAC are as follows: The District QAC shall conduct medical audit of all deaths related to sterilization, maternity deaths and deaths arising out of suspected medical negligence and send reports to the State QAC office. The State QAC shall deliberate on the report. Shall collect information on all hospitalization cases related to complications following sterilization as well as sterilization failure and maternity deaths and deaths arising out of suspected medical negligence. Shall process all cases of failure, complications requiring hospitalization, and deaths following sterilization for payment of compensation and will pursue these cases with the insurance company or otherwise. Shall review all static institutions i.e. Government and accredited private/ngos and selected camps providing sterilization services and providing maternity, Child survival and other medical care for quality of care as per the standards laid down, and recommend remedial action for institutions not adhering to the standards. A minimum of three members shall constitute the quorum. Presently the QAC also looking after the quality of all the trainings done under RCH. Monitoring of delivery of critical services & NRHM trainings (IMNCI, SBA, Immunization, EmOC, LSAS, NSU, BCC for promoting Breastfeeding, Minilap, MVA, ASHA). In Bihar state, there is a quality assurance cell housed in the State Institute of Health & Family Welfare. The key responsibility of this cell has been to coordinate with multiple stakeholders and keep a track on the trainings happening in the state. There are members from the SHSB, SIHFW, Faculty of various medical colleges, retired medical college faculty members, and health officials, members from the professional organizations, and officials from the development partners are on its panel. The monitoring visits are proposed to be undertaken by the members to different districts and sub districts for initial handholding and to ensure quality training. As a part of this, standard monitoring formats available with the state are to be used. The experience till now has been that many of the doctor members are reluctant to undertake field visits. This is more so when the 91

92 NRHM STATE PROGRAMME IMPLEMENTATION PLAN trainings happen in such districts from where same day return is not feasible. The key underlining reason for this has been found out to be the implementation of RCH I TA and DA norms. As it is well known, these norms were defined more than ten years ago. The different monitors undertaking field visits tend to spend from their pockets for the monitoring visits. In the last ten years, the cost of living has gone up substantially and thus it is proposed to review the financial norms for the disbursement of TA and DA while on official duty. After discussions with the stakeholders, it is suggested that the following norms may be adopted by the SHSB/GoB pending more clear guidelines from the GoI. S No Category Description Honorarium Travel Cost per monitoring day 1. State/Division Government officials and doctors With same day return 2. State/Division With night stay Government officials involved and doctors 3. Medical college With same day faculty/retired return professionals 4. Medical college With night stay faculty/retired involved professionals 5. Free lance professionals With same day (by invitation) return 6. Free lance professionals With night stay (by invitation) involved 800 per day AC Scorpio/Travera (@Rs 2000 per day) per AC Scorpio/Travera 2750 night (@Rs 2000 per day) 800 per day AC Scorpio/Travera 2800 (@Rs 2000 per day) 1500 per night AC Scorpio/Travera (@Rs 2000 per day) per day AC Scorpio/Travera 3000 (@Rs 2000 per day) 2000 per AC Scorpio/Travera 3000 night (@Rs 2000 per day) In a month, on an average, 150 monitoring days would be involved for the training monitoring. 92

93 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Training Successful Implementation of any programme depends on the capacity building of the personnel engaged. In RCH II also,human resource base will be created by enhancing the capacities through training.the sensitization of health personnel towards various RCH interventions is one of the major focus of the capacity building initiatives under RCH - II. Various trainings will be provided to State and district level managers, medical officers, nursing staff, ANMs, AWWs, ASHA and others. The training will be provided at the State Institute of H & FW, Regional training Institutes, ANM training schools, District hospital,phcs and also in Railways, ESI,private sector hospitals where there is enough case load for a proper training. Some of the trainings will be contracted out to the NGOs and private players also, so that any limitation of State infrastructure is overcome easily. [Available in detail in NGO chapter]. As BCC will be a major training aspect, it has been dealt in a separate chapter. All the technical training programmes will ensure that.along with the theoretical inputs, proper practical exposure is also provided. Apart from this each training programme will stress on the managerial aspect and on the communication with the clients. The TOTs will ensure that the trainers not only master the contents of the training topic but also aquire skills as teachers/trainers or facilitators and motivators.the state official, trainers, professionals and functionaries who excel in implementing training programmes will be recognized through awards and citations. A rational selection criterion will be used to select the trainees for the trainings where the no. of trainees are limited. Moreover promotion and posting policy will be linked to training and the functionary will have to undergo training to avail the promotion. There will be provision for proper rational posting so that the personnel trained, utilize their training in their day to day work. A feedback system will be developed to assess the quality of the training. From time to time, presence of state/regional observers will be ensured to assess the quality of district level trainings and workshops. Detailed Records and data about personnel undergone training should be available with all concerned at all levels. SIHFW will coordinate and monitor this with the help of district Data Officers 93

94 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Training Institutes SIHFW The State Institute of Health and Family Welfare (SIHFW) is the premier training institute in the state of Bihar. SIHFW needs to be further strengthened as the apex institute in the state of Bihar for co-ordination and implementation of all capacity building initiatives under RCH II program. SIHFW has the required infrastructure and facilities, which need to be reinforced further so that it can conduct the various training programs on continuous basis. As the nodal agency for training activities in the State, SIHFW will have following major tasks: To develop annual training calendars based on the district action plans in close co-ordination with RHFWTCs and ANMTCs. To conduct clinical and non-clinical training programs for medical officers. To support RHFWTCs and ANMTCs to conduct timely induction and refresher training programs for ANMs and LHVs. To facilitate ongoing assessment of training needs of functionaries at all levels Co-ordinate and implement integrated skill development and specialized skill development training programs. Conducting TOTs with RHFWTCs and ANMTCs To co-ordinate with SHSB for need based hiring of resource persons for the training programs In addition, adequate provisions will be made for the institute to hire need based services of electricians, plumbers, carpenters, etc. on contract basis. RHFWTCs There are Eight Regional Health and Family Welfare Training Centers (RHFWTCs) in the state Three for male and five for female health staff. All the sanctioned posts of trainers at these institutes are filled. However, functioning of all RHFWTCs is severely affected due to lack of proper infrastructure. The State proposes to use the facility Survey to do a detailed assessment of the needs of these training centers. Based on the report of the facility survey, adequate resources will be provided to all RHFWTCs to upgrade their respective infrastructure and maintenance support. Location of the RHFWTCs in the State: RFWTC Male Patna (non residential) Muzaffarpur Bhagalpur RFWTC Female Patna Gaya Muzaffarpur Saran Purnea 94

95 NRHM STATE PROGRAMME IMPLEMENTATION PLAN The Facility Survey will also assess the need for new Regional Health and Family Welfare Training Centers (RHFWTCs) in the state. ANMTCs There are 22 ANMTCs in Bihar; the training capacity of these institutes varies from 60 to 90 participants per batch. Most of these training centers were functioning sub-optiminaly in absence of proper infrastructure and other essential support but after the facility survey was completed with the help of UNICEF, GoB has been able to restart 20 ANM schools. Based on the report of the facility survey, adequate resources will be provided for all ANMTCs to upgrade their respective infrastructure and maintenance support. Further status of faculty positions/trainers and their requirements at ANMTCs would be assessed in course of facility survey and then adequate provisions will be made to address their needs. Key Training Activities The wide range of training activities to be conducted under RCH II program by various agencies and training institutes is outlined below. The trainings not mentioned in training plan would be taken up with the help of development partners.adequate changes will be made to make all the trainings as per GOI guidelines. Maternal Health Provide comprehensive skill up gradation training to frontline ANC service providers (ANMs and LHVs) to ensure delivery of quality ANC services Conduct training to build capacity of LHVs for effective supervision and monitoring. Train Aaganwadi Workers and PRI members would help in identification and motivation of pregnant women for healthy antenatal care practices and for utilization of ANC services. Impart refresher training to Gynecologists and Obstetricians on safe delivery practices and referral procedures Train all ANMs, LHVs, and Nurses in identification of danger signs during delivery, referral procedures and PNC services. Train NGOs, Aaganwadi Workers and PRI members in raising community awareness and knowledge about importance of institutional delivery, safe delivery practices at home, referral and PNC services. Child Health Train frontline Health workers, Aaganwadi Workers, PRIs, local NGOs and CBOs in correct breastfeeding and complementary feeding practices 95

96 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Provide comprehensive skill up gradation training to immunization service providers (LHVs/ANMs), particularly in injection safety, safe disposal of wastes and management of adverse effects. Conduct training to build capacity of Medical Officers, MOICs and DIOs for effective management, supervision and monitoring of immunization services Train Cold Chain handlers for proper maintenance and upkeep of Cold Chain equipment Train Aaganwadi Workers and PRI members in identification of children eligible for immunisation, in motivation of caregivers to avail immunisation services and in follow-up of dropouts Identify key persons to join IMNCI master training pool Train members of master trainer pool in national level course Recruit and train district trainers (using state master trainer pool) Train all health and ICDS staff in a phased manner Train frontline health workers and Aaganwadi workers in health education techniques to build community capacity for early recognition of childhood illnesses, home-based care and careseeking Family Planning Train partners such as NGO and civil society networks, religious organisations and leaders, PRIs, ICDS, Education, General Administration, Corporate Associations and Professional bodies (IAP, IMA) in promotion of Family Planning, at state, district and block levels (Re) train frontline health workers, Aaganwadi Workers and PRIs as motivators and counselors for family planning services through IPC and counseling Impart technical skill-enhancement training to existing and newly appointed frontline health workers on provision of various spacing (Oral contraceptive, condom, IUD insertion, emergency contraception) and terminal (female and male sterilization) methods of Family Planning. Train doctors in various reversible and terminal FP procedures (MTP, Minilap, NSV and IUD). Adolescent Health Conduct annual orientation and training of all health service providers on adolescent health needs at state, district and block levels Train/sensitize community leaders, school teachers, PRIs, NGO networks, Anganwadi Workers, towards the health needs of the adolescents 96

97 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Train NGO and civil society networks, religious organisations and leaders, PRI members and teachers in promotion of safe reproductive health practices and family planning among adolescents. (Re) train frontline health workers and schoolteachers as motivators and counsellors for safe reproductive health practices and family planning among adolescents through IPC and counseling (Re) train frontline health workers to provide RTI/STI curative services for adolescents 97

98 NRHM STATE PROGRAMME IMPLEMENTATION PLAN IEC/BCC The Annual Action Plan for IEC/BCC has been prepared in the light of the number of initiatives taken by Dept. of Health, GoB, and State Health Society, Bihar, in the implementation of NRHM. It follows in essence, form and content, the National Communication Strategy. The National PIP for RCH and instructions and guidelines received from GoI and GoB from time to time has also been kept in mind. The selection and implementation of set of behavior change have been adopted with a view to improve a wide range of family care-giving and care-seeking practices, and enhance supportive environments for improved household health practices at community, institutional and policy level. The IEC/BCC Programme will focus on building an environment favoring health seeking practices, preferably through low cost and no cost interventions, especially for the disadvantaged and the marginalized sections of society. This outlook will set the tone and tenor of the mobilization process for effectuating a positive change in the existing socio-cultural mores, systems and processes. PUBLICITY: Print & Electronic Media Materials will be developed and publicized on different issues eg. Dial 102 (Ambulance Service), Dial 1911 (Doctor s Consultancy), ICU Service, JBSY, Promotion of Breast Feeding, Family Planning including Non Scalpel Vasectomy, Immunization, Urban Health, Adolescent and Sexual Reproductive Health, PNDT Act, Role of ASHA under NRHM, Role of Mamta, Importance of Super Speciality Hospitals and various PPP activities initiated by SHSB etc., through various print and electronic media. Health Materials will be publicized on Bihar Text Book & Different types of Certificates issued by Govt. of Bihar and others. Outdoor Media - Hoardings, Glow Signs, Laminated Board, Flex Banners, posters, etc., on issues related to RCH and NRHM will be put up at vantage points will be displayed at important locations like at District Offices, Block Offices, PHCs, Haat points, Bus Stands, Railway stations, etc. Monthly magazine brought out by the I & P.R. Dept. is being again sponsored by SHSB. Space has been allocated in the magazine for publicizing about health related programmes. Exhibitions, Melas, Nukkad Natak functions will be organized in each district from time to time to expand reach of different programmes. Folk Media will also be used as a tool for publicity. Health related Posters/Banners will be displayed on Mail Van. At the District/State level - Advocacy Programmes, workshops seminars, press conferences, etc., will be organised for different target groups including Politicians, Media Personnel, Bureaucrats, NGOs, School Children, etc. Mobility Support: Vehicles will be hired on rent on a monthly basis at the State to provide mobility support to the IEC component. 98

99 NRHM STATE PROGRAMME IMPLEMENTATION PLAN BCC/IEC Bihar is a state with high cultural heterogeneity. It has been a challenging area to address for the issues of behaviour change in a heterogeneous population. Even if the language of communication in Bihar is Hindi/maithili/maghahi/angika/bhojpuri etc the use of words and styles differs from area to area. It indicates that no common strategy is going to work for the entire state as different areas have different dialects of communication. Use of BCC has been one of the key components in any health sector strategy. It is essential to modify risk prone life styles and practices to promote healthier lifestyles and practices. In past the state have had many major rounds of social mobilizations and awareness generation which have helped to take key health messages to even the most interior of the rural areas. But still there is a lot of space for the improvement. High prevalence rate of malaria, kalazar. TB, filaria and sickle cell anaemia indicates the magnitude of the problem in the state which can be reduced through behavior change approach. All these need area specific strategies for the positive change like to motivate the people through behavior change communication for the use of bed nets avoid water logging in and around habitation area and collection of garbage in a common place away from the habitation. The approach would be adopted to impart attention precise to the existing problems district wise focused manner. BCC strategy Development of a service oriented BCC strategy should be based on an assessment of the current status of knowledge, attitudes, beliefs and practices regarding issues concerned with MMR, IMR, TFR and ARSH; and factors likely to influence necessary change in behaviour. Creation of awareness of key aspects such as breast feeding and PNDT act is particularly important. Based on evidence, the strategy should aim to determine appropriate combination of messages and media and a mechanism for assessing impact at appropriate stages. The institutional arrangement including role of state and district and strengthening capacities for BCC is again important. Behaviour Change Communication: The Annual Action Plan for for Behaviour Change Communication has been prepared in the light of the health priorities of the Government of Bihar and the programmes it is committed to implement under the NRHM. It draws its approach from the national communication strategy as well as NRHM and RCH guidelines. 99

100 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Despite its third year of operation, the NRHM in the state has been implemented without a comprehensive communication strategy, which is largely due to lack of skilled human resource and professionals within the State Health Society and Health department to carry out this specialized function of strategic communication. The action plan therefore proposes certain initiatives that focus on institutional strengthening of the State Health Society with human resource building consisting of communication professionals. It also lays emphasis on capacity building of the Programme Managers and the District Managers in strategic communication in order to ensure that communication activities do not merely remain adhoc interventions but are based on research, evidence; are local / region specific and are built on a strong monitoring & evaluation system. The strategic approach will also ensure that different elements of communication and channels are employed in a manner they complement and supplement one another leading to greater impact. The interventions will focus on : Improving family care-giving and care-seeking practices Enhance supportive environment for improved household practices at community, institution and policy level Promote health seeking practices through low cost and no cost interventions Pay attention to disadvantaged and marginalized sections of the society Key Activities for the Year Establishment of BCC Cell in State Health Society In order to effectively manage the communication interventions for different programme under NRHM, a teams of experts and professionals need to be built. Under the Mission Director of NRHM i.e. The Executive Director, State Health Society, the following structure is proposed to be established. 100

101 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Executive Director State Health Society BCC Cell BCC Coordinator Training Coordinator Field Coordinator M & E Coordinator Designer / DTP Assistant IEC Logistics Assistant MIS Assistant State Health Society will set up the BCC Cell with development of terms of reference, job descriptions, identification and recruitment of suitable personnel with required skills and expertise as well their orientation. The BCC Cell under the leadership and over all direction of the Executive Director, State Health Society, will then be responsible to manage NRHM s communication activities in the state. 101

102 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Capacity Building of Programme Managers & District Managers Communication understanding and sensitivity is essential before any attempt to initiate activities to achieve goals of BCC under NRHM. Since this discipline is becoming more and more research and evidenced based, it is necessary for those to understand the concept, tools and advance techniques, who are supposed to undertake and supervise these activities in the state. It is a well recognized fact that accomplishment of NRHM goals largely depends upon quality of BCC inputs and its impact on behaviour and social change. To build the capacities of senior managers and mid-level managers of the health department and that of the State Health Society, a training workshop will be organiesd. Inputs from tools employed during capacity assessment of State Health Society and specific need assessment for this training will feed into the design of the training workshop. The capacity assessment exercise will aim to find : individual capacity of officials of SHS to carry out / implement state wide IEC / BCC activitiesexperience & skill capacity in designing and developing appropriate material & programme training skill for the use of IEC / BCC material capacity in communication monitoring- dissemination and tracking of progress capacity for storage and appropriate distribution IEC / BCC material Besides this, it will contain topics such as Understanding of communication as a process Multistage thinking Frame work and elements of communication research Designing a communication campaign Elements of an effective communication plan Channels and tools for communicating the message Multi channel approach Skills to use communication material Communication monitoring Evaluation All these topics will be dealt in the light of new research and thinking in the area of development communication. 3. Development of Health Communication Strategy The health communication strategy for the state will be developed through a participatory process involving experts, programme managers and government officers and will be consistent to the overall programme 102

103 NRHM STATE PROGRAMME IMPLEMENTATION PLAN strategy for NRHM and RCH. It will aim to reposition different programmes and services under the NRHM in a health framework -that is, offering good health as the reward for families leading to other economic and social benefits. The communication strategy will attempt to cover the following : Review the current status of NRHM programmes in the state Identify potential communication strategies Select the most appropriate approach Identify primary, secondary and tertiary audience segments Introduce the action plan with audience-media-message framework from which will evolve the communication plan for every programme The strength of any communication lies in it being is contextual and specific. It is essential to formulate a state specific communication strategy to reach to the masse with right kind of messages and through appropriate channels. Bihar is socially and economically backward but culturally very rich. It has many kinds of festivals associated with agriculture seasons, melas, huge religious congregations, community gathering etc which provide a unique opportunity to disseminate messages. Can this cultural and traditional richness become central theme of proposed communication strategy of Bihar? These are kind of questions for which experts will brainstorm. SHSB will lead the process of communication strategy development with technical inputs as well as formations of core groups of national and state level experts for development of Bihar specific communication strategy. SHSB will work in carrying out a comprehensive formative research and to pilot some concepts in the identified programme areas that will help in designing the strategy. This research will include : review of existing state communication plan, if any, social and cultural norms, practices & customs, opportunities for entertainments and festivals, occupation-livelihood, daily life style socio-economic indicators available and popular means of communication. The core group will provide strategic communication recommendations and guidelines. Broadly out come of this strategy development initiative will be Strategic Communication positioning for the state of Bihar Communication goals of the state Means to achieve communication goals - resources SHS's preparedness to accomplish these goals - infrastructure, allocations and capacities This communication strategy will help the state health planners to Increase impact of communication drives / campaigns initiated by the state 103

104 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Use time, people and resources more efficiently Exploit opportunities - use of cultural and traditional richness of Bihar Prevent potential problems 4. Communication Plans for Different Programmes under NRHM While the institutional strengthening and communication strategy development process will be carried out, communication plans for different programmes under NRHM will be prepared and implemented under the PIP with technical support from different internal / national agencies and partners. Broadly, the multimedia communication around the above issues will follow the following approach : The state and district health communication plans for different programmes / issues will be prepared by the State Health Society. The communication plan will have following components : Identification of issues to be communicated - NRHM's objectives Identification and planning regarding communication channels guided by the state communication strategy Capacity building of service providers- IPC, skills to use material and issues Distribution and dissemination plan of communication material Monitoring and evaluation mechanisms SHSB will work in the development of communication plans and materials for various programmes covered under NRHM Part A, B and C of the SPIP. Inter Personal Communication, counseling by trained functionaries supported with various social mobilization and mass media activities will be built into communication plan for each programme under NRHM. 5. Skill Building of Frontline Functionaries Inter Personal Communication being the core element of the communication package and the lead medium, it is imperative to build the skills of frontline functionaries who are in direct interface with the communities at household and / or facility level. SHSB will create a pool of trainers at State, District and Block levels on : Use of Interpersonal Communication and counseling techniques to promote health seeking behaviors in the context of issues identified under RCH II. Appropriate and effective use of communication tools and materials 104

105 NRHM STATE PROGRAMME IMPLEMENTATION PLAN In order to build the skills of service providers around a number of issues, State Health Society will develop and use a training module based on Facts for Life (FFL) framework. A detailed training and monitoring plan using cascade approach and also SATCOM training technology (on pilot basis) will be developed and implemented. 6. Institutional Strengthening of IEC Bureau In order to mainstream strategic communication in all health programmes, revival and strengthening of IEC Bureau as the nodal body for implementation of all health communication is necessary. State Health department will review the current status of the Bureau and prepare an action plan plug the gaps in terms of human resource as well as directives and operational guidelines. This will serve a long term objective of sustained communication interventions as against the campaign mode of communication activities. A well planned IEC/BCC strategy and implementation framework is being placed and District Level IEC plans is being prepared. This year our focus was to make programmes based on this. The basic constraint here was to reinforce the need to understand the importance of IEC/BCC planning for local specific and outcome based BCC programmes. The state lacks a rigorous planning unit that conceptualizes and strategizes the programmes and an implementing team that realizes these programmes to the expected levels. We are planning for adding this as part of this PIP.Currently, the key strategy adopted by the state is folk art based on Kalajathas, wall writings, printed posters and handouts, TV/Radio interventions etc, some innovative strategies were adopted. It has been found that the current state level centralisation of this needs to be shifted to local level strategies, for which a policy has been formulated. This year, we are also planning to have specific focus on IEC areas for each month. Objectives of Behaviour Change Communication: Empowering the family and individuals to take health related decisions based on information and analysis Motivating the community to play a proactive role in improving their health status Effective greater utilization of health services through an improved public understanding of health care Mainstreaming gender and equity and strengthening governance through BCC strategy Creating competencies and enabling environment to assist with the above objectives Key strategy and activities for Behavior Change Communication Developing IEC materials and designing campaigns for area specific and different age groups- by social, linguistic and ethnic characteristic Distributing BCC kit (flip chart, flash cards, resource book on local food, 105

106 NRHM STATE PROGRAMME IMPLEMENTATION PLAN complimentary feeding decision chart, films etc) to the Mitanins and building their capacity through training for its proper and effective use. Key areas on RCH behavior The BCC/IEC cell will be set up at the directorate. To establish BCC/IEC cell will need to have necessary equipments like computers with adequate software back up fordesigning, printers, printing materials, stationeries and furniture etc. Strengthening of the BCC/IEC cell will be done by in sourcing technical experts (3 technical experts) of the subject like nutrition, communication, medical doctors, graphic artist and designersfor the effective designing of the communication strategies etc. The function of the BCC cell would be To design the behaviour matrix- communication strategies and media materials in order to ensure in-house production. The in-house materials production (films, radio programs, posters, kalajattha, etc) this will serve as reference materials on health and will also be used by other department for IEC. The cell has to make operational framework for BCC. It will work in coordination with the other relevant departments by incorporating the ideas and components relevant to the context of the subject. Intersectoral coordination for BCC on common intervention with W&CD, PHED, Education, Health, SCERT, Unicef, CGSACS Doordarshan etc 94 Major emphasis would be given on awareness generation on behaviour change. The action planned for this is to use combination of mediums for the reach and penetration of the messages. Radio would be used as a strategy at the district level for the penetration of the messages and for the dissemination of the district specific messages Comprehensive approach shall be taken up to address the health related problems like imparting life skill education to the adolescent groups, distributing BCC kit to the ASHAs, using combinations of mediums for the dissemination of the messages. Advertising of different programmes of NRHM in different types of certificates issued by BDO/CO and Block Informatics Centre established by Rural Development Department, Govt. of Bihar Under the Rural Development Department, GoB in all the 533 blocks, Block Informatic Centres have been established whose implementation and maintenance has been given to an outsourced agency under PPP for 3 years. Major work of these centres is generation of various certificates to be issued by CO/BDO and SDO. Various certificates to be issued are Caste certificate, Income Certificate, OBC certificate, Birth and Death certificate, LPC certificate, Character certificate, Residential proof certificate etc. Altogether in a day yearly 60,000 certificates are issued, that means lakh in a month and about 2.00 crore per annum. These certificates can be a very good medium of advertisement as the certificates are obtained by people belonging to different status and are preserved properly for a long period of time. The certificates shall have the certificates on the front side however back side will be blank. The concerned Department has also authorized the Outsourced agency to generate advertisements for printing on the back side of the certificate. 106

107 NRHM STATE PROGRAMME IMPLEMENTATION PLAN The Proposal The SHS aims to utilize this opportunity to advertise NRHM s various programmes on these certificates through which information and benefits of the programmes can reach to nearly 1.5 to 2.00 crore families. These advertisements shall exist on these certificates for ever and can act as an effective medium for Government s advocacy. Budget Expense Estimate: Coloured advertisement per Certificate cost -Rs.1,50 p and for black and white advertisement Rs.1.00 p. For advertisements on approximate 2.00 crore certificates, anticipated expenditure would be Rs.3.00 crores. 107

108 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Procurement of Equipments/Instruments and Drugs/Supplies Details annexed Strengthening Life Saving Skills for Anesthesia (LSAS) Part A Procuring equipment for the Anesthesia departments in six medical colleges In Bihar state, LSAS training is being undertaken in all six Government Medical Colleges for the last two years. A total of 55 doctors have been trained in LSAS till now. All the six medical colleges in the state are imparting this training. Monitoring visits to all Medical Colleges has been undertaken by UNICEF Health Officer Dr O P Kansal, Dr Himanshu Bhushan from GoI and Dr A K Tiwari, Programme officer for Anesthesia trainings, in the last one year. An exposure visit was also organized to Gujarat comprising State Programme Officer, all Heads of the departments of Anesthesiology and Health officer, UNICEF in April, In the last one year, there have been many formal and informal discussions with the heads of the Anesthesia departments of all the medical colleges. With the technology update taking place all around, the anesthesia departments in the state need strengthening of the basic infrastructure. The departmental heads had submitted a proposal to this effect about a year ago. It is proposed to spend Rs. Nine crore (@Rs One and half crore for each of these colleges) to help them procure the equipment. This in terms will help the trainees of LSAS training grasp the skills as per the current technology. A simple indicative list of the equipment required is given in the table below. S No Equipment Requirement 1 Anesthesia workstation For all colleges 2 Boyle s apparatus latest 3 sets for each model college 3 Fibreoptic nasopharyngolarryngoscope One for each college 4 Anesthesia emergency One for each resuscitation kit college 5 Ethylene Oxide sterlizer One for each college It is worth mentioning that the funds to the state medical colleges would be released as per the need and therefore fresh proposals would be invited from them after the GoI approval. Additional Suggested Action Points: 1. Third party review of Anesthesia trainings: It is requested to get a review, of the LSAS training process in Bihar, conducted by Anesthesiologists of National repute already associated with GoI. Based on the assessment, the State Health Society, Bihar can be requested to fill in the gaps. 2. Reorientation of Anesthesia trainers: There are two to three Anesthesiologists in each medical college who were trained in LSAS training about two years ago. A reorientation of all these trainers, for two days in Patna by GoI identified trainers, can be helpful in adhering to the standard training protocols and thus improving the quality of the trainings. A tentative amount of Rs Five lakhs is being proposed for this. 108

109 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Identification of five district hospitals having good anesthesia facilities where the trainees may be deputed for 10 weeks during the total training period of 18 weeks. 4. Continuous field monitoring: The State has an established Quality Assurance Cell. Quality check of LSAS trainings also form a part of this cell activity. A regular (once a month for each medical college) monitoring visit should be conducted. 5. Immediate posting plans for the LSAS trained doctors in the designated FRUs should also follow. 6. Infrastructure strengthening process at the FRU level to give requisite working environment to the LSAS trained doctor should also be completed. 7. Voluntary application/nomination system for the future batches of LSAS trainings should be proactively encouraged by the state. 109

110 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Programme Management Programme management arrangements have been made at state, district and block level. The entire NRHM including RCH is governed by the highest body i.e. State Health Mission chaired by the Hon ble CM. The SHSB functions under the overall guidance of the State Health Mission. State Health Mission Composition Chairperson : Chief Minister Co-Chairperson : Minister of Health and Family Welfare, State Government Convener : Principal Secretary/Secretary (Family Welfare) Members : Ministers in charge of Departments relevant to NRHM such as AYUSH, Women and Child Development, Medical Education, Public Health Engineering, Water and Sanitation, Panchayati Raj, Rural Development, Social Welfare, Urban Development, Planning, Finance, etc. Nominated public representatives (5 to 10 members) such as MPs, MLAs, Chairmen, Zila Parishad, urban local bodies (women should be adequately represented) Official representatives: Chief Secretary/Development Commissioners and Principal Secretaries/Secretaries in-charge of relevant departments such as Women and Child Development, Public Health Engineering, Panchayati Raj, Rural Development, Tribal Welfare, Urban Development/Affairs, Finance, Planning and Representative, MoHFW, GoI, Director (Health Services)/Director (AYUSH). Nominated non-official members (5 to 8 members) such as health experts, representatives of medical associations, NGOs, etc Representatives of Development Partners. State Health Society Objectives of the Society To provide additional managerial and technical support to the Department of H &FW, Government of Bihar for implementation of National Rural Health Mission which includes RCH II, General Curative Care, National Disease Control Programme and AYUSH 110

111 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Governing Body Governing Body has following members. (i.) Development Commissioner, Govt. of Bihar- Chairperson (ii.) Finance Commissioner, Govt. of Bihar- Deputy Chairperson (iii.) Secretary, Dept. of Health & Family Welfare, Govt. of Bihar- Chief Executive Officer (iv.) Secretary, Dept. of Medical Education and ISM, Govt. of Bihar- Member (v.) Secretary, Dept. of Planning- Member (vi.) Project Director, BSACS- Member (vii.) Director, ICDS, Bihar- Member (viii.) Executive Director, SHSB- Member Secretary Executive Committee Executive Committee consists of following members. (i.) Secretary, Dept. of Health & Family Welfare, Govt. of Bihar To preside. (ii.) Executive Director, SHSB- Member Secretary (iii.) Director in Chief, Health Services, Govt. of Bihar- Member (iv.) Joint Secretary/ Deputy Secretary, Dept. of H & FW, Govt. of Bihar- Member (v.) Additional Director, Dept. of H & FW, Govt. of Bihar- Member (vi.) Representative of UNICEF- Member (vii.) Representative of WHO- Member (viii.) Representative of European Commission- Member (ix.) Representative of Ministry of H & FW, GOI- Member (x.) Regional Director of H & FW, GOI- Member Project Appraisal Committee (PAC) comprises of (i.) Executive Director, SHSB (ii.) Director in Chief, Health Services, Govt. of Bihar (iii.) State Representative, UNICEF, Bihar 111

112 NRHM STATE PROGRAMME IMPLEMENTATION PLAN (iv.) Regional Coordinator, WHO (v.) Regional Director, Regional Health Directorate, GOI (vi.) Programme Officer- SHSB- Tuberculosis (vii.) Programme Officer- SHSB- Kala Azar (viii.) Programme Officer- SHSB- Leprosy (ix.) Programme Officer- SHSB- Blindness (x.) Assistant Engineer-PWD, Bihar (xi.) Joint Secretary, Finance Department, Govt. of Bihar (xii.) A representative of Vigilance Department A project Appraisal Committee (PAC) shall consider the district plans and other expenditure proposals. All proposals will be submitted to the concerned authority having delegated powers provided for final approval. In case the designated authority does not agree with the recommendations of the PAC, she/he shall record the reasons for such disagreement and may include the proposal in the full meeting of the Governing Body which shall have the full powers to accept/ reject the recommendations of the PAC provided that the reasons for rejecting the PAC recommendations shall be recorded in the minutes of the GB. Financial powers of the bodies/office bearers Type of Expenditure Extent of powers A. Approval of District/city plans Full powers to the Governing Body, provided that the plan(s) have been endorsed by the Project Appraisal Committee (PAC). B. Allocations of funds Full powers to the Governing Body. C. Approving programme and campaign Full powers to the Governing Body. activities under NRHM D. Hiring of contractual staff, including sanction of compensation package For Staff of Category A &B of Organogram-Full powers to the Chairperson of the GB provided the contracts shall be for a period not exceeding 11 months at a time. 112

113 NRHM STATE PROGRAMME IMPLEMENTATION PLAN For Staff of Category C of Organogram- Full powers to the Executive Director subject to the compensation package approved by the GB, provided the contracts shall be for a period not exceeding 11 months at a time. E. Release of funds for implementation of plans Full powers to the ED. approved by GB/EC F. All related activities in pursuance of State / Full powers to the ED. District plan approved by GB, such as Advertisement charges, Advance to contractors, Repayment of earnest money/security deposit, Freight charges, demurrage, Furniture & fixtures(within Budget limit),stationery, conveyance, electricity & water charges, Insurance, legal charges, postage, telephone, Fax, Repair and maintenance of equipment, Hiring of taxis, Auditors, all trainings, payment of TA/DA /Honoraria to resource persons, workshops, training material, books, TA/DA to society staff, payment related to documentation etc. State Level (State Programme Management Unit): Following are the Support staff of State Programme Management Unit SL Designation No. Salary Pm Salary Pa 10% Total (E+F) 1 State Programme Manager Consultant NRHM Data Asstt. Cum System Analysis Consultant Cold Chain Consultant - Maternal Health Consultant-Child Health Media Expert Consultant Procurement and Logistics Consultant Accounts Manager(Salary 9 Rs.15000/- Pension Rs.Rs ) Accountant

114 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Store Keeper Clerk cum Steno Data Assistant Computer Operator Accountant Executive Assistant Computer Operator-cum-Steno Total A 10% hike in salaries per year has been recommended in the PIP and is part of RCH II budget. The Overall picture of programme management functioning is as follows Governing Body Executive Committee Secretary Health & family welfare-cum- CEO SHSB Executive Director, SHSB State Management Unit 38 District Health Societies Rogi Kalyan Samitis at the Hospitals till Block levels District Health Societies The society shall direct its resources towards performance of the following key tasks:- To act as a nodal forum for all stake holders-line departments, PRI, NGO, to participate in planning, implementation and monitoring of the various Health & Family Welfare Programmes and projects in the district. To receive, manage and account for the funds State level Societies in the Health Sector) and Govt. of India for Implementation of Centrally Sponsored Schemes in the Districts. Strengthen the technical/management capacity of the District Health Administration through recruitment of individual/ institutional experts from the open market. 114

115 NRHM STATE PROGRAMME IMPLEMENTATION PLAN To facilitate preparation of integrated district health development plans. To mobilize financial/non-financial resources for complementing /supplement the NRHM activity in the district. To assist Hospital Management Society in the district. To undertake such other activity for strengthening Health and Family Welfare Activities in the district as may be identified from time to time including mechanism for intra and inter sectoral convergence of inputs and structures. Governing body of DHS 1. District Magistrate & Collector Chairperson 2. District Development Commissioner (CEO Zilla Parishad) Vice Chairperson 3. District Social Welfare Officer Member 4. Executive Officer, Municiplity, Saharsa Member 5. Addl. Chief Medical Officer Member 6. District RCH Officer Member 7. Deputy Superintendent of the District Hospital Member 8. Civil Surgeon Member Secretary Executive Body of DHS 1 Civil Surgeon of the District Chairperson 2 Additional Chief Medical Officer Cum member Sec. DBCS, Member Saharsa. 3 District RCH Officer, Member 4 District Leprosy Officer, Member 5 District T.B. Officer, Member 6 District Malaria Officer, Member 7 District Programme Manager (ICDS) Member 8 Chief Executive Officers Nagar Nigam, Member 9 Deputy Superintendent, Sadar Hospital Member Secretary 10 Sec. IMA Member 11 Sec. Indian Red Cross Society, Member 115

116 NRHM STATE PROGRAMME IMPLEMENTATION PLAN District Programme Management Support unit Consist of Following Personnel:- 1. District Programme Manager 2. District Accounts Manager 3. District Data Asstts Financial Management FUND FLOW MECHANISMS AT STATE Presently the State Health Society is getting Grants-in-Aid from GoI through electronic transfer by crediting the A/c of SHS. These funds are transferred to District Health Society A/c as Untied funds as per their respective District Action Plans, which then get flowed to the CHCs, PHCs, district hospitals and RKS for smooth conduct of the activities of RCH- II. On the same lines of the GOI regarding transfer of funds, SHS is under the process of implementing the system of e-transfer of funds to the districts and blocks. This process is likely to be completed very soon. 116

117 NRHM STATE PROGRAMME IMPLEMENTATION PLAN FUND FLOW MOHFW, NEW DELHI By E-Transfer STATE HEALTH SOCIETY BLOCKS DISTRICT HEALTH SOCIETY through A/c payee cheques PHC, CHC R.K.S NGOs OTHER AGENCIES OPERATION OF BANK ACCOUNTS The Account of State Health Society is being operated as per the delegated powers. The persons authorized as per the powers delegated to them are also operating the bank accounts of DHS. ACCOUNTING PROCEDURES FOLLOWED The State is following the Double Entry System of accounting on Cash Basis. For the sake of convenience in consolidation of accounts districts are also instructed to follow the same system. 117

118 NRHM STATE PROGRAMME IMPLEMENTATION PLAN In addition to this for proper accounting and maintenance of books, a manual cum guidelines had been issued to the districts. Also the monthly auditor appointed at each district is reporting on the accounting procedures followed by the districts on a monthly basis, along with the deviations, if any. FINANCIAL MANAGEMENT AT STATE The Financial Management group at state consists of the State Finance Consultant and state accounts officer. Similarly at districts also the DAM is looking after the financial matters FINANCIAL MONITORING The financial monitoring is being done through the understated mechanisms- 1. Analysis of SOEs submitted by the districts and its comparison with audited expenditures on monthly basis and reconciliation of the same by the financial consultant. 2. Training cum discussion meets with all the districts officials at regular intervals. 3. AUDITS: a) Comprehensive audit (Annual) as per the Directions of GoI. The auditor for the F.Y has been appointed and they have initiated the audit of DHS s accounts. b) Monthly Audit is being conducted and reports are submitted to state regularly which are then reviewed. c) Audit by CGA officials is also going on as on date. Appointment of CA at SHSB & C.A. Level Due to increase in funds flow & for maintenance of Accounts as per NRHM guidelines, all the DHS were directed to appoint C.A. at a monthly cost of Rs.20, 000/- P.M. Similarly; CA. at SHSB level is to be appointed soon. Budget: Proposed Budget Audit of SHSB/DHS by CA for Rs. 6,00,000/- Appointment of CA at PM x 12months 3,00,000/- CA at DHS level 20,000x38x12 91,20,000/- Total 1,00,20,000/- 118

119 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Constitution of Internal Audit wing at SHSB: Internal Audit wing is proposed to be constituted in in which services of 6 retired officers form Recognised Audit & Accounts Services will be engaged, who will be well versed in Audit work. Budget: Proposed Budget Last pay drawn Pension = Approx exp of 20,000x6x12 14,40,000/- Rs.20,000/-PM TA/DA for Audit 1000x6x30x12 21,60,000/- Training of SHSB/DAM/BHM) FM Group Head Quarter 36,00,000 level=6x1500x12=1,08,000/- DAM=38x1500x4= 2,28,000/- BHM=538x1500x4=32,28,000/- Total 1,00,20,000/- 119

120 CEO ED ED Cell Steno cum CO PA/DA-1 Clerk cum-steno E/H - 2 Computer Operator-1 I/C Adm. Storekeeper Pharmacist PO T.B. PO Imm PO Fi PO N POK POBl. POL PM P&A IEC MCH CC DO & SA MF M A/C Tech. Wing ind nes s Steno cum CO CP DA-1 CO-3 Steno cum CO FO Accountant- 3 Astt. Eng. DA-2 1P & A - Personnel & Administration 2POBl - Programme Officer Blindness 3PON - Programme Officer Nutrition 4POK - Programme Officer Kala-Azar 5PO Fi - Programme Officer Filaria 6PO Imm - Programme Officer Immunization 7MF - Manager Finance 8MA/C - Manager Accounts 9PM - Programme Manager 1FO - Finance Officer 1CO - Computer Operator 1DO & SA - Data Officer & System Analyst 1POL - Program Officer Leprosy 1MCH - Maternal & Child Health 1CC - Cold Chain 1Asst. Eng - Assistant Engineer 1CP - Computer Programmer 1DA - Data Assistant 1PA - Private Assistant Steno cum CO-1

121 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Convergence and Coordination Coordination with other departments such as ICDS, PHED, Education and Panchayat Raj is important for tackling health issues. The involvement of representative of these departments help the health service providers in reducing the maternal mortality, Infant Mortality and increase the coverage of Family Planning Service and Adolescent Health Service. The state would take certain initiatives to ensure a synergistic effort from the community level to the state level which is defined in part E along with a detailed budget 18. Role of State, District and Blocks The role of State, District and Block are well defined. The role of each one has been clearly indicated in the workplan (Annex 3 d) as per activity wise. The decentralization process has given more roles to Districts and Blocks to perform in executing the various programs. The State mainly looking after Monitoring, Policy decisions, Centralize capital purchase, technical support etc and help the district in execute the actions planned. 19. Monitoring and Evaluation One of the major weaknesses of the RCH program in the Bihar is the absence of an effective Monitoring and Evaluation system that would provide accurate and reliable information to program managers and stakeholders and enable them to determine whether or not results are being achieved and thereby assist them in improving program performance. A triangulated process of Monitoring and Evaluation would enable cross checking and easy collection, entry, retrieval and analysis of data. Activities Strengthening and up gradation of monitoring and evaluation cell Mobility support Equipping and furnishing demographic cells Conducting survey and concurrent evaluation Formation of Databank Revised CNAA for all levels would be persuaded and guidelines for preparation district plans Web/internet based computer software for use at district and state level Reporting formats for providing requisite information 121

122 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Road map of each health centre for easy communication Triangulation of data Triangulation Process for Monitoring and Evaluation Computerized MIS Community Monitoring Focused Studies Monitoring Key progress indicators Evaluation Input Indicators Staff position, Training & orientation, supplies, frequency of immunization Output Indicators Maternal Health Indicators Child Health Indicators Family Planning Adolescent Key Finanacial Indicators Percentage funds received by state according to schedule Percentage funds disbursed to districts Key Development Indicators MMR IMR NMR TFR Key Development Indicators The key development indicators for measuring progress in reaching the overall project development objectives for the RCH programme in the state are as follows. Maternal Mortality Rate 122

123 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Infant Mortality Rate Neonatal Mortality Rate Total Fertility Rate Key progress indicators Key progress indicators enable the monitoring of delivery of project inputs and the achievement of project outputs. Table : Examples of Input Indicators Institutional Strengthening: Infrastructure Institutional Strengthening: Human Resource No. of new No. of health facilities personnel constructed appointed No. of new No. of health facilities personnel upgraded trained for No. of essential capacity equipment building Programme HMIS Supervision management No. of programme managers appointed at state/district levels No. of programme managers trained at state / district levels Number of operational equipment such as computers supplied to reinforce HMIS Number of new formats developed Percentage of work computerized supplied Key financial indicators Key financial indicators help assess the project's budgetary and financial health. Percentage of funds received by state according to schedule Percentage of funds disbursed to districts Percentage of funds disbursed to districts according to schedule (within 15 days) Percentage of utilization of funds against allocation by state / districts The National Rural Health Mission has been launched with the aim to provide effective health care to rural population. The programme seeks to decentralize with adequate devolution of powers and delegation of responsibilities has to have an appropriate implementation mechanism that is accountable. In order to facilitate this process the NRHM has proposed a structure right from the village to the national levels with details on key functions and financial powers. To capacitate the effective delivery of the programme there is a need proper a proper HMIS system Regular monitoring, timely review of the NRHM activities should be carried out. The quality of MIES in State HQ and in districts is very poor. Reporting and recording of RCH formats (Plan and monthly 123

124 NRHM STATE PROGRAMME IMPLEMENTATION PLAN reporting) are irregular, incomplete, inconsistent and few districts are not reporting at all. Formats are not filled up completely at the sub center level. There information is not properly reviewed at the PHC level. No feedback is provided upon that information. For overall management of the programme, there is a Mission Directorate and a State Programme Management Unit in the state. The Unit is responsible for overall monitoring and evaluation of the programme in the state and the districts. The data gathering is being facilitated by the state, District and PHC data Centres. The numerous formats being used have been reviewed and it is found that data needs to be compiled only as per RCH, NRHM programme and State needs. Hence the new MIES formats have been shared with all the health functionaries and it is expected that they shall be reporting in the new formats from the 3 rd quarter after brief orientation training. At district level, there is a District Health Society who will be responsible for the data dissemination from the sub-district level to the district level. Data Manager/HMIS expert at the State level and Data Assistant at the district level will be responsible for management of HMIS. As such, there will be a Monitoring Team constituted each at state and district level to monitor the implementation of the NRHM activities. The Team will comprise of representatives from the Mission Directorate and Programme Committee for various health programmes. The Team will also comprise of representatives from Govt. of India. There is Hospital Management Committee/ Rogi Kalyan Samity at all PHCs and CHCs. The PHC / CHC Health committee will monitor the performance of SC under their jurisdiction and will submit the report. The PHC/ CHC health committee will monitor and evaluate the SC performance.and performance will be submitted to the District, which will compile and sent it to the state. REPORTS REQUIRED FROM DHS Monthly Fund flow statement Form -9 (accurate and fully filled) ASHA selection and training report Mobile Medical unit (if working ) Janani Evam Baal Suraksha Yojana Reports (no. of institutional deliveries, Deliveries under JBSY,No. of Pvt Institutions accredited) Immunization reports. Vaccine wise coverage Training reports of the current trainings being given in the district or being under taken by district officials 124

125 NRHM STATE PROGRAMME IMPLEMENTATION PLAN X 7 PHC working, Status of telephones working, No. of ambulance and their usage, monitoring of doctors and ANMs presence, No. of OPD patients, No. of IPD, No. of referrals, No. of deliveries being conducted Rogi Kalyan Samitis formation and working, meetings of RKS Sub centre untied funds, Joint A/c of ANM and Panchayat member (female), UCs of untied funds Integration of AYUSH at PHC level Availability of essential drugs, Vaccines, AD syringes in DH, SDH, PHC, SC Contract Appointment of doctors, ANMs, Staff Nurses and other Staff Health melas, No. of beneficiaries Family planning services, male steris, female steris, IUD, MNGO working (if present) Other Special programmes specific to the district Quarterly Finance Management Report The DPM along with the DAM (in financial matters) shall be responsible for compilation and timely reporting Table : HMIS Forms Form No. Information Filled by Form No.1 General information, no. of births, Cases of complicated ANM pregnancies and deliveries, sick newborns, RTI/STD cases, oral rehydration performance data [action plan by ANM or SC] Form No. 2 Deliveries, MTPs,RTI/STD, Immunization, need assessment of individual ANMs [action plan for PHC] PHC level Form No. 3 Sterilization,,immunization, services in obstetric care STI/RTI Sub division [action plan for FRU/Subdivision/DH] level Form No. 4 District action plan District Form No. 5 State action plan State level Form No. 6 Monthly report by ANM ANM Form No. 7 Monthly report by PHC PHC Form No. 8 Monthly report by FRU/Subdivision FRU Form No. 9 Monthly report by District District 125

126 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Action plan Forms Form 5 1. State Staff position, 2. Training & orientation, 3. supplies, Form 4 District Action Plan Compilation of Action Plans submitted by all PHCs, FRUs, Sub-Divisional Hospitals at the District Hospitals and submitted to the State Form 1 HSC Action Plan Prepared by: ANM with the help of DFWO Submission: Once in a year, Feb-March Form 2 PHC Action Plan Prepared by: PHC, LHVs & ANMs Submission: Once in a Year, Feb-March Form 3 FRU/SDH Action Plan Prepared by: Sub Divisional Hospitals Submission: Once in a Year, Feb-March Reporting Forms Form-9 Compiled at: District Level Responsibility: CS/ACMO Flow of form: District to State Submission: 25th of each month Form-8 Form-7 Compiled at: FRU/SDH Level Responsibility: MOIC Flow of form: Hospital to District Submission: Monthly Compiled at: PHC Level Responsibility: MOIC Flow of form: PHC to District Submission: Monthly Form-6 Compiled at: HSC Level Responsibility: ANM Flow of form: HSC to PHC Submission: Monthly 126

127 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Synergie with NRHM Additionalities The NRHM is an effort to bring about the architectural change to overall program management to enable rationalization of resources and simultaneously to augment then limited resources so that equity in health is ensured. The commonality of initiatives in the following areas would be complementing the similar efforts under NRHM; Infrastructures for facility development, Manpower recruitment, Capacity building through training, program management, institutional strengthening, organizational development, Communitization, Promotional efforts for demand generation and Improved monitoring & evaluation systems developed under RCH II Public Private Partnership Convergence & Coordination. The convergence approach which was mooted earlier now finds a clear policy initiative and procedural development by health and all health determinants sectors so that a joint effort is made in tandem from planning to impact evaluation / outcome to ensure investments in health reach the poor / unnerved/underserved/excluded segment of the population. These common efforts would also strengthen gender equity through adolescent and other initiatives of both RCH & NRHM to provide a safety net to young women and girl children. 127

128 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Sustainability The usage of government services in Bihar has certainly picked up with number of patients increasing manifolds due to free drugs and availability of doctors at PHC level. Similarly there has been an unprecedented increase in number of deliveries being conducted at government health facilities under Janani Baal Suraksha Yojana This can be largely attributed to huge influx of funds under NRHM. To hedge the growth from lack of funds and for its sustainability Government of Bihar has already applied user charges for pathology and radiology services. The ambulance user charges are being determined by Rogi Kalyan Samitis. The state already has paying wards in our medical colleges and GoB is contemplating having such wards in all district hospitals too. For sustainability of manpower incentives for specialist services and for postings in rural areas have been proposed in this Programme Implementation Plan. Government is working on Dynamic ACP and Cadre division of doctors for providing them better benefits. Private parties are also being encouraged to make investments in Health sector so that the sector doesn t become dependent on NRHM funds. However they would be urged to take up mapping of available facilities and also analysis of demand before investing and providing services so that any duplication may be avoided. Moreover GoB is also increasing its allocation to health sector. This year the state government proposed to establish Emergency Medical Service, Dialysis Unit, Telemedicine system under PPP initiative. The state also increasing the number of Adll PHCs to be outsource to the NGOs. 128

129 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Extra Inclusions in RCH IFA (Details Annexed) Maternal and perinatal death inquiry and Response: Maternal and perinatal death inquiry (MAPEDIR) is an operational tool that strengthens community participation in evidence-based planning. MAPEDIR aims to help healthcare providers and community members understand the avoidable factors that underlie maternal and perinatal deaths and to identify ways to prevent these deaths. The main objective of introducing MAPEDIR is to develop a framework for the assessment of maternal and perinatal deaths and implementation of effective, high impact strategic interventions through: 1. Sensitizing communities to maternal and perinatal health issues, including the need for birth preparedness, complication readiness, 2. Identifying maternal deaths and conducting community-based inquiries with close acquaintances of the women to find ways to prevent maternal deaths; 3. Sharing the findings with communities, helping them interpret the data and develop appropriate interventions and advocate for improvements in health care-seeking; and 4. Using the findings to advocate with policy makers for improvements in maternal health care. Maternal and perinatal death inquiry and Response: In the year , UNICEF has piloted the MAPEDIR in Vaishali District. GoB proposes to take will take it to scale to 2 more districts (Kishanganj and Jehanabad) in with UNICEF support as part of the next Annual NRHM State Plan. Major Activities Identification of Staff: Supervisors, Interviewers and Notifiers Identification and selection and training of the supervisors and interviewers (ANM and LHVs) will be conducted supported by UNICEF. Selection of Notifiers (ASHA workers)band their one day orientation will take place. Capacity Building of Staff: Supervisors, Interviewers and Notifiers Once the identification process is over, a four day training of the Interviewers and the supervisors will be conducted to educate them over the entire concept of MAPEDIR and the implementation process.this training will be conducted with UNICEF support. Once the training of supervisors is over, a one day orientation of the notifiers from the all the Panchayats of all the blocks will be organized to equip them, with the process of notification of deaths and reporting to the supervisors 129

130 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Notification of Cases This activity will be taken up by the notifiers once they undergo the orientation program and are placed in their respective Panchayat. The activity will consist of verifying the information shared by the informants, Filling-up the Notification Format and Contacting the Supervisors Interviews Interviews will be conducted by skilled and trained interviewers trained during the 5 day capacity building program. This activity takes place once the supervisor assigns the case to the interviewer. The interviewer will visit the household where the death took place and will interview the closest person who stood when the death took place. The recorded information in the prescribed format will be submitted to the supervisor who then will verify the recordings and promote it for entry and analysis. Data Entry and Analysis of information Data Entry and Analysis will take place only when the above processes of Notification, Interview and Verification are over. All entry will take place at the District level and analyzed at UNICEF level Community Sensitization Program At the monthly Mahila Mandal meetings sensitization of the community members functionaries will be done for generating awareness on the causes of maternal of death, precautionary measures and community initiatives. Other forums for the same will be explored. Orientation and Sensitization of Health Functionaries At the block and District Level one day orientation of the Health Functionaries will be carried out to develop a consensus on the process. Advocacy Meetings Finally, the analyzed data are to be utilized for advocacy and policy modification at the district and state level. These advocacy meetings will be very strategic in nature where decisions regarding effective service delivery and service effectiveness will be targeted. Costs incurred per Maternal death investigate/non maternal death notified Honorarium & Travel Informants Notifiers Interviewers Supervisors Total per maternal death investigated Rs

131 NRHM STATE PROGRAMME IMPLEMENTATION PLAN Work plan Annexure 3 d 24. Budget Annex 3e and 3c 131

132 PART- B NRHM Flexible Pool / NRHM Additiona lities

133 1. Decentralization For effective decentralization in principle as well as practice, health societies have been established at all levels of the healthcare delivery structure. Systematic involvement of various stakeholders at all levels through these societies has helped make healthcare delivery responsive to the needs of the people via participatory planning and removal of bottlenecks at implementation levels. State Health Society provides overall guidance and supervision for effective planning and implementation, and also coordinates activities across the board. The State Health Mission, the Governing Body and the Executive Committee meet at regular intervals and take decisions regarding all matters. District level activities are taken care of through the District Health Society. Rogi Kalyan Samitis at PHC, CHC, Sub Divisional Hospitals, District Hospitals and Medical Colleges have been set up. The formation of societies under NRHM has given a new direction to management and overall functioning of the health department towards the achievement of its goals. 133

134 ASHA One of the key components of the National Rural Health Mission is to provide every village in the country with a trained female community health activist ASHA or Accredited Social Health Activist. Selected from the village itself and accountable to it, the ASHA is trained to work as an interface between the community and the public health system. Under NRHM, ASHAs (revised as per the decadal growth in 2008) are to be selected and trained in Bihar. The previous target was (as per 2001 census). The first orientation training of seven days has been completed for about 60,016 ASHAs. The 2nd, 3rd and 4th round /2, 3 & 4th module training is being done by PHED and its NGOs. The PHED had proposed a total cost of Rs cr. which has now been reworked to Rs Crores. A total no. of 76 State Level trainers/master Trainers were trained till June 2008 and 393 district level trainers/block resource persons are being trained. The 5 th round/module of training is to be started just after the completion of 2 nd, 3 rd & 4 th round of training. A total number of ASHAs have been selected so far. Orientation training of seven days has been provided to till now. The ASHAs are given the copies of each module (Hindi version) and reading material in the form of flip charts for their better understanding and also dissemination of key health messages among villagers. Table 1: ASHA Status (Target, Selection and Training) Revised Selection Target (As Selected as Trained with Sl. District per 2.3 % per annum decadal on Module No. growth rate) /Phase 1 I II III IV V 1 Araria Arwal Aurangabad Banka Begusarai Bhagalpur Bhojpur Buxar Champaran(E) Champaran(W)

135 11 Darbhanga Gaya Gopalganj Jamui Jehanabad Kaimur Katihar Khagaria Kishanganj Lakhisarai Madhepura Madhubani Munger Muzaffarpur Nalanda Nawada Patna Purnia Rohtas Saharsa Samastipur Saran Sheikhpura Sheohar Sitamarhi Siwan Supaul Vaishali Total ASHA is the first port of call for any health related demands of deprived sections of the population, especially women and children, who find it difficult to access health services and she will provide her service mainly under the following heads- 135

136 Table 1: The compensation package of ASHA Sl. No. Programme & Relevant Task Amount of Compensation 1. Janani & Bal Suraksha Yojana For 200/-(Only Rs.Two hundred) Per Delivery and Full Immunization of the New Born Pregnant Woman 2. Mobilizing all the children of the village Rs. 150/-(Only Rs. One hundred Immunization fifty only) Per Month 3. Providing DOTS under Tuberculosis Control Program Rs 250 per patient. 4. For identifying Patient of Leprosy and Rs. 300/- (Only Rs. Three hundred) him/her to PHC Per Patient 5. Training D.A. Per Rs. 100/- (Only Rs. One hundred) Per Day(During the Training) T.A. Per Training (To & Rs. 50/- (Only Rs. Fifty) Per Meeting 6. To participate in ASHA Divas organized at Rs. 75/- (Only Rs. Seventy Five) Per Meeting 7. For motivating for Rs. 150/- (Only Rs. One hundred Fifty) on Completion of Surgery 8. For motivating client for vasectomy/ Rs. 200/- (Only Rs. Two hundred) on Completion of Surgery 9. For 6 no. home visits under HBNC and Rs. 200/- (Only Rs. Two hundred) on Completion of the 6 th visit Programme Description 1.11 At the State Level Personnel The Project Manager and Deputy Project Manager at the State level have been appointed. Additional personnel including Statistical assistant, data assistant and office attendant have been provided for effective implementation and execution of different aspects of work. ASHA Mentoring Group- A Mentoring Group comprising of leading NGOs and well known experts on community health is under the process of formation, to provide guidance and advice on matter relating to selection, training and support for ASHA. Development of IEC and Monitoring Material For effective documentation, information dissemination and reporting, ASHA Flip Chart, ASHA Activity Diary, ASHA Register, IEC Material, Monitoring and Reporting Formats and resource materials for meetings and for Behavior Change Communication will be ensured. 136

137 Monitoring and Supervision and Operation Research and Documentation: This will ensure basic field level assessment, working towards the gap identified, analyzing and assessing the outcome and thus eventually working towards a holistic strategy development. This will include the following components: a. Periodic Surveys at District Level (once in three months) b. Operational and Action Research from State Level (every six months) c. Field Visits every month by the Consultants ASHA d. Monitoring of the Training being conducted e. Community monitoring ASHA Sammelan and exposure visit: ASHA Sammelan will act as a platform where ASHAs accompanied by Block Health Manager, Block Health Organizer, District Nodal Officer and Senior Nurse of one district/block meet the ASHAs of another district/block to share their experiences of work with District & Block Health Officials, Medical staffs and beneficiaries. This will help in networking, information sharing and build a kind of connectivity between the workers and the State. Workshop, Seminars and Consultative meetings: - This will involve experts on health from the national level along with members of ASHA Mentoring Group for analysis of the operation research and monitoring to work towards further strategy development At the District Level Additional Personnel Community Mobilizer/ District Project Manager ASHA She/He will be appointed in the capacity of Community Mobilizer and will act as a Nodal Officer at the district level for effective programme management, implementation and execution. Data Assistant: She/He will assist the community mobilizer and existing staff of the District PMU in all the ASHA related work. ASHA Help Desk: An ASHA help desk will be formed at the district level whose overall in-charge will be the community mobilizer. This will be expanded to the block level for strengthening of referral support system, to redress grievances of ASHAs, if any and to work as an information networking and management system At the Block Level Block ASHA Manager/ Block Level Organizer An Officer will be appointed as a block level organizer for effective programme management, implementation and execution and to act as a link and network between the ASHAs and the District and will be assisted by a facilitator 1 on every 20 ASHAs. The Facilitator will be the 21 st ASHA worker. This will help in building up and developing the necessary skill required for a community health worker in a sustainable way. 137

138 ASHA Help Desk: An ASHA Help Desk will be formed also at the block level. Overall in-charge of Block level ASHA Help Desk will be block level organizer and MOIC. This shall be in network with the District Level ASHA Help Desk. It will act as a network integrating the Village, Block and the District. It will help in strengthening referral support system, redress grievances of ASHAs, if any, and work as an information networking and management system At the Village Level Community Monitoring and Community Need Assessment: Community-based Monitoring ensures that the services reach those for whom they are meant, for those residing in rural areas, especially the poor, women and children. Community Monitoring is also seen as an important aspect of promoting community led action in the field of health and to understand if the work is moving towards the decided purpose. Although, ASHA hails from the same village, she may not be having knowledge and information on the health status of the village population. For this purpose, she will be advised to visit every household and undertake a sample survey of the residents of the village to understand their health status. In this way she will come to know the villagers, the common diseases which are prevalent amongst the villagers, the number of pregnant women, the number of newborn, educational and socio-economic status of different categories of people, the health status of weaker sections especially scheduled castes/scheduled tribes etc. She will be provided with a simple format for conducting the surveys. The ASHA Activity Diary will also help her keep a record of the base level. In this she should be supported by the AWW and the Village Health & Sanitation Committee. Such a review will help to identify obstacles in the work, so that appropriate changes can be made to cross the obstacles by the team of the block level organizers. Networking with VHSC, PRI and SHGs All ASHAs will be involved in this Village Health and Sanitation Committee of the Panchayat, as Members. ASHAs will coordinate with Gram Panchayat in developing the village health plan, along with the Block Level Organizer, Block Medical Officer and Block Facilitator. The untied funds placed with the Sub-Centre or the Panchayat will be used for this purpose. The SHGs, Woman s Health Committees, Village Health and Sanitation Committees of the Gram Panchayat will be major sources of support to ASHA. The Panchayat members will ensure secure and congenial environment for enabling ASHAs to function effectively to achieve the desired goal ASHA Training The second phase of ASHA training which includes the 2 nd, 3 rd and 4 th modules is being done by PHED and it s NGOs. The State Level ToT has been completed and the district level training is going on. The District resource person will in turn train the ASHAs at the Block Level. Additionally against the revised ASHA target, the new incumbents shall have to be provided trainings on Module 1, 2,3 and

139 1.16. ASHA Drug Kit and it s replenishment To ensure provision of ASHA Drug Kit to new ASHAs and replenishment as it is one of the key components of NRHM Emergency Services of ASHA Bihar has been experiencing regular floods which have created havocs in lives of lakhs of people both economically and psychologically. During the time of floods, health related problems become extremely acute. In such a situation the role of ASHA becomes extremely crucial. Thus ASHAs will be provided intensive training/capacity building preferably of three days and would then be deputed in 16 flood prone districts or similar natural disaster areas Motivations for ASHA Provision of Two Sarees to ASHA The provision of Sarees will ensure the following:- The availability of Sarees will help in building up of better motivation of the ASHA workers. Identification in any work helps in rooting identity for the worker and the work itself. The availability of Sarees will help in doing so. Sarees will help in easy deliverance of work and make the worker more accessible by the community as it will help in easy identification of the ASHA worker. It will help in boosting the morale of the ASHA worker and shall make the relationship stronger and would help in connecting the ASHA worker and the State. Provision of One Umbrella to ASHA The provision of Umbrella will ensure the following:- The availability of Umbrella will act as an aid to the ASHA worker in extreme weather conditions, which will facilitate the health facility/services in a smooth way The availability of Umbrella will help her comply with her nature of work It will help in building up of motivation of the ASHA worker, enhance her identity. It will help in boosting the morale of the ASHA worker and making the relationship stronger and ensure connectivity between the ASHA worker and the District Capacity Building/Academic Support Programme: a) Enabling ASHA 10 th pass For upgradation of academic strength of ASHA, SHSB will provide examination fees for the 10 th examination of open schooling mode/board/ignou to 1000 ASHAs in 1 st Phase. Fee for the same to be provided by SHSB. b) Training for Help Desk The person/officer involved in operationalising the ASHA help desk at District level and Block level will be trained. 139

140 1.20. ASHA Divas ASHA Divas will be held per month. This will include the following components- Monthly Meetings for ASHA Divas of ASHAs, ANMs and AWWs shall provide the necessary platform to share the work experiences, identify the loop holes and work towards the same. Best ASHA worker and ANM worker felicitation as per their monthly performance at the ASHA Divas will provide motivation. The performance will be rated as per the ASHA Activity Diary. Provision of I-Card will be done to the newly selected ASHA workers. Replenishment of ASHA Drug Kit for at least the next two months. This will ensure treatment of common ailments and first level prompt care and referrals initiated based on symptoms of necessary cases. For this, effective access to basic drugs in every village should be ensured through ASHA Drug Kit. Key Dimension of ASHA Programme:- The structural mechanism relating to a support system for ASHAs will ensure the facilitation of effective service delivery and a clear communication channel from the Block to the State. The Human resource in form of a strong network system will provide the necessary support for effective implementation and execution of the ASHA Programme. Continued training and capacity building to the ASHAs will facilitate the service delivery and ensure community broad basing of the programme. Inter-sectoral convergence among different health related institutions and individuals will ensure effective service delivery. The ASHA Help Desk will ensure an extensive and intensive communication and management system right up to the community level. Empowering ASHA through various motivational methods including provision of Sarees and umbrella, best ASHA felicitation, performance based incentive, capacity building, training, documenting the work through ASHA activity diary and register, incentive to ASHA for mobilizing ANC and PNC Cases for check-up and ASHA help desk will assist and facilitate overall development of the worker. Additionally, the ASHA being a facilitator at the Block Level will also go in a long way towards developing the necessary skills of a Community Health Worker, making the whole process sustainable and empowering the worker and the community itself. 140

141 A Community based monitoring system coupled with operational research and continued evaluation will help in field level analysis and seminars for consultation of the same will help in holistic strategy development. Budget: Sr. No. Particulars Tentative Budget (A) AT THE STATE LEVEL 1 Personnel on contract 1. Project Manager (MBA/PG in HRD) - Rs.25,000/- per month x12 months = Rs.3,00,000 5,40,000/- 2. Deputy Project Manager (Master in Social Works) Rs.20000/- per month x 12= Rs.2,40,000/- Total of (1)+(2)= Rs.5,40,000/- 3 Development of IEC and monitoring materials (ASHA flip chart, 2,61,40,500/- ASHA Activity Diary, ASHA Register, IEC material, reporting format, monitoring formats and resource materials for meetings) = 300 x = 2,61,40,500/- 4 Monitoring and supervision 2,00,000/- 5 Operation research and documentation 2,00,000/- 6 ASHA Sammelan and exposure Rs. 150/- per ASHA 1,30,70,250/- (Rs.100/- Hon. + Rs.50/- TA/DA)= 150 x = 1,30,70,250/- 7 Workshops, seminars and Meetings 2,00,000/- 8 ASHA Mentoring Group Budget 2,00,000/- 9 Contingency 1,00,000/- Total (A) 4,06,50,750/- (B) ASHA Support System at the District Level 1 Strengthening of the District PMU for undertaking ASHA support system Additional Personnel (a) Community Mobilizer/District Project Manager-ASHA (Master in Social Work) Rs.20,000/- per month x 12 months = Rs.2,40,000/- who will report to District Nodal Officer 21,60,000/- 141

142 (b) Data Assistant (Graduate with Basic Computer knowledge) - to strengthen the District PMU to take additional work. He/She will assist the existing staff of District PMU in all the work related to NRHM including ASHA related work. Rs.8,000/- per month x12 months = Rs. 96,000/- (c) TA/DA to be paid from District Health Society (Programme Management Cost) for monitoring visits and collection of information Telephone, fax, computer, stationeries etc to be used from District PMU (3000 x 12 x 38 = 13,68,000.00) (d) ASHA Help Desk at the district level (As In-charge Community Mobilizer) = 1000/- x 38 district x 12 months =4,56, (C) ASHA Support System at the Block Level (A) Block ASHA Manager/An officer Block Level Organizer in all the blocks. (Rs x 533 x 12 months = Rs. 7,67,52,000.00) (B) ASHA Help Desk at the Block Level (as in-charge Block Level Organizer and MOIC) = 500/- x 533 x 12= 31,98,000/- (D) ASHA Support System at Village Level Community Monitoring and Community need assessment 1 (20 ASHA and block facilitator, PRIs, SHG, two beneficiaries and NGO representative.)(rs.150/- x 2500 x 12) = 45,00,000/- (E) ASHA Trainings 1 One day Orientation programme of State Level resource person = 65,000/ days training of District Resource Team (38 district x Rs.2,35,000/-)= 89,30,000/ days training of ASHA at Block level (2489 batches x Rs.1,00,000/-) = 24,89,00,000/- 7,99,50,000/- 45,00,000/- 8,68,95,000/- (Rs crores was made available in , of which approx. Rs

143 4 Documentation and Development of IEC materials = 5,00,000/- lakhs has been spent. Therefore of the total requirement of Rs. 25,83,95,000/- additional fund required for is 13,82,92,850/- and the balance available amount in SHSB may be ratified for use in ) Total (B+C+D+E) 17,35,05,000/- (F) ASHA Drug Kit & Replenishment 1 Drug Rs. 600/- for ASHA Replensihment of Drug ASHAs x Rs.200/- 1,48,62,600/- Total 2,25,55800 (G) Emergency Services of ASHA Deputation/ engagement of ASHA in Flood and other natural 1 calamities for flood prone district (20 days x Rs.100 per day x approx 3000 ASHA= 60,00,000.00) 66,00,000/- Capacity Building/Training of ASHA in Flood and other natural 2 calamities for flood prone district ( 2 days x Rs. 100 per day x approx 3000 ASHA = 6,00,000.00) (H) Motivation of ASHA 1 Provision of two Sarees to ASHAs (87135 ASHAxRs.600( two Sarees) =5,22,81,000/- 6,31,72,875/- 2 Provision of one umbrella to ASHAs (87135 ASHAs x Rs.125/-) =1,08,91,875/- (I) Capacity Building/Academic Support Programme 1 Approx ASHAs in the State to be enrolled into 10 th grade or Bachelor s Preparatory Programme through Open Schools or IGNOU. Fee for the same to be provided by SHSB. The amount 10,00,000/- being requested is less, more shall be requested in case of god response to the Rs.1000 x 1000 students =10,00,000 2 Training for ASHA Help Desk (1104 x 500/-)= 5,52,000/- Provisioned in IEC component of Part A Total (F+G+H+I) 10,47,28,675/- 143

144 1 (J) ASHA Divas TA/DA for ASHA Rs.75 per ASHAs per month (Rs x 75x12) = 7,84,21,500/- 2 Best performance award to ASHAs at district Rs.2000 per block= 3 ASHAs from each Rs.1000 for 1 st, Rs.500 for 2 nd and Rs. 300 for 3 rd prize, Rs. 200 for Certificate printing and distribution = Rs x 533) = 10,66,000/- (For this activity the administrative system/procedure shall be chalked out with support of Development Partners) 3 Identity Card (Rs. 20 x 87135) = 17,42,700/- 8,12,30,200/- Total (J) 8,12,30,200/- Grand Total( A+B+C+D+E+F+G+H+I+J) 38,87,14,625/- Forty nine crores Eighty six lakhs Thirty four thousand Eight hundred and Seventy five Rs. only. 144

145 Total Budget under ASHA Scheme Sl Particulars Amount (Rs.) 1 ASHA Support System at State Level 4,06,50,750/- 2 ASHA Support System at District Level 21,60,000/- 3 ASHA Support System at Block Level 7,99,50,000/- 4 ASHA Support System at Village Level 45,00,000/- 5 ASHA Trainings 8,68,95,000/- 6 ASHA Drug Kit & Replenishment 2,25,55,800/- 7 Emergency Services of ASHA 66,00,000/- 8 Motivation of ASHA 6,31,72,875/- 9 Capacity Building/Academic Support Programme 10,00,000/- 10 ASHA Divas 8,12,30,200/- Total Budget for ASHA 38,87,14,625/- Work-plan for ASHA Program Activities Q1 Q2 Q3 Q4 Development for IEC and monitoring material (IEC material, reporting format, ASHA Flip Chart, ASHA Activity Diary, ASHA Register, monitoring formats and resource material for meetings) Monitoring and supervision Operation research and documentation ASHA sammelan and exposure visits Workshops, seminars and Meetings Trainings Emergency Services of ASHA Empowerment of ASHA Capacity Building ASHA Divas 145

146 1.21 Untied Fund for Health Sub Centre, APHC and PHC The objective of the activity is to facilitate meeting urgent yet discrete activities that need relatively small sums of money at Health Sub Centers. The suggested areas where Untied Funds can be used mentioned below: Cover minor modifications to sub center-curtains to ensure privacy, repair of taps, installation of bulbs, other minor repairs, which can be done at the local level; Ad hoc payments for cleaning up sub center, especially after childbirth; transport of emergencies to appropriate referral centers; Purchase of consumables such as bandages in sub center; Purchase of bleaching powder and disinfectants for use in common areas of the village; Labour supplies for environmental sanitation, such as clearing/ larvicidal measures for stagnant water Payment/reward to ASHA for certain identified activities. Budget Budget Head Untied Fund Proposed Budget (in Crores) Untied fund for sub-centre Rs. 10,000 x 8858 no. 8,85,80,000 Untied fund for APHCs 1243 APHC x 25,000 3, 10, 75,000 Untied fund for PHCs 533 PHC x 25, , 25, 000 For meetings at HSC Rs x 38 district PHC level ANMs 533 PHCs x Rs.3000) 15,99,000 Orientation on Guidelines for Untied Funds for HSC Quarterly review meeting of the ANMs under the chairmanship of PHC Medical Officer to monitor the usage of the fund Rs.1000 per meeting x 4 quarter x 38 districts 1,52,000 Total 13,48,07,

147 1.22 Village Health and Sanitation Committee Government of Bihar has decided to merge Village Health and Sanitation Committee with Lok Swasthya Pariwar Kalyan and Gramin Swaschata Samiti constituted by Department of Panchayat Raj in Bihar. Budget Budget Head Untied Fund for VHSC Proposed Budget (in Crores) Untied fund for VHSCs villages x 10, (Fund of Rs cr is available in SHSB, so the balance amount of Rs.35,07,70,000/- is Training of members of VHSC regarding functioning mechanism at the PHC level required) 533 PHCs x Rs ,32,500 Total 35,21,02,500/ Seed Money for Rogi Kalyan Samitis Aims and Objectives The objectives of the RKS is :» Upgrade and modernize the health services provided by the hospital and any associated outreach services» Supervise the implementation of National Health Programme at the hospital and other health institutions that may be placed under its administrative jurisdiction» Organize outreach services / health camps at facilities under the jurisdiction of the hospital» Monitor quality of hospital services; obtain regular feedback from the community and users of the hospital services» Generate resources locally through donations, user fees and other means Functions of the RKS To achieve the above objective, the Society utilizes it s resources for undertaking the following activities/ initiatives:» Acquire equipment, furniture, ambulance (through, donation, rent or any other means) for the hospital 147

148 Budget» Expand the hospital building, in consultation with and subject to any guidelines that may be laid down by the GoBMake arrangements for the maintenance of hospital building (including residential buildings), vehicles and equipments available with the hospital» Improve boarding/lodging arrangements for the patients and their attendants» Enter into partnership arrangement with the private sector (including individuals) for the improvement of support services such as cleaning services, laundry services, diagnostic facilities and ambulatory services etc» Develop/lease out vacant land in the premises of the hospital for commercial purposes with a view to improve financial position of the Society» Encourage community participation in the maintenance and upkeep of the hospital» Promote measures for resource conservation through adoption of wards by institutions or individuals» Adopt sustainable and environmental friendly measures for the day-to-day management of the hospital, e.g. scientific hospital waste disposal system, solar lighting systems, solar refrigeration systems, water harvesting and water re-charging systems etc. Budget Head Rogi Kalyan Samiti Proposed Budget (in Crores) District Hospitals 27 hospitals X 5 lakhs 1.35 Sub-divisional hospitals 23 hospitals X 5 lakhs 1.15 Referral hospitals 70 hospitals x 1 lakhs 0.70 PHCs 533 PHCs x 1 lakhs 5.33 Sensitization workshop for RKS members (653 x 3 members =1959) at the sub-divisional level (TA, Food, Resource materials, resource persons etc) Exposure visit of members of RKS of 10 nonperforming districts to districts where RKS are performing 217 participants x 9 divisions x Rs.1000= 2 members/rks x 10 hospitals x 10 districts =200 x Rs.2000=4,00,000 Provisioned in IEC componet (Part A) Provisioned in IEC componet (Part A) Total 8,53,00,000/- 148

149 Infrastructure Development 2.1 Construction/Establishment of Health Sub Centre (HSC) NRHM aims to ensure HSC facility on the Govt. of India population norms of 1 per 5000 population in general areas and 1 per 3000 populations in tribal areas. As per 2001 Census, population of the Bihar State is approximately 8,29,98,509. Existing facility of HSCs are 8858 out of total requirement of To facilitate the above population the state requires 7765 HSCs additionaly to achieve the total target. It is proposed to create 1553 HSCs every year for next five years. The revised estimate 9.50 lakhs as per GoI norms. The State proposes to share 25% expenses in the construction of these HSCs and for land acquisition. The balance 75% the state has put under this PIP for financial support from NRHM. These Health Sub Centres shall either be constructed or shall be taken up on rental basis. The cost provided also includes cost of land acquisition if Govt. land is not available. Till such time construction is complete the state shall take buildings for these facilities on rental also. NRHM Action - Plan Expected Details of Budget Proposed Proposed Physical Out Basis of Costing ( No. of Units X Unit Cost ) Budget Activity Come Creation of Initiating Rs Total Rs 9.50 lakh Contribution of Contribution HSC construction of Lakhs per unit GoI (75% of of GOB 100 HSC lakhs i.e lakhs = per unit ) lakhs per unit) 100 x 9.50= Rs Rs Rs Lakhs Lakhs Lakhs In the year funds for construction of 1985 HSCs were released to Building Constrution Department, which has initiated necessary actions. All though construction of 500 HSCs were proposed in and under NRHM GoI released Rs. 30 Crores. In the year it is proposed to construct buildings of next 100 HSCs where land is available. For this an amount of Rs lakhs is required. For Construction work two agencies have been identified BCD and District Health Society, Bihar. 149

150 2.2 CONSTRUCTION OF PHC NRHM aims to ensure PHCs on the Govt. of India population norm of 1 per populations in general areas and 1 per population in tribal/ remote areas. As per 2001 census, population of Bihar state is approximately The existing facility of PHCs is 1243, whereas the total requirement is 2787 PHCs. There are 121 PHCs which do not have their own building. Therefore 1665 PHCs buildings require to be setup by Unit cost of construction and land acquisition is lacs as per NRHM guidelines. Some of the facilities will be taken up on a rental basis. The total built-up area of the PHCs will be 63 hundred Sq feet, which will include 1500 sq. ft. for PHC & 4800 sq. ft. for its residential quarters. These PHCs would either be constructed or shall be taken up on rental basis. The cost provided also includes cost of land acquisition if Govt. land is not available for construction. Till such time construction is complete the state shall take buildings for these facilities on rental also. In addition, it is proposed to construct residential quarters for the staff in 500 old APHCs (previously sanctioned) in an area of 3000 Sq. ft. Proposed Activity 1. Construction of residential quarters of 200 old APHCs for Staff nurses NRHM Action - Plan Expected Physical Out Come Construction to be done in an area of 3000 sq. ft. (1000 sq. ft. x 3 Rs. 30 lakhs per APHCs. Funds to be released to the Construction Agency. Proposed Budget Rs Lakhs. Details of Budget Basis of Costing ( No. of Units X Unit Cost) 2. Construction of building of 51 APHCs where land is available Funds to be released to BCD. An amount of Rs lakhs is required for the construction. Against these Rs. 31 lakhs has already been released to BCD. Total fund required in will be Rs. 3,79,67, The rest to be carried over in Rs. 3,79,67, Rs. 3,79,67, Total Rs. 63,79,67, Say Rs lakhs 150

151 2.3 UPGRADATION OF COMMUNITY HEALTH CENTRE (CHC) NRHM aims to ensure CHCs on the Govt. of India population norm of 1 per 1.20 Lakhs populations. The Govt. of Bihar plans to upgrade all its PHCs and Referral Hospitals below the headquarter level to CHC as per IPHS standards. In the state of Bihar the total no of existing PHCs are 533 and the no of Referral Hospital is 70. Hence a total of 603 units are needed to be upgraded to CHC standard and converted to 30-bedded hospitals. It is proposed to upgrade 200 facilities every year. As per NRHM guideline the entire cost of construction would be borne by GOI. It is proposed to take up upgradation of 100 PHCs to CHCs in the year and the balance PHCs/Referral hospitals will be upgraded to CHCs in next year. The unit cost of construction and land acquisition will be around Rs. 40 lakhs. The upgradation of hospital buildings shall be taken up from funds provided by the State Govt. The doctors and staff quarters shall be provided under the NRHM. In case adequate land is not available the fund can also be used for land acquisition. The doctors quarters would also be taken up on rental basis. The cost provided also includes cost of land acquisition if Govt. land is not available. The costs also include provision of equipment at these hospitals either as per IPHS standard or as required. Proposed Activity Creation and Up gradation of CHCs as per IPHS Standard. Up gradation of Community Health Centre As Per IPHS NRHM Action - Plan Expected Physical Out Come Details of Budget Proposed Basis of Costing (No. Of Budget Units X Unit Cost) Preparation and Finalization of Maps. Rs lacs Unit Rs. 40 lacs Finalization of Construction Agency & (Contribution of GOI Initiating Renovation of CHCs. Rs. 40 lakhs x Funds to be released for the construction 100 = Rs Lakhs agency. 100 CHCs shall be taken up Quarters for Doctors and Staffs, for upgradation. for the Purchase of New Surgical Rs lakhs has already instruments, Equipments, Furniture, been approved by the GoI in and has been received and the amount shall be expended this year in

152 2.4 Infrastructure and Service improvement as per IPHS in 48 (District and Sub- Divisional) Hospitals for Accreditation / ISO : 9000 certification of Health Facilities The state of Bihar has 25 District Hospitals & 23 Sub Division Hospital at present. Construction for 11 District Hospitals are under process and have been nearly completed. Most of these District hospitals are 100 to 200 bedded. The state has already appointed one hospital consultancy firm to carryout the situation analysis of these District Hospitals and prepares a master plan in terms of Infrastructure, Equipment and Manpower for strengthening these hospitals as per IPHS. The state with the help of NHSRC is in the process of ISO accreditation/certification for its District Hospital at Bhojpur. This year Bihar would like to outsource this task through NHSRC or some competent agencies to take up it s 23 DHs and 25 SDHs under ISO certification across the state for addressing quality issues. The state also intends to develop the hospitals at Rajvanshi Nagar, Rajendra Nagar, Gardiner Road, Gardanibagh and Guru Govind Singh Hospitals at Patna into super speciality hospitals. The preparation of Master Plan will be completed within six months after which the state will take up the strengthening work. The upgradation would include upgradation of Civil Infrastructure as well as provision of equipment. The cost provided also includes cost of land acquisition if Govt. land is not available. The costs also include provision of equipment at these hospital either as per IPHS standard or as required. The costs also include provision of equipment at these hospitals either as per IPHS standard or as required. Budget: Activity Amount ( In Rs ) Strengthening/Up gradation of District Hospitals, Sub-Divisional 3,40,00,000/- Hospitals and Super-Specialty Hospitals as per IPHS Standard Accreditation/ISO certification for 48 (District Hospitals + SDH) 9,60,00,000/- x Rs lakhs Total 13,00,00,000/- 2.5 Upgradation of Infrastructure of ANM Training Schools In year , a State coordination committee for the strengthening ANM and GNM schools has been activated under the chairmanship of the Additional Commissioner, Health. The Executive Director, SHSB, 152

153 officers from the Directorate and SHSB and UNICEF are its members. The committee has chalked a comprehensive strategy for the rejuvenation of the ANM and GNM schools. Key decisions made till now include Streamlining the student intake in all ANM and GNM schools up to their full capacity Ensuring that the vacant faculty and staff positions in all the schools are filled through contractual appointments to undertake teaching assignment sas per INC norms Finalizing five ANM schools in PPP mode Formulation of the managing committee at respective ANM and GNM schools to look after the local management affairs Strengthening the hands of the principals of these institutes Reviewing the progress on a regular basis Initiatives have been taken in Operationalisation of 22 ANM schools in terms of - site assessment, basic renovation, provision of kitchen items, audiovisual equipments, lab equipments provision of study material, capacity building of faculty, standard curriculum development for the ANMs and GNMs Facilitation in accreditation from Nursing Council of India. It is proposed to upgrade the Infrastructure of 22 ANM and 6 GNM Training Schools. In addition, the state is willing to open up more ANM and GNM schools as per the GoI s letter in this regard. The approximate cost of up gradation of each ANM/GNM Training Schools is expected to be Rs 50 lakhs per Unit. It was proposed to upgrade the Infrastructure of 12 ANM Training Schools in PIP and a fund for the same to the tune of Rs.3.00 crores is available. Additional funds are requested for the remaining 9 ANM schools and 6 GNM schools. The state is preparing a separate proposal to upscale the standards of nursing education. Additionally under PPP 5 ANM schools are proposed to be operationalised. M.Sc/B.Sc. nursing faculty for nursing school to be taken from hindi speaking states like MP, Pondicherry, for which Govt of India shall be approached for coordinating the same. Budget S No Description App. cost Duration Total 1 Upgradation of infrastructure of 12 Rs. 600 lakhs Rs. 6,00,00,000/- 153

154 ANM Training School including provision of furniture & equipment 2 Strengthening of Nursing cell in the GoB 3 Hiring of additional faculty for all ANM and GNM schools (Above fund is already available from SPIP , 50 lakhs 50,00,000 Rs lakhs Every year 50,00,000 Total 7,00,00,000/- 2.6 Annual Maintenance Grant During the course of up-gradation in setting up of different units in the different health facilities of the state, maintenance will also be essentially required. It is proposed that all district hospitals and sub divisional hospital are Rs.5 lacs and Rs.1 lakh. Fund for the same was approved in Budget Activities Disbursement of the Grant at the end of the meeting on the same day to the respective medical officers (district hospitals (23) and sub divisional hospital Rs.5 lacs, Referrals/PHCs Rs.1 lakh) Total purposed budget Rs.8,20,80,000 Contractual Manpower 3.1. Incentives, Contractual Salaries and Bonus As human resources are the most important resource steps shall be taken to motivate them through various benefits and incentives like Cellphone facility for all ANMs, MOICs, Programme Officers, CDPOs etc. and rural and specialist incentives. All the doctors posted in the rural area would get an additional incentive of Rs A provision for Rs.50,000/- per PHC per year will be given as incentive to the PHCs for better performing in services. All the doctors performing specialist duties including the MBBS doctors trained for specialized tasks e.g. Life saving Anesthesia skills etc. will get an incentive of Rs

155 Budget: Sub-Heads Incentive for PHC doctors & Rs. 50,000 for better performance in implementing programmes Salaries for contractual Staff Nurses (2900 existing and 910 new) Contract Salaries for ANMs (around 8000) in year ANM will be paid by NRHM (Rest 4500 ANM will be paid by Treasury Root) Mobile facility for all health Rs. 50,000/ - per year for about 250 PHCs Rs.7500 per month Rs.6000 per month (12 Months Consolidated Salaries for Contractual ANMs) District officials, PHC in charge, CDPOs and 500 per Proposed Budget (Rs. In lakhs) month Total Block Programme Management Unit The state has already established Block Programme Management Unit in all the 398 Block PHCs. This year the state will establish the next 135 Block Programme Management Unit. Each BPMU consist of One Block Health Manager and One Accountant. It has been observed that after the establishment of BPMUs the implementation of National Programmes has been managed efficiently and getting improved results. Budget A. Recurring Expenses of 533 BPMUs Sl Particulars Qty Rate (Rs.) Amount (Rs.) 1 Salary of Block Health Manager /- pm 1,44,000/- 2 Salary of Block Accountant /- pm 84,000/- 3 Mobility and Office Expenses /- pm 3,00,000/- Recurring Expenses Per BPMU per Year 5,28,000/- Recurring Expenses of 533 BPMUs per Year 28,14,24,000/- B. Establishment Expenses for 135 BPMUs 155

156 Sl Particulars Qty Rate (Rs.) Amount (Rs.) 1 Computer System with Printer 1 50,000/- 50,000/- 2 Furniture 1 10,000/- 10,000/- Establishment Expenses Per BPMU per Year 60,000/- Establishment Expenses of 135 BPMUs 81,00,000/- Total Budget for for Block Programme Management Unit (A + B) = Rs. 28,95,24,000/ Additional Manpower for State Health Society, Bihar NRHM being a large programme covering various components, SHSB requires more manpower to run the programmes. The State Health Society requires additional manpower other than State Programme Management Support to manage all the Programmes under NRHM umbrella. This year state also proposes to put 2 nos. Executive Engineers and 1 Bio-Medical engineer under SHSB for monitoring the construction and equipment activity under NRHM. The details of Manpower as follows with Budget: Details of Staff Sl Post Salary (pm) Salary (pa) 1 Accountant (RNTCP) Pharmacist (RNTCP) Data Assistant (RNTCP) Computer Operator (RNTCP) Accountant (NBCP) Computer Operator/Data Assistant (NBCP) Steno-cum-LDC (NBCP) Computer Programmer (NLEP) Data Officer (Malaria/Kalazar) Computer Operator (Malaria/Kalazar) Store Keeper (Malaria /Kalazar) Accountant (Filaria) Computer Operator (Filaria) Total Per Annum /- 10% annual increment as approved by the Governing Body of SHSB, therefore the total required = Rs.18,94,200/- 156

157 Details of Programme Officers For Government officials on deputation new salary slab as such is proposed- Sl. Name Salary Pm Salary (pa) 1 Administrative Officer- SHSB Programme Office - TB Programme Officer-Kalazar/IDSP Programme Officer -Blindness Programme Officer- IDD/Filaria State Immunization Officer Programme Officer-Malaria Programme Officer - Leprosy Total Salary of ProgrammeOfficers ,90,088 Details of Engineers Sl. Name Salary Pm Salary (pa) 1 Executive Engineer - SHSB 2 no x 2 2 Bio-Medical Engineer SHSB 1 no x 1 10,20,000 Total Salary for Engineers Total Budget for Additional Manpower at SHSB = Rs. 62,04,288/ Additional Manpower under NRHM Being a big state, Bihar requires more manpower to provide services at various facility levels. Moreover the infrastructure development is happening at a snail s pace. To expedite this, it is proposed to hire 1 Assistant Engineer at each district and 1 Junior Engineer for every four (4) blocks) on contract Budget Sl. Name Salary Pm Salary (pa) 1 Hiring of AE on contract Rs.22,000/- x 38 districts x 9 months 75,24,000 2 Hiring of JE Rs.15,000 x 9 months x 133 blocks 1,79,55,000 Total Salary 2,54,79,000/- 157

158 PPP Initiatives in State 4.1 Emergency Medical Service /102 Ambulance Service The Toll free number 102 was launched during and is running in all the six regional headquarters successfully. Under this scheme Ambulance for emergency transport is being provided in all the districts of Bihar. The empanelled ambulance & ambulance available in Govt. institutions are made available on receipt of calls from the beneficiaries. This service has been outsourced to a private agency for Operationalisation. The Telephone Charges for the free toll free number is paid to BSNL by SHSB. The amount required would be for payment of incoming calls received from the beneficiaries. In the year (figures till December 2008) requisitions have been successfully met by this service. Budget summary of 102 : Budget Head 102 Emergency Service Proposed Budget (in Crores) Control Room (including office rent, salary of staff (24x7), stationary, 2 outgoing telephones for compliance of 102 & for reporting to Headquarter) Rs. 41, x 6 units = Rs, x 12 months =Rs. 29,52, Per Control Room Rs. 15, pm x 6 = 90, x 12 months 40,32, Total 40,32,000/ Doctor on Call & Samadhan: Dial 1911 A scheme is operational in the state wherein patients can dial a number and call for doctors. For this a special toll free number of 1911 has been provided for w.e.f The objective of the scheme is to give medical assistance to the patient at their home at any time as well as act as a Samadhan of Rogi Shikayat. Doctors and Specialists have been empanelled for this scheme. Pathology labs have also been attached to collect samples for tests from patient s home. Budget summary of 1911: Budget Head 1911 Doctor on Call service Sub-Heads Control room 3,500 per person (Two person) = 7, per control room is Proposed Budget (in Crores) 5,04,

159 Telephone bill Provision of Annual Maintenance of EPBAX paid to the outsourced agency. Rs. 7, x 6 = Rs. 42,000 x 12 months Each control room is being paid telephone bill (i) Doctors conferencing Rs. 1, x 12 months = 18,000 x 6 control rooms = 1,08, & (ii) Rogi Jan Shikayat Rs. 2, x 12 months = 24,000 x 6 control room = Rs. 1,44, Rs. 10, per annum x 6 control room 2,52,000 60, Total 8,16,000/ Additional PHC management by NGOs The state has started to outsource the management of Adll. PHCs to the NGOs. In the state has given 44 Adll PHCs to the NGOs for management. The result was good and it has been observed that the NGOs are properly managing the PHCs. This year the state proposes to outsource another 56 Adll PHCs to the NGOs for management. Last year 44 PHCs were Rs.75,500/- pm per Adll. PHC. This year the state proposes to provide Rs.1,00,000/- per APHC to additional APHCs. Budget Sl No Particulars Amount (Rs.) 1 Recurring Cost for existing 44 Adll 75,500 x 12 3,98,64,000/- month 2 Cost of New 56 Adll. Rs.75,500/- x 12 months 5,07,36,000/- (This fund shall be asked for subject to evaluation of the already running APHCs at pt. 1 above) Total 3,98,64,000/- 159

160 4.4. American Association of Physicians of Indian Origin (AAPIO) AAPIO survey on Specific Disease: The Ministry of Overseas Affairs, Govt. of India and American Association of Physicians of Indian Origin (AAPIO) signed an MoU at the Pravasi Bharatiya Divas in Jan 2006 to conduct a study on 5 specific diseases. Thereafter a meeting of Core Committee was held in New Delhi in this regard. As a follow-up to the above activities this project was included in the Annual Plan of NRHM in and a provision of Rs.50 lakhs was made in the PIP. The sum of Rs.1.56 Crores for the project has already been approved. This year the State again proposes another installment of Rs.56 lakhs in the State PIP State Health Resource Center State Health Resource Center has been established in State Health Society, Bihar with a two year contract starting from January 08. M/s HOSMAC has been awarded this work and the total budget cost has been divided into two parts- Retainership Fee Amount payable on completion of milestones A total of Rs crores was approved in previous year s PIP and the balance amount available in SHSB of Rs.1,38,44,799/- shall be utilized in the FY Services of Hospital Waste Treatment and Disposal in all Government Health facilities up to PHC in Bihar (IMEP) Bio medical waste management has emerged as a critical and important function within the ambit of providing quality healthcare in the country. It is now considered an important issue of environment and occupational safety. As per the Bio-Medical Waste (Management & Handling) Rules, 1998, all the waste generated in the hospital has to be managed by the occupier in a proper scientific manner. The GoI has also issued the IMEP guidelines for SCs, PHCs and CHCs. The state has outsourced the Biomedical Waste Management system for all the Government hospitals. 160

161 Strategy/Project Description State Health Society Bihar is implementing National Rural Health Mission (NRHM) to carry out necessary architectural correction in the basic health care delivery system. In order to provide quality services to the public, SHSB has sought Public Private Partnership in providing proper Hospital Waste Treatment and Disposal Services, in all Health facilities right from Medical Colleges to the PHCs. Services to be provided 1. Provide Service of Hospital Waste Treatment and Disposal in all Medical Colleges, District Hospitals, Sub-Divisional Hospitals, Referral Hospitals and PHCs of the State. 2. Install, Operate and maintain appropriate Common Biomedical Waste Treatment facility, as per the Biomedical Waste (Management & Handling) Rules, 1998 and subsequent amendments in it. 3. Provide one day orientation training to all the health service providers. 4. Maintain the above-mentioned arrangement for a period of minimum 10 years. The Common Biomedical Waste Treatment facilities are proposed to be established at various locations across the State Setting up a Bio-Medical Waste Management System: 1. The state has started a CWTF facility at Indira Gandhi Institute of Medical Sciences, Patna (autonomous institute). The facility has been approached for undertaking waste treatment for all PHCs to DHs in all the eight districts of Patna division. Status Registration of the health facilities with IGIMS and with Bihar State Pollution Control Board being ensured. Anticipated to be fully functional in all the eight districts by March As per the rules each CWTF should cater to all facilities in 100 Km radius, keeping this in mind, more CWTF are to be operationalised in each of the division except Patna (which already has such a facility). To implement the IMEP in a comprehensive systematic manner, Private Parties have been invited through National Open Tender. SHSB has already finalized two agencies for undertaking the BWM project that would set up CBWM Treatment facilities at various locations in the State and cater to all the PHCs to DHs to MCHs in all the Divisions except Patna. The agency shall ensure segregation and collection of waste, disinfection, treatment, transportation, handling and disposal of waste both within and outside the healthcare setting; also ensure use of protective devices and safety precautions. The objective being to ensure waste management, waste minimization and infection control. Trainings to be provided to health care workers and officers in Infection Management and Environment Plan implementation by the respective agencies. Payment is to be made on a per bed per day monthly basis to both IGIMS and the Private Agencies. Status - The project is in the finalization stage, agencies have been finalised and approval of the Governing Body of SHSB is awaited on the Contract to be signed with both the agencies 161

162 and further approval of the Bihar State Pollution Control Board is awaited. GOI had approved an amount of Rs crores for the project in PIP Budget Activities Dissemination and Sensitization workshops on IMEP Guidelines at divisional levels Training of in-house staff (ANM, Safai Karmacharis, clinical support staff) on recognizing, segregating and disposing of bio-medical wastes Operationalization of Biomedical Waste Rs lacs pm per PHC (533), Rs lacs per Referral Hospital and SDH (113) and Rs lacs per DH (36) and Rs 0.45 lacs pm per Medical College (6) Total Total proposed budget (in Rs.) 1,00,000/- 10,00,000/- 9,36,16,000/- 9,47,16,000/- (The fund received for the activity in , may be approved for utilization in this FY of ) Work plan Activities Dissemination and Sensitization workshops on IMEP Guidelines at divisional level Training of in-house staff (ANM, Safai Karmacharis, clinical support staff) on recognizing, segregating and disposing of bio-medical wastes Operationalization of BMW at PHCs, SDH, Referral Hospitals, DHs and Medical Colleges Q1 Q2 Q3 Q Dialysis Units in various Government Hospitals of Bihar It is proposed to set up & Operationalising Dialysis Units through Public Private Partnership (PPP) in 25 Hospitals of Bihar. This would require operation, maintenance and reporting 24-hours 7 days a week Dialysis units in Hospitals. 162

163 The State Government shall provide vacant space in the premises of the Hospital itself with additional space for washing and RO plant installation (incase it is not in-built). The space provided shall be approx sq.ft. including RO plant. The agency has to provide everything from equipments & machine, logistics, consumables etc to suitable medical personnel to man these units. The agency has to also ensure the installation, maintenance, functioning with provision of technical manpower round the clock. No rates shall be charged from the patients. Tender bids have already been floated for the same and M/s Apollo Hospitals, Chennai have been finalized for undertaking the task. Government/SHSB shall pay a monthly rental to the agency, based on the monthly cost as projected by them in the financial bid. Status Negotiations are on with M/s Apollo on the costing for the Dialysis unit GOI had approved Rs.3.00 crores for the project in the last PIP. Budget Activities Project cost for one Dialysis unit with 8 Dialysis machines (covering suitable manpower, power, diesel, water, general medical indent & consumables, CMC, RO membrane changing, resin changing, pre-filter changing, activated carbon filter changing, sedimentation filter changing, insurance of equipments, building maintenance, administrative expense, contingency, depreciation on equipments etc) Total proposed budget Rs lacs x 1 year x 6 units= Rs.3.00 Crores (The previously approved Rs.3.00 is available with the State which may be ratified for expenditure in ) 4.8. Setting Up of Ultra-Modern Diagnostic Centers in Regional Diagnostic Centers (RDCs) and all Government Medical College Hospitals of Bihar State Health Society Bihar is implementing the National Rural Health Mission (NRHM) to improve the availability of and access to quality health care for people. Setting up of Ultra-Modern Diagnostic Centres through Public Private Partnership (PPP) in 9 Regional Diagnostic Centres (RDCs) and 6 Medical College Hospitals (MCHs) of Bihar has been initiated. Project Area Regional Diagnostic Centers in Ara, Gaya, Bhagalpur, Munger, Muzaffarpur, Motihari, Purnea, Saharsa and Chapra. Government Medical College Hospitals PMCH, NMCH, SKMCH, DMCH, ANMMCH, JLMNCH 163

164 M/s Softline, New Delhi and M/s Doyen Diagnostics, Kolkata have been contracted to set up the Ultra-Modern Diagnostic Centers. Project Scope To operate, maintain and report 24-hours Ultra-Modern Diagnostic Centers in RDCs & MCHs and report the progress to the RDDs (who would be in-charge of monitoring the RDCs project) and the Superintendents (who would be in-charge of monitoring the MCH project) and the SHSB. Project Condition - The State Government has created the buildings for Regional Diagnostic Centers at all the towns mentioned in Project Area. In the case of MCHs, space shall be provided in the premises of the MCH itself at the discretion of the Superintendent of the concerned MCH. The agency has to provide everything from equipments & machine, logistics, consumables etc to personnel; the said RDC/MCH will only provide space for the Diagnostic Centre along with space for storage at a nominal monthly rent payable to the DHS of the concerned district (in the case of RDC) and the Rogi Kalyan Samiti of the concerned MCH (in the case of MCH) by the agency. The agency has to ensure the installation, maintenance, functioning with provision of expert technical manpower round the clock. Rates (to be charged from the users) shall be applicable as per AIIMS, New Delhi for the basic, standard and other specialized tests under each Diagnostic head. The project is on a revenue sharing model The project is for ten (10) years depending upon performance further extension will be considered. Facilities that will be provided in RDCs and MCHs are Pathology- Bio-Chemistry, Radiology Digital x-ray, CT scan, MRI, ECG, Mammography. GOI had approved the project in the SPIP The state requires budget in this regard only for reimbursement to the Private Parties by the RKS of the concerned hospital for providing free services to BPL patients. All the remaining cost for setting up centers will be borne by the private providers. Budget Activities Total proposed budget Reimbursement cost to the Private Parties by the RKS of the Rs.200 x 1000 BPL patients x 12 concerned hospital for providing free services to BPL patients months x 15 units= Rs.3.60 Crores 164

165 4.9. Providing Telemedicine Services in Government Health Facilities SHSB has sought Public Private Partnership in providing Telemedicine Services in Government Hospitals of Bihar. Additionally the State is also in consultation with ISRO for providing technical support for the same either based on Gujarat or Orissa model. The project shall be initially piloted in two or three districts. Project Goal: The goal of this project is to establish a model for application of Telemedicine to address the issues of improving accessibility, more efficient use, ensure equitable distribution and enhancing the quality of available health services across the state. Project Objectives: The overall objective of the assignment is to provide a comprehensive model for Telemedicine in the state of Bihar. The specific objectives of the assignment are - Establish and Provide Telemedicine Network for accessibility of healthcare service facilities in the State linking 2-3 District Hospitals to Patna Medical College Hospital (PMCH) of the State. To reduce the cost of health services by providing specialized service through the network. Upgrade the skills of existing Medical staff at the DHs and PMCH. To ensure routine Management and Administration of the activities To provide timely reports and information to the SHS, Bihar for audit and review To ensure Maintenance, Servicing & Up-gradation of the Telemedicine Facility Project Timeframe- the Project is planned for a period of five years, and after that based on evaluation by the SHSB the project may be extended. Scope of Work The outsourced agency will provide complete technical support in terms of designing the telemedicine network for DH & PMCH, supply of hardware and software required, installation and operationalization and maintenance of telemedicine system including necessary training. The agency shall also facilitate defining and formalizing linkages between DHs and MCH and thus facilitate consultation through telemedicine. The detailed roles and responsibilities of the private partners to meet the aforesaid objectives are as follows: Providing the necessary equipment and software for establishment of the above system. Install, Operate and maintain appropriate Telemedicine facility. Sufficient bandwidth to transfer Data Real time videoconferencing with Patient Transfer of diagnostic data on real time basis or/and Store & Forward basis, as the case may be through V-sat/Broadband/ISDN The facility should enable transmission of patients medical records, including images, and provide a live two-way audio and video link between patient and specialist Building the capacity at DH as well as associated PMCH to operate and use the system by providing training. Technical manpower support to run the system to operationalise the project. Continued technical back up for maintenance of the system. 165

166 Ensuring Quality Standards Providing detailed reports of Telemedicine services as per the Proformas provided at the time of signing of the contract, or as issued by the SHS from time to time. The Telemedicine framework shall be at the secondary and tertiary levels: Level 1 District Hospital Level 2 PMCH Tele Medicine Equipment The Software should be able to use any Digital Imaging and Communications in Medical (DICOM standard compliant) equipment. Attachments for capturing and transferring DICOM standard images from various available medical devices, including X Rays; CT Scans; MRIs, and Ultrasound Images Devices for creating high resolution virtual slides from various Pathological images and transferring them The agency shall provide the following equipment at the DHs under this project:- 1. ECG suitable for neonatal, pediatric and adult patients 2. EMG suitable for neonatal, pediatric and adult patients 3. Ultrasound scanner (should be able to do various diagnosis like cardiology, obstetrics & gynecology, radiology etc) 4. Color Doppler ultrasound scanner 5. Endoscope 6. Digital Microscope 7. Indirect Ophthalmoscope 8. Funds Camera 9. Multipara monitor (ECG, Temp, NIBP, SPO2, Heart rate) suitable for neonatal, paediatric and adult patients 10. Electronic Stethoscope 11. Pulmonory function test 12. TMT machine 13. ENT Audiometry 14. Mammography 15. Glucometer 16. Fetal Heart Rate Monitor (for measuring the heart rate of foetus) 17. EEG Note: 1. All the above mentioned instruments would be able to connect to the computer (DICOM compatible) for obtaining digital data. 2. The hardware/software so installed would also be able to send data generated from Digital X-Ray, CT scan and MRI mechanism, which may be installed by the Government. Ailments to be covered under the facility Software would be capable of handling and transferring any type of medical data which may be text, audio, video or image. The Medical areas which would be handled include: Cardiology Radiology Oncology Pathology Ophthalmology 166

167 Nephrology/Diabetes Urology Neurology Psychiatric Dermatology Gynaecology Cosmetic Surgery Vector borne deceases The following Telemedicine software package modules would be used a). Electronic Medical Record (EMR) b). Tele-Cardiology c). Tele-Radiology d). Tele-pathology e). Tele-dermatology f). Tele-endoscopies g). Tele- Ophthalmology h) Video Conferencing Indicators for assessment of the utility of telemedicine system 1. Number of Online Consultations a. Gross Number b. Timings i. Routine ii. Emergency c. As percentage of total seen d. How many physically sent e. How saved the need for transfer f. Whether any dramatic savings (e.g. Life /death matters) ensued 2. Number of investigations a. On line Routine / Emergency investigations. b. Number and type of specialized investigations, waiting time and reporting time 3. Follow up visits 4. Number and type of procedures a. At PHCs b. At centers where staff is referred to. 5. Training of Health and paramedical staff in telemedicine. Expected results: a. Number b. Level of skills and confidence. Speed: Patients can be diagnosed and treated quickly, without the need for a potentially life-threatening journey to a larger hospital. Service extended: Referral process strengthened and specialist advice available at PHC level. Economical: In terms of cost of travel to a hospital for a second opinion and in service itself, once facility set up. Improved quality of health services. 167

168 Institutionalize linkages between PHCs and hospitals through formal arrangements to provide instant consultation to PHCs and also honor referral cases from PHCs. Builds trust: Patients with low level of education are often suspicious of visiting a city specialist. Teleconferencing offers frequent consultation with the specialist, building confidence and improving patients compliance to treatment, thus patient satisfaction will increase Through linkages with specialists and hospital, PHCs will be able to cater to wider spectrum of needs/expectations. Budget Activities Operational cost for providing telemedicine facility in the state in this FY Total proposed budget Rs.3.00 Crores Note : GOI had approved the project and budget in the previous PIP and ratification is solicited for the same for this FY Work plan Activities Floating of tender, Awarding of contract and finalization of interactions with ISRO Pre-Commissioning period Implementation of the project Q1 Q2 Q3 Q Outsourcing of Pathology and Radiology Services from PHCs to DHs Under this scheme Pathology and Radiology services have been outsourced to different Private agencies. The agencies have and/or are in the process of setting up centers/diagnostic labs/collection centers at the hospitals/facilities. The state has fixed the rates on which the agency charges from the patient. The state has to only provide space at the hospitals to the agency for running the Pathology and Diagnostic Centre. However under the project service expansion has been done and Ultrasound facility has to be provided at various locations at DHs and SDHs. For the purpose of establishment of Central Reporting System (CRS) for X-ray and Ultrasound Units is being done at IGIMS, Patna. The purpose being CR system will connect all the Ultrasound and X-ray centers of IGEMS set up in Government Hospitals under this contract, with Teleradiology in a phased manner. 168

169 The Agency shall provide all necessary hardware, software and manpower for establishing the network between IGIMS and each of its Radiology unit having X-Ray and Ultrasound facilities for running the Tele-Radiology service. SHSB has to provide space in coordination with DoH, GOB; radiologist to report on the ultrasound and x-ray images (preferably retired persons), telephone line with broad band connection and necessary power connections. The state requires budget in this regard only. All the remaining cost for setting up centers and providing services will be borne by the private providers. Budget Activities Total proposed budget Telephone line with broad band connection and necessary Rs.1,00,000 x 12 months =12,00,000 power connections Sourcing of private radiologists to report on the ultrasound and x-ray images through the CRS at IGIMS incase of nonavailability of Government per x 6 x 12= 18,00,000 month for 6 radiologists Total 30,00,000/ Operationalising Mobile Medical Unit SHS, Bihar on behalf of the Department of Health, Government of Bihar, has invited Private Service Providers for providing Mobile Medical Units (each unit fitted with GPS- Global Positioning System) to provide primary health care facilities in the hard to reach rural areas of various districts of Bihar. Three agencies have been awarded the contract for operationalising mobile medical units in all the districts. Scope of Work Private Service Providers for providing mobile health care services in rural Bihar of curative, preventive and rehabilitative nature, to be provided by the service provider along with all deliverables like Mobile Clinic (each unit fitted with GPS- Global Positioning System), professional manpower, and other such services, to provide and supplement primary health care services for the far flung areas in the various districts of Bihar and to provide a visible face for the Mission. 169

170 Project Objective To provide and supplement regular, accessible and quality primary health care services for the farthest areas in the districts of Bihar and to provide visible face for the mission and the Government, also establishing the concept of Healthy Living among the rural mass Project Scope The detailed roles and responsibilities of the private partners to meet the aforesaid objectives are as follows: Providing the requisite vehicle and equipments and software for Operationalization of the MMU. Install, Operate and maintain appropriate GPS facility. Technical manpower support to run the MMU and provide the services Continued technical back up for maintenance of the system. Ensuring Quality Standards Providing detailed reports and maintain database of information of MMU services as per the Proformas provided at the time of signing of the contract, or as issued by the SHS from time to time. Vehicle Type for MMU o o o o o Brand new GPS fitted, fully Air Conditioned TATA 709 chasis or equivalent vehicle of similar dimension from reputed manufacturers for MMU An accompanying vehicle of TATA Sumo or Mahindra Bolero or equivalent specification make vehicle for Carriage of Medical persons and also to be used as ambulance for transporting patients in case of emergency. The body of vehicle should be suitably modified to serve this dual purpose. Mobile Van should be designed keeping in mind the following criteria -ease of deployment, female privacy, community acceptance and cost. Web enabled MIS has to be ensured along with a Control room at Patna or Commissioner HQ. Temporary shed facility shall have to be ensured at the site for the patients in waiting. Manpower The manpower to be employed for the program is to be appointed by the Private agency as such-1 Doctor, 1 Nurse, 1 Pharmacist (van supervisor),1 OT assistant, 1 X-ray technician, 1 ANM, 1 Driver (Qualification requirements annexed) Equipments to be provided in the MMU Medical Equipments -Semi Auto-Analyzer, Portable X ray unit, Portable ECG, Microscope, Screen, Stretcher, O.T Table with standard accessories, Stools, Dressing Trolley/Instrument trolley, Dressing drums, Oxygen Cylinder, Suction Machine., Ophthalmoscope, Refraction set, Horoscope, Mobile light or Ceiling light (OT Light),Centrifugal Machine, Hemoglobin meter, Glucometer, Autoclave, Incubator, Urine Analyzer, Vaccine carrier, Weighing machines-adult and infant, Stethoscope, BP Instrument, Kits like Suture removal kit, Pregnancy test kit, IUD insertion kit, Starter, Regent kit, HIV testing kit, General Instrument kit, First Aid kit, various, tests and surgery kits, Normal Ambulance appliances or accessories like foldable furniture, waste basket, linen, mattress, mackintosh sheets, fire extinguisher etc Silent DG set, Audio-Visual Equipment with projection system for IEC especially with, 40 LCD, P&A System, Cell phone Service Areas The Medical areas which would be handled include: 1. Free General OPD/ Doctor Consult 170

171 2. Free Drugs - Free dispensation and procurement of medicines as per the Essential Drug List prescribed by GoB for PHCs (Annexed) has to be ensured by the private agency 3. Emergency Services during epidemics and Disasters 4. Network and referral between PHC/CHC/Private clinics 5. Generating health indicators and monitoring behavioral changes 6. Gynec clinic 7. Antenatal Clinics 8. Post Natal Care 9. Infants and Child Care including immunization with Vitamin A supplementation (support for the same to be provided by the Government) 10. Diagnosis, Referral and Rehabilitation for Non-communicable diseases eg. Cardiac Diseases, Hypertension, Diabetes, etc 11. Adolescent and Reproductive Health 12. Other Services like Treatment of Minor Injuries and Burns, Aseptic Dressing, TT immunization, Treatment of Minor burns, Minor Suturing and removal referral etc 13. Minor lab investigations 14. Eye examination 15. ENT examination 16. HIV testing 17. Promotion of contraceptive services including IUD insertion. 18. Prophylaxis and treatment of Anemia with IFA Tablets. 19. IEC and counseling along with preventive health screening and health awareness programs 20. Service related to different public health programmes. 21. Pathological services. 22. Radiology Services X-ray and Ultra-sound 23. Preventive Health Screening and Health awareness programs 24. Medical camps will have to be conducted whenever emergency need be Commissioning Period- 2 months from the date of contract signing Budget Activities Total proposed budget (in Rs.) Projected cost for 1 MMU project at district level Rs.4.68 lakhs x38 units x 9 months =16,00,56,000/- Total 16,00,56,000/ Monitoring and Evaluation State Data Centre The State has One Data Centre which collects data from all PHCs, Sadar Hospitals & Sub. Div. Hospitals of all districts on a daily basis through land line phones and mobile phones. The collected data are stored and maintained in a computerised format and they are sent to respective programme officers according to their requirements. The collected data includes all the parameters required under RCH/NRHM for monitoring. The Data Centre has the following facilities:- 171

172 (1) Computer Programmers- 2 (Two) (2) Supervisor- 2 (Two) (3) Computer Operators- 20 (Twenty) (4) Server with UPS - 1 (One) (5) Computers (including one server) with UPS - 22 (Twenty two) (6) Fax Machine with Auto Sending & Receiving Facility - 1 (One) (7) Laser Printers with Fax & Photo Copy Facility - 4 (Four) (8) Telephone connection (with Broadband connection) - 20 (Twenty) (9) Invertor - 1 (One) (10) Software - As Required (11) EPABX-Telephone Network System - 1 (One) (12) All necessary furniture s - As Required District & Block Data Centres The Data Centers at each and every hospital (PHC, Sadar Hospital, Sub-Divisional Hospital etc.) are being established through outsourcing. The main purpose of these Data Centers of Hospitals is to gather and maintain health related data under RCH/NRHM programme in their computer system and they upload the gathered health related data on the web-server of SHSB on daily basis. The Data Centers contain one computer with UPS, Laser printer, Phone connection, Internet connection, Computer operator, Misc. etc.the GPRS enabled mobile sets have been given to each and every data centers. The total no. of Data Centers to be established is 685 and the estimated cost is Rs. 7500/- per Data Centre per month. The District/Block Data Centres units would be as such: Primary Health Centre (PHC): 533 Sub-Divisional Hospital (SCH): 43 (23+20 (new)) District Hospital: 38 (25+13 (new)) RDD: 09 District Health Society: 38 Medical Colleges & Hospitals: 24 (6 x 4) Total Data Centre: 685 Budget Activities Total proposed budget (in Rs.) State Data Centre (monthly payment of the Data Centre is Rs /-, therefore, Rs x 12 Rs /- District & Block Data Centres Rs. 7500/- x 12 x 685 Rs /- Total 6,37,50,000/- 172

173 4.15. Generic Drug Shop Under the PPP initiative Generic Drug Stores shall be set up at all MCHs, DHs and PHCs. The Private agency has to keep 188 types of drugs at the store. The state has provided only space for this purpose to the agency and the agency shares a % revenue share with the Government. The state has also fixed rates for the Generic Drug as per MRP. No additional cost is involved Nutrition Rehabilitation Centres (NRCs) for Treatment of Severe and Acute Malnutrition (SAM) Child malnutrition extracts a heavy toll on both human and economic development, accounting for more than 50 % of child deaths world wide. The consequences of malnutrition are serious leading to stunting, mental and physical retardation, weak immune defense and impaired development. More than one-third of worlds malnourished children live in India. In India, as revealed by the recent National Survey (NFHS-3, ), malnutrition burden in children under three years of age is 46 %. With the current population of India of 1100 million, it is expected that 2.6 million under-five would be suffering from severe and acute malnutrition which is the major killer of children under five years of age. It can be direct or indirect cause of child death by increasing the case fatality rate in children suffering from such common illnesses as diarrhea and pneumonia. The risk of death in these children is 5-20 times higher compared to well-nourished children. Severe and acute malnutrition is defined by a very low weight for height, below -3 z scores of the median WHO growth standards, presence of visible severe wasting or bipedal Oedema, or mid-upper arm circumference (MUAC) of <11 or 11.5 cm in children between 6-60 months. MALNUTRITION IN BIHAR: In Bihar, malnutrition is a serious concern with a high prevalence of 58.4 % as revealed by the National Health and Family welfare Survey (NFHS-3, ). Children suffering from severe and acute malnutrition are reported to be 8.33 %. Based on population figures, it is estimated that in Bihar, 2.5 million children under five years of age are threatened to face the consequences of severe malnutrition. With the situation of nutrition among children being far from satisfactory, it will not be surprising to find that these children who have already arrived in a poor state of nutritional status, with further deterioration are at a high risk of morbidity and mortality. A z score is the number of standard deviation below or above the reference mean or median value. 173

174 MEASURES TO MANAGE MALNUTRITION: While mild and moderate forms of malnutrition in the absence of any minor or major illness among children can be addressed through Anganwadi centres, by supporting mothers to ensure service utilization and appropriate feeding and care practices at the household level; the treatment of children with severe and acute malnutrition calls for facility-based treatment by admitting children to a health facility or a therapeutic feeding centre. This is mainly because these children generally are seen to suffer from acute respiratory infections, diarrhea and pneumonia. A decision was thus taken to set up Nutrition Rehabilitation Centers which is a unit for the management of SAM children where they are kept under observation and provided with medical and nutritional care. In additional to curative care, special focus is given on timely, adequate and appropriate feeding to children. Efforts are also made to build the capacity of mothers through counseling to identify the nutrition and health problems in their child. Initial discussions with UNICEF on establishment of NRCs in the 2007 flood affected districts, resulted to be extremely productive. It was thought worthwhile to pilot NRCs for treatment of children suffering from severe forms of malnutrition in 2 flood affected districts with support from UNICEF for supervision and monitoring of activities, especially in the initial period of management of NRCs. Thus the NRCs were established in the districts of Muzaffarpur and East Champaran during August-September The proposal includes the establishment cost and the running cost for the two piloted NRCs in the management of child malnutrition. Budget Activities Running cost of two NRCs for one month = 2,05,600/- x 2 = 4,11,200/-, therefore for one year, x 12 months Total proposed budget (in Rs.) 49,34,400 Total 49,34,400/ Hospital Maintenance (Funded by State Govt) The state has outsourced the maintenance of Hospitals to private agencies. The amount require for this purpose is borne by the state government. The activities include Maintenance of Hospital Premises. Generator Facility. Cleanliness of Hospitals. 174

175 Washing Diet Providing Ward Management Services in Government Hospitals It is proposed to provide Ward Management Services including Ward Boys for about 1900 health facilities in Bihar like the 100, 300 and 500 bedded District Hospitals, 100 bedded Sub-Divisional Hospitals, 30 bedded Referal and Primary Health Centres and 6 bedded Additional Primary Health Centers and also Govt. Medical College Hospitals. The task shall be done under PPP, wherein the agency shall be responsible for the following services- Providing one ward boy for 10 or less than 10 beds and at the rate of one boy per additional 10 beds. Ensuring 7x24 hours services of Ward Boys. Shall provide one wheel chair for 10 beds or less one wheel stretch for additional 20 beds. Deploying all Ward Boys in uniform dress bearing a unique identification no. with name. Assisting the nurses in the detoxification unit. Attending to the personal hygiene of bed-ridden patients. Escorting the patients to labs, other specialists & wards. Monitoring the visitors and checking patients for possession of drugs. Conducting physical exercises for the patients. Assisting in detoxification of toilets and ward etc. Daily replacement of used bed-sheets by clean bed-sheets with proper care. Any other task related to ward management prescribed by the authority. Payment shall be made on a per bed per month for all the hospitals. In the FY , it is to be piloted in 5 District Hospitals therefore initially fund is required as such - Budget x 2500 beds x 12 months=30.00 lakhs Provision for HR Consultancy services SHSB has invited offers from Human Resource Consultancy Services for assisting State Health Society in selection and recruitment of doctors, nurses, paramedical staffs and other managerial and clerical staff under guidance and direction of State Health Society, Bihar. Responsibilities of the Human Resources Consultant: The Consultant will be required to prepare panel of names for selection for the post as per reservation roster. Applications would be invited through open advertisements. Selection process may include open written test or interview or marks obtained or combination of these processes in the qualifying examination depending upon the no. of applicants and urgency. The mode of selection to be adopted will be the sole discretion of the State Health Society. 175

176 To achieve this objective, Human Resources Consultant shall be responsible for the following services:- Will have to set up an office for this purpose. Will be providing all office equipments and professional manpower for this purpose. SHSB shall provide only space. All works like processing, data entry, scrutiny, selection, panel formation as per reservation roaster and recruitment etc. Any other task related to Human Resources Consultancy Services prescribed by the authority Advanced Life Saving Ambulances Budget Rs.22,50,000/- per year SHSB is endeavoring to provide prompt quality pre hospital care to patients, trauma victims, pregnant women, for the purpose of which Emergency Network service is being piloted under PPP in Patna District. The objective is to save lives of Road Traffic Accidents, cardiac emergencies, fire victims and other emergency cases. Description There will be 5 Advance Life saving Ambulances (Trauma, Critical & Cardiac Care) & 5 Basic Life saving Ambulances which will run within Patna Municipal Corporation area and its sub urban areas. Every Ambulance shall be manned by a Driver, an Emergency Medical Technician and trained Helper to provide basic care during transportation of patients.). For each trip made by the Ambulance to anywhere within the limits of Patna Municipal Corporation and its sub-urban areas, a charge of Rs. 300/- shall be collected by the outsourced agency from the patients. The agency has to set up a Control Room in Patna which would operate for 24 hours in a minimum of 3000 sq. ft. area through dedicated toll free three digit telephone numbers (102). The agency has to provide 10 parallel lines with hunting facilities. The Control Room will receive emergency calls related to Medical Services and from Police and Fire Fighting Services to cater to Medical Emergencies. The agency shall provide GIS (Geographic Information System) maps, GPS (Global positioning systems) / AVLT (Automatic Vehicle Location Track) and all the other necessary hardware/software for Computer Telephonic Integration. The agency shall keep a record of the contact numbers and location of each of the 10 Ambulances, all Hospitals of city which can provide medical emergency, all the Police Stations, Police Control Room, Police Head-quarters and Fire Services in the city. The agency shall bear all expenses relating to hire of space, water, electricity charges, furniture, furnishing etc in running the Control Room. The Control Room shall also keep battery / generator backup facility so that services could be provided un-interrupted round the clock. Support activities- The agency has to also undertake the following-listing of Govt and private hospitals which can provide emergency services round the clock. Necessary training of hospital personnel to take up Emergency cases. Dissemination of the scheme and the toll free numbers for police, fire, health, education and general public so that this service can be utilized. Budget- Items Amount (Cost/month) Cost of Emergency service network in x 9= Patna (annual cost for running 10 ambulances) Total 89,01,000 IEC of the project, dissemination, 25 lakhs being provisioned in IEC, Training (Part monitoring and training A budget) 176

177 7. Mobilisation and Management Support for Disaster Management In Bihar, the northern part is extremely flood prone. Due to the confluence of many rivers as well as its proximity to the hills of Nepal, the population living in about twenty two districts in Bihar suffers from floods every year. In the year 2007, the floods have been among the most devastating in decades. East Champaran, Darbhanga and Madhubani districts of Bihar, have been affected by floods most of the years and face floods almost every year, only the extent and the intensity vary. In 2007 however, over 24 million people in some 8,500 villages in 22 districts in Bihar (including 2.5 million children below 5 years) were affected by floods. As per the department of disaster management, over 800 people lost their lives. The most affected districts are Muzaffarpur, Sitamarhi, East Champaran, Saharsa, Supaul, Madhubani, Darbhanga, Katihar, Samastipur, Sheohar, Khagaria, Madhepura, Araria, Begusarai, Gopalganj and West Champaran. There is a need to strengthen local capacities and develop the community potential to tackle the flood moving towards early recovery. There are essentially two types of the vulnerable affected in need of immediate assistance: a) those who are displaced; b) those who are in original locations but cut off. In year 2008, the floods were mainly due to the rivers, in Kosi region, changing their course, which was an outcome of a major breach in the eastern embankment of Kosi River in Kusha (Indo-Nepal) border in mid- August The Department of Disaster Management, Bihar has estimated that 2.95 million people across 979 villages are facing the perils of present floods in the five districts-araria, Supaul, Saharsa, Madhepura and Purnea. About 1.18 lakh are expected to be the vulnerable segment of pregnant and nursing women and about 4.4 lakhs are likely to be children less than 5 years of age. Preparedness is the best response: Global and National experience in disaster situations indicates that immediate and appropriate response mitigates the agony of affected population. In flood related disaster, due to several factors, such as, the timing of flooding, the magnitude of floods, large number of people affected, scope of displacement, and low awareness among the affected on the health hazards, there has been an acute risk of outbreaks of water borne and vector borne diseases, such as gastroenteritis, malaria, dengue fever, leptospirosis and diarrhoea in the flood affected areas. Children under five, pregnant mothers, elderly and patients are at the highest risk of becoming victims to epidemics. Another factor which increases vulnerability is the socioeconomic profile of the affected. A large majority of them belong to socially marginalized communities who are poor as well. Providing clean potable water, protecting the area from epidemics, Safe delivery options for the pregnant mothers, rehydrating the diarrhea affected people of all age groups with ORS, immunizing children from 6 months-10 years in the affected area with measles vaccine, essential treatment for the sick etc are some of the absolute priorities for the health personnel during a disaster. 177

178 To protect the health of the affected population based on the past experience, it is proposed to preposition certain important health response supplies during the current year at State level. These supplies can be sent to the affected populace at the earliest to provide relief. The calculations are being done assuming the affected population to be 20 million and based on last year s initiatives and expenditure by the state- With the experiences of the last year the state would like to propose a revolving fund for the preparedness and relief for the flood affected people in the State: Budget: Activity Unit Rate Amount ( In Rs ) Setting up of State Health Disaster Management 1 58,750 x 12 7,05,000 Cell in Health Department, GoB months Mobilizing medical teams from Non flooded ( a team 12,95,000 districts for one week of two Doctors and two paramedics for 7 days) Transportation,Mobility & Monitoring state & Rs.5.00 lakhs district level for 16 districts per district Total 1,00,00,000/- 8. Health Management Information System (1) Web Server System The State Health Society has established one web-server with 512 kbps leased-line connection for on-line uploading and reporting of Health related data through web-server application of State Health Society, Bihar. The following system shall be introduced in parallel to the existing system of Data centers: 1. Online uploading of Health related data directly from Data Centers of PHC/Hospitals. 2. Compilation and reporting of Health related data through developed application software in very less time. 3. The reports will be more accurate and consistent. 4. The DM/CS/DHS can view the different reports of Health services of their own district in on-line mode, therefore proper action can be taken quickly. 5. The officers/staff of state level can view the reports of Health services of all districts in online mode, therefore proper action can be taken promptly. 178

179 6. According to requirement, any new report can be added and the information can be obtained from PHC/Hospitals in online mode quickly. 7. More security and safety of Health related database. Therefore further up-gradation and maintenance of web-server are required in coming financial year like blade server (more storage capacity and very high speed processing), maintenance support of web-server etc. The website for all 38 districts are also required to be designed, created and maintained along with the renovation of website of State Health Society, Bihar. Budget S. No Items Amount (Rs.) 1 Leased Line(512 KBPS) Rs /- 2 Up gradation of Leased Line - (1MBPS) Rs /- 3 Antivirus (No. of antivirus-3) Rs /-(Rs x 3) 4 Web-site: (Design, Creation, Maintenance, Registration, Rs /- Hosting of state and all 38 districts) 5 Blade Server(One Blade) Rs /- 6 One Additional Blade Rs /- 7 Maintenance Rs /- 8 Software development Rs /- Total Rs. 19,87,644/- (2) HMIS Reports As we know that NRHM aims to continuously improve and refine its strategies based on the inputs and feedback received from the State and from various review missions. One of our priorities is to build a robust Health Management Information System (HMIS) that is used for improving, planning and programme implementation at all levels. NRHM has introduced Revised HMIS formats and they are as follows: SN Form No. Form Name Used at Frequency 1 NRHM/HSC/3/M Monthly format for SC s and Monthly (5 th of HSC equivalent facilities following month) 2 NRHM/PSC/3/M Monthly format for PHC s and Monthly (5 th of PSC equivalent facilities following month) 3 NRHM/CSC/3/M Monthly format for CHC s and Monthly (5 th of CSC equivalent facilities following month) 4 NRHM/SDH/3/M Monthly format for SDH and Monthly (5 th of SDH equivalent hospitals following month) 5 NRHM/DH/3/M Monthly format for DH and Monthly (5 th of DH equivalent hospitals following month) 179

180 6 NRHM/DHQ/3/M Monthly format for District DHQ Monthly (10 th of following month) 7 NRHM/DHQ/2/Q Quarterly format for District DHQ Quarterly (10 th ) 8 NRHM/DHQ/1/A Annual format for District DHQ Annual (5 th ) 9 NRHM/SG/2/Q Quarterly format for State HQ State HQ Quarterly (20 th ) 10 NRHM/SG/1/A Annual format for State HQ State HQ Annual (15 th April) 11 NRHM/GOI/3/M Monthly Consolidated State HQ/DHQ Monthly (20 th of following month) 12 NRHM/GOI/2/M Quarterly Consolidated State HQ/DHQ Quarterly (20 th of following month) 13 NRHM/GOI/1/A Annual Consolidated State HQ/DHQ Annual (30 th April) It is required to implement the Revised HMIS formats up to sub-center level. (A) Printing of Formats Sl.No. Form No. No. of Pages/ Format Total No. of Pages used at one Health Institution Total No. of Health Institution Total No. of Pages used at all Institution/Yr Details 1 NRHM/HSC/3/M 4 48(12x4) x48 2 NRHM/PHC/3/M 6 72(12x6) x72 3 NRHM/CHC/3/M 7 84(12x7) x84 4 NRHM/SDH/3/M 7 84(12x7) x84 5 NRHM/DH/3/M 7 84(12x7) x84 6 NRHM/DHQ/3/M 1 12(12x1) x12 7 NRHM/DHQ/2/Q 2 8(4x2) x8 8 NRHM/DHQ/1/A 2 2(1x2) x2 9 NRHM/SG/2/Q 1 4(4x1) 1 4 1x4 10 NRHM/SG/1/A 3 3(1x3) 1 3 1x3 11 NRHM/GoI/3/M 6 72(12x6) x72 12 NRHM/GoI/2/Q 2 8(4x2) x8 13 NRHM/GoI/1/A 7 7(1x7) x7 Total Surplus No. of Forms (including wastage and others-10%) Grand Total of Pages Total Printing Cost Rs per page) Rs /- B: Transportation of Formats No. of pages sent per district= /38 = 22207(approx.) Transportation Costs per district=rs

181 Total Transportation Cost for all 38 districts=38xrs.1000= Rs /- C: Training At Block Level (PHCs, District Hospitals, Sub-Divisional Hospitals) Training on Revised HMIS formats at District Level has been completed, so Training on Revised HMIS Formats at Block Level (i.e. PHC, District Hospital and Sub-Divisional Hospital levels) has to be performed. Therefore it is required to train the followings :- Deputy superintendent of District & Sub-Divisional Hospitals MOIC of PHCs BHM BAM The training has to be performed to improve the quality of data. So the master trainer of each and every district will train Deputy Superintendent, MOIC, BHM and BAM in their respective district. Hence Fund require for giving TA/DA to all trainees and for training materials, stationeries and other cost. The TA/DA given to trainees is Rs. 200/- per trainee (Only one time) and miscellaneous cost is Rs. 50/- per trainee (Only one time) Therefore budget calculation is as follows:- (a) Total no. of trainees = 1680 The details are as follows:- SN Designation Number 1 Deputy superintendent of District 38 (25+13 (new)) Hospital 2 Deputy superintendent of Sub- 43 (23+20 (new)) Divisional Hospital 3 MOIC of PHC BHM BAM 533 Total 1680 Budget S. No Items Amount (Rs.) 1 Web Server System 19,87,644/- 2 HMIS Reports A Printing of Formats 8,81,873 B Transportation of Formats C Training of Formats at Block level (TA/DA Cost = Rs. 200/- 4,20,000 per trainee (only one time) x 1680= Rs /- + Misc. cost = Rs. 50/- per trainee (one time) 50 x 1680=84000/-) Total 32,89,517/- 181

182 9. Strengthening of Cold Chain Effective cold chain maintenance is the key to ensuring proper availability and potency of vaccines at all levels. However the recently concluded Vaccine Management assessment (VMAT) in Bihar in 2008 and the National Cold chain assessment (July 2008) observed several deficiencies in cold chain storage and management in Bihar. With a steadily increasing immunization coverage for Routine Immunization, rise in demand for Immunization services throughout the state, the consumption of large quantities of vaccines in frequent Supplementary Immunization activities and the possibility of introduction of newer vaccines in the near future, it is necessary that the capacity of existing cold chain stores as well as the proper management of immunization related logistics be strengthened on a urgent basis. For this there is need for refurbishment of existing cold chain stores at all levels, particularly at the level of the larger state, 9 regional and 38 district stores. Often there is lack of storage space in the existing health stores leading to dumping of critical immunization related logistics like AD syringes, vaccine carriers and cold boxes in the open, exposing them to the vagaries of nature and sometimes leading to their damage. Renovation of existing stores would help in creating more organized dry space for both proper storage of material as well as proper loading, packing and unloading of Immunization related logistics. The state store in particular receives large quantities of materials and a separate ware house is needed to store immunization related logistics. Provision to hire storage space on arrival of large quantities of material should also exist. In all stores across the state there is also a need for proper electrification and wiring to ensure longevity of electrical cold chain equipment and for reducing their frequent breakdown. The lack of dedicated support manpower for immunization logistics management and for cold chain equipment repair at all levels was observed during the aforesaid cold chain assessments and it was recommended that At each of these facilities there should be a full time dedicated store manager. Where the load of operations is high (SVS and RVS) the store manager should have adequate support staff to help him. (VMAT Bihar 2008) The National cold chain assessment also recommended that a there should be a cold chain technician along with a cold chain handler at all district stores and a cold chain handler at all PHCs. Since provision of regular staff in these positions is not possible it is envisaged that contractual persons be hired for these activities. Budget 9.1 Infrastructure Strengthening for Cold Chain Items Units Amount Refurbishment and integration of existing Warehouse facilities for R.I. as well as provision for hiring external storage space for (during Immunization Campaigns) Logistics at State 15,00,000/

183 Refurbishment of existing Cold chain room for district stores in all districts with proper electrification,earthing for electrical cold chain equipment and shelves and dry space for non elecrtical cold chain equipment and 7 Lakhs per district Earthing and wiring of existing Cold chain rooms in all 10000/- per PHC Total 572 3,34,30, Mainstreaming AYUSH under NRHM The Indian systems of medicine have age old acceptance in the communities in India and in most places they form the first line of treatment in case of common ailments. Of these, Ayurveda is the most ancient medical system with an impressive record of safety and efficacy. Other components such as Yoga, Naturopathy are being practised by the young and old alike, to promote good health. Now days, practice of Yoga has become a part of every day life. It has aroused a world wide awakening among the people, which plays an important role in prevention and mitigation of diseases. Practice of Yoga prevents psychosomatic disorders and improves an individual s resistance and ability to endure stressful situation. Ayurveda, Yoga, Unani, Siddha and Homoeopathy (AYUSH) are rationally recognised systems of medicine and have been integrated into the national health delivery system. India enjoys the distinction of having the largest network of traditional health care, which are fully functional with a network of registered practitioners, research institutions and licensed pharmacies. The NRHM seeks to revitalize local health traditions and mainstream AYUSH (including manpower and drugs), to strengthen the Public Health System at all levels. It is decided that AYUSH medications shall be included in the drug kit of ASHA, The additional supply of generic drugs for common ailments at SC/PHC/CHC levels under the Mission shall also include AYUSH formulations. At the CHC level two rooms shall be provided for AYUSH practitioner and pharmacist under the Indian Public Health Standards (IPHS) model. At the same time, it has been decided to place or provision one Ayush doctor on contract at the APHCs for the purpose and to ensure complete coverage of the population. Activities Improving the availability of AYUSH treatment faculties and integrating it with the existing Health Care Service. Strategies Integrate and mainstream ISM &H in health care delivery system including National Programmes. Encourage and facilitate in setting up of Ayush wings-cum-specialty centres and ISM clinics. Facilitate and Strengthen Quality Control Laboratory. 183

184 Strengthening the Drug Standardization and Research Activities on AYUSH. Develop Advocacy for AYUSH. Establish Sectoral linkages for AYUSH activities Delivery System 1. Integration of AYUSH services in 1234 APHC with appointment of contractual AYUSH Doctors. 2. Appointment of paramedics where AYUSH Doctors shall be posted. 3. Strengthening of AYUSH Dispensaries with provision of storage equipments. 5. Making provision for AYUSH Drugs at all levels. 6. Establishment of specialized therapy centers/yush wings in District Head Quarter Hospitals & Medical Colleges. 7. AYUSH doctors to be involved in all National Health Care programmes, especially in the priority areas like IMR, MMR, JSY, Control of Malaria, Filaria, and other communicable diseases etc. 8. Training of AYUSH doctors in Primary Health Care and NDCP. 9. All AYUSH institutions will be strengthened with necessary infrastructure like building, equipment, manpower etc. 10. Yoga trainings were held in various District hospitls to provide Yogic therapy for specific diseases and also as a synergistic therapy to all other systems of treatment. Integration of AYUSH with ASHA 1. Training module for ASHAs and ANMs has to be updated to incorporate information of AYUSH. 2. Training & capacity building to be undertaken by the Director, SIHFW and necessary training material for the purpose to be modified and provided accordingly. 3. Drug kit that will be provided to ASHA contains one AYUSH preparation in the form of iron supplement. But other drugs which are used in the treatment of common diseases control of communicable diseases as well as drugs promoting the maternal and child health as well as improving quality of life could be included subsequently. Drug Management 1. Provision of supply drugs per AYUSH dispensary has been projected as per NRHM norm. 3. Provision of medicines for District AYUSH wings and Specialty Therapy Centres is proposed to be operated in the State. Special Initiatives for Mainstreaming and Strengthening of Ayush (a) Ayush department in Bihar contain 3 units known as Ayurvedic Unani and Homeopathic. Government of Bihar running individual dispensary in rural area and a district level joint dispensary of each 3 units (Ayurvedic, Unani and Homeopathic). Following details of rural and district dispensary is given with their required fund far medicine, machines and miscellaneous expenditures. Sl. Dispensaries N o. 1. District Joint Hospitals (i) Ayurvedic No. of dispensa ries Medicine 184 Machines & equipments For miscellaneous expenditure 26 25,000x26=6,50,000 25,000x26=6,50,000 10,000x26=2,60,000 (ii) Unani 26 25,000x26=6,50,000 2,50,00x26=6,50,000 10,000x26=2,60,000 (iii) Homeopathic 26 25,000x26=6,50,000 25,000x26=6,50,000 10,000x26=2,60, Rural Dispensaries (i) Ayurvedic 69 25,000x69=17,25,000 25,000x69=17,25,000 5,000x25=3,45,000

185 (b) Sl. N o. (ii) Unani 30 25,000x30=7,50,000 25,000x30=7,50,000 5,000x30=1,50,000 (iii) Homeopathic 29 25,000x29=7,25,000 25,000x29=7,25,000 5,000x29=1,45,000 Total ,50, ,50, ,20, Ayush Units are also functioning in additional primary health centre in general health services. The details of the APHC (Ayush) and their required medicines, machine and equipments and other expenses are given as follows:- Dispensaries 1. APHC(Ayus h) (i) Ayurvedic No. of dispensari es Medicine Machines & equipments For miscellaneous expenditure ,000x263=65,75,000 25,000x263=65,75,000 10,000x263=26,30,000 (ii)unani 77 25,000x77=19,25,000 25,000x77=19,25,000 10,000x77=7,70,000 (iii) 59 25,000x59=1,47, ,000x59=1,47, ,000x59=5,90,000 Homeopathic Total ,75, ,75, ,90, (c) Ayush treatment facility is required to attach with Allopathic hospitals. For this purpose in each 15 Sadar Hospital is proposed to open Ayush system of treatment with OPD and IPD of 3 system of medicine, (Ayurvedic, Unani and Homeopathic). The following provision is given as follows:- (i) Contraction and Renovation- 10,00, (ii) Machines and Equipments- 1,50, (iii) Medicine and Diet- 7,00, (iv) Training of Paramedical staffs- 1,00, (v) One time miscellaneous expenditure- 2,00, Total 35,00, Total required for 15 Sadar Hospitals and 3 units of each (Ayurvedic, Unani & Homeopathic)- 35,00,000 x3 x16=16,80,00, (d) Strengthening the Quality Control Laboratory The quantum of Ayurvedic and Homoeopathic medicines used / procured in both public and private health sectors is huge. There has been wide ranging concern about spurious, counterfeit and sub standard drugs. In order to prevent the spread of sub standard drugs and to ensure that the drugs manufactured or sold or distributed throughout the state are of standard quality, drug regulation and enforcement unit has to be established in the state. The drug regulatory mechanism to be strengthened at the state level to improve the quality of drugs used in AYUSH and ensure proper standardization. (e). Strengthening the Drug Standardisation and Research Activities on AYUSH Standardisation- As research is an important activity in the process of development of a drug used for preventive and curative purpose, it has been found that the major drawback in the development of AYUSH is lack of research and development activity on the drugs used for the System. It is estimated that there are 10,000/- plant species found all over the world having medicinal properties. The following activities will be undertaken to strengthen the drug standardisation and research activities on AYUSH: 1. It has been proposed to evaluate the chemical, pharmacological and clinical efficacy of the plant drugs. 2. The phytochemical entities responsible for the therapeutic activity of the plant drugs used in AYUSH system will be evaluated through intensive R & D activity. 185

186 3. The pharmacologically viable drugs will be screened clinically under WHO guideline to establish the therapeutic activity. 4. Clinical trial on different diseases like Psoriasis, Liver disorders, Diabetics, Asthma will be conducted to establish the effect of various drugs used for such diseases. 5. It has also been proposed to conduct literary research like translation of manuscripts and its publications. 6. Re-vitalisation of the local health traditions and the knowledge of traditional drugs used by experienced local health traditioners will be gathered and documented. (f). Strengthening of the State and District Management System of AYUSH 1. It is proposed to create necessary Managerial post in the State and District level for effective supervision and implementation of different activities. 2. Necessary vehicles with supporting manpower has also been proposed to strengthen the supervisory 3. Joint monitoring visits to health centres to be undertaken by both AYUSH and Health Care Officials at the District level s/state level. BUDGET AYUSH - Part A Requirement of the funds from NRHM 1. Ayurvedic, Unani and Homeopathic dispensaries- (i) Provision of 1 Ayush doctor at each APHC on Rs.20,000/- x 1243 APHC x 9 months 22,37,40, (ii) Salary of Paramedics 3900 x 1243 x 9 months (iii) Salary of Pharmacists x 1243 x 9 months 2. Training of Ayush Doctors & Paramedical staffs w.r.t Ayush wing-4,15,00, IEC 1,00,00, Grand Total (A) 39,15,84, AYUSH Part B I. Requirement of the funds from the Ayush Departments for Ayush Dispensaries 1. For Ayush dispensaries & additional PHCs already existing (i) For Medicine- 1,51,25, (ii) Machine and equipments- 1,51,25, (iii) Other Miscellaneous- 48,10, Sub-Total 3,50,60, New Ayush OPD and IPD in 15 Sadar Hospital 13,65,00, Total II Rs /- II. Requirement of the funds from the Ayush Departments to uplift Ayush Medical Education for Government Ayush Medical Colleges 1. Government TIBI College & Hospital (Unani), Patna 186

187 Rs. in Crores (i) Building construction- 6.40/- (ii) Machine and equipments- 1.00/- (iii)quality Testing Lab- 1.00/- (iv) Pharmacy- 1.00/- (v) Herbal Gardian -.20/- (vi) Medicine and Diet /- Sub-total 9.65/- 2. Government RBTS Homeopathic Medical College, Muzaffarpur Rs. in Crores (i) Building construction- 0.35/- (ii) Machine and equipments- 0.20/- (iii)quality Testing Lab- 1.00/- (iv) Pharmacy- 1.00/- (v) Medicine and Diet- 0.02/- Sub-total 2.57/- 3. Government Ayurvedic College, Begusarai Rs. in Crores (i) Building construction- 3.00/- (ii) Machine and equipments- 1.00/- (iii) Medicine and Diet- 0.02/- Sub-total 4.02/- 4. Government Ayurvedic College Hospital, Patna Rs. in Crores (i) Building construction /- (ii) Machine and equipments- 9.70/- (iii)renovation and Beutification /- (iv) Medicine and Diet- 0.50/- Sub-total /- 5. Government Ayurvedic College, Patna Rs. in Crores (i) Building construction- 3.00/- (ii) Machine and equipments- 6.75/- (iii) Quality Testing Lab- 0.80/- (iv) Herbal Gardan- 0.20/- (v) Animal House- 0.05/- Sub-total 10.80/- Total II Rs Grant total required for teaching institutions and dispensaries (I + II) = Rs.58,69,80,000/- 187

188 Sl. No. Summary Budget of NRHM Part B Budget Head Modified Budget Decentralization 1.11 ASHA Support System at State Level ASHA Support System at District Level ASHA Support System at Block Level ASHA Support System at Village Level Available under ASHA Trainings ASHA Drug Kit & Replenishment Emergency Services of ASHA Motivation of ASHA Capacity Building/Academic Support programme ASHA Divas Total ASHA Untied Fund for Health Sub Center, Additional Primary Health Center and Primary Health Center % 1.22 Village Health and Sanitation Committee Rogi Kalyan Samiti Total Decentralization Infrastructure Strengthening 2.1 Construction of HSCs (100 no. x Rs.9.50 lakhs) Construction of PHCs a Construction of residential quarters of 200 old APHCs for staff nurses b Construction of building of 51 APHCs where land is available Up gradation of CHCs as per IPHS standards (100 CHCs x Rs lakhs) Infrastructure and service improvement as per IPHS in 20 (DH & SDH) hospitals for accreditation or ISO : 9000 certification 2.5 Upgradation of ANM Training Schools Annual Maintenance Grant Total Infrastructure strengthening Contractual Manpower 3.1 Contractual Salaries, Incentives and Bonus (PHC doctors and staffs, contractual staff nurses, ANM, mobile services) a Incentive for PHC doctors & Rs. 50,000 for better performance in implementing programmes (Rs. 50,000/ - per PHC per year) 3.1b Salaries for contractual Staff Nurses (2900 existing and 910 new) (Rs

189 per month) 3.1c Contract Salaries for ANMsRs.6000 per month x 3500 (12 Months Consolidated Salaries for Contractual ANMs) d Mobile facility for all health functionaries (District officials, PHC in charge, CDPOs and 500 per month) 3.2 Block Programme Management Unit Addl. Manpower for SHSB Addl. Manpower for NRHM Total Contractual Manpower PPP Initiatives Ambulance service Doctor on Call & Samadhan Addl. PHC management by NGOs American Association of Physicians of Indian Origin (AAPIO) SHRC (HOSMAC) Services of Hospital Waste Treatment and Disposal in all Government Health facilities up to PHC in Bihar (IMEP) 4.7 Dialysis unit in various Government Hospitals of Bihar Setting Up of Ultra-Modern Diagnostic Centers in Regional Diagnostic Centers (RDCs) and all Government Medical College Hospitals of Bihar Providing Telemedicine Services in Government Health Facilities Outsourcing of Pathology and Radiology Services from PHCs to DHs Operationalising MMU (38 units x Rs.4.68 lakhs x 9 months) Monitoring and Evaluation (State, District, Block Data Centre) Generic Drug Shop No Funds required 4.16 Nutritional Rehabilitation Centre Hospital Maintenance 4.18 Providing Ward Management Services in Government Hospitals Provision for HR Consultancy services Advanced Life Saving Ambulance (Rs.9,98,000/- x 9 months) Total PPP Initiatives Procurement of Supplies 5.1 Delivery kits at the HSC/ANM/ASHA (no x Rs.25/-) 50,00, SBA Drug kits with SBA-ANMs/Nurses etc (no x Rs.245/-) Availability of Sanitary Napkins at Govt. Health Facilities 5.4 Procurement of beds for PHCs to DHs Total Procurement of Supplies Procurement of Drugs 6.1 Cost of IFA for Pregnant & Lactating mothers (Details annexed) Cost of IFA for (1-5) years children (Details annexed)

190 6.3 Cost of IFA for adolescent girls (Details annexed) Total Procurement of Drugs Mobilisation & Management support for Disaster Management Health Management Information System Strengthening of Cold Chain (Infrastructure strengthening) Refurbishment of existing Warehouse for R.I. as well as provision for hiring external storage space for (during Immunization Campaigns) Logistics at State /- Refurbishment of existing Cold chain room for district stores in all districts with proper electrification,earthing for electrical cold chain equipment and shelves and dry space for non elecrtical cold chain equipment and 7 Lakhs per district x 38 districts Earthing and wiring of existing Cold chain rooms in all 10000/- per PHC x 533 PHCs 10 POL of Generators for cold Rs. 600 per day per WIC. Rs. 500 per day per district and Rs. 400 per day per PHC Preparation of Action Plan Preparation of District Health Action Plan (Rs.1 lakh per district x 38) Preparation of State Health Action 3 lakhs Mainstreaming Ayush under NRHM 391,584, Total 4,356,800,

191 PART- C Routine Immunization

192 Progress of Routine Immunization in Bihar: The aim is to immunize all the children and pregnant mothers under Universal Immunization Programme, in order to reduce IMR, MMR and NMR through routine immunization of all children and mothers from six vaccine preventable disease in the state. The State of Bihar has shown excellent Progress over the Years as shown in the Graphs below. Evaluated % of Fully Immunized Child in Bihar *** Ongoing Immunization Survey being carried out by SHSB outsourced to FRDS(Formative Research & Development Services) in the 1st quarter of 2008 (completed in 10 randomly selected districts). In the next quarter another 10 districts are being taken NFHS CES 2002 CES 2005 NFHS CES DLHS,2008/09 Survey By 06 FRDS *** Data source- NHFS & CES Average % of Annual Increase/Decrease in full Immunization from NFHS-II to NFHS III (a comparison among some of the states along with Bihar) Andhra Pradesh Punjab Tamil Nadu Karnataka Kerala Rajasthan Assam West Bangal Bihar Data source NFHS 192

193 Antigenwise Reported % of Cumulative Coverage Bihar (Jan 07 Dec 07) Some of the initiatives for increasing Immunization-coverage is given below. Micro-plans have been prepared for each District to ensure full coverage. Vaccines & Auto-Disposable (AD) Syringes provided free of cost to all beneficiaries. Alternate System of Vaccine Delivery has been put in place for delivery of Vaccines at Immunization sites (@ Rs 50/- per session site). Support is being provided for POL to PHCs/Districts/WICs/WIFs for maintenance of Cold Chain on a daily basis. Mobility support is given to all the Diistricts and all DIO`s for Supervision of R.I.in the field. Alternate Vaccinators are per month where ever there is a shortage in the Districts. All the Electrical Cold-chain Equipment in the Field are Under Annual Maintenance Contract, which is out-sourced by the State Health Society. Generator are also out-sourced in all the PHC for un-interrupted Power Supply to all the PHCs /ILR Points. Fund has been provided for the Construction of Safety-Pits in every Block-PHC for the safe disposal of AD-Syringes. All the H.W. (ANM) is being trained based on the Health Workers Immunization Module in phases for Improving Immunization all across the State. Special Post Flood catch up Immunization Campaign in the Five Most Flood Affected Districts of Bihar has been conducted following the massive floods. 193

194 No. of R.I. Session Site Monitored Muskan Ek Abhiyan It has been decided by the Government of Bihar to attain 100% immunization of infants and pregnant women, for which tracking of pregnant women and infants are being undertaken through Muskan Ek Abhiyaan. Objective: To achieve 100% immunization of Infants and Pregnant Women Muskan Operational Strategy Convergence with ICDS and Health for our-reach-service delivery. For Routine Immunization Aaganwadi Centers are acting as the service delivery unit as well as Headquarters for AWWs and ASHAs For 8 10 AWWs, ANM are designated as Team Leader 194

195 Components: Tracking of all Pregnant Women and Newborns. House-to-house survey. Registration of all Pregnant Women and Children from 0 2 yrs age group Immunization sessions at Anganwadi Centers on each Friday. Field Verification in the form of Supportive Supervision by both MO`s & CDPO`s are also planned under Muskan to Improve Immunization coverage in the Blocks Due List register to Track and Identify Due Beneficiaries for every RI-Session. Mahila Mandal Meetings in the AWC to improve Health & Nutrition, in the Village. Percentage of Sessions Held Vs Planned

196 % Presence of ANM / AWW / ASHA at Session Sites ANM Presence Mobilizer Presence ICDS Presence ASHA Presence * Note : Year Aug 2005 to Dec 2005 (5 months) : N Year Jan 2006 to Dec 2006 (12 months) : N Year Jan 2007 to Dec 2007 (12 months) : N Year Jan 2008 to Nov 2008 (11 months) : N Catch up round for Immunization, Health and Nutrition improvement Of children and pregnant women In Flood Affected districts in Bihar Oct 2008 Background and Objective. Following a breach in the river embankment at Kusha in Nepal On 18 th August 2008, river Kosi had changed its course and shifted over120 km eastwards. As a result, large areas of Supaul, Madhepura, Purnea, Saharsa and Araria in Bihar were inundated. For over two months normal activity was disrupted and access to many areas impossible. However, with waters slowly receding and with the advent of normalcy the Department of Health, Government of Bihar, launched a post flood health and nutrition Catch up Round from October 20 th -27 th, 2008, in the five flood-affected districts of Bihar. The round aimed at providing appropriate focused interventions for health and nutrition to vulnerable populations such as expecting mothers and children previously displaced or living in hitherto inaccessible areas and at catching-up and thereafter restoring routine health services like immunization throughout the flood-affected districts. Interventions: The interventions identified for delivery during the round were as follows: Intervention Role Age group Catch-up Routine Proven to decrease morbidity and mortality Pregnant women and children immunization through 6 vaccine preventable diseases. as per EPI schedule 196

197 Catch up Vitamin A doses De-worming tablets Low osmolarity ORS Zinc Proven to prevent diarrhea as well as used to prevent measles and its complications Effective against intestinal parasites Prevention and treatment of dehydration due to diarrhea Prevention of pneumonia and prevents as well as limits diarrhea incidence 9 months to 5 years 2 years to 5 years All children affected with diarrhea; 6 months to 5 years Along with ORS The Coverage achieved during the Catch-up round were vaccine doses for routine immunization, vitamin A doses (91.8% of total estimated eligible children), tablets of Albendazole (65.75% of estimated eligible children) and courses of Zinc and ORS for children with diarrhea. Primary vaccine coverage (coverage of infants with EPI vaccines schedule by 1 completed year) was targeted against the estimated population of infants and pregnant women eligible for vaccine doses in a two-month period (two months being the duration of disruption of routine immunization services due to floods) and the following percent coverage was achieved for various antigens. % Coverage Achieved during Catchup Round TT1 TT2+B BCG OPV0 OPV1 OPV2 OPV3 DPT1 DPT2 DPT3 Measles Fully Immunized Vitamin A* Deworming tablet* % S e s s i o n s h e l d o u t o f t h o s e p l a n n e d d u r i n g c a t c h - u p r o u n d A r a r i a M a d h e p u r a P u r n e a S a h a r s a S u p a u l 5 f l o o d a f f e t c e d d i s t r i c t s Catch-up Round Antigen Wise % Coverage achieved (of 2 monthly estimated target) for Pregnant women & Children# 197

198 District Pregnant women Infants (birth to 1 year) 9m-5y 6m-5y TT1 TT2+ B BCG OP V0 OPV 1 OPV 2 OPV 3 DPT 1 DPT 2 DPT 3 Msls Full Imnzed Vit A* Deworm tablet* ARARIA MADHEPUR A PURNEA SAHARSA SUPAUL Grand Total * Annual targets are taken for VitA and Deworming tablets as biannual supplementary dose was administered during Catch-up round Catch-up Round Coverage Report Antigen Wise# District ARARIA MADHEPURA PURNEA SAHARSA SUPAUL Grand Total Session Planned Session Held of TT TT TTB BCG OPV OPV OPV OPV DPT DPT DPT Measles Fully Immunized Vitamin 'A' Deworming ORS & Zinc # Provisional reports Future Plans In order to ensure full-immunization status of infants in the flood affected areas, it is necessary that coverage of subsequent doses of OPV and DPT (2 nd and 3 rd doses) also be achieved at a level similar to that of the first dose. Two more catch-up rounds with the vaccination component in these districts spaced 4-6 weeks apart would give opportunity to achieve this. Bundling of a number of interventions had led to greater acceptability of services by the beneficiaries, empowering of the village level service provider and closer monitoring by multiple stakeholders 198

199 involved in the various program components followed in the catch-up strategy. This approach could be scaled up to cover a larger geographical area during regular sessions of Routine Immunization. 199

200 Introduction Strategic Plan for Measles Mortality Reduction In Bihar 2009 Vaccine preventable diseases still remain major causes of morbidity, disability and mortality, with an estimated deaths (Chart 1 below) occurring annually in the Bihar State. This document outlines measles control acceleration strategies that Governments and stakeholders in immunization in the Bihar State will implement from 2009 onwards. Chart 1: Estimated Measles Mortality by Indian State 2006 (Source: Preliminary results from a workshop held at NPSU, New Delhi, May 2007) 70,000 60,000 Measles Deaths 50,000 Measles Deaths 40,000 30,000 20,000 10,000 - LAKSHADWEEP A&N ISLANDS D&N HAVELI PONDICHERRY GOA SIKKIM DAMAN & DIU HIMACHAL PRADESH CHANDIGARH MIZORAM KERALA DELHI TAMIL NADU ARUNACHAL PR. MANIPUR JAMMU & KASHMIR TRIPURA MEGHALAYA NAGALAND PUNJAB UTTARANCHAL HARYANA KARNATAKA CHHATTISGARH MAHARASHTRA GUJARAT ORISSA ANDHRA PRADESH WEST BENGAL ASSAM JHARKHAND MADHYA PRADESH RAJASTHAN BIHAR UTTAR PRADESH State Health Society, Bihar- is proposing this strategic plan aimed at guiding measles mortality reduction in Bihar. As a resource mobilization tool, the plan summarizes the requirements for measles control including routine measles immunization, supplemental immunization activities and Measles surveillance, as well as the projected State Health Society, Bihar support needs. For the purpose of monitoring progress with implementation, a set of milestones is included. Measles related Morbidity and mortality in Bihar 200

201 U5MR B i h a r Non-Measles Mortality Rate Measles Mortality Rate Target for Child Mortality Potential Contribution of Accelerated Measles Control to Achieving MDG4 in India, 2006 Reduction of Measles associated mortality would be a key intervention for Bihar to achieve the 4 th Millennium development goal. About half of the goal would be achievable just by reducing the measles deaths in the state. Of all the states in India, Bihar is poised to benefit most from Measles SIA leading to Measles mortality reduction. Measles outbreaks in Bihar In the year (till Jan), Fourteen measles outbreaks were investigated in Bihar and the following age distribution of cases was determined. There were 485 cases (Age distribution of 394 cases available) and 26 deaths reported from these outbreaks (Case Fatality rate 5.36). One outbreak was confirmed with laboratory diagnosis and the remaining was through clinical examination. 88 % of the cases were between one and nine completed years justifying the age bracket to be covered during measles catch-up round. 201

202 S No Measles outbreaks in Bihar (status till 30th Jan 2009) Age distribution Number Month of Number 120- District of outbreak of cases deaths 179 months months months months >179 months 1 Champaran East March Patna April Patna April * Patna April Supaul November Bhagalpur November * Madhubani December Madhepura December Madhepura December Madhepura December Champaran West December Darbangha December Vaishali January Champaran East January Bihar total BIHAR Strategic Action Plan for Measles Mortality reduction Strategies It is envisaged that the State Health Society, Bihar with the support of other partners realize the stated measles control goal and objective using the following strategies 1. Strengthen routine immunization (EPI) to raise routine measles coverage to 80% and above. 2. Establish measles surveillance 3. Establish a measles laboratory network for the confirmation of cases/epidemics. 4. Provide a second opportunity for measles vaccination a. Initially through a catch up supplementary mass campaigns for the children aged 9 months to 9 completed years 202

203 b. Follow up SIAs every 3-5 years for successive birth cohorts and c. Introducing second dose of Measles vaccine in EPI schedule when the evaluated routine coverage of the first dose goes above 80% in all districts throughout the state. 5. Improve the clinical management of measles cases through the IMNCI approach. Implementation Roles The Department of Health and State Health Society, Bihar will implement phased activities for measles control in the context of systems strengthening and development. This will require the collaboration of various stakeholders in the field of immunization. Role of Govt of India The primary responsibility for the realization of this plan lies with the Ministry of Health Govt of India. The key roles will include: Adoption of the National strategies, and developing appropriate national plans related to Measles morbidity reduction. Securing funds, vaccines and supplies for immunization and providing the same to the State of Bihar. Developing modules for training and program communication for Measles Supplementary Immunization Providing guidelines and support for surveillance of measles and setting up of Mealses laboratories. Role of partners The State Health Society Bihar will form a Measles Technical Advisory group, Bihar headed by the Executive Director and comprised of the State Program Officer Immunization and IDSP and representatives of the UNICEF, NPSP-WHO, IMA, IAP and NIPI. This task force will be the focal committee for day-to-day implementation of the plan. Besides implementing the plan, the task force will prepare guidelines for district activities, budget norms, reporting forms tally sheets, monitoring checklists for measles campaign and other control activities. UNICEF: Member of technical advisory group on Measles Mortality reduction Measles Surveillance Support during the initial phase of sentinel surveillance State level coordinator For the Supplementary Catch-up immunization campaign 203

204 Trainings and capacity building Micro planning Monitoring Social Mobilization and IEC Logistics and cold chain monitoring Ensuring safe injection practices Data compilation analysis Post coverage surveys NPSP-WHO Member of technical advisory group on Measles Mortality reduction Role in surveillance Support in outbreak based surveillance Setting up laboratories for serological confirmation of Measles. Role in SIA catch-up Trainings and capacity building Micro planning Monitoring of activity NIPI, IAP, IMA Members of Measles Technical Advisory group. Logistics and vaccine requirement for Measles SIA Logistics and vaccine requirement for Measles Mortality reduction activities Item Requirement details Requirement Units 1 Measles vaccine 1 dose per child with 1.33 wastage factor with 100% coverage doses 2 Measles diluent 1 dose per child with 1.33 wastage factor with 100% coverage doses ml AD syringe 1 Per child vaccinated with 10% wastage syringes 4 5 ml Disposal syringes 1 per 5 dose vial with 10% wastage syringes 5 Hubcutters 1 per team with 10% buffer hubcutters 6 Mealses Eliza kits 100 per lab with 10% buffer 990 kits Timeline for activity Development of strategy and POA Adoption of strategy by TAG Mealses Bihar Initiation of vaccine procurement activities Measles campaign activity timeline Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 204

205 Development of guidelines and forms etc. Review and planning for districts Planning workshop for districts (at region) Provision of Logistics and finance support District planning and preparation activities Campaign in districts Evaluation of campaign Measles surveillance Pulse Polio Programme (P.E. Progress in the State) In the last one and half years several initiatives have been taken by the Government of Bihar for eradication of Polio form the state. It has been observed that majority of P1 cases was restricted to the most inaccessible areas of Kosi river, covering 20 blocks and 10 districts. A Kosi Operational-Plan was developed for intensification of overal Polio.Eradication. Activities in these high risk Areas(both SIA & Surveillance), the salient features of the plan are : Intensification of human resources in Kosi areas New Geo political boundaries were formed respective of districts boundaries called grids for implementation of Kosi Operational Plan. Intensified Monitoring of the Polio rounds by WHO, UNICEF and State Monitors. Bihar has shown excellent progress till 2008, as regards IEAG Observation for India is concerned. Among the three kind of Polio Virus, Bihar has eradicated P-2 Polio Virus since 1999, and the Endemic Transmission of P-1 cases, which is the most dreaded & Virulent of the three, has stopped circulating in Bihar since, June/08 with multiple mopv-i SIA Rounds. Circulation of P-3 Cases has also declined in the State after completion of few effective SIA`s with mopv III rounds in Bihar in 2007/08. With the highest ever sensitivity of AFP-Surveillance in the State, Bihar is very close to the Goal of Polio Eradication in the Country. 205

206 A. Baseline information S.No. Beneficiaries Target Pregnant Women to 1yr infants yr yr yr yr yr S.No. Routine Immunization Sessions Session planned in Urban Areas Session planned in Rural Areas Total Sessions Planned No. of session with hired vaccinators* No. of hired vaccinators* 4488 * No. of sessions and vaccinators hired in and planned in for B. Trend of IMR S.No. Year IMR of the State/UT

207 C. District - Wise Coverage reports ( in Numbers) S.No. Name of District Yearly Target ( ) Infants Pregnant Women Yearly Target ( ) Infants Pregnant Women Measles TT2+Booster BCG Araria Arwal Aurangabad Banka Begusarai Bhagalpur Bhojpur Buxor Champaran (E) Champaran (W) Darbhanga Gaya Gopalganj Jahanabad Jamui Kaimur Katihar Khagaria Kishanganj Lakhisarai Madhepura Madhubani Munger Muzaffarpur Nalanda Nawada Patna Purnia Rohtas Saharsa Samastipur Saran Sheikhpura Sheohar Sitamarhi Siwan Supaul Vaishali Total

208 S.N o. C. District - Wise Coverage reports ( in Numbers) Yearly Target ( ) Name of District Yearly Target ( ) OPV- 1 OPV -3 DPT - 1 DPT -3 Infants Infants Araria Arwal Aurangabad Banka Begusarai Bhagalpur Bhojpur Buxor Champaran (E) Champaran (W) Darbhanga Gaya Gopalganj Jahanabad Jamui Kaimur Katihar Khagaria Kishanganj Lakhisarai Madhepura Madhubani Munger Muzaffarpur Nalanda Nawada Patna Purnia Rohtas Saharsa Samastipur Saran Sheikhpura Sheohar Sitamarhi Siwan Supaul Vaishali Total

209 S.N o. C. District - Wise Coverage reports ( in Numbers) Name of District Yearly Target ( ) Infants Yearly Target ( ) Infants Hep B- Birth Hep B-1 Hep B JE-routine (Wherever applicable Vit A- Ist Dose Araria Arwal Aurangabad Banka Begusarai Bhagalpur Bhojpur Buxor Champaran (E) Champaran (W) Darbhanga Gaya Gopalganj Jahanabad Jamui Kaimur Katihar Khagaria Kishanganj Lakhisarai Madhepura Madhubani Munger Muzaffarpur Nalanda Nawada Patna Purnia Rohtas Saharsa Samastipur Saran Sheikhpura Sheohar Sitamarhi Siwan Supaul Vaishali Total Not Applicable 209

210 S.No. D. District - wise VPD reports in ( in numbers) Teta nus Dipthe Pertus N (oth Polio Name of District ria is Tetanus er) Measles -P1 Cases Deaths Cases Deaths Cases Deaths Cases Deaths 1 Araria 6 2 Aurangabad 1 3 Banka Begusarai 12 5 Bhagalpur Champaran (E) Champaran (W) Darbhanga Gaya 1 10 Jamui Katihar 5 12 Khagaria Kishanganj 1 14 Lakhisarai 1 15 Madhepura Madhubani Munger 2 18 Muzaffarpur Nalanda 7 20 Nawada 5 21 Patna Purnia 9 23 Saharsa Samastipur Saran Sheikhpura 2 27 Sitamarhi 7 28 Siwan 2 29 Supaul Vaishali Grand Total As on Jan Cases Deaths Cases Deaths Polio- P3 Cases Deaths Cases AES Deaths 210

211 VPDs No. of Outbreaks reported E. Total VPD outbreaks in State/UT No. of OutbreaksInvestigated # # No. of cases in Outbreaks # 08 No. of Deaths in Outbreaks # Measures Taken Remarks Diphtheria 34 Pertusis 786 Measles AES Outbreak response, Vit-A supplementation, treatment of cases # Report for till Dec '08 F. District Wise - AEFI Surveillance S.No. Name of District AEFI Committee constituted ( Y/N) Serious AEFI Cases ( till Dec ' 08) AEFI Deaths (till Dec'08) No. of FIRs sent No. of PIRs sent No. of DIRs sent Remarks 1 Araria Yes 2 Arwal Yes 3 Aurangabad Yes 4 Banka Yes 5 Begusarai Yes 6 Bhagalpur Yes 7 Bhojpur Yes 8 Gaya Yes 1 9 Gopalganj Yes 10 Kaimur Yes 11 Khagaria Yes 12 Kishanganj Yes 13 Lakhisarai Yes 14 Madhubani Yes 3 15 Munger Yes 2 16 Nalanda Yes 17 Nawada Yes 18 Saharsa Yes 19 Sheikhpura Yes 20 Sitamarhi Yes 21 Siwan Yes 22 Vaishali Yes 1 23 Darbhanga 1 24 Samastipur 1 25 Katihaar 1 Total

212 G. RIMS status S.No. Name of District RIMS Installed Computer RIMS uploaded* & Operational Assistant Apr'08 May'08 Jun'08 Jul'08 Aug'08 Sep'08 Oct'08 Nov'08 Dec'08 1 Banka Yes Yes Yes No Yes Yes Yes Yes Yes Yes 2 Bhagalpur Yes 3 Bhojpur Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 4 Buxar Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 5 Champaran-W Yes 6 Darbhanga Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 7 Gopalganj Yes Yes Yes 8 Kaimur Yes Yes Yes Yes Yes Yes Yes Yes 9 Kishanganj Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 10 Madhubani Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 11 Munger Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 12 Saharsa Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 13 Samastipur Yes 14 Saran Yes 15 Sheikhpura Yes 16 Sheohar Yes 17 Sitamarhi Yes 18 Siwan Yes 19 Supaul Yes STATE / UT ** Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes *Write Yes/No for the month the district has uploaded RIMS data of district **Write Yes /No for the month the State/UT has uploaded State/UT level data 212

213 Item H. Vaccine, Cold Chain and Other logistics Requirement Stock ( Functional)** Cold Chain Equipments- WIC WIF ILR-140 L (Small) ILR-300 L (Large) DF-140 L (Small) DF-300 L (Large) Cold Boxes L Cold Boxes S Vaccine Carriers Ice Pack Vaccine Van 46 Not Required Vaccine stock and requirement ( including 25% wastage and 25% buffer) TT BCG OPV DPT* Measles Hep B JE(Routine) Remarks Including 5 replacements & 4 New for Replacement out of 1 and One new Syringes including wastage of 10% and 25% buffer 0.1ml ml Reconstitutional Syringes New ANM recruitment in Hub Cutters Very few process & further functional additional Hubcutter needed. ** As on 31st Dec '08 * Note : DPT is to be given instead of DT at 5 yrs w.e.f

214 District wise and Head wise allocation of budget for Routine Immunization activities in Year SL No. Name of District P.W. ANM State Total Allotment for the year Number of Alternate immunis Vaccinator ation Site District Profile used for calculation of Budget AWC ASHA HSC APHC BPHC Reffral + SDH District Hospital/ Metarnit y Hospital WIC + WIF Slums Under served Areas 1 Araria Arwal Aurangabad Banka Begusarai Bhagalpur Bhojpur Buxar Champaran - E Champaran - W Darbhanga Gaya Gopalganj Jahanabad Jamui Katihar Kaimur Khagaria Kishanganj Lakhisarai Madhepura Madhubani Munger Muzaffarpur Nalanda Nawada Patna Purnia Rohtas Saran Samastipur Saharsa Sheikhpura Sheohar Siwan Sitamarhi Supaul Vaishali RDD/State State Total

215 Mobility Support Cold chain maintenance Mobility support to District Officials Rs per district (38). Mobility support for supervision at state Rs per year. machine per year for 2200 machine ( DF+ILR) and 10 WIC and 3 Rs per year and maintenance of vaccine per van for 47 vans. * 22,00,000 for AMC given at State level to one agency for repair of existing ILR & DF has been deducted from Rs. 50,00,000 alloted and the remaining 28,00,000 is divided for WIC/WIF maintainance of Vaccine vans as per approved rates. the final remaining amount of could be utilised for Minor Repair for district and regional Cold chain stores among the Rs WIC/WIF Vaccine Van Minor Repair

216 Focus on slum & underserved areas in urban areas: for 3565 slums and underserved Rs. 350 per month per slum for one session * population ( Each AWC in a slum has 1500 population therefore 7 slums =10000 population Alternate vaccinators honorarium (details in separate sheet) Mobilization of children through ASHA or other Rs. 150 per month per per worker for sessions per month for remaining 5 months as the State has budget the same under Muskan in RCH PIP. The state has projected this for month incase the same is not extended beyond Oct.09 Alternative vaccine delivery in hard to reach areas Alternative vaccine delivery in hard to reach areas in 4500 session per Rs. 100 per session Alternative Vaccine Deliery in other Rs. 50 per session for session ANMs for 104 days

217 Computer Assistants support Printing and dissemination Review meetings Computer Assistants support for State Rs per person per month for 2 persons Computer Assistants support for District Rs per person per month for one computer assistant in each 38 districts Printing and dissemination of Immunization cards, tally sheets, monitoring forms Rs. 5 beneficiaries for beneficiaries with 10% buffer. Support for Quarterly State level review meetings of district Rs. 1250/-/participant/day ( CMO/DIO/Dist Cold chain Officer) for 30 participants per meeting. Quarterly review meetings exclusive for RI at district level with one Block Mos, CDPO, and other stake Rs. 100 per participants for 5 participants per per PHCs 515 Quarterly review meetings exclusive for RI at block Rs. 50/- PP as honorarium for ASHAs and Rs. 25 per persons for meeting expenses for ASHAs

218

219 Trainings (separate annexure attached with details) Microplanning District level orientation for 2 days for ANMs MPHW, LHV Health Assistants Nurse, Mid wife Bees and other specialist as per traning norm of RCH for 9000 persons in 600 batches three days training of Mos on RI for 5000 persons in a group of 30 person per batch. One day refresher training of distict Computer assistants on RIMS/HIMS and immunization formats for 40 persons in two batch. One day cold chain handlers training for block level cold chain hadlers by State and district cold chain officers in 28 batchs. For 542 cold chain handlers One day training of block level data handlers by DIOs and District cold chain officer for 542 person. To develop microplan at subcentre Rs 100/- per sub - centre For consolidation of microplans at block Rs per block/ PHC(515) and at district Rs per district for38 districts

220 220

221 POL for vaccine delivery Consumables Injection safety POL for vaccine delivery from State to district and from district to Rs per district for 38 districts. Consumables for computer including provision for internet access for RIMs Rs. 400 per month per district for 38districts. Red/Black plastic bags Rs. 2/bags/session for (@ Rs 2 per bag for 2 bags a month per ANM Bleach / Hypochlorite Rs. 500 per PHC/CHC per year for 515 PHC Twin Rs. 400 per PHC/CHC per year for 515 PHCs

222 State specific requirement. POL of Generators for cold Rs. 600 per day per WIC. Rs. 500 per day per district and Rs. 400 per day per PHC. Catch Up campaigns for flood prone Rs per district for 5 districts. Ticklers bags for RI card counter rs. 250 per bags per AWC for workers Taken Rs 170 per bag for AWC Measles Mortality Rs per district year year for 19 districts. Pits construction TOTAL

223 223

224 S.no. District Name ANM - C Total Training load Health Workers training on Routine Immunization - Consolidated Budget Total No. of training Batches ( 25 person per batch) No of trainers per batch Honorarium + TA to 400 per participants 224 Honararium for per day ( subject to atleast 2 lectature per guest faculty per day) for 2 days Working lunch & Refreshments Rs 200 per participants + faculty per day for 2 days Incidential Exp for Photocopy, Job aids, flip charts, T.V./LCD hiring 250 per participants per days for 2 days Grand Total 1 Araria Arwal Aurangabad Banka Begusarai Bhagalpur Bhojpur Buxar Champaran - E Champaran - W Darbhanga Gaya Gopalganj Jahanabad Jamui Katihar Kaimur Khagaria Kishanganj Lakhisarai Madhepura Madhubani Munger Muzaffarpur Nalanda Nawada Patna Purnia Rohtas Saran Samastipur Saharsa Sheikhpura Sheohar

225 35 Siwan Sitamarhi Supaul Vaishali Total Rates for training as per GOI guideline vide letter no. D.O.No.A-11033/101/2007-Trg dated S.no. District Name No. of PHCs Cold Chain Handler training on Routine Immunization - Consolidated Budget No. of Cold Chain Handler (2 per PHC & 2 per district) Total Training load Total No. of training Batches ( 25 person per batch) 225 No of trainers per batch Honorarium + TA to 400 per participants Honararium for per day ( subject to atleast 2 lectature per guest faculty per day) for 1 days Working lunch & Refreshments Rs 200 per Grand Total participants + faculty per day for one day 1 Araria Arwal Aurangabad Banka Begusarai Bhagalpur Bhojpur Buxar Champaran - E Champaran - W Darbhanga Gaya Gopalganj Jahanabad Jamui Katihar Kaimur Khagaria Kishanganj Lakhisarai Madhepura Madhubani

226 23 Munger Muzaffarpur Nalanda Nawada Patna Purnia Rohtas Saran Samastipur Saharsa Sheikhpura Sheohar Siwan Sitamarhi Supaul Vaishali Total Rates for training as per GOI guideline vide letter no. D.O.No.A-11033/101/2007-Trg dated UNICEF will provide one trainer and all training materials for participants S.no. District Name No. of PHCs Block level Data Handler training on Routine Immunization - Consolidated Budget Honararium for Total No. of trainers/faculty Honorarium + TA Total training No per day ( to Participants Training Batches ( 25 trainers subject to atleast 400 per load person per per batch lectature per guest participants batch) faculty per day) for 1 days No. of Data Handler (1 per PHC & 2 per district) 226 Working lunch & Refreshments Rs 200 per participants + faculty per day for one day Incidential Exp for Photocopy, Job aids, flip charts, T.V./LCD hiring 250 per participants per days for one day Grand Total 1 Araria Arwal Aurangabad Banka Begusarai Bhagalpur Bhojpur Buxar Champaran - E

227 10 Champaran - W Darbhanga Gaya Gopalganj Jahanabad Jamui Katihar Kaimur Khagaria Kishanganj Lakhisarai Madhepura Madhubani Munger Muzaffarpur Nalanda Nawada Patna Purnia Rohtas Saran Samastipur Saharsa Sheikhpura Sheohar Siwan Sitamarhi Supaul Vaishali Total Rates for training as per GOI guideline vide letter no. D.O.No.A-11033/101/2007-Trg dated S.no. District Name PHC PHC x 5 Calculation for Alternate Vaccinator (requirement and Honorarium APHC HSCs Total ANM - R ANM - C 227 Total ANM Diff of Personnel Altern ate Vaccin ator require d Honararium for Alternate Rs 1400/- per month No. of Contractu al ANM One month Honararium for Break period for Contractual Rs 1400/- per ANM Grand Total 1 Araria

228 2 Arwal Aurangabad Banka Begusarai Bhagalpur Bhojpur Buxar Champaran - E Champaran - W Darbhanga Gaya Gopalganj Jahanabad Jamui Katihar Kaimur Khagaria Kishanganj Lakhisarai Madhepura Madhubani Munger Muzaffarpur Nalanda Nawada Patna Purnia Rohtas Saran Samastipur Saharsa Sheikhpura Sheohar Siwan Sitamarhi Supaul

229 38 Vaishali Total

230 PART- D National Disease Control Programmes (NDCP)

231 IDSP (Integrated Disease Surveillance Program) Surveillance is essential for the early detection of emerging (new) or re-emerging (resurgent) infectious diseases. In the absence of surveillance, disease may spread unrecognised by those responsible for health care or public health agencies, because many individual health care workers would see sick people in small numbers. By the time the outbreak is recognized, it may be too late for intervention measures. Continuous monitoring is essential for detecting the early signals of outbreak of any epidemic of a new or resurgent disease. For disease surveillance to prevent emerging epidemics, the time taken for effective action should be short. Integrated Disease Surveillance Program (IDSP) is intended to be the backbone of public health delivery system in the state. It is expected to provide essential data to monitor progress of on- going disease control programs and help in optimizing the allocation of resources. It will be able to detect early warning signals of impending outbreaks and help initiate an effective and timely response. IDSP will also facilitate the study of disease patterns in the state and identify new emerging diseases. It will play a crucial role in obtaining political and public support for the health programs in the state. Profile of Bihar : Bihar is located in the North East of India. It has a land with a covered area of 94,163 Sq. Km. It is mainly divided into two regions known as North of Ganges, and south of Ganges regions. The State is geographically classified into 38 districts and 72 Sub divisions and 533 blocks. The population of Bihar as per 2001 Census is million with a urban population of as the density population per Sq. Km. is 880 against national figure of 324. There are 32 towns with a population of 50,000 or more and having about 40,000 villages in the state. The present sex ratio is 919 females per 1000 males (India Figure 933). The total literacy rate is 46.4%. It is mainly a rural inhabited state. The percentage of rural population is 66.08% against the India s population of 72.2%. Diseases conditions under the surveillance program (i) Regular Surveillance: Vector Borne Disease: Malaria & Kala-azar Water Borne Disease: Acute Diarrhoeal Disease (Cholera) & Typhoid Respiratory Diseases: Tuberculosis Vaccine Preventable Diseases: Measles Diseases under eradication: Polio Other Conditions: Road Traffic Accidents 231

232 Table 2: Integrated IDSP (Integrated Disease Surveillance Program) S.N. Heads Units Unit Cost Total 1 Infrastructure a State Surveillance Cell at DMS & DHS 1 1,500,000 1,500,000 b District Level Laboratory ,000 3,900,000 c Manuals ,000 2 Laboratory a Equipment ,900,000 b Reagents and consumables ,800,000 3 Communication a Telephone & Fax ,000 4 Salary a Data Entry Operator ,000 b Accounts Assistant ,000 5 Social Mobilization ,170,000 6 Training ,000 3,900,000 7 Biological Waste Management, 5% overhead expenses ,000 GRAND TOTAL 24,406,000 ( = ) An amount One Crore Forteen lakhs (Rs. 1,14,00,000/-) was released to to State. Hence balance fund requirment will be Rs. 1,30,06,000/- lakhs (One crore Thirty lakhs six thousands only). 232

233 IDSP (Integrated Disease Surveillance Project) SL No Name of District District Level IDSP Fund State Level IDSP Fund Araria Arwal Aurangabad Banka Begusarai Bhagalpur Bhojpur Buxar Darbhanga East Champaran Gaya Gopalganj Jamui Jehanabad Kaimur Katihar Khagaria Kishanganj Lakhisarai Madhepura Madhubani Munger Muzaffarpur Nalanda Nawada Patna Purnia Rohtas Saharsa Samastipur Saran Sheikhpura Sheohar Sitamarhi Siwan Supaul Vaishali West Champaran Unit Cost State Level Total 21,831, ,574, Note- (i) District Level IDSP fund (ii) State Level IDSP Fund Total ( = ) 233

234 An amount One Crore Forteen lakhs (Rs. 1,14,00,000/-) was released to State. Hence, balance fund requirement will be Rs. 1,30,06,007/- lakhs (One Crore Thrity lakhs Six thousands Seven only), 234

235 Iodine Deficiency Disorder Addressing Iodine Deficiency Disorders in Bihar. Introduction: Iodine deficiency is a world wide public health problem. It is the major cause of brain damage loss of energy, learning disability, poor motivation, poor human resource development and child survival. Thus, it remains a major threat to the health and development of school children and pregnant women. Children with iodine deficiency have intelligence (I.Q) 13.5 points less than that of children from areas where there is no iron deficiency. The only solution to this is simple and affordable, which is consumption of iodised salt. IDD elimination Programme was launched in the late 1960s. By 1988 legislative measures were put in place to ban the sale of non-iodised salt in the entire state. During the United Nations General Assembly Special Session for Children (2002), India has committed to eliminate IDD by Although, in national policy commitments, India commits to eliminate IDD by 2010, there is an urgent need to accelerate the strategy in India, especially when a decreasing trend, 49% to 37% ( to ), has been seen in households consuming adequately iodised salt. Iodine Deficiency Disorders in Bihar: In Bihar the northern part of the state lies in the sub-himalayan region in which the existence of severe to moderate iodine deficiency in this region is well established. A recent study was undertaken in Bihar with support from UNICEF for Government of Bihar, to track progress towards sustainable elimination of IDD from the state. The results of the study reveal that iodine deficiency continues to be a public health problem. A high proportion of population (31.5%) has very low urinary iodine excretion suggesting existence of severe iodine deficiency in many pockets. Only 40.1% of the households consume adequately iodised salt. The findings of this study warrant instituting corrective measure on a war footing to ensure that the population of Bihar has access to adequately iodised salt and at least 80% of the households receive and use adequately iodised salt. Major Objectives: Creating universal demand for iodised salt at consumption level Strengthening the monitoring system at the production level Role of Each Department: Awareness generation among consumers is a corner stone of the strategy and all possible means to disseminate information about the benefits of consuming iodised salt and to trigger behaviour change among the population. This surely requires the contribution of stakeholders outside the Health Department. In this regard the ICDS with its extended network of AWCs is a strong link through which the vulnerable population groups in the community can be reached out 235

236 The priority of Iodine Deficiency Disorders should also be shouldered by the Education department. Schools provide an excellent infrastructure for promotional activities to reach out to masses thru children. Teachers can be trained for encouraging students to influence their families in purchasing iodised salt highlighting the benefit of IQ difference in children with iodine deficiency. Thus, a series of activities could be organized for awareness creation among children, who in turn can be expected to serve as change agents for influencing their families. Health: Health is the nodal department, while ICDS and Education will be the collaborating Departments. These have been specified under the role of departments of ICDS and Higher Education. To begin with the district will form a co-ordination Committee to take decisions on priority actions and review the progress of work once every quarter. However, the State Health Department will ensure the following: - Formation of District Co-ordination Committee to prioritize actions and review progress quarterly. Functions of District Co-ordination Committee: 1. To facilitate Orientation and Planning Meetings for awareness generation and to strengthen monitoring of salt quality 2. To support organization and implementation of awareness campaigns through schools and AWCs to reach out to the communities. 3. To monitor campaigns/activities under the 3 departments and prepare district reports 4. To institute follow-up actions in blocks areas with low or no iodine salt sale and consumption. - Directives to be issued to medical colleges and district hospitals and super specialty hospitals, for using iodised salt in cooking meals for the patients. - Civil Surgeon to hold meetings of lab technician and Food Inspectors in his district. - State Nutrition cell to ensure the following to districts and districts to distribute to AWCS, through CDPOs and to Schools through BEOs. - Reporting format - Distribution of STKs - Distribution of IEC material - Financial Support. ICDS: - Same Letter signed by Civil Surgeon, DPO and DSE for co-ordination by the functionaries of three district departments to organize and conduct joint training of ANMs and AWWs. - Directives to be re-issued as a reminder for use of iodised salt in supplementary food AWCs. 236

237 - DPOs/DWOs to plan and conduct the orientation of CDPOs and LS. - CDPOs/LS to organize and carryout block level training of AWWs and their ANM along with MOICs and BEO - MOIC/CDPO to ensure supply of ST Kits, IEC materials, cash assistance etc to AWCs - Prepare a monitoring plan and carry out monitoring of the planned activities jointly in the village or community by involving the leaders, youth or school children. - Every AWW to prepare an Activity Report including a report on monitoring of salt - MOIC and CDPO to conduct joint review meetings with ANMs and AWWs in her/his block on 25th of every month. - DPO/CSEO to hold meeting of BEOs on 28 th of every month and receive reports for all schools in his district by 28 th of every month. - These meetings also to be utilized for planning activities for the next month with time line budget and role specificity. - MOIC and CDPO to facilitate organizing of activities in villages/tolas, AWW to take the lead. - ANM and AWW to prepare a joint report of activities to CS and DWO /DPO. - A copy of the report will be given to DSM. - DSM will forward a copy to RSM. - CS will forward a copy to MIS Cell of State Nutrition Cell. - MIS Cell will share a district-wise compiled report with UNICEF. Education: - Directives from DEO using iodised salt only in MDM in schools. - District DEO to facilitate and complete training of BEOs on IDD/USI - BEO to conduct training of Nodal Teachers along with MOIC/CDPO at the Block - Support Nodal Teachers to prepare a plan of activities and budget for the schools. - Submit a copy of plan and the budget of schools to DEOs office. - All students in the school to be sensitized with the problem of IDD and the benefits of iodised salt. Sensitizing School Children on IDD/IS School teacher shall take a 30 minutes class, and would explain to children why iodine is important, causes of iodine deficiency disorder, and consequences of IDD with emphasis on physical and mental development. Explain that iodised salt helps bring back iodine to the body. Thus iodised salt is important, but both iodised and non-iodised salt is available. Give emphasis to the difference in the IQ points up to 13, in children with iodine deficiency thus affecting leaning and school performance which further reflects on workout put and productivity. Thus good health can be ensured only with daily consumption of iodised salt. 237

238 Activities within the school: - Essay/Story competition -Poetry Writing - Exhibitions -Play/Skits - Slogan writing -Songs -All children participating, to get a certificate and the best child/ children to get a prize) Monitoring salt for iodine content in the class room: All children requested to bring few pinches of salt from their homes Teacher to supervise the testing of salt using the kit, by each child. Children would be classified into two groups. Group 1 will have children with salt samples tested with adequate iodine. Group II will have children with salt samples tested with no iodine or inadequate iodine. Counseling to Group I: Your salt is of good quality and would allow you to perform well in school if you continue consuming iodised salt as you are and pay attention to your studies in the school. Insist that your parents always buy iodised salt only. Counseling to GroupII. Your salt does not contain iodine. Your are being left out from its benefits. If this continues, you are likely to face some serious risks. Your growth can be retarded and at the same time your school performance would be negatively affected. This can happen to your brothers and sisters, as they are also consuming the same salt without iodine or less amount of iodine that is required by the body. When we have the same session repeated next month, your salt test should show blue colour which means you have convinced your parents to buy salt which is iodised. In general, the Teacher should say, we want to see all children in group I and none in the other group. So our class should have children all using iodised salt. - BEOs to ensure supply of ST Kits, IEC materials, cash assistance etc to schools - Prepare a monitoring plan and carry out monitoring of the planned activities in the school along with MOICs and CDPOs. - Head Masters to facilitate organizing of activities within and outside school, Nodal Teacher to take the lead. Activities outside the school: - Organize Salt monitoring for advocacy in the community - Each Nodal Teacher to choose 20 children living in different localities - Each student to visit houses and shops around them for monitoring and advocacy. - Slogans to be used for Prabhat Pheri - Human Chain - Marathon/Bicycle Race - All children to get a certificate, and the best performer to get a prize. 238

239 - Each nodal teacher to prepare report for her class. - Every school to prepare an Activity Report including a report on monitoring of salt - BEO to conduct review meetings with Head Masters/Nodal Teachers on 25 th and collect the report for all schools in his block 25 th of every month. - DEO to hold meeting of BEOs on 28 th of every month and receive reports for all schools in his district by 28 th of every month. - These meetings also to be utilized for planning activities for the next month with time line budget and role specificity. Monitoring and Reporting: The monitoring of the activities will be done by the block level officers of all three departments. A plan for monitoring will be ensured and will prepared during the planning meetings. Each AWC/ANM will prepare a report and forward it to MOIC, CDPO BDO. The schools will prepare the activity report and forward it to BEO and BDO. The MOICs will compile and send the report to CS while, the CDPO will compile and send the report to DPO/DWO with a copy to CS. The BEO will compile for all schools in the block and forward it to DEO with a copy to CS. Civil Surgeon Office will prepare a final compiled report for the district and forward it to State Nutrition Cell, copy to Directorate ICDS and Education, Government of Bihar, Patna. State Nutrition Cell and UNICEF along with Directors of respective departments will hold review meetings to discuss progress and strengthen efforts in low consumptions areas. State Nutrition Cell with support from UNICEF will also facilitate State Task Force Meeting in end September to take stock of achievements and future course of actions. 239

240 Budget for Intensified IDD / USI Activities in 38 District of Bihar Sl No. Name of District No. of PHC Rs.1000 Rs. 500 Activities in 1000 Activates at AWC & 500 IEC Rs ARWAL AURANGABAD BANKA BEGUSARAI BHAGALPUR BHOJPUR BUXAR DARBHANGA EAST CHAMPARAN GAYA GOPALGANJ JAHANABAD JAMUI KAIMUR KATIHAR KHAGARIA KISHANGANJ LAKHISARAI MADHUBANI MUNGER MUZAFFARPUR NALANDA NAWADA PATNA

241 25 ROHTAS SAMASTIPUR SARAN SEOHAR SHEIKHPURA SITAMARHI SIWAN VAISHALI WEST CHAMPARAN Supaul Saharsa Purnia Madhepura Araria Total Particulars Rate Total Amount in Rs. Sl No. 1 Training Rs / PHC Awareness Generation Rs. 500 / PHC Activities in School Rs / PHC IEC Material Rs. 400 / PHC Activities in AWC & Communities Rs Grand Total Total Eighteen Lakh. 241

242

243 PROJECT IMPLEMENTATION PLAN FOR NATIONAL PROGRAMME FOR CONTROL OF BLINDNESS

244 PROJECT IMPLEMENTATION PLAN FOR NATIONAL PROGRAMME FOR CONTROL OF BLINDNESS

245 Introduction National Programme for Control of Blindness (NPCB) was launched in the year 1976 as a 100% centrally sponsored scheme with the goal of reducing the prevalence of blindness. The goal set for the terminal year of the 10th Plan is to reduce the prevalence of blindness to 0.8% by 2007 prevalence of Blindness is 1% ( Survey) and 0.3% of population by The four pronged strategy of the programme is: strengthening service delivery, developing human resources for eye care, promoting outreach activities and public awareness and developing institutional capacity. NATIONAL POLICY : One of the basic human right is THE RIGHT TO SIGHT we have to ensure that no citizen goes blind needlessly, or bring blind does not remain so, if by reasonable skill and resources his sight can be prevented from deteriorating, of if already lost can be restored. 245

246 National Programme for Control of Blindness (Financial Year ) There are two main Programmes under National Programme for Control of Blindness: (1) Cataract Operation (2) School Eye Screenings Programme: Cataract Operation:- Cataract Operations are being done in district Hospitals against the target fixed by state. In addition in the NGOs governed hospitals under the monitoring of District Health Society- Blindness Division. The following table shows the last six year s physical record of Cataract Operation:- Sl. No. Year Target Achievement Percentage Till Feb, School Eye Screening Programme :- Teachers are being trained, to conduct eye screening of the school children and to advise for using proper spectacles by the needy children with defective eyes is one of the main activities of the Programme. In addition to this free distribution of spectacles among the families belonging to below Poverty Line (BPL) is also a major component of the activities. 246

247 The following table shows the last four year s physical record of SES :- Sl. No. Year No. of school children underwent Eye Screening ,97, ,43, up to June, Review Meeting: - A Two days Review Meeting of Additional Chief Medical Officer who is also the District Programme Officer of National Programme for Control of Blindness is proposed in near feature in which representative of Govt. of India shall also be requested to attend. State Level Workshop:- Three days State Level Workshop of Eye specialist/eye surgeon of district level is also proposed in which representative of Govt. of India shall also be invited to attend. Vision Centre:- In remote rural areas where there is no facility of eye care, Govt. of India has provision for setting up vision centre made available. by the NGOs where all facilities for eye care shall be Training :- Under the NPCB training to Medical Officer of PHC, PMOAs and Nurses shall be imparted. Medical Officers shall be trained for three days, PMOAs for five days and training to the Nurses as per Govt. of India guideline. 28 days IEC:- In order to make aware the people about how to take care of their eyes to acquaint them where to report for eye check up 247

248 in case of any vision problem through hand bill, pump let, poster, banner, cable net work, hoarding and Doordarshan etc. Causes of Blindness in Bihar State : Following is the table showing the causes of blindness according to their magnitude of importance in the overall situation of blindness problem. Cataract Refractive Errors Corneal Blindness Glaucoma Surgical Complications Posterior segment disorders Others Emerging Causes of Blindness : Diabetic retinopathy Glaucoma Childhood blindness 248

249 Comparison of Prevalence of Blindness National Surveys Parameter Estd. Prevalence of Blindness (Visual Acuity <6/60 on Blindness & National Survey National Survey Bihar Plan of Action and Budgetary requirements during Recurring Grants in Aid to NGOs for performing free Cataract Operation and other Intra Ocular Surgeries. Sl.No. ICCE IOL Phaco Total Cataract operation and other Intra Ocular Surgeries 1,50,00,000 9,00,00,000 10,50,00,000 Drug and Consumable Sutures Spectacles Transportation/POL Organization & Publicity Icl, Viscoelastics & Addl. Consumables Total Target: % 80% 100% 249

250 Plan of action and Budgetary requirements during Sl. No. Name of Activity Estimated Cost. (Rupees in Lakhs) 1. Remuneration, other activities & contingencies (Annex-A) Grant-in-Aid other Components-) Cash Grant for Salaries & SOC TOTAL: Budgetary requirement during Annexure-A Sl.No. Particulars Cost p.a. 1. Review Meeting 80, Flexi pool fund (for staff remuneration & other ) 10,80, TA/DA for Staff 96, POL/Vehicle Maintenance 72, Stationary and Consumables 52, State level Workshop 120,000 Total 15,00,000 Annexure-B Grant in Aid other components- 1. Recurring GIA for Eye Donation 150, Vision Centre ( 25,000/- per vision centres ) 625, Eye Bank 5,00, Eye Donation Centre 1,00, Training 5,00, IEC ( Schedule A) 5,00, GIA for free Cataract Operation for 38/ DHS-Blindness 4,40,00,000 Division 8. GIA for School Eye Screening for 38 DHS- Blindness Division 10,00,000 Total:- 4,73,75,

251 Schedule :- 1 IEC CAMPAIGN: PROPOSED BUDGET FOR IEC ACTIVITES DURING Sl.No. IEC Materials Tentative Quantity Rate (approx) Estimated Cost (Rs.) 1. Hand Bill (For Eye) 1 Lakh 0.25/- piece 25, Hand Bill (For Children)1 Lakh 0.25/- piece 25, Leaflet 50 thousand 0.50/- piece 25, Poster 40 thousand 1.25/- piece 50, Banner 1000 (Five thousand) (38 District 80/- piece 80,000 & Head Quarter) 6. Cable Head Quarter 3500/- 61, Hoarding (38 District & Head Quarter /- 2,34,000 TOTAL 5,00,,

252 Sl. No. Plan of Action and Budgetary requirements during Recurring Grants in Aid to NGOs for performing free Cataract Operation and other Intra Ocular Surgeries. Name of Dist. Target Total fund allocated by GOI for Cataract Operation for 38 DHS-Blindness Division during (Rs. in lacs) Total fund allocated by GOI for School Screening Programme for 38 DHS- Blindness Division during (Rs. in lacs) Remarks Fund directly allocated by GOI for DHS 1. Araria Do - 2. Arwal Do - 3. Aurangabad Do - 4. Banka Do - 5. Begusarai Do - 6. Bhagalpur Do - 7. Bhojpur Do - 8. Buxar Do - 9. Darbhanga Do E.Champn Do Gaya Do Gopalganj Do Jamui Do Jehanabad Do Kaimur Do Katihar Do Khagaria Do Kishanganj Do Lakhisarai Do Madhepura Do Madhubani Do Munger Do Muzaffarpur Do Nalanda Do Nawada Do Patna Do Purnia Do Rohtas Do Saharsa Do Samastipur Do Saran Do Sheikhpura Do Sheohar Do Sitamarhi Do Siwan Do Supaul Do Vaishali Do W.Chamn Do - Total

253 Recurring Grants in Aid to NGOs for performing free Cataract Operation and other Intra Ocular Surgeries. Sl.N Name of Target 750/- Phaco Total o. Dist. (20%) (80%) 1. Araria , ,200, ,400, Arwal , , , Aurangabad , ,800, ,100, Banka , , ,050, Begusarai , ,400, ,800, Bhagalpur , ,600, ,200, Bhojpur , ,600, ,200, Buxar , ,800, ,100, Darbhanga , ,600, ,200, E.Champn , ,500, ,750, Gaya ,300, ,800, ,100, Gopalganj , ,200, ,400, Jamui , , ,050, Jehanabad , ,200, ,400, Kaimur , ,200, ,400, Katihar , ,400, ,800, Khagaria , , ,050, Kishanganj , ,200, ,400, Lakhisarai , , , Madhepura , , , Madhubani , , ,050, Munger , ,200, ,400, Muzaffarpur ,100, ,600, ,700, Nalanda ,100, ,600, ,700, Nawada , ,800, ,100, Patna ,200, ,200, ,400, Purnia , ,400, ,800, Rohtas , ,200, ,400, Saharsa , ,200, ,400, Samastipur , ,200, ,400, Saran , ,800, ,100, Sheikhpura , , , Sheohar , , , Sitamarhi , , , Siwan , ,500, ,750, Supaul , , , Vaishali , ,100, ,450, W.Chamn , ,800, ,100, Total ,000, ,000, ,000,

254 (Details of GIA for strengthening /expansion of eye care units in NGOs sector, Eye bank, eye donation Centres, IEC,Training etc. under NPCB during Sl.no Grant in Aid for various schemes. Balance available as on Fund received from GOI during fund utilised/ disbursed Balance as on Cataract Operation (for DBCS) - 7,000, ,000, School Eye Screening 28, ,000, ,028, Eye Donation 100, , , Vision Centre - 563, , Eye Banks Eye Donation Centres 150, , Training 222, , , IEC Activities 184, , , SBCS remuneration and other activities (108,620.35) 800, , , Cash Grant Non recurring GIA to NGOs Total:- 576, ,313, ,132, ,757, Note:- Grant in aid of central assistance received from GOI,MH& FW, New Delhi vide letter no. T.12012/11/2006-BC dated for implementation of the following various new scheme under NPCB during Received in Financial year through ECS dt. on Name of Activities: 254 F/Y fund received on Fund received from GOI during F/Y Total fund received during the F/Y from GOI Cataract Operation (for DBCS) School Eye Screening Recurring GIA for Eye donation Non recurring GIA for Vision Centre Training Activities IEC Activities SBCS staff remuneration and other activities Total:

255 Sl.No a) Details of GIA for Procurement of Ophthalmic Equipments under NPCB during Grant in Aid for various Schemes 1 Procurement for Ophthalmic equipments (DBCS) 2 Medical Colleges:_ Balance available as on Budget Allocated GIA released by GOI Expenditure/ Disbursed 7,991, Balance as on ,991, S.K. Medical College & Hospital, Muzaffarpur - 3,000, ,000, ,000, Total:- 7,991, ,000, ,000, ,991,

256 Schedule :- 2 Fund allocated to DHS as per PIP allocation during the financial year Sl.No. Name of District Year Target GIA for free cataract operation for 38 DHS of Rs. 4,40,00,000 GIA for School Eye Screening for 38 DHS of Rs. 10,00,000 Fund allocated to DHS as per PIP allocation Total Rs.4,50,00,000 1 Araria , Arwal , Aurangabad , Banka , Begusarai ,200, Bhagalpur ,800, Bhojpur ,800, Buxar , Darbhanga ,800, E.Champn , Gaya ,500, Gopalganj , Jamui , Jehanabad , Kaimur , Katihar ,200, Khagaria , Kishanganj , Lakhisarai , Madhepura , Madhubani , Munger , Muzaffarpur ,300, Nalanda ,300, Nawada , Patna ,600, Purnia ,200, Rohtas , Saharsa , Samastipur , Saran , Sheikhpura , Sheohar , Sitamarhi , Siwan , Supaul , Viashali , W.Chamn , Total ,000, ( Rupees four Crore fifty lac(s) only.) 256

257 Sl. No. Budget summary for Year Name of activities DHS (Blindnes ) SHSB (Blindness) Remarks Remuneration,other activities & contingencies ( Annex.-A) - 1,500, SHSB,level Recurring GIA for Eye donation - 150, Vision Centre - 625, Eye Bank - 500, Eye Donation Centre - 100, Disbursement of fund to DHS after approval. Training 500, SHSB,level IEC 500, SHSB,level Fund GIA for Cataract Operation 44,000, disbursement to DHS GIA for SES 1,000, after approval. Cash grant for salaries & SOC 3,000, SHSB, level Total:- 45,000, ,875, ,875,

258 ACTION PLAN ( ) National Leprosy Eradication Programme (NLEP) BIHAR 258

259 Executive Summary: National Leprosy Eradication Programme (11 th five Year Plan ) State Action Plan BIHAR Even though new case detection rate and prevalence rate are going down, yet new cases continue to come up in large numbers in state. The promotion of self reporting is now crucial to case detection, as case finding campaigns become less and less cost effective. It is important to identify and remove barriers that may prevent new cases coming forward and a greater emphasis on the assessment of disability at diagnosis, so that those at particular can be recognized and managed appropriately. Leprosy being a disease associated with poverty, it is presumed there are still hidden cases in the SC and among the underprivileged in other categories, in both rural and urban areas. Under special initiatives, to promote self reporting, focus will be on wide dissemination of key messages of leprosy i.e. curable, early signs, no need to be feared and support, in the urban and rural areas. This will reduce stigma & discrimination against persons affected with leprosy. The key messages along with proactive involvement of the community will bring about health behavior at individual, household and community level. The out come of strategy will be promote further integration with general health care system by providing operational and technical on the job training. The better equipped and motivated GHC system will provide quality leprosy services on all working days to the affected communities, following the principles of equity and social justice. 259

260 Background: National Leprosy Control Programme was started by Govt. of India in 1955 based on Dapsone Monotherapy through units implementing survey, education and treatment activities. It was only in 1970s that a definite cure was identified in the form of Multi Drug Therapy. The MDT came into wide use from 1982, following the recommendation by WHO study Group, Geneva in October Government of India established a high power committee under chairmanship of Dr. M. S. Swaminathan in 1981 for dealing with the problem of leprosy. Based on its recommendations the National Leprosy Eradication Programme (NLEP) was launched in 1983 with objective to arrest the disease activities in all the known cases of leprosy. In order to strengthen the process of eradication, the World Bank supported the project in two phases. The first phase was started in and ended on 31st March The second phase started in year and ended on 31 st December Now since 2005 the project is being continued with GOI funds. The cost of infrastructure is borne by the state funds. Additional support is received from World Health Organisation and ILEP (International Federation of Anti-Leprosy Associations). Multi Drug Therapy (MDT) was supplied free of cost by Novartis through WHO. In Bihar whole state was covered under MDT in November In Bihar till date more than 15 lakhs patients treated with leprosy. The PR reduced to 14.2/10000 populations in year Integration of leprosy services in to general health care system started in and fully integrated in Five rounds of Modified Leprosy Elimination Campaigns (MLECs) and four rounds of Block Level Awareness campaigns have been already successfully conducted in the state during the period 1998 to These activities resulted in detection of more than 4 lakh cases. 260

261 MDT in Bihar: MDT started in Bihar in phased manner. In composite state of Bihar, first phase MDT was started in two districts in 1982 (Bhagalpur & Rohtas). 13 more districts added in MDT was launched in whole state in Current status: From onwards when entire state was brought under MDT, a steady decline in PR was recorded. The PR of 17.3/10000 populations in declined to 1.04/10000 populations on 31 st March Now state is at the verge of elimination considering PR 1.04/10000 populations on March districts reached elimination and 23 districts have PR between 1 to 2 as on 31 st March At present the NLEP is fully integrated into General Health Care System from subcentre to District Hospitals/Medical Colleges. District Nucleus is formed at 36 out of 38 districts to monitor and supervise the programme. The IEC activities including Inter Personal Communication are continued and therefore stigma has significantly come down. At present most of leprosy affected deformed patients are living with their family and leprosy patients are coming at health institutions voluntarily. 261

262 STATE PROFILE Bihar is the third largest populated state in the country. There are 38 districts in the state. Bihar is divided in two geographical areas- North and south areas POPULATION (2001 census)* *Estimated Population as on March MALES FEMALES SEX RATIO (females/1000 males) 921 DENSITY OF POPULATION (Persons/ Square Km) 880 URBAN POPULATION % LITERACY RATE (census 2001) in % 47 MALE LITERACY in % 59.7 MALE LITERATE in numbers FEMALE LITERACY in % 33.1 FEMALE LITERATE in numbers BIRTH RATE (PER 1000) 30.9 DEATH RATE (PER 1000) 7.9 District Hospital 24 Sub- Divisional Hospital 23 Referral Hospital 71 Primary Health Centre (PHCs) 484 Additional Primary Health Centre (APHCs) 1243 Health Sub-Centre 8858 No. of Villages

263 Situational Analysis As on September 2008/ Districts/Blocks/Urbans Indicators recommended by GOI for Monitoring & Supervision: The Government of India has recommended the following three indicators:- (I) Major indicators: (1) Annual New Case Detection Rate(ANCDR) per population (2) Treatment Completion Rate (3) Prevalence Rate (II) Additional Indicators: (1) Proportions of Grade I disability among new cases (2) Proportions of Grade II disability among new cases (3) Proportions of child cases among new cases (4) Proportions of female cases among new cases (5) Proportions of MB cases among new cases (III) Indicators for patient management and follow up: (1) The proportion of new cases correctly diagnosed (2) The proportion of treatment defaulters (3) Number of relapse reported during year (4) The proportion of patients who develop new or additional disabilities during MDT. 263

264 Shift in focus from PR to ANCDR: Since a shift in focus from PR to ANCDR was introduced, as it is a better indicator for epidemiological analysis. Sl. No. District Active Balance case at the end of September 2008 PD Ratio Female (%) New Visible Deformity (%) Grade II Child % MB % PR/ 10,000 NCDR per 100,000 1 Aurangabad Bhojpur Buxar Bhagalpur Banka Darbhanga Katihar Muzaffarpur Nawadah Patna Purnia Kishanganj Araria Rohtas Kaimur Siwan Sitamarhi Sheohar W.Champaran Begusarai E.Champaran Gaya Gopalganj Jehanabad Arwal Khagaria Madhubani Madhepura Munger

265 30 Sheikhpura Jamui Lakhisarai Nalanda Saharsa Supaul Samastipur Saran Vaishali Total ANCDR: (20.9/100000) ANCDR(quarterly) of 21 districts is > 20/ of population. These districts are Aurangabad, Banka, Muzaffarpur, Nawada, Patna, Kishanganj, Araria, Rohatas, Kaimur, Siwan, Seohar, East Champaran, Gaya, jahanabad, Arawal, Madhubani, Munger, Sheikhpura, Lakhisarai, Nalanda and Saran. Therefore overall ANCDR of state is also > 20/ population 265

266 Treatment Completion Rate- ( ): S.N. Districts Treatment Completion Rate(%) Rural(%) Urban(%) Total(%) 1. Patna Bhojpur Buxar Aurangabad Arawal 92.9 No urban Gaya Nalanda Nawada Rohtas Vaishali Bhagalpur Banka Khagaria Muzaffarpur Samastipur East Champaran Sitamarhi Seohar Gopalganj Saran Araria Saharsa Supaul West Champaran Siwan State TCR of Bihar state is more than 90% but in urban areas of few districts TCR is less than 90% and these districts are Patna, Bhagalpur, Saran, Saharasa. TCR of urban Vaishali is very less 47.3%. 266

267 SWOT analysis: After analysis following are strengths, weaknesses, opportunities and threats in state. Strengths: 1. trained district nucleus 2. Trained experienced & motivated staff 3. Better awareness and reduced stigma 4. Adequacy of MDT 5. Adequacy of fund form GOI and ILEP 6. Better comprehensive infrastructure from subcentre to Medical college 7. Integration of leprosy services with GHCs staff 8. Training materials are available 9. Regular NLEP staff meetings and monitoring 10. Good coordination State Health System, WHO & ILEP 11. Enough people willing to work for the cause. Weakness: 1. Large state with many districts 2. Reduction in ILEP support 3. No WHO zonal coordinators 4. Complicated procedures for fund utilization for leprosy work at district level 5. Inadequacy of fund for vehicle operation and complicated procedure for hiring of vehicle 6. Less support from public opinion leaders 7. Poor POD services 8. Leprosy being last priority of health programme 9. Inadequate funds for rehabilitation and mobility aids 10. Inadequate coordination between staff 11. Vehicles Using in other programmes by DM and Civil Surgeons 12. Inadequate training of NGOs/local practitioners 13. incomplete data of deformities 14. Less effective counseling 267

268 Opportunities: 1. Integration with NRHM (a) Support from ASHA (b) Additional flexible funds (c) Better monitoring and supervision (d) Better infrastructure and man power 2. Integration with GHS 3. Involvement of Medical Colleges/Hospitals/NGOs 4. Full utilization of dermatologists, physicians and orthopaedic surgeons for diagnosis and rehabilitation 5. Support of ILEP/NGOs/WHO Threats: 1. Complacency among staff and less political commitment 2. Priority to other programmes 3. Transfer of programme officers at state and district 4. Public stigma 5. No self dependence of sufferer State will use this SWOT analysis for making strategies and plans in NLEP. National Leprosy Eradication Programme (11 th five year plan ) Objectives: To further reduce the leprosy burden Provision of high quality leprosy services for all persons affected by leprosy, through general health care system including referral services for complications and chronic care. Enhanced Disability prevention and Medical Rehabilitation (DPMR) services for deformity in leprosy affected persons. Enhanced advocacy in order to reduce stigma and stop discrimination against leprosy affected persons and their families. 268

269 Capacity building among health service personal in integrated setting both for rural and urban areas. Strengthen the monitoring and supervision component of the surveillance system. Strategy: (1) Integrated Leprosy Services and Special initiatives. (2) Disability Prevention and Medical Rehabilitation (DPMR) (3) Information, Education and Communication (4) Training and capacity building. (5) Supervision, monitoring and review. (6) Infrastructure maintenance Activities as per objectives and strategy: 1. Integrated Leprosy Services and Special initiatives 1.1 Integrated Leprosy Services through all Primary Health Care facilities will continue to be provided in the rural areas. 1.2 All the urban areas will be covered under urban leprosy control programme integrating services from all the partners available in the areas, including private practitioners. 1.3 Involvement of multipurpose health functionaries, ASHA in villages, and selected NGOs in urban areas are to be engaged for case follow up during treatment to ensure regular MDT collection and consumption, so that all the cases put under treatment gets cured in shortest possible time. 1.4 Emphasis will be laid on providing best quality leprosy services through the GHC system. This means easy availability of services on all working days to all patients, correct diagnosis and adequate counseling to patients 269

270 and family members, provide MDT to patients whenever approached, regular monitoring of patient during treatment. Treatment completion by all under treatment patients will be desired outcome of the programme. 1.5 The system of referral of difficult cases to the district hospital for diagnosis and management, which has already been started, will eb further strengthened with capacity building of persons involved at PHC as well district Hospital level. 1.6 The laboratory facilities at District Hospitals for smear examination to diagnose difficult cases will be strengthened. 1.7 Desegregated data for female, schedule tribe and schedule caste patients are to be maintained. 1.8 Regular monitoring and surveillance at state, District and Block level will be continued to locate weak areas, so that needed plan for corrective action can be taken in time. Services through ASHA: After sensitization of ASHA in Leprosy they will be involved to refer a suspected case of leprosy from their villages for diagnosis at PHC and after diagnosis to follow up the patients for completion of their treatment, ASHA will be entitled to receive incentive as below- (i) On confirmed diagnosis of cases brought by them Rs 100/- (ii) On completion of full course of treatment within specified time PB Leprosy case Rs. 200/- MB Leprosy case Rs. 400/- Number of new leprosy cases detected cases in % MB cases % PB cases (It is expected that 50% of new MB and new PB cases will be brought by ASHA. 50% of PB new cases = % of new MB cases = 4284) 270

271 Budget: For MB cases = Rs *4284 cases = Rs For PB cases = Rs *5236 = Rs Total Cost of services through ASHA = Rs Urban Leprosy Control : Total number of town ships selected for ULCP 24 Total number of medium city(i) selected for ULCP 6 Budget Rs.75000/- for one town ship x 24 = /- Rs /- for one medium city(i) x 6 = Rs /- Total cost of Urban Leprosy Control = /- 2. Disability Prevention and Medical Rehabilitation - More emphasis will be given on Disability prevention among new leprosy cases and RCS services for deformed persons due to leprosy. 2.1 Prevention of Disability: Health workers will suspect cases of leprosy reaction, relapse, insensitive hands and feet and refer to PHC for diagnosis. They will also empower patients with self care procedure for prevention of deformity. All PHC Medical Officers will diagnose cases of reaction/neuritis, provide counseling and treat them. Severe reaction/neuritis cases will be referred to the District Hospital if not responded within two weeks of starting treatment. Service and care for impairment such as ulcers, cracks and wounds, septic hand or feet etc. will be available from all the health facilities routinely. Complicated ulcer cases will be referred to District Hospital. 271

272 Microcellular Rubber (MCR) footwear are to be provided to all needy patients ( under treatment and RFT) by the District nucleus staff at the concerned health facility. An appropriate system of need assessment, procurement and supply will be maintained and improved. PHC will provide follow up treatment to all patients referred back by the secondary and tertiary level units for reaction, complication or post surgery care. Operational guidelines on DPMR for primary and secondary level have been distributed to all districts and PHCs. 2.2 Medical Rehabilitation: Enlisting of disability cases has been completed in 24 districts and in remaining 14 districts enlisting is under process. In districts the patients fit for RCS are being referred to identified RCS units(department of PMR at PMCH, Patna and DMCH Darbhanga). An estimated 200 RCS will be done during this year. Budget for RCS support and patient welfare for 200 patients is kept. In addition to this TLM Hospital Muzaffarpur will continue to do RCS with ILEP support. It is planned to start RCS in Magadh Medical college, Gaya in this year Incentive to patients undergoing RCS: Provision to patients undergoing Rs to offset wage loss to BPL families as recommended by GoI. It is proposed that the above provision may be applied for for surgical Nerve Decompression also. Further it is suggested that leprosy is a disease associated with poverty, the provision of Rs to offset wage loss may be given to all leprosy patients undergoing RCS/Nerve decompression surgery. Incentive to Institutions: Provision to support Government Medical Colleges/PMR centres in the form of Rs per RCS case has been kept for procurement of supply and material and other ancillary expenditure. 272

273 Need based supply of MCR footwear to the needy patients will continue during year through District Societies, NGOs and concerned institutions.as grade I patients with insensitive feet have been included under DPMR plan for MCR supply the number of foot wear requirement will increase. Budget: (1) Provision to compensate wage loss to BPL persons affected with leprosy undergoing Reconstructive/Nerve Decompression surgery around 200 persons are expected to be operated. The reimbursement of Rs is sought to be provided for Rs per person*2*20 days = Rs Transportation for 2 persons(4-5 times) = Rs Total (one RCS) = Rs For 100 RCS *100 = Rs (2) Provision of incentive to Govt. institutions- For 100 RCS *100 = Rs (3) MCR foot wear pairs of MCR foot Rs *Rs = Rs Total cost of DPMR = Information, Education & Communication: Introduction Leprosy is an age old disease. As there was no known remedy for the disease in the earlier days, the viciousness of disease, disfigurement and disability caused by the disease resulting in making the affected persons heavily, led to a number of myths, misconceptions, apprehensions and inhibitions in the minds of people. This resulted in to developing such a high degree of stigma against the disease that the community wanted to avoid all contacts with such persons. The leprosy affected persons were forced to leave their home 273

274 and live in segregated areas. This is the only disease where sufferer had to live in separate colonies, villages and in distant islands. At present the situation has changed to a greater extent. Now there is cure for leprosy and patient can live in their home during treatment. Because of early treatment deformities and disabilities have reduced. Many discriminatory laws have been repealed all over the world. Yet there is discrimination against the person affected by leprosy, which need to be removed from the public mind, so that these persons can lead normal life like any other human being. Determinants of stigma: Stigma is perpetuated by (1) Lack of knowledge (2) Attitude (3) Fear (4) Blame & shame Intervention strategies: Spreading awareness: Spread the demystifying messages and its interpretations, mainly regarding nature of disease, whether leprosy cases are untouchable, role of immunity in occurrence of leprosy, what is burnt case and so on. However, mere information and education, to all and sundry about the signs and symptoms of leprosy and its curability, shall not work. It is imperative to break the barrier between persons affected by leprosy and the rest of the society, by appealing to the people s emotions and their ability to empathies with those they feared and shunned. With reducing number of leprosy cases in community, awareness about curability of disease, lessening number of deformity due to leprosy, stigma associated with the disease has become slightly less. The effective way to deal with this difficult challenge of stigma removal is to embark on intensive inter personal communication (IPC) with the target groups The strategy involves, coordinates and facilitated by (1) civil societies (2) social activists (3) Health service providers (4) Community/opinion leaders (5) Corporate sectors (6) Media (7) Institutions under NRHM such as ASHA and other health functionaries, Rogi Kalyan Samities and Village Health & Sanitation Committees, Health Melas at district and block level etc. An IEC campaign towards achieving Leprosy free India recommended by GOI will be followed on following concept 274

275 The effort to further reducing leprosy burden in the communities have to be prioritized so that visible deformity in newly detected cases is reduced to minimum. Early reporting and complete treatment of leprosy cases prevent disability. Quality of services provided to leprosy affected persons be at optimum level to reduce suffering and prevent consequences in all cases put on treatment. Leprosy patients will not be stigmatized and discriminated and would lead to a socially and economically productive life. Budget and norms for IEC: Mass media- Electronic Media Rs Print media Rs Out door media- Rallies(including Rs.5000/- per district. Budget Rs x 38 districts = /- Rural Media: School Rs.500/- for one quiz. In each block 5 school quiz will be conducted. Budget Rs x 484 blocks x 5 = Rs /- Sensitisation meeting with PRI members-rs.4000/- per meeting at each block Rs.4000/. * 484 blocks = /. Total cost of IEC = Rs /- 275

276 4. Training Plan(training and capacity building): 4.1 Leprosy training to GHC staff(new entrants) To improve quality of leprosy diagnosis, complications management, DPMR and programme monitoring the key medical and paramedical staffs will be provided trainings newly appointed contractual MOs will be provided four days modular training on leprosy and NLEP(including DPMR). Budget Venue District head quarter training hall. Trainers(2trainers) Rs.300/- per day for two days Rs x 2 days x 2 trainers = Rs.1200/- TA for Rs.80/- per day for 30 trainees for 2 days Rs x 30 trainees x 2 days = Rs.4800/- DA for Rs.80/- per day for 30 trainees for 2 days. Rs x 30 trainees x 2 days = Rs.4800/- Working lunch & Rs.150/- for 35 persons for 2 days Rs x 2 days x 35 = Rs.10500/- Learning materials, stationary Rs.250/- per head for 30 trainees. Rs x 30 = 7500/- Miscellaneous Rs.2500/- per batch. Total expenditure for 2 days training of new MOs for one batch = Rs.31300/- Total number of batches in all districts of Bihar 47 Total Expenditure Rs x 47 batches = Rs /- 4.2 One days refresher training of PHC medical officers: Total number of regular MOs in position 2712 Total number of batches 90(batches distributed districtwise) 90 batches x Rs Total expenditure =Rs /- 276

277 Consumables: For SHS(leprosy) Rs.28000/- and for DHS(leprosy) Rs.14000/- per district will be provided. Office expenses: For SHS(leprosy) Rs.38000/- and for DHS(leprosy) Rs.18000/- per district will be provided. Vehicle Operation & Hiring: Vehicle operation/pol/hiring for SHS(leprosy) Rs.85000/- for two vehicles and for DHS(leprosy) Rs.75000/- one vehicle for one district will be kept. Drugs, Materials & supplies: For supportive medicine Rs.25000/- per district. For laboratory reagents- Rs.12000/- per year per district. For patient welfare Rs.6000/- per year per district. Printing: Required numbers of DPMR registers, formats and other formats will be printed at state head quarter and supplied to districts. (State Officers and WHO/ILEP Coordinators will also monitor the supply of different logistics at each level) Professional Services: Audit fees will be met by State Health & FW Society for centralized audit of 38 DLS & SLS head quarter for preparation of consolidation Audit Report. 277

278 Contractual Services: As per annexure 1 NLEP Monitoring and Review: Monitoring of: - NCDR,TCR,PR & other NLEP indicators - Regularity of treatment & timely RFT - Reports(MPR,MDT indents,tour reports etc) - Implementation of DPMR trainings with support of ILEP, RCS & other referral & IEC activities. - On the job training on DPMR formats, modified SIS & MDT stock management up to subcentre level DPMR/SIS/MDT management & monitoring of -MDT stock situation in patient month BCPs -MDT indenting -MDT supply -Availability of prednisolone at PHCs. Review Meetings of DLOs and members of District nucleus four times in one year 278

279 STATE HEALTH SOCIETY (Leprosy), BIHAR Budget for Year Anexxure 1 1 Sl. No. 1.1 Category of Expenditure : Component & Sub Component wise Under SHS(Leprosy) NLEP contractual services(staff) 40 Drivers for 38 districts & for State Leprosy DLS SHSB (Leprosy) Total of activities 1.2 DEO at State Leprosy Rs.8000/ Rs.400/- PM for 38 DLS for account work of Leprosy Audit Rs.6000/- x 39(38 DHS + 1 SHS -L) Total contratual services(1.1 to 1.6) Office expences SHS(leprosy) for rent,telephone,electricity, P & T charges, miscellaneous-rs.38000/- per year DLS(leprosy) for rent,telephone,electricity, P & T charges, miscellaneous-rs.18000/- per district/ year Total - Office expences(2.1 to 2.2) Consumables Consumables for DHS(leprosy) : Stationery etc.@ Rs /- per dist/year Consumables for SHS(leprosy) : Stationery etc.@ Rs /- per year Total - Consumables(3.1 to 3.2) Vehicle operation/hiring & POL/ Maintenance 4.1 One vehicle for each DHS(leprosy)-Rs per vehicle/district Two vehicles for SHS(Leprosy)-Rs.85000/- per vehicle Total - Vehicle operation(4.1 to 4.2) Drugs, materials & supplies 5.1 Supportive medicines-rs /-per district/year

280 5.2 Laboratory reagents & equipments -Rs.12000/-per district/year Patient welfare-rs.6000/- per district/year Printing of forms/dpmr registers etc Total - Drugs,materials & supplies(5.1 to 5.4) IEC 6.1 Mass media: 6.11 Electronic media-radio/doordarshan Print media-news papers Out door media: 6.21 Sensitisation meeting with PRI members-rs.4000/- per meeting at each block Rural media: School quiz-rs.500/-per quiz (10quiz per block for 484 blocks)) Health Mellas/Fairs-Rs.5000/- per Mela(one Health mela/district) Total -IEC Training days modular training of new entrant MOs-Rs.27300/- per batch for 47 batches 1 days reorientation training for 2700 Mos-Rs.13650/- per batch for 90 batches Training of ASHA(half day)-for 659 Batches (40 ASHA / Batch) Total - Training(7.1 to 7.6) Disability Prevention and Medical Rehabilitation (DPMR) 8.1 MCR & other footwears-4560 Rs.250/- per pair Aids & appliances-rs.12500/- per district Welfare allowance for RCS 5000/- per patient for 120 patients Incentive to institution for RCSRs.5000/ - per RCS for 80 RCS

281 Total - DPMR(8.1 to 8.4) Services through ASHA(performance based incentive to ASHA) For PB new cases-4840(pb Rs.300/- per case For MB new cases-3872(mb Rs.500/- per case Total - Services through ASHA(9.1 to 9.2) Urban Leprosy Control Programme: 10.1 For 24 townships-rs.75000/- per town For 6 medium I cities-rs /- per medium city Total -Urban leprosy control(10.1 to 1 0.2) Review meetings of DLOs four times in a year- Rs.30000/- per meeting Grand Total (Rs. Two Crore sevety eight lac ninety seven thousands & eight hundred only) 281

282 Fund Allocation to State Leprosy Cell Sl. Expenditure Under SHS (Leprosy) Component & Sub Component w ise No. Amount Rs. 1 Two Driver's Remuneration for State Leprosy Rs. 4500/ DEO at State Leprosy Rs. 8000/ Audit Fee for State Leprosy Cell Telephone, Fax, P &T charges, Rs /- per year Consumables : Stationery Rs /- per year Two vehicles for SHS 85000/- Per vehicle / year Printing of Forms / DPMR registers et Electronic media-radio / Doordarshan Print media-news papers MCR & other Footwears Rs.250/- per pair Review meeting of DLOs four times in a Rs /- per meeting Total

283 Fund Allocation to District Health Society (Leprosy) Contractual services Sl. No. District Populatiom March 2008 (Est.) Number of Block PHC PD Ratio Number of ASHAs Driver's Rs. 4500/ - per month Honorarium for Accounts work of Rs. 400/ - per month Audit Rs. 6000/ - DLS(leprosy) for rent,telephone,electricity, P & T charges, miscellaneous - Rs.18000/- per district/ year Consumable Expenses (Stationery & Rs / - per year Vehicle Operation / hirin g, POL & Rs / - per vehicle / district 1 Aurangabad Bhojpur Buxar Bhagalpur Banka Darbhanga Katihar Muzaffarpur Nawada Patna Purnea Kishanganj Araria Rohtas Kaimur Siwan Sitamarhi Sheohar W.Champaran Begusarai E.Champaran Gaya Gopalganj Jehanabad Arwal Khagaria Madhubani Madhepura Munger Sheikhpura Jamui Lakhisarai Nalanda Saharsa Supaul Samastipur Saran Vaishali Total

284 Drugs, materials & supplies Training Sl. No. District Supportive Rs / - per year Laboratory reagents & Rs / - per year Patient Rs. 6000/ - per year School Rs. 500/- per quiz (10 quiz per Blocks) Sensitisation meetings with PRI Rs. 4000/- per meeting at block level Health Melas / Rs. 5000/- per mela (One Health Mela / District) Two days modular training of new entrant Rs.27300/- per batch for 47 batch No.of Batch Amount One day reorientation training of Rs /- batch for 90 batches No. of Batch Amount 1 Aurangabad Bhojpur Buxar Bhagalpur Banka Darbhanga Katihar Muzaffarpur Nawada Patna Purnea Kishanganj Araria Rohtas Kaimur Siwan Sitamarhi Sheohar W.Champaran Begusarai E.Champaran Gaya Gopalganj Jehanabad Arwal Khagaria Madhubani Madhepura Munger Sheikhpura Jamui Lakhisarai Nalanda Saharsa Supaul Samastipur Saran Vaishali Total

285 Sl. No. District Training Training of ASHA (half Rs. 3200/- per Batch of 40 No. of Batch Amount DPMR Aids & Rs.12500/- per district Services through ASHA (performance based Incentive to ASHA, 10 PB & 8 MB / BLOCK / YEAR) Urban Leprosy Control Programme Number of RCS RCS Welfare allowance for RCS patients (Rs. 5000/- / RCS) Incentive to Institution for RCS (Rs. 5000/- / RCS) 1 Aurangabad Bhojpur Buxar Bhagalpur Banka Darbhanga Katihar Muzaffarpur Nawada Patna Purnea Kishanganj Araria Rohtas Kaimur Siwan Sitamarhi Sheohar W.Champaran Begusarai E.Champaran Gaya Gopalganj Jehanabad Arwal Khagaria Madhubani Madhepura Munger Sheikhpura Jamui Lakhisarai Nalanda Saharsa Supaul Samastipur Saran Vaishali Total

286 Activity Chart for Action Plan (Gantt Chart) Annexure - 2 Sl. No. Activity Persons responsible Time Frame Jan 09 Feb 09 Mar 09 Apr 09 May 09 Jun 09 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10 I Planning of Activities 1.1 Development of Action Plan for and its submission to GOI after aproval of SHS, Bihar 1.2 Approval of State Action Plan GOI State Leprosy Officer, WHO/ILEP Coordinators Development of budgetary and State Leprosy operational guidelines for each and Officer, every activity as per approved WHO/ILEP action plan Coordinators Briefing of CS and DLOs on Action Plan and development of detialed districtwise operational plan with specific time frame in the first review and planning meeting at State HQ State Leprosy Officer, WHO/ILEP Coordinators, CS and DLOs By 19th Jan By 30th Jan By 10th May 2009 By 15th May Budgetary allocation for each district State Health Society & SLO By 20th May Approval of District Action Plan and its budget in District Health Society CS and DLO By 30th May 2009 Statrt activities as per the action plan and continue activities on routine Concern officers at State, Dist and PHC level 1st June 2009 to 31st March 2010 II Prcurement Plan 2.1 Purchase of logistics such as 286

287 MCR Chappals (Through a State level committee) Supportive Medicine e.g.prednisolone 2.4 Splint, Crutches, Lab reagents 2.5 Printing of Formats III Training day training for MOs a batch of 30 MOs x 47 batches 2 days reorientation training for Medical Officers at Distt./PHC a batch of 30 Mos x 90 batches Refreshal training for one day for Health Supervisors/LHV/Pharmacists a batch of 30 x 50 batches 5 days training of lab technicians a batch of 15 LTs x 3 batches 1 day training of 'A'Grade nurses in 48 batches 3.6 Half day training of ASHA State Leprosy Officer CS and DLO State Leprosy Officer State Leprosy Officer State Leprosy Officer, WHO/ILEP Coordinators, DLOs By making 5 State level teams June/July 2009 May/June 2009 June/July 2009 By July 2009 Aug to Dec Sept CS, DLO, to Dec. District Nucleus 2009 Sept CS, DLO, to Dec. District Nucleus 2009 ILEP State Leprosy Officer, WHO/ILEP Coordinators In October 2009 Aug to Dec CS,DLO,District May 2009 Nucleus & to Aug. BPHC staff 2009 IV Disability Prevention and Medical Rehabilation (DPMR) 287

288 4.4 RCS operations at Dept of PMR, Patna Medical College, Patna and operations at Darbhanga Medical College, Darbhanga & TLM Muzaffarpur DLO Patna,DLO Darbhanga, April 2009 DLO to March Muzaffarpur, 2010 District Nucleus and Medical Collages V Information, Education, Communication (IEC) 5.1 Radio Spots/Doordarshan 5.2 Meeting (Political Advocacy, for MLA, MLC ) 5.3 Hoarding 5.5 Posters 5.6 Cable Spot 5.7 Wall panting 5.8 Rallies (including banners etc.) State Leprosy Officer State Leprosy Officer, WHO/ILEP Coordinators DLS - CS, DLO, District Nucleus DLS - CS, DLO, District Nucleus, PHC staff DLS - CS, DLO, District Nucleus DLS - CS, DLO, District Nucleus, PHC staff DLS - CS, DLO, District Nucleus, PHC staff June 2009 to March 2010 During Winter session June 2009 to Aug June 2009 to Aug June 2009 to March 2010 June 2009 to Dec Antileprosy Week 288

289 5.9 Quiz 5.10 Cinema slides 5.12 Meeting with Zilla Parishad 5.13 Orientation camp for NGO and Mahila Mandals 5.14 Press Advertisement 5.16 Health Mellas/Fairs 5.18 Monitoring & Supervision DLS - CS, DLO, District Nucleus, PHC staff DLS - CS, DLO, District Nucleus DLS - CS, DLO, District Nucleus, PHC staff DLS - CS, DLO, District Nucleus DLS - CS, DLO, District Nucleus, PHC staff DLS - CS, DLO, District Nucleus, PHC staff DLS - CS, DLO, District Nucleus, PHC staff In January 2010 June 2009 to March 2010 Oct to Dec Jan to Febr Jan to Feb June 2009 to Sept October 09 to March 2010 VI Epidemiological Situation Analysis 6.1 Status of Implementation of Action Plan for MDT Stock Situation Analysis A State NLEP Every Coordination month from Committee April 2009 under the to March chairmanship of

290 6.3 Districtwise analysis based on the field observations of DLOs, WHO/ILEP Coordinators and State Officers involving 6 DLOs in a month on rotation 6.4 Quality of Diagnosis Regularity of treatment and timely RFT Quality of information and implementation of SIS Availability of MDT stock and other logistics Capacity of GHCS staff and integration Implementation of Action Plan including DPMR Briefing of Executive Director, SHS on the minutes of State NLEP Coordination Meeting and sharing the same with Director in Chief, Secretary Health, DDGL, etc. Additional Director and State Leprosy Officer, Leprosy will continuously monitor the programme at each level and do analysis in State NLEP Coordination Meeting at State HQ Following will be the members of committee Additional Director Health Services,State Leprosy Officer and Controlling Officer, Bihar State Coordinator (WHO/GOI), NLEP, Bihar ILEP Members Representative from PMCH, Patna DLOs from identified districts on rotation Epidemiologist SSAU 290

291 6.5 Reviews State NLEP Coordination Committee Every month from April 2009 to March 2010 VII A review meeting of all DLOs will be called at State HQ every quarter to review all the activities in detail. Zonal review meetings at each zone District will review NLEP in routine monthly meetings Block will review NLEP in routine weekly meetings DLOs and District Nucleus will participate in weekly PHC meeting on rotation and review NLEP at that level Please tick mark in the square when the activity is completed and mark a question mark when due date is passed Executive Director, SHS, Add. Director, State Leprosy Officer, WHO/ILEP Coordinators, State Leprosy Officer Add. Director, WHO/ILEP Coordinators, May, August, November, February in Alternate month Every CS, DLO, month from District Nucleus Apr to Mar I/C MO PHC Every week from Apr to Mar Every week DLO and from Apr. District Nucleus 2009 to on rotation Mar

292

293 293

294 Annual Plan for Programme Performance & Budget for the year 1 st April 2009 to 31 st March 2010 State: Bihar (GFATM) Objectives: 3.1.To achieve and maintain a cure rate of at least 85% among newly detected infectious (new sputum smear positive) cases, and 4.2. To achieve and maintain detection of at least 70% of such cases in the population Formatted: Bullets and Numbering This action plan and budget have been approved by the STCS. Signature of the STO Name Dr.N.M. Sharma Section-A General Information about the State 1 State Population (in lakh) GFATM Districts Number of GFATM districts in the State 30 3 Urban population Tribal population 8 5 Hilly population 6 6 Any other known groups of special population for specific interventions (e.g. nomadic, migrant, industrial workers, urban slums, etc.) (These population statistics may be obtained from Census data /State Statistical Dept/ District plans) No. of districts without DTC: 3 No. of districts that submitted annual action plans, which have been consolidated in this state plan: 30 Organization of services in the state: S. No. Name of the District Projected Population (in Lakhs) Please indicate number of TUs of each type Govt NGO Public Sector* 294 Please indicate no. of DMCs of each type in the district NGO Private Sector^ Araria Arwal Aurangabad Banka Begusarai Bhagalpur Bhojpur Buxar Darbhanga Gaya Gopalganj Jamui Jehanabad Kaimur

295 Khagaria Kisanganj Lakhisharai Madhepura Madhubani Nalanda Nawadah W.Champaran Rohtas Saharsa Saran Sheikhpura Sheohar Sitamarhi Siwan Supaul *Public Sector includes Medical Colleges, Govt. health department, other Govt. department and PSUs i.e. as defined in PMR report ^ Similarly, Private Sect or includes Private Medical College, Private Practitioners, Private Clinics/Nursing Homes and Corporate sector 295

296 RNTCP performance indicators: Important: Please give the performance for the last 4 quarters i.e. Oct to September Name of the District (also indicate if it is notified hilly or tribal district Total number of patients put on treatment * Annualised total case detection rate (per lakh pop.) No of new smear positive cases put on treatment * Annualised New smear positive case detection rate (per lakh pop) Cure rate for cases detected in the last 4 correspondin g quarters Plan for the next year Annualized NSP case detection rate Araria Arwal Aurangabad Banka Begusarai Bhagalpur Bhojpur Buxar Darbhanga Gaya Gopalganj Jamui Jehanabad Kaimur Khagaria Kisanganj Lakhisharai Madhepura Madhubani Nalanda Nawadah W.Champaran Rohtas Saharsa Saran Sheikhpura Sheohar Sitamarhi Siwan Supaul Cure rate Total * Patients put on treatment under DOTS regimens only are to be included. 296

297 Section B List Priority areas at the State level for achieving the objectives planned: S.No. Priority areas Activity planned under each priority area 1 1 a)filling up of all State and District level Contractual Staff. Human Resource 1 b) Filling up the posts of DTOs & MOTCs, 2 a) Training of untrained DTOs & MO TCs at National & state level and also of STS, STLS, LTs 2 Training 2 b) Training and Refresher trainings of MOs & Para Medical Staff 2 c) Training of ASHA as DOT providers 2 d)training and retraining of All contractual staff of RNTCP 3 IEC 3 a) Printing of IEC Materials for the State 3 b)involvement of masses through generating awareness via the print and electronic Media. 4 Involvement of other sectors/ NGOs/PP 3 c) Sensitisation of local MLAs and PRI members, empowering the community by making them aware of the RNTCP facilities 4 a) Sensitisation workshop for other sectors, NGOs and PPs. On the revised schemes 5 Strengthening of IRL, Lab network and Implementation of EQA 4 b) Increased involvement of Faith Based and community based organisations. 4 c) Involving IMA in RNTCP in the State 5 a)starting more DMCs especially in the APHCs with the help of NGOs 6 Minimizing Initial Defaulters 5 c)visit of IRL to all the 38 districts with at least one OSE and One Panel Testing. 6 a) Ensuring in all districts line listing of all sputum smear +ve patients diagnosed on regular basis 6 b) Regular data exchange for feedback within district regarding referral for treatment. 297

298 Priority Districts for Supervision and Monitoring by State during the next year Activity S No District Reason for inclusion in priority list 1 Supaul Low case Detection 2 Buxar Low case Detection 3 Bhojpur Low case Detection 4 Gaya Low case Detection 5 Madhepura Low case Detection 6 Kaimur Low case Detection 7 Saran Low case Detection Section C Consolidated Plan for Performance and Expenditure under each head, including estimates submitted by all districts, and the requirements at the State Level 1. Civil Works No. required as per the norms in the state No. already upgraded/ present in the state No. planned to be upgraded during next financial year Pl provide justification if an increase is planned in excess of norms (use separate sheet if required) Estimated Expenditure on the activity Quarter in which the planned activity expected to be completed (a) (b) (c) (d) (e) (f) STDC/ IRL SDS DTCs Upgradation of DTCs 3 rd Quarter 2009 TUs Up gradation of TUs + Maintenance of TUs DMCs Up gradation of DMcs + maintenance civil works of DMCs TOTAL Rs /- 3 rd Quarter th Quarter

299 2. Laboratory Materials Activity Purchase of Lab Materials by Districts Amount permissible as per the norms in the state Amount actually spent in the last 4 quarters Procurement planned during the current financial year (in Rupees) Estimated Expenditure for the next financial year for which plan is being submitted (Rs.) (a) (b) (c) (d) (e) 1,00,53, ,10,50,000 Justification/ Remarks for (d) Lab materials for EQA activity at STDC 3. Honorarium Activity Honorarium for DOT providers (both tribal and non tribal districts) Honorarium for DOT providers of Cat IV patients Amount permissible as per the norms in the state Amount actually spent in the last 4 quarters Expenditure (in Rs) planned for current financial year Estimated Expenditure for the next financial year for which plan is being submitted (Rs.) Justification/ Remarks for (d) (a) (b) (c) (d) (e) 18,76, ,60,00,000/- Community volunteers in all the districts* No. presently involved in RNTCP ,000 Additional enrolment proposed for the next fin. Year * These community volunteers are other than salaried employees of Central/State government and are involved in provision of DOT e.g. Anganwadi workers, trained dais, village health guides, ASHA, other volunteers, etc. 299

300 4. IEC/Publicity: Permissible budget for State and all Districts as per Norms: Rs. 50,26,500 Estimated IEC budget for all Districts, as per action plans (please enclose consolidation summary): Rs. Estimated IEC activities and Budget at the State level (excluding districts) for the next financial year proposed as per action plan detailed below: Rs. Target Group/ Objective Patients and General public / for awareness generation and social mobilizati on Activity (All activities to be planned as per local needs, catering to the target groups specified) Outdoors: - wall paintings - Hoardings - Tin plates - Banners - others Outreach activities: - Patient provider interaction meetings - Community meetings - Mike publicity - Others Activities Planned at State Level No. of activities held in last 4 quarters No of activities proposed in the next financial year, quarterwise Apr- Jun July- Sep Oct- Dec Jan- Mar Total activitie s propose d during next fin. year Estima ted Cost per activit y unit Total expenditure for the activity during the next fin. Year 20,00, Puppet shows/ street plays/etc. School activities Print publicity - Posters - Pamphlets - Others 2,20,000 Media activities on Cable/local channels Radio Any other activity Opinion leaders/ NGOs for advocacy Sensitization meetings Media activities Power point Presentations / one to one interaction Information Booklets/ brochures 300

301 Health Care providers public and private Any Other Activities proposed World TB Day activities Any other public event - CMEs - Interaction meetings - one to one interaction meetings - Information Booklets - Any other Communication Facilitators (each for 5-6 districts) 12, ,32000 Total Budget 60,28,700/- Item 5. Equipment Maintenance: Computer Photocopier Fax Binocular Microscopes No. actually present in the state Amount actually spent in the last 4 quarters Amount Proposed for Maintenance during current financial yr. Estimated Expenditure for the next financial year for which plan is being submitted (Rs.) (a) (b) (c) (d) (e) ,00, ,25,000 (RNTCP) STDC/ IRL Equipment 11,00,000 Any Other (pl. specify) TOTAL /- Justification/ Remarks for (d) 301

302 6. Training: Activity Training of DTOs (at National level) Training of MO-TCs Training of MOs (Govt + Non-Govt) Training of LTs of DMCs- Govt + Non Govt Training of MPWs Training of MPHS, pharmacists, nursing staff, BEO etc Training of Comm Volunteers Training of Pvt Practitioners Other trainings # No. in the state No. already trained in RNTCP No. planned to be trained in RNTCP during each quarter of next FY (c) Q1 Q2 Q3 Q4 Expenditure (in Rs) planned for current financial year Estimated Expenditure for the next financial year (Rs.) (a) (b) (d) (e) (f) Justification/ remarks Re- training of MOs Re- Training of LTs of DMCs Re- Training of MPWs Re- Training of MPHS, pharmacists, nursing staff, BEO Re- Training of CVs Re-training of Pvt Practitioners TB/HIV Training of MO- TCs and MOs TB/HIV Training of STLS, LTs, MPWs, MPHS, Nursing Staff, Community Volunteers etc TB/HIV Training of STS Provision for Update Training at Various Levels # Review Meetings at State Level Any Other Training Activity # Please specify TOTAL Rs.52,41,000/- 302

303 7. Vehicle Maintenance: Type of Vehicle Number permissible as per the norms in the state Number actually present Amount spent on POL and Maintenance in the previous 4 quarters 303 Expenditure (in Rs) planned for current financial year Estimated Expenditure for the next financial year for which plan is being submitted (Rs.) (a) (b) (c) (d) (e) (f) Four Wheelers Two Wheelers ,71,000/- TOTAL 41,71,000/- Hiring of Four Wheeler 8. Vehicle Hiring*: Number permissible as per the norms in the state Number actually requiring hired vehicles Amount spent in the prev. 4 qtrs Expenditure (in Rs) planned for current financial year Estimated Expenditure for the next financial year for which plan is being submitted (Rs.) Justification/ remarks Justification/ remarks (a) (b) (c) (d) (e) (f) For STC/ STDC 95,29,600/- For DTO For MO- TC TOTAL 95,29,600/- * Vehicle Hiring permissible only where RNTCP vehicles have not been provided 9. NGO/ PP Support: Activity No. of currently involved in RNTCP in the state Additional enrolment planned for this year Amount spent in the previous 4 quarters Expenditure (in Rs) planned for current financial year Estimated Expenditure for the next financial year (Rs.) (a) (b) (c) (d) (e) (f) NGOs involvement scheme Rs NGOs involvement scheme Rs NGOs involvement scheme NGOs involvement scheme Rs NGOs involvement scheme Rs NGOs involvement unsigned Private practitioners scheme Rs Private practitioners scheme Rs Private practitioners scheme 3A Private practitioners scheme 3B Prvt Pract. scheme 4A Rs Justification/ remarks

304 Pvt Pract. Scheme 4B TOTAL Rs70,00,000/- NGO/ PP Support: (New schemes w.e.f ) Activity No. of currently involved in RNTCP Additional enrolment planned for this year Amount spent in the previous 4 quarters ACSM Scheme: TB advocacy, communication, and social mobilization SC Scheme: Sputum Collection Centre/s Transport Scheme: Sputum Pick-Up and Transport Service DMC Scheme: Designated Microscopy Cum Treatment Centre (A & B) LT Scheme: Strengthening RNTCP diagnostic 304 Expenditure (in Rs) planned for current financial year Estimated Expenditure for the next financial year for which plan is being submitted (Rs.) Justification/ remarks (a) (b) (c) (d) (e) (f) services Culture and DST Scheme: Providing Quality Assured Culture and Drug Susceptibility Testing Services Adherence scheme: Promoting treatment adherence Slum Scheme: Improving TB control in Urban Slums Tuberculosis Unit Model TB-HIV Scheme: Delivering TB-HIV interventions to high HIV Risk groups (HRGs) TOTAL 20,78,000/- * orzeku esa NGO/PPP ds dk;zjr cy ds vuqlkj dh jkf k iz;kzir gksxha 10. Miscellaneous: Activity* Amount permissible as e.g. TA/DA, per the norms in Stationary, the state etc Amount spent in the previous 4 quarters Expenditure (in Rs) planned for current financial year Estimated Expenditure for the next financial year (Rs.) (a) (b) (c) (d) (e) ,84,000 Justification/ remarks

305 11. Contractual Services: TOTAL 90,84,000/- * Please mention the main activities proposed to be met out through this head Category of Staff No. permissible as per the norms in the state No. actually present in the state No. planned to be additionally hired during this year Amount spent in the previous 4 quarters Expenditure (in Rs) planned for current fin. year (a) (b) (c) (d) (e) TB/HIV Coord. Urban TB Coord. MO-STCS State Accountant State IEC Officer Pharmacist Secretarial Asst MO-DTC STS STLS TBHV 49 DEO Accountant part time Contractual LT Driver Any other contractual post approved under RNTCP Estimated Expenditure for the next financial year (Rs.) TOTAL 4,57,47,500/- Justification / remarks * orzeku esa Contractual Staff ds dk;zjr cy ds vuqlkj dh jkf k iz;kzir gksxha 12. Printing: Activity Printing-State level:* Amount permissible as per the norms in the state Amount spent in the previous 4 quarters Expenditure (in Rs) planned for current financial year Estimated Expenditure for the next financial year for which plan is being submitted (Rs.) (a) (b) (c) (d) (e) ,02,000/- Justification/ remarks 305

306 Printing- Distt. Level:* * Please specify items to be printed in this column * foxr o"kz esa gq, NikbZ dk;z dks ns[krs gq, dh jkf k iz;kzir gksxha 13. Research and Studies (excluding OR in Medical Colleges): Rs. 6,00,000/- Any Operational Research projects planned (Yes/No) (If yes, enclose annexure providing details of the Topic of the Study, Investigators and Other details) Whether submitted for approval/ already approved? (Yes/No) Estimated Total Budget 306

307 14. Medical Colleges Activity Contractual Staff: MO-Medical College (Total approved in state 3 STLS in Medical Colleges (Total no in state 3 ) LT for Medical College (Total no in state 3 ) TBHV for Medical College (Total no in state 3) Amount permissible as per norms Estimated Expenditure for the next financial year(rs.) (a) (b) (c) Rs.12,96,000/- Rs.12,96,000/- Justification/ remarks Research and Studies: 1,00,000/- Thesis of PG Students Operations Research* Travel Expenses for attending STF/ZTF/NTF meetings IEC: Meetings and CME planned 7,00,000/- Equipment Maintenance at Nodal Centres * Expenditure on OR can only be incurred after due approvals of STF/ STCS/ZTF/CTD (as applicable) 15. Procurement of Vehicles: Equipment 4-wheeler ** 2-wheeler No. actually present in the state No. planned for procurement this year (only if permissible as per norms) Estimated Expenditure for the next financial year for which plan is being submitted (Rs.) (a) (b) (c) (d) 8,85,000/- Justification/ remarks ** Only if authorized in writing by the Central TB Division 307

308 16. Procurement of Equipment: Equipment Office Equipment (Computer, modem, scanner, printer, UPS etc.) Any Other No. actually present in the state No. planned for this year (only as per norms) Estimated Expenditure for the next financial year for which plan is being submitted (Rs.) (a) (b) (c) (d) Justification/ remarks 308

309 Section D: Summary of proposed budget for the state Category of Expenditure Budget estimate for the coming FY (To be based on the planned activities and expenditure in Section C) 1. Civil works Laboratory materials Honorarium IEC/ Publicity Equipment maintenance Training Vehicle maintenance Vehicle hiring NGO/PP support Miscellaneous Contractual services Printing Research and studies Medical Colleges Procurement vehicles Procurement equipment ,84,63,800/- TOTAL ** Only if authorized in writing by the Central TB Division 309

310 Annual Plan for Programme Performance & Budget for the year 1 st April 2009 to 31 st March 2010 State: BIHAR (World Bank) Objectives: 1.3. To achieve and maintain a cure rate of at least 85% among newly detected infectious (new sputum smear positive) cases, and 2.4. To achieve and maintain detection of at least 70% of such cases in the population Formatted: Bullets and Numbering This action plan and budget have been approved by the STCS. Signature of the STO Name : Dr. N.M.Sharma Section-A General Information about the State 1 State Population (in lakh) (World Bank Districts) Number of districts in the State (World Bank Districts) 8 3 Urban population Tribal population Hilly population 0 6 Any other known groups of special population for specific interventions (e.g. nomadic, migrant, industrial workers, urban slums, etc.) 1.55 (These population statistics may be obtained from Census data /State Statistical Dept/ District plans) No. of districts without DTC: None No. of districts that submitted annual action plans, which have been consolidated in this state plan: 8 Organization of services in the state: S. No. Name of the District Projected Population (in Please indicate number of TUs of each type Please indicate no. of DMCs of each type in the district Lakhs) Govt NGO Public Sector* NGO Private Sector^ 1 Katihar Purnia Samstipur E. Champaran Muzaffarpur Patna Vaishali Munger Total *Public Sector includes Medical Colleges, Govt. health department, other Govt. department and PSUs i.e. as defined in PMR report 310

311 ^ Similarly, Private Sector includes Private Medical College, Private Practitioners, Private Clinics/Nursing Homes and Corporate sector RNTCP performance indicators: Important: Please give the performance for the last 4 quarters i.e. Oct 07 to September 08 Section B List Priority areas at the State level for achieving the objectives planned: Name of the District (also indicate if it is notified hilly or tribal district Total number of patients put on treatment* Annualised total case detection rate (per lakh pop.) No of new smear positive cases put on treatment * Annualised New smear positive case detection rate (per lakh pop) Cure rate for cases detected in the last 4 correspondi ng quarters Plan for the next year Annualized NSP case detection rate Cure rate Katihar Purnia Samstipur E. Champaran Muzaffarpur Patna Vaishali Munger Total * Patients put on treatment under DOTS regimens only are to be included. S.No. Priority areas Activity planned under each priority area 1 1 a)filling up of all State and District level Contractual Human Resource Staff. 311

312 1 b) Filling up the posts of DTOs & MOTCs, 2 Training 2 a) Training of untrained DTOs & MO TCs at National & state level and also of STS, STLS, LTs 2 b) Training and Refresher trainings of MOs & Para Medical Staff 2 c) Training of ASHA as DOT providers 2 d)training and retraining of All contractual staff of RNTCP 3 IEC 3 a) Printing of IEC Materials for the State 3 b)involvement of masses through generating awareness via the print and electronic Media. 4 Involvement of other sectors/ NGOs/PP 3 c) Sensitisation of local MLAs and PRI members, empowering the community by making them aware of the RNTCP facilities 4 a) Sensitisation workshop for other sectors, NGOs and PPs. On the revised schemes 4 b) Increased involvement of Faith Based and community based organisations. 4 c) Involving IMA in RNTCP in the State 5 Strengthening of IRL, Lab network and Implementation of EQA 5 a)starting more DMCs especially in the APHCs with the help of NGOs 5 b)construction of IRL and initiation of DOTS Plus action plan. 5 c)visit of IRL to all the 38 districts with at least one OSE and One Panel Testing. 6 Minimizing Initial Defaulters 6 a) Ensuring in all districts line listing of all sputum smear +ve patients diagnosed on regular basis 6 b) Regular data exchange for feedback within district regarding referral for treatment. Priority Districts for Supervision and Monitoring by State during the next year S No District Reason for inclusion in priority list 1 Vaishali No contractual Supervisory Staff in the District 312

313 (STS/STLS) Section C Consolidated Plan for Performance and Expenditure under each head, including estimates submitted by all districts, and the requirements at the State Level 1. Civil Works Activity No. required as per the norms in the state No. already upgraded/ present in the state No. planned to be upgraded during next financial year Pl provide justification if an increase is planned in excess of norms (use separate sheet if required) Estimated Expenditure on the activity Quarter in which the planned activity expected to be completed (a) (b) (c) (d) (e) (f) STDC/ IRL civil work By 3 rd Quarter IRL SDS Inadequate Storage space By 2 nd Quarter of 2009 DTCs TUs Up gradation By 2 nd Quarter of 2009 DMCs Up gradation By 2 nd Quarter of 2009 TOTAL 32,46,

314 2. Laboratory Materials Activity Amount permissible as per the norms in the state Purchase of Lab Materials by Districts Lab materials for EQA activity at STDC Amount actually spent in the last 4 quarters Procurement planned during the current financial year (in Rupees) Estimated Expenditure for the next financial year for which plan is being submitted (Rs.) Justification/ Remarks for (d) (a) (b) (c) (d) (e) 42,375,00 10,244, ,07,000/- Project increase in Case detection and also increase in cost of Lab Consumables 3. Honorarium Activity Honorarium for DOT providers (both tribal and non tribal districts) Honorarium for DOT providers of Cat IV patients Amount permissible as per the norms in the state Amount actually spent in the last 4 quarters Expenditure (in Rs) planned for current financial year Estimated Expenditure for the next financial year for which plan is being submitted (Rs.) Justification/ Remarks for (d) (a) (b) (c) (d) (e) ,00,000* Committed honoraria to DOT Providers Community volunteers in all the districts* No. presently involved in Additional enrolment proposed for the RNTCP next fin. year ,000 * These community volunteers are other than salaried employees of Central/State government and are involved in provision of DOT e.g. Anganwadi workers, trained dais, village health guides, ASHA, other volunteers, etc. * orzeku esa Dot Privder dk;zjr cy ds vuqlkj yk[k dh jkf k iz;kzir gksxha 4. IEC/Publicity: Permissible budget for State and all Districts as per Norms: Rs.(10,00, ,187,50) 314

315 Estimated IEC budget for all Districts, as per action plans (please enclose consolidation summary): Rs.23,00,000 Estimated IEC activities and Budget at the State level (excluding districts) for the next financial year proposed as per action plan detailed below: Rs. 23,00,000 Target Group/ Objective Patients and General public / for awareness generation and social mobilizati on Activity (All activities to be planned as per local needs, catering to the target groups specified) Outdoors: - wall paintings - Hoardings - Tin plates - Banners - others Outreach activities: - Patient provider interaction meetings - Community meetings - Mike publicity - Others Activities Planned at State Level No. of activities held in last 4 quarters No of activities proposed in the next financial year, quarterwise Apr- Jun July- Sep Oct- Dec Jan- Mar Total activitie s propose d during next fin. year Estima ted Cost per activit y unit Total expenditur e for the activity during the next fin. Year 14,00,000 Puppet shows/ street plays/etc. School activities 3,00,000 Print publicity - Posters - Pamphlets - Others Media activities on Cable/local channels Radio Any other activity 8,00,000 12,00,000 Opinion leaders/ NGOs for advocacy Sensitization meetings Media activities 2,00,000 Power point Presentations / one to one interaction Information 2,00,000 Booklets/ brochures World TB Day 2,00,000 activities 315

316 Health Care providers public and private Any Other Activities proposed Any other public event - CMEs - Interaction meetings - one to one interaction meetings - Information Booklets - Any other Communication Facilitators (each for 5-6 districts) 2,65,000 Total Budget 45,65,000 Item 5. Equipment Maintenance: Computer (maintenance includes AMC, software and hardware upgrades, Printer Cartridges and Internet expenses) No. actually present in the state Amount actually spent in the last 4 quarters Amount Proposed for Maintenance during current financial yr. Estimated Expenditure for the next financial year for which plan is being submitted (Rs.) Justification/ Remarks for (d) (a) (b) (c) (d) (e) 8 81,808 58,000 3,40,000 Upgradation of Computers for Windows based Epicenter +AMC Binocular Microscopes (RNTCP) ,12,500 4,80,000 STDC/ IRL Equipment 95,000 Any Other ( Fax & OHP ) TOTAL 9,15, Training: Activity Training of DTOs (at National level) Training of MO-TCs Training of MOs (Govt + Non-Govt) Training of LTs of DMCs- Govt + Non No. in the state No. already trained in RNTCP No. planned to be trained in RNTCP during each quarter of next FY (c) 316 Expenditure (in Rs) planned for current financial year Estimated Expenditure for the next financial year (Rs.) Q1 Q2 Q3 Q4 (a) (b) (d) (e) (f) Justification/ remarks

317 Govt Training of MPWs Training of MPHS, pharmacists, nursing staff, BEO etc Training of Comm Volunteers Training of Pvt Practitioners Other trainings # Re- training of MOs Re- Training of LTs of DMCs Re- Training of MPWs Re- Training of MPHS, pharmacists, nursing staff, BEO Re- Training of CVs Re-training of Pvt Practitioners TB/HIV Training of MO-TCs and MOs TB/HIV Training of STLS, LTs, MPWs, MPHS, Nursing Staff, Community Volunteers etc TB/HIV Training of STS Provision for Update Training at Various Levels # Review Meetings at State Level Any Other Training Activity # Please specify TOTAL 28,60, Vehicle Maintenance: Type of Vehicle Number permissible as per the norms in the state Number actually present Amount spent on POL and Maintenance in the previous 4 quarters Expenditure (in Rs) planned for current financial year Estimated Expenditure for the next financial year for which plan is being submitted (Rs.) (a) (b) (c) (d) (e) (f) Four Wheelers 8 4 5,00,000 Two Wheelers ,53,026 9,71,974 17,77,000 TOTAL 22,77,000 Justification/ remarks 317

318 8. Vehicle Hiring*: Hiring of Number Four permissible Wheeler as per the norms in the state Number actually requiring hired vehicles Amount spent in the prev. 4 qtrs Expenditure (in Rs) planned for current financial year Estimated Expenditure for the next financial year for which plan is being submitted (Rs.) (a) (b) (c) (d) (e) (f) For STC/ STDC For DTO 4 4 1,88,628 6,51,372 For MO- TC Justification/ remarks Proposed to increase the no. Of TUs TOTAL 45,06,000/- * Vehicle Hiring permissible only where RNTCP vehicles have not been provided 9. NGO/ PP Support: Activity No. of currently involved in RNTCP in the state Additional enrolment planned for this year Amount spent in the previous 4 quarters Expenditure (in Rs) planned for current financial year Estimated Expenditure for the next financial year (Rs.) (a) (b) (c) (d) (e) (f) NGOs involvement scheme Rs /- NGOs involvement scheme Rs /- NGOs involvement scheme 3 NGOs involvement scheme Rs /- NGOs involvement scheme Rs /- NGOs involvement unsigned Rs.0/- Private practitioners scheme Rs.81200/- Private practitioners scheme Rs /- Private practitioners scheme 3A Private practitioners scheme 3B Prvt Pract. scheme 4A Pvt Pract. Scheme 4B TOTAL 1,01,25,000/- NGO/ PP Support: (New schemes w.e.f ) Justification/ remarks Activity ACSM Scheme: TB advocacy, communication, and social mobilization No. of currently involved in RNTCP Additional enrolment planned for this year Amount spent in the previous 4 quarters 318 Expenditure (in Rs) planned for current financial year Estimated Expenditure for the next financial year for which plan is being submitted (Rs.) Justification/ remarks (a) (b) (c) (d) (e) (f)

319 SC Scheme: Sputum Collection Centre/s Transport Scheme: Sputum Pick-Up and Transport Service DMC Scheme: Designated Microscopy Cum Treatment Centre (A & B) LT Scheme: Strengthening RNTCP diagnostic services Culture and DST Scheme: Providing Quality Assured Culture and Drug Susceptibility Testing Services Adherence scheme: Promoting treatment adherence Slum Scheme: Improving TB control in Urban Slums Tuberculosis Unit Model TB-HIV Scheme: Delivering TB-HIV interventions to high HIV Risk groups (HRGs) , ,00, ,65, TOTAL 79,11,000/- * orzeku esa NGO/PPP ds dk;zjr cy ds vuqlkj yk[k dh jkf k izkir gksxha 10. Miscellaneous: Activity* e.g. TA/DA, Stationary, etc Amount permissib le as per the norms in the state Amount spent in the previous 4 quarters Expenditure (in Rs) planned for current financial year Estimated Expenditure for the next financial year (Rs.) (a) (b) (c) (d) (e) State Level 7,00,000 7,00,000 District Level 42,37,500 2,08,047 10,50,000 45,14,000 Justification/ remarks TOTAL 52,14,000 * Please mention the main activities proposed to be met out through this head 319

320 11. Contractual Services: Category of Staff No. permissible as per the norms in the state No. actuall y present in the state No. planned to be additionall y hired during this year Amount spent in the previous 4 quarters Expendit ure (in Rs) planned for current fin. year (a) (b) (c) (d) (e) TB/HIV Coord Urban TB Coord. MO-STCS State Accountant State IEC Officer Pharmacist Secretarial Asst MO-DTC STS STLS TBHV DEO Districts DEO State Accountant part time Contractual LT Driver Any other contractual post approved under RNTCP Estimated Expenditure for the next financial year (Rs.) TOTAL 2,90,82,000/- Justificatio n/ remarks 12. Printing: Activity Printing-State level:* (All Modules,Guidelines,For ms,registers,iec materials) Printing- Distt. Level:* Amount permissible as per the norms in the state Amount spent in the previous 4 quarters Expenditure (in Rs) planned for current financial year Estimated Expenditure for the next financial year for which plan is being submitted (Rs.) Justification/ remarks (a) (b) (c) (d) (e) ,74,000/- No printing carried out in the new formats,no IEC material at state /district * Please specify items to be printed in this column * foxr o"kz esa gq, NikbZ dk;z dks ns[krs gq, yk[k dh jkf k iz;kzir gksxha 320

321 13. Research and Studies (excluding OR in Medical Colleges): Rs. 6,00,000/- Any Operational Research projects planned (Yes/No) (If yes, enclose annexure providing details of the Topic of the Study, Investigators and Other details) Whether submitted for approval/ already approved? (Yes/No) Estimated Total Budget 14. Medical Colleges Activity Contractual Staff: MO-Medical College STLS in Medical Colleges LT for Medical College TBHV for Medical College Research and Studies: Thesis of PG Students Operations Research* Travel Expenses for attending STF/ZTF/NTF meetings IEC: Meetings and CME planned Equipment Maintenance at Nodal Centres Amount permissible as per norms Estimated Expenditure for the next financial year(rs.) (a) (b) (c) Total:28,47,200/- Justification/ remarks 15. Procurement of Vehicles: Equipment No. actually present in the state No. planned for procurement this year (only if permissible as per norms) 321 Estimated Expenditure for the next financial year for which plan is being submitted (Rs.) Justification/ remarks (a) (b) (c) (d) 4-wheeler ** 2-wheeler ,00,000/- ** Only if authorized in writing by the Central TB Division 16. Procurement of Equipment: Equipment Office Equipment (Computer, Photocopier No. actually present in the state LCD projector 2 No. planned for this year (only as per norms) Estimated Expenditure for the next financial year for which plan is being submitted (Rs.) (a) (b) (c) (d) 3 3 7,80,000/ Justification/ remarks

322 Section D: Summary of proposed budget for the state Category of Expenditure Budget estimate for the coming FY (To be based on the planned activities and expenditure in Section C) 1. Civil works Laboratory materials Honorarium IEC/ Publicity Equipment maintenance Training Vehicle maintenance Vehicle hiring NGO/PP support Miscellaneous Contractual services Printing Research and studies Medical Colleges Procurement vehicles Procurement equipment TOTAL 9,30,09,200/- ** Only if authorized in writing by the Central TB Division 322

323 Printing Details Sr No 1 Items name TB Register Quantity (No of copies) No of pages for print including cover (back and front) Lab Register Treatment Card Identity Card Lab form for Sputum Examination TB Transfer form Referral for treatment form CF TU qtrly report SC TU qtrly report RT TU qtrly report PMR TU qtrly report PHI monthly Report Supervisory Registers (triplicate paging no) Desk Referance RNTCP at a glance (80 x 3) = EQA coding (blinding) register EQA - RBRC roaster for STLSs rechecking and umpire rechecking EQA - Register for Quality control of prepared reagents EQA reporting format - annexure M (for TU) EQA reporting format - annexure M (for district) EQA reporting format - annexure E (for district) EQA reporting format - annexure B EQA reporting format - Annexure C EQA reporting format - Annexure D EQA reporting format - checklist for STLS EQA reporting format - annexure F EQA - IRL visit to DTC - OSE District Issue voucher (DIV) District worksheet for Reporting Drug Requirement (WRDR) TU report for Reconstitution of Drugs Drug Stock Register Line list of VCTC VCTC monthly report Health provider guide (Local language) PP module

324 36 Revised Strategy for monitoring and supervision EQA Module - RNTCP Laboratory Network guidelines for Quality Assurance of smear microscopy for diagnosing TB.B Mycobacterial Culture Sensitivity forms NGO Guidelines PP guidelines+b District Drug Store Manual Reconstitution Register Additional Drug Request Referral for treatment Register RNTCP Modules with Exercise book and answer book for training of MO (1-4 Module) RNTCP MO training Exercise (E1, E2, E3) and answer books (EA1-3) 167 (13+2) + (19+2) + (22+2) + (32+2) = RNTCP Modules for training of MO-TC (5-9 Module) RNTCP Modules for training of STS with Exercise book 167 (131+2) + (26+2) 49 RNTCP Modules for training of STLS RNTCP Modules for training of LT RNTCP Modules for training of Medical college faculty RNTCP Modules for training of MPWs Modules for training in TB-HIV of MO Modules for training in TB-HIV of STS & STLS Modules for training in TB-HIV of VCTC counsellor District PMR report Strategy document for the supervision and monitoring Guidelines for quality assuarance of smear microscopy for diagnosing tuberculosis Technical & operational guidelines One page Display for DOT Provider One page Display for DOT Provider pead PWB Financial Management Manual for state & district societies norms and basis of costing Pages for Training in pediatric PWBs (Hindi) Pages for Training in pediatric PWBs (English) Programme review checklist for DMs & CMOs Quarterly report - Medical College IE - Form 1: Review of TU reports and TB registers & Worksheet for form IE - Form 1: Worksheet for form IE - Form 2: Data collection at the district level IE - Form 3: Data collection at the DMC level IE - Form 4: Data collection at the DOT Centre

325 72 IE - Form 5:Patients Interview IE - Form 6 :Triangulation IE - Form 8: Form for interview of non-nsp patients IE - Form 9: Form for observations at the TU Drug store IE - Form 11: for review of the Medical College during Internal Evaluation 25 1 IE - Form 12: Check List For Financial Management Physical Verification Sheet (PVS) Adequacy of Drug Stocks (ADS) Expiry Age Analysis of Drug Stocks (EAADS) Training certificates Enrolment certificate (NGOs & PPs) Certificate of appreciation Pamphlets Posters (Sputum Microscopy) Posters (diagnosis) Posters (Treatment) Posters (DOTS) Plastic digital printed boards for Approved DOT centers Plastic digital printed boards for designated Pvt Sputum Microscopy centre Table Flip type calendars Flip charts Banners for workshop Banners for training Digital printed banners DOTS Digital printed banners diagnosis Digital printed banners Treatment RNTCP diary Car bumper stickers Plastic coated

326 Bihar SPIP Malaria Filaria Kalazar 326