Short Programme Review. Child Health Programme in Rajasthan

Transcription

1 Short Programme Review Child Health Programme in Rajasthan 2010

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3 Preliminary Facilitator Meeting Dr ML Jain lighting the lamp to formally inaugurate the proceedings on 21 Sep 2010 Shri BN Sharma, Principal Secretary Health and Family Welfare, addressing the workshop on the closing day. Presentations during inaugural session

4 Plenary Sessions

5 REPORT ON SHORT PROGRAMME REVIEW ON CHILD HEALTH IN RAJASTHAN Directorate of Health & Medical Services, Government of Rajasthan Institute of Health Management Research (IIHMR), Jaipur Norway India Partnership Initiative (NIPI) World Health Organization, Country Office for India 2010

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7 Contents Abbreviations... i Executive summary... iii 1. BACKGROUND Background information of Rajasthan State Child health situation in Rajasthan Child health programmes in Rajasthan The Short Programme Review Objectives Proposed Participants Methods Used Preliminary data collection and adaptation of Worksheets Data Sources: Period of Review Formation of review team Preliminary Workshop Steps of SPR Inaugural Session Goals and Objectives of the Child Health Programme Neonatal and Child Health Status Intervention Coverage Interventions and delivery of packages Coverage Indicators Summary of status of the child health programme Summary of technical areas along the continuum of care: Status of Implementation Summary of Strengths and Weaknesses Maternal Group Newborn Group Child Group... 22

8 6.3. Identifying the main problems Core problems, Solutions and Recommendations Listing the Core Problems Reorganization of Small groups Group Activity: Completing Worksheet Decide on next steps Presentation of findings and finalization of recommendations Final Recommendations Group I. Policy, Planning and Management / Monitoring and Evaluation Group II. Human Resources, Training and Strengthening Health Systems Group III. Health Communication / IEC and Development of Community Supports Core Group: Scaling up of existing interventions for Child Health Annexure I: Day wise summary of Steps completed Annexure II: Worksheet 1 Annexure III : Worksheet 2 Annexure IV: Worksheet 3 Annexure V : Worksheet 4 Annexure VI : Worksheet 5 Annexure VII: Worksheet 6 (Consolidated) Annexure VIII: Worksheet 7 Annexure IX : List of Participants Annexure X : List of Documents Reviewed Annexure XI : Timetable References

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10 Acknowledgement It was indeed a great pleasure to host the Short Programme Review on Child Health in Rajasthan, the first workshop on the SPR CH package in India. On behalf of the entire organizing team, I express my sincere thanks to Shri BN Sharma, Principal Secretary Health and Family Welfare, Government of Rajasthan for his keen interest, support and involvement in the programme which got the entire process rolling. I wish to thank the World Health Organization for taking the initiative to organize the Short Programme Review in Rajasthan. Special thanks are due to Dr Samira Aboubaker, Dr Mikael Ostergren, Dr Harish Kumar, Dr Rajesh Mehta and Dr Paul Francis, for their expert role and guidance throughout the programme. My special thanks to Dr Subodh S Gupta for his excellent efforts in coordinating the programme on behalf of WHO. I acknowledge the active participation and contribution of Dr Kaliprasad Pappu, National Coordinator, NIPI and overall support provided by UNOPS-NIPI for organizing this workshop. I thank Dr ML Jain, Director RCH, Directorate of Medical and Health Services, Government of Rajasthan for his unflinching support, active participation and valuable inputs. The success of this workshop owes much to his pivotal role in constituting the team participants representing the state government in this review. I also acknowledge the efforts of Dr Anuradha Aswal, Nodal Officer Training and Child Health, Directorate of Medical and Health Services, Government of Rajasthan for coordinating the state team of participants and helping in data review. I wish to thank Dr Avatar Singh Dua, UNICEF State Office, Jaipur, Dr Karanveer Singh, Programme Officer Child Health, NIPI; Dr SP Yadav, Senior Programme Officer, NIPI, Rajasthan; Dr Shiv Chandra Mathur, Executive Director, RHSRC and Dr Akhilesh Bhargava, Director SIHFW, Jaipur, for sparing time to provide key information on State programmes during interviews before this workshop. Much of the success of this workshop goes to the active involvement and participation shown by all the participants. Inputs given by the state programme managers and the field experience brought in by the district level officials and programme coordinators were vital to this review. Inputs and active participation by faculty from departments of Preventive and Social Medicine and Paediatrics, SMS Medical College, Jaipur and representatives from NIHFW (New Delhi), UNICEF India (New Delhi),, CARE India (Rajasthan), Save the Children (Rajasthan) and Vatsalya (Jaipur), IIHMR Bangaluru, is gratefully acknowledged. I must specially mention the contribution of Dr Suresh Joshi, Professor, and IIHMR Jaipur, whose overall guidance, expertise and lead facilitation were crucial for the success of this workshop. I take this opportunity to compliment the local organizing team from IIHMR led by Dr Vinod Kumar SV, Assistant Professor IIHMR for their flawless conduct of the event. I acknowledge the efforts of Mr Gowtham Ghosh Research Officer, IIHMR Jaipur whose efforts and dedication were evident in the data review. I appreciate the efforts of Dr Vivek Lal, Assistant Professor, IIHMR Jaipur in the preparations and conduct of the workshop. The Institute s administration, finance and computer department deserve special thanks for extending valuable logistic and other support in facilitating the programme. Shiv Dutt Gupta, MD,FAMS,Ph.D [Johns Hopkins University] Director Institute of Health Management Research Jaipur

11 Abbreviations AIDS ANC ANM ARI ASHA AWC AWW AYUSH BEmOC CEmOC CHC CHW DLHS DMHS EmOC F-IMNCI FRU FWS HBPNC HIV HMIS HW ICDS IEC IIHMR IMNCI IMR IVR JSY LHV LSAS MCHN MD MDG Acquired Immunodeficiency Syndrome Ante Natal Care Auxiliary Nurse Midwife Acute Respiratory Infection Accredited Social Health Activist Anganwadi Centre Anganwadi Worker Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homeopathy Basic Emergency Obstetric Care Comprehensive Emergency Obstetric Care Community Health Centre Community Health Worker District Level Household Survey Directorate of Medical and Health Services Emergency Obstetric Care Facility based Integrated Management of Neonatal and Childhood Illness First Referral Unit Family Welfare Statistics Home Based Post natal Care Human Immunodeficiency Virus Health Management Information System Health Worker Integrated Child Development Services Scheme Information, Education and Communication Institute of Health Management Research Integrated Management of Neonatal and Childhood Illness Infant Mortality Rate Interactive voice response Janani Suraksha Yojana Lady Health Visitor Life Saving Anesthesia Skills Maternal Child health and Nutrition Day Mission Director Millennium Development Goals i

12 MMR MNCH MO MoHFW MTC NFHS NGO NIHFW NIPI NMR NRHM NSSK PCTS PHC PHS PIP PNC PPTCT RCH RHS RHSDP RI ROP SBA SC SEARO SHSRC SIHFW SPR SPR-CH SRS UBR UNICEF VHND VHSC WCD WHO Maternal Mortality Rate Maternal Newborn and Child Health Medical Officer Ministry of Health and Family Welfare Malnutrition Treatment Centre National Family Health Survey Non-governmental Organization National Institute of Health and Family Welfare Norway India Partnership Initiative Neonatal Mortality Rate National Rural Health Mission Navjat Shishu Suraksha Karyakram Pregnancy and Child Health Tracking System Primary Health Centre Principal Health Secretary Program Implementation Plan Post Natal Care Prevention of Parent to Child Transmission Reproductive and Child Health Rapid Household Survey Rajasthan Health Systems Development Project Routine Immunization Record of Proceedings Skilled Birth Attendant Sub Centre South East Asia Regional Office State Health Systems Resource Centre State Institute of Health and Family Welfare Short Program Review Short Program Review- Child Health Sample Registration System Universal Birth Registration United Nations Children Fund Village Health and Nutrition Day Village Health and Sanitation Committee Women and Child Health Department World Health Organization ii

13 Short programme Review Executive summary India is a signatory to Millennium Development Goals. However, as per the Countdown report 2010, India is unlikely to achieve MDG 4 of reducing the under-five mortality rate (U5MR) by two-third. As health is a state subject in India, strategic directions for health programs are mostly decided at this level. Moreover, there are lots of variations between different states in India. Therefore, it was decided to conduct Short Program Review for Child Health (SPR CH) at state level in India. Rajasthan, being one of the focus states for Norway India Partnership Initiative and having supportive environment for new initiatives in health sector, was chosen for the first Short Program Review in India. Consequent to massive investments in the health sector targeting child health through the RCH II(under NRHM) and ICDS programmes, there have been visible improvements in health status of children in Rajasthan, being reflected in the decline in the IMR and improvements in various other morbidity and mortality indicators, but the improvements have not been adequate. According to SRS 2009, Rajasthan has an infant mortality rate of 63 per 1000 live births and Under5 Mortality rate of 80 per 1000 live births which is 10 points higher than the national figure. Decline in IMR has been much less than what would be required to reach the XIth plan goals of reducing IMR to 32/1000 live births by the year 2012.Furthermore, the Newborn mortality in the state has remained almost static for past seven years. This is highlighted by the fact that Rajasthan alone contributes to around 8.4% of country s total new born mortality even though it has just 6% of the national population. SPR-CH is a review package developed at global level to help decision- making at national or state level. The package helps programme managers to identify which areas need strengthening based on previous experiences and to set new priorities if necessary. As a process, SPR-CH reviews all the interventions for child health at various levels (facility based, community level or outreach) directed anywhere along the continuum of care for the mother and child- pregnancy, delivery, the post-natal period, infancy and older childhood. It also reviews activities in all the areas which are part of process of implementation of child health programs; including policy, planning and financing, human resources and training, systems supports (drug, delivery, supervision, referral etc.), communication, community supports and monitoring and evaluation. For conducting SPR-CH, a review team of close to 50 members was conceived and included State level programme managers and consultants, District Programme Managers, Divisional MCH Coordinators and block level service delivery personnel. In addition, Academic and Research Institutions (IIHMR Jaipur, SIHFW, SMS Medical College), local and international iii

14 Child Health in Rajasthan NGOs (Save the Children, Vatsalya, CARE) and UN Agencies (WHO, UNICEF and UNOPS) also participated in the review process. A one day workshop was held on 20th September, 2010 for reviewing overall preparations, finalizing the worksheets ( filled in by reviewing and gathering information from different published documents & other sources) and training of facilitators. The workshop on Short program review of Child health in Rajasthan was held from 21 st September to 25 th September, 2010 at IIHMR, Rajasthan India. SPR-CH adopted a systematic participatory approach consisting of 7 sequential steps which the team completed in a week. Participants reviewed the available data on maternal and child health and decided the implementation status of the child health interventions. The review team was divided into three smaller groups viz Maternal Health, Newborn Health and Child Health Groups. Participants worked on sequential worksheets of the SPR review process, discussing and reviewing available data gathered from data review as well as from the policy/programme documents. Lists of documents used in the data review as well as during the SPR is appended vide Annexure X. In addition group discussions enabled sharing of views, experiences and individual discussion with selected individuals provided more insights. Findings from group discussions were later presented in the plenary for finalization. Based on the findings, participants defined the main problems for further analysis. The participants were then regrouped into three thematic groups policy/planning, management and monitoring & evaluation; Human Resources and Training; Community supports and IEC, based on the activity areas forming part of the implementation. Thematic groups discussed and reviewed the problems and identified possible solutions, which were used as the basis for developing detailed recommendations about what the program should do in major activity areas. The recommendations developed by thematic groups were presented before the officials of the state government and various stakeholders. The feedbacks were recorded and the recommendations were forwarded to a core team for finalization and prioritization. The core team had representation from all the stakeholders including the state government, UN agencies (WHO, UNOPS-NIPI, UNICEF). Representatives from IIHMR were also part of the core team. The final recommendations were prioritized into two categories - immediate and successive, taking into consideration their relative importance and feasibility of incorporation in the next or successive PIPs. The core team also decided to organize a meeting to formally disseminate the findings of the report to all key stakeholders. The recommendations which merit immediate priority are enumerated below: iv

15 Short programme Review Policy Planning, Management, Monitoring and Evaluation State to ensure that result based monitoring of performance is operational along the monitoring cascade whereby the state officials monitor the performance of districts, district officials monitor the performance of the blocks and so on till the sub centre level. State Health Department to organize capacity building workshops on Programme Planning and Management for block, district and state level officials to promote data based and need based planning. Health Directorate to ensure that specific and appropriate plans for improving access to services are developed by the desert/ tribal districts and other districts for their difficult to reach areas and support provided for implementation State government to develop joint planning and joint review mechanisms for ICDS and Child Health Programmes at district and sub-district level to address Malnutrition, anaemia and child development in under 3 children. Joint Supervision by supervisors of Health and ICDS should be done. HMIS department to develop a plan for orientation of frontline workers and managers to improve data quality. State Demographic Cell and HMIS department to plan and conduct orientation/training of block and district level officials to improve data analysis and provision of appropriate feedback State to introduce Neonatal and PNC indicators in the monitoring system State to assign responsibility to individual officials and programme managers of SPMU at State level for specific areas of child health programmes with regard to monitoring of progress, data collections, analysis and feedback. Departments of Maternal and Child health and ICDS to periodically evaluate quality of care at health facilities and community level Human Resources, training and strengthening health systems Principal Health Secretary (PHS) to lead strengthening of Human Resource Development Strategy/policy (with adequate reflection of requirement forecasting skills/ set mix required for MNCH, including policy for induction training development and transfers ) Director RCH to develop a procedure to get quality assurance of trainings conducted. MD NRHM to lead Review of existing drug supply management to identify specific gaps and develop state specific solutions MD NRHM to issue directives for urgent prioritization and integration of supportive supervision for MNCH services Director RCH to explore implementation of mechanisms similar to those followed by immunization division for maintenance of equipments and apply lessons learnt. v

16 Child Health in Rajasthan Health communication, IEC and development of community supports Ensure provision of IEC materials as well as AV aids at facility level (CHC and 24X7 PHC level) Strengthen relevant section on health communication in the state PIP with an activity plan including R and D with budget allocations. IEC Activities for child health focusing on the Key Messages Complete the ongoing training of VHSCs within one year followed by hand holding support through allocation of a set of villages to PHC level supervisors Capacity building of supervisors to be completed in the next six months. Expedite the process of training of ASHA on module 5. Core Group: Scaling up of existing interventions for Child Health Scale-up of IMNCI in all districts; Ensure supplies for IMNCI drugs at all levels Rapid scale-up of F-IMNCI in high-focus districts on priority basis Strengthening of community-based management of newborn and childhood illnesses through ASHA and Anganwadi Workers Strengthening of infra-structure and services for Facility-based Newborn Care in highfocus districts (includes Special Care Newborn Unit, Neonatal Stabilization Unit and Newborn Care Corners) vi

17 Short programme Review 1. BACKGROUND India is a signatory to Millennium Development Goals. However, as per the Countdown report 2010, India is unlikely to achieve MDG 4 of reducing the under-five mortality rate by two-third. According to SRS 2009, Rajasthan has an infant mortality rate of 63 per 1000 live births which is 10 points higher than the national figure. There is thus an urgent need to improve intervention coverage and reduce child deaths to come on track towards achieving MDG 4. SPR-CH has been developed at global level to help decision- making at national or state level. SPR-CH package helps programme managers to identify which areas need strengthening based on previous experiences and to set new priorities if necessary. SPR-CH reviews all the interventions for child health directed anywhere along the continuum of care for the mother and child- pregnancy, delivery, the post-natal period, infancy and older childhood. Interventions may be facility- based (first-level or referral facilities); outreach; or related to behavior change communication or community mobilization directed at the level of home or community. It also reviews activities in all the areas which are part of process of implementation of child health programmes; including policy, planning and financing, human resources and training, systems supports (drug, delivery, supervision, referral etc.), communication, community supports and monitoring and evaluation. As health is a state subject in India, strategic directions for health programs are mostly decided at this level. Moreover, there are lots of variations between different states in India. Therefore, it was decided to conduct Short Program Review for Child Health at state level in India. Rajasthan, being one of the focus states for Norway India Partnership Initiatives and having supportive environment for new initiatives in health sector, was chosen for the first Short Program Review in India. 1.1 Background information of Rajasthan State Covering an area of 342,239 sq km (132,150 sq mi) Rajasthan is the largest state in the Republic of India. Jaipur is the capital of the State. The population of the state is 56.5 million according to 2001 census, which is 5.49 percent of the national population. The ratio of the rural and urban population is 77:23. The growth rate of population in the state at % was higher than that of the country %. Rajasthan has one of the largest concentrations of SC (17.15%) and ST (12.56%) population in the country. Socio-economic indicators are, in general lower than the country average % and 43.85% of its total urban and rural female population respectively is literate, the corresponding figures for India being 64.8% and 53.7% respectively. The sex ratio is 921 (per thousand males) compared to the country average of 933. The health indicators particularly IMR and MMR have shown downward trends in the recent surveys (18, 25). Moreover the Crude Birth Rate is also steadily coming down. This is a positive indication that state is moving in the direction to achieve goals set for health sector. 1

18 1.2 Child health situation in Rajasthan Child Health in Rajasthan Out of about 26.1 million children born every year in India, 9.38 lakh newborns die before one month of life. Rajasthan alone contributes to 8.4% of country s total new born mortality even though it has just 6% of country s population. In Rajasthan nearly 1.6 million children are born every year while a hundred thousand die before they are one year old (1). NFHS surveys showed a decreasing trend in IMR, declining from 80 (infants deaths per thousand live births) in (20) to 65 in (18). Registrar general of India has released the latest estimates of Infant Mortality Rate (IMR), Crude birth rate (CBR), Crude Death Rate(CDR) for India and all States/Union Territories, according to which IMR of Rajasthan has declined from 65 to 63/1000 live births in 2008 (25). IMR in rural areas has declined from 72/1000 in 2007 to 69/1000 in 2008 and in urban areas it has declined from 40/1000 in 2007 to 38/1000 in 2008 (25). Neonatal mortality rate in Rajasthan is 44/ 1000 live births (India -- 36/1000 live births), contributing to about 50% of all deaths in childhood. Despite massive investments under RCH-II Programme and NRHM, and visible improvements in health system, the decline in IMR has been inadequate: much less than what would be required to reach the XIth plan goals of reducing IMR to 32/1000 live births by the year While there has been some decline in the mortality among infants from one month to one year of life, the Newborn mortality has remained almost static for past seven years. The nutritional status of children in Rajasthan has improved substantially since NFHS-2 (20), but 44% of its children under age five years are still underweight (NFHS-3) (18). The problem of anemia requires radical changes in prophylactic measures as 79.6% of the children under-3 years in rural Rajasthan are still anaemic (NFHS-3) (18). According to DLHS-3 (14) ( ) 69.8% of children of ARI/fever and 59.7% of children with diarrhoea had access to treatment. The usage of ORS among children suffering from Diarrhoea was 30.6% in (DLHS-3) (14). Access to health care and care seeking for sickness among children has definitely improved. Latest data on care seeking for ARI in any health facility among children <2 years of age was 89.9 percent for the state. More needs to be done to improve routine immunization coverage. The coverage of complete immunization in Rajasthan was 53.8% (CES-2009) (28) 1.3 Child health programmes in Rajasthan As in most of the states of the country Reproductive and Child Health Programme (RCH II) and Integrated Child Development Services Scheme (ICDS) constitute the two major programmes of the state directed at child health and nutrition. RCH II under the NRHM is the state government s flagship programme for maternal and child health. Conceived with a broad perspective the programme caters for the health of mothers and children bundling the child health interventions across the prenatal to 5 year continuum and has been in action since Integrated Child Development Services Scheme (ICDS) by Department of Women and Child (WCD) is another major programme in the state catering to the health and nutrition interventions for children under six years. 2

19 Short programme Review Although the two programmes are under separate departments, there are activities where coordination and joint efforts are being done to execute the services. ASHA Sahyogini, a common community level worker who is responsible for delivery of services through both RCH and ICDS is one of the examples of such coordination. Based on the fact that three main preventable causes viz, Birth Asphyxia, Prematurity and Infections, contribute to more than 80% of the newborn deaths, State Plan had envisaged a set of interventions to be delivered at home, community and Facility levels (4). Accordingly the concept of having a network of Facility Based Newborn Care Centers (FBNCs) was planned to be established at District Hospitals & Medical college hospitals and linkages with IMNCI and JSY were also conceived thus connecting home, community and institutional level interventions. Navjat Shishu Suraksha Karyakram (NSSK) was also launched with the aim of reducing NMR by providing immediate essential newborn care and resuscitation at birth to every newborn in the institutional setup. Setting up 38 Malnutrition Treatment Centers was planned and is being implemented in a phased manner to tackle the problem of underweight and malnourished children. Expansion of IMNCI from the current status of 9 districts to cover all districts and launch of Facility based IMNCI (F-IMNCI) is under process. The State Plan focuses on the quality of district level IMNCI trainings and strengthening and improvement of the supervision activity for IMNCI trained workers by engaging the supervisory cadre. Yashoda scheme being implemented by NIPI in its 3 focus districts was adopted for implementation in all districts of State. Maternal and Child Health Nutrition (MCHN) Days held at village level under joint collaborative effort of RCH II and ICDS aims to address the issue of improving routine immunization coverage and level of Vitamin A supplementation among under 5 children. 2. The Short Programme Review 2.1 Objectives The overall objective of this review was to identify priorities and to formulate strategic directions for child health interventions to be implemented in the state of Rajasthan. Specific Objectives To review the status of the child health programme being implemented in the state; Assess progress towards programme goals and objectives and identify the data gaps; Assess how well the programme implemented its plans in to deliver child health interventions; Identify the problems programme has faced and to suggest solutions; Develop recommendations about what the programme needs to do; Decide on next steps for incorporating recommendations into the work plan. 3

20 Child Health in Rajasthan 2.2 Proposed Participants For conducting SPR, a review team of close to 50 members was conceived and was proposed to include State level programme managers and consultants, District Programme Managers, Divisional MCH coordinators and block level service delivery personnel. In addition, Academic and Research Institutions (IIHMR, NIHFW, SIHFW, SMS Medical College), Local and international NGOs (VATSALYA, Save the Children and CARE India) and UN Agencies (WHO, UNICEF and UNOPS) also participated in the review process. 2.3 Methods Used Preliminary data collection and adaptation of Worksheets The Data Review Team from IIHMR, Jaipur did the preliminary data collection and interview of key personnel to gather background data on child health situation in Rajasthan. Worksheets of SPR-CH package were used for the purpose. Some of the items/indicators which were not found relevant in context of India were removed and new ones were incorporated wherever found necessary. Worksheets were filled in by reviewing and collecting information from published documents of various health surveys as well as state programme implementation plans of the past three years. Apart from reviewing the documents, some key officials and experts were interviewed to assess the coverage of various intervention packages and their implementation and performance. Information about relevant programmes from the experience and views of experts who had been associated with the programmes for a long time was also incorporated in the worksheets. Various child health programmes delivered by the Department of Medical and Health services at the state level, were covered in the worksheets Data Sources: In India health services and morbidity data are derived from three main sources: (a) The National Family Health Survey (NFHS) It is a large scale nationwide multiround household survey conducted on a representative sample of households throughout India. The survey provides state wise as well as national information on Fertility, Infant and Child Mortality, Maternal and Child Health, Reproductive Health, Nutrition Anaemia, practice of Family Planning, Utilization and quality of health and family planning services. Three rounds of NFHS have been conducted since 1992 NFHS I ( ), NFHS II ( ), NFHS III ( ) (b) District Level Household Survey (DLHS) It is a nationwide district level survey designed to provide information on health care and utilization indicators on Maternal and child health, reproductive health and family planning. Three rounds of DLHS have been conducted since 1998 DLHS I ( ), DLHS II ( ) and DLHS III ( ) 4

21 Short programme Review (c) The report of the Registrar General of India (RGI): Office of the Registrar General, India, initiated the scheme of sample registration of births and deaths in India popularly known as Sample Registration System (SRS) in on a pilot basis and on full scale from The SRS since then has been providing data on regular basis. Based on a dual record system the SRS System in India consists of continuous enumeration of births and deaths in a sample of villages/urban blocks by a resident part time enumerator, and an independent six monthly retrospective survey by a full time supervisor. The data obtained through these two sources are matched. SRS bulletins published annually provide up-to-date data on Birth Rate, Death Rate, Growth Rate and Infant Mortality Rates at National and State Levels. Apart from above sources, the team also incorporated findings from recent coverage evaluation survey (28) and state HMIS. Family Welfare Statistics of India (22) (2009) published by the Ministry of Health and Family Welfare, GoI and relevant research papers pertaining to Maternal and Child Health in Rajasthan were also reviewed for reference and data collection. The complete list of documents reviewed is appended vide Annexure X Period of Review Since the last set of comprehensive data on various indicators relevant to this review is provided by NFHS III ( ), it was decided to keep NFHS-III as the baseline and any data on corresponding indicators obtained subsequently (including SRS, DLHS-III,CES-2009, HMIS, other sources) was included in the most recent data Formation of review team In accordance with the composition of the proposed review team mentioned earlier, representatives from various stakeholders including State Government, International Organizations, NGOs working in the field of maternal and child health, academic institutions were included to make the 51 member review team. Representatives from the state Government were finalized in consultation with the Department of Medical & Health services, Government of Rajasthan, and included state level programme managers and consultants, district programme managers, divisional MCH coordinators and block level service delivery personnel. The team members comprised of nodal persons, experts working in the area of child health and programme managers concerned with child health interventions and had the following affiliations: Department of Medical & Health Services, Government of Rajasthan State Programme Managers and consultants including - Maternal Health - IMNCI - Immunization - Nutrition - Health Communication - HMIS/ Statistics Health Professionals including Medical Officers/Programme Managers/Coordinators form District/Block and PHC levels 5

22 Child Health in Rajasthan International Organizations : WHO (Headquarters / SEARO/India Country Office) NIPI ( India and State Offices) UNICEF (India and State Offices) Academic / Research / Training Institutions : IIHMR (Jaipur and Bengaluru) NIHFW, New Delhi SMS Medical College and Hospital, Jaipur SIHFW, Jaipur RSHRC NGOs working in the field of Maternal and Child Health CARE India State Office Save the Children State Office Vatsalya, Jaipur Preliminary Workshop A one day preliminary workshop was held on 20 th September, 2010 for reviewing overall preparations, finalizing the worksheets and training of facilitators. Representatives from the Department of Medical & Health services - Govt. Rajasthan, Institute of Health Management Research (IIHMR), Norway India Partnership Initiative (NIPI), WHO and UNICEF participated. 2.4 Steps of SPR 6

23 Short programme Review 2.5 Inaugural Session The workshop was formally inaugurated on 20 Sep 2010 by Dr ML Jain, Director RCH, Directorate of Medical and Health Services, GoR amidst the presence all the participants of the 5 day programme. The inaugural session comprised of a presentation on the status of child health in Rajasthan by Dr ML Jain. Dr Paul F Francis, National Professional Officer and Cluster Focal Point, FHR, WHO SEARO, briefed the participants on the objectives of SPR. Dr Kaliprasad Pappu, National Coordinator NIPI and Dr SD Gupta, Director IIHMR, Jaipur also spoke on the occasion. 3. Goals and Objectives of the Child Health Programme As part of Step 1 of the SPR, goals and objectives of the child health programme were discussed in the first technical session on Day 1. Working in a plenary the group discussed the programme goals and objectives as per filled Worksheet 1 which included the programme goals and objectives from the two major programmes on child health RCH II and ICDS. In addition goals / objectives of relevance to child health from disease control and other programmes were also included. Participants discussed whether goals and objectives were written clearly and whether they were realistic and measurable. It was agreed upon that though most of the child health related goals and objectives are clearly laid out, some of them were either too general or were not measurable. Goals: The participants concluded that the Goals laid out under various programmes were satisfactory except the one for Reducing Newborn Deaths which was felt to be too general and lacking clarity as to what reduction to achieve. Objectives : The review team concluded that program implementation plans of the state as described in Worksheet 1, does have many objectives which are clear and measurable but there were certain others which were either not measurable or were not really framed as objectives. The objectives like strengthening IEC activities, and strengthening of newborn facilities at tertiary level hospitals were not measurable while some activities like setting up of level II neonatal ICUs were put under program objectives. 7

24 4. Neonatal and Child Health Status Child Health in Rajasthan Continuing in the afternoon session on Day 1, the group worked in plenary to review and discus the indicators for maternal, newborn and child health status. In the facilitator guided discussion, the group reviewed worksheet 2 (which was prefilled). Each indicator was reviewed by asking the following questions: Are data available? Has the target been met? (if a target has previously been established) How has it changed over time? Is it going up or going down? Does it differ between different regions or groups? Are there any problems with the validity or reliability of the data are new or different methods needed? Consensus was arrived at for each indicator and the status was marked by: (a) Ticking for indicators with positive results; (b) crossing those with negative results and (c) shading those with need for more data. Summary of Key Findings : The group reviewed available data and discussed trends to identify areas where the programme has been doing well and those where the programme is off track and needs to do more. In addition the discussion also focussed on finding data gaps and identified indicators with need for data collection. The program has been doing well for improving coverage of delivery by skilled birth attendants mainly by the marked increase in institutional delivery under Janani Suraksha Yojana. This is likely to reduce maternal mortality. There were a number of indicators where the progressive trends were either not on track, static or had no set targets. Neonatal Mortality rate was identified as a key area where significant efforts would be required. Moreover, there was no set target in the state plan for this indicator. Infant Mortality and under five mortality rates had shown decline but the group concluded that going by the present trends, achievement of MDG targets was unlikely. Review of data on childhood morbidity showed that comparable data was available only for the prevalence of ARI/Pneumonia and Diarrhoea. It was found that there was a declining trend in childhood morbidity represented by these conditions. Decline in prevalence of anaemia among children had been insufficient and prevalence of low birth weight babies had been relatively static. Data on causes of death in infants and mothers were limited to few research papers and there was no available data on causes on child mortality. It was concluded that there was a definite need to have more data on state specific causes of death among these groups. More data was required on the prevalence of micronutrient deficiencies, especially Vitamin A. 8

25 Short programme Review 5. Intervention Coverage Step 2 of the SPR aimed at assessing the interventions included in the child health programme, delivery mechanisms and review of the intervention coverage indicators. The participants were divided in three smaller groups maternal, newborn and child. Each group had a facilitator and rapporteur for the session. In accordance with the SPR guidelines (29), worksheets were first discussed within the small groups, each group covering its respective area. Updates and conclusions were finalized by the rapporteur in consensus with members of the group. Updates were then shared in a plenary with the rapporteurs of each group making their presentations followed by discussion and further update of the worksheets. This process was done in sequence for worksheets 3 and Interventions and delivery of packages The group reviewed and discussed worksheet 3 considering the following aspects Interventions that are currently delivered Levels at which the interventions are currently delivered Description of packages under which the interventions are delivered Extent of implementation : whether complete or partial Accordingly the findings were discussed and summarized under the three heads: (a) Availability and levels of delivery of interventions. Interventions available were appropriate in terms of requirement and the levels at which they are being delivered. The groups did not identify any such intervention which is lacking and needs to be introduced afresh except IYCF, which is already being planned to be implemented. (b) Description of packages under which the interventions are delivered : Maternal: ANC, BEmOC, CEmOC, PPTCT, Safe Delivery Package, PNC/HBPNC Newborn: NSSK, FBNC, IMNCI, Yashoda, PNC/HBPNC, RI, Control of Malnutrition, PPTCT Child: IMNCI, RI, ICDS, IYCF (under planning), (c) Extent of Implementation: There was considerable variation in the extent of implementation of various intervention packages. Packages which have been implemented throughout the state include ANC, PNC, BEmOC, CEmOC, NSSK, RI, Control of Malnutrition, Supplementary Nutrition (Under ICDS), Control of ARI / Diarrhoea. Packages with limited implementation include: IMNCI : Currently implemented in 9 districts. Being expanded to all districts. Yashoda : Implemented in 3 NIPI focus districts. Taken up for implementation in all districts. HBPNC : Only in 3 NIPI action districts. PPTCT : Currently implemented in 10 districts. 9

26 Child Health in Rajasthan 5.1 Coverage Indicators Participants split again into the small groups to review worksheet 4 (Prefilled) to review the coverage indicators. Each indicator was reviewed by asking the following questions: Are data available? Has the target been met? (if a target has previously been established) How has it changed over time? Is it going up or going down? Does it differ between different regions or groups? Are there any problems with the validity or reliability of the data are new or different methods needed? Consensus was arrived at for each indicator and the status was recorded by rapporteur by : (a) Ticking for indicators with positive results; (b) crossing those with negative results and (c) shading those with need for more data. Summary of Key Findings: The groups reviewed available coverage data and discussed trends to identify areas where the programme has been doing well; those where the programme is off track and needs to do more and areas where there were major issues. In addition the discussion also focussed on data gaps and identified indicators with need for data collection. (a) Coverage indicators with positive trends and realistic targets Programme was found to be doing well with regards to the intranatal and immediate post natal care, being reflected in positive trends in the data on Appropriate Cord care and Hygiene for Deliveries at Home and Immediate Postnatal Visit. NFHS III data showed that 89.5% of babies delivered at home had the cord cut with a clean instrument. Similarly the proportion of mothers/ newborns receiving a care contact within first two days of delivery increased from 7.7% in (20); to 37.3 % in (14). With the current rise of institutional deliveries to above 70% (28) and universal PNC visit in case of institutional deliveries; the target of achieving 80% immediate PNC visit mentioned in the State PIP appears realistic. Micronutrient supplementation (except in case of Vitamin A) was another area where the indicators have shown a healthy trend. Proportion of mothers who received iron supplementation during pregnancy has gone up steadily from 29.2 % in to 39.3% in (20) and was 57.7% in (18). Proportion of children living in household using iodized salt has also increased from 35.1% in (18) to 58% in (28) Care seeking for pneumonia has also risen promisingly. Proportion of children with suspected pneumonia taken to appropriate provider has increased from 64.7% in (18) to 89.9% in 2009 (28) which is sync with the set target of 90% access in the State PIP for (4). 10

27 Short programme Review (b) Coverage indicators with positive trends but programme needs to do more Proportion of institutional deliveries has increased steadily from 22.5% in (9) to being 31.4% in (11) to 45.4% in (14). The impact of JSY was visible in significant further increase in the proportion of institutional deliveries shown to be close to 70% as per the CES by UNICEF in 2009 (28). But the figure is still far from the desired target of 90% by 2011 kept under the state PIP (4). There are disparities in terms of rural urban differences and inter-district variations and although the trends are good, achievement of target is unlikely. Appropriate complimentary feeding for children in the age group of 6-9 months has been quite low and the proportion of infants aged 6-9 months who received appropriate breast feed and complimentary feeding stood at 43.7% in (14). Management of diarrhoeal diseases in children has also shown a positive trend. Proportion of children with diarrhea who received ORT rose from 4.7% in (14) to 30.6% in (14) and the latest data puts the figure at 45% (28). Though has been a progress in improving access of such children to ORT but it falls short of the target of increasing it to 60% by 2010 (4). (c) Coverage indicators with negative results major issues; programme needs to do more The review team identified a number of coverage indicators for priority interventions showing negative results, ie, with downward or static trends. Additionally, there were some which have fallen short of achieving the targets or with widespread disparity in coverage among sub-groups. Considering the intervention of adequate antenatal care, coverage measure reviewed was the proportion of mothers who received at least 3 antenatal visits. The latest coverage figure stood at 55.2% in 2009 (28) which is far short of the target of 80% by (4) Moreover there were wide regional and subgroup differences. Proportion of mothers who received 2 doses of Tetanus Toxoid had risen from 28.3% in (9) to 59.1% in (11) and then declined to 50.9% in (14). There were significant rural urban and subgroup variations too. Identification and treatment of maternal emergencies such as eclampsia and obstructed labour was reviewed by looking at the proportion of rural pregnancies having a caesarian; which was 2.2% in (18). This is less than one fourth of the corresponding figure of 9.9 % in urban areas. Prevention of hypothermia as assessed by reviewing the data on babies delivered at home; who were dried, wrapped (and not bathed) immediately after birth shows that the proportion was 34.2% (18) of the total babies born at home. Immediate initiation of breastfeeding as seen from the trends in proportion of mothers who initiated breast feeding within one hour of birth did show an increase from 14.5 % in (11) to 41.4 % in (14) but the findings from the Coverage Evaluation Survey 2009 show an alarmingly low figure of 27.7% (28). Moreover, there are widespread regional differences in the practice. The proportion of babies who received a prelacteal feed was 71.6 % in (18). Proportion of infants under 6 months exclusively breastfed continues to be relatively low at 65.4 %. (18) 11

28 Child Health in Rajasthan Routine Immunization coverage is another area of major concern. Coverage of 0 dose OPV has dipped from 33.8% in (11) to 33.1% in (14) Most recent HMIS data also reports coverage of 40% for 0 OPV. Percentage of children aged months who received measles vaccine increased from 35.9% in (11) to 67.3% in (14). CES 2009 however, revealed coverage of 65.6 % ( 28). State target of achieving coverage of 80% by 2010 (4) thus seems unlikely. Vitamin A supplementation has not kept pace with the laid down targets. Proportion of children who received a dose of Vitamin A increased from 22.4% in (11) to 52.5% in (14) and 60.5% in 2009 (28) which falls short of the target of 90% by as laid down under the XI Five Year Plan Goals for Rajasthan. Considering the proportion of children who received appropriate antimalarials, the figure of 9.0 % for (18) is in fact less than that of 13.9 % in (20) 6. Summary of status of the child health programme Step 3 of the SPR was to critically review the activity areas in the field of child health Programme along the continuum of care, find the status of implementation, reasons for the observed performance and identify the strengths and weaknesses of the programme using worksheet 5. The Worksheet had 6 cross cutting areas as heads under which the review was to be undertaken namely (a) Policy, Planning and Management; (b) Human Resources and Training (further divided into In-service and Pre Service Training);(c) Health Communication/IEC; (d) Development of Community Supports; (e) Strengthening Health Systems and (f) Monitoring and Evaluation. Day 3 was fully dedicated to discussion and review of worksheet 5. The participants continued in smaller groups i.e, maternal, newborn and child health groups. Customized worksheets for each small groups were used. Each group had a facilitator and rapporteur for the session. As in Step 2, the worksheet was first discussed within the small groups, each group covering its respective area. Some supporting data filled in the worksheets along with the plan documents were utilized for assistance. In addition, field experience of the participants helped to guide the discussion. Updates and conclusions were finalized by the rapporteur in consensus with members of the group. Updates were then shared in a plenary with the rapporteurs of each group making their presentations followed by discussion and further update of the worksheets. 6.1 Summary of technical areas along the continuum of care: Each group started by reviewing the activity areas in their respective areas as applicable in the continuum of care. Discussion initially sought to identify the activity areas delivering the intervention packages and then proceeded to decide the status of implementation. 12

29 Short programme Review Status of Implementation Policy, Planning and Management Status of implementation was complete in most of the activity areas under this head for all the three groups (Table 6.1). Maternal group had all activity areas being fully implemented except No 5 (Annual budget adequate to complete all activities in the last plan). Activity area No 4 (Planning done collaboratively with other divisions and with donors) was considered to be partially implemented with regards to the packages under the New Born group. For the child group, activity area No1 (Practice standards and guidelines updated and being used) was in a partial state of implementation for F-IMNCI excepting which all others were considered to have a full status of implementation. Table 6.1 GroupWise summary of activity areas and status of implementation (Activity Head: Policy, Planning and Management) Groups (Intervention Packages) S No Activity Area Maternal (ANC, SBA, EmOC, PNC) Newborn (PNC, FBNC) Status of Implementation (Fully, Partially or not at all) Child (IMNCI, UIP, Facility based interventions) 1 Practice standards and guidelines updated and being used Fully Fully Fully (Partially for F IMNCI) 2 Essential drug list available Fully Fully Fully 3 Budgeted plans developed annually at the state and district levels Fully Fully Fully 4 Planning done collaboratively with other divisions and with donors Fully Partially Fully 5 Annual budget adequate to complete all activities in the last plan Partially Fully Fully 13

30 Human Resources / Training (In Service) Child Health in Rajasthan Status of implementation was mostly inadequate in majority of the activity areas under this head and all the three groups marked them as partially implemented.(table 6.2) Table 6.2 Groupwise summary of activity areas and status of implementation (Activity Head : Human Resources / Training (In Service)) Groups (Intervention Packages) S No Activity Area Maternal (ANC, SBA, EmOC, PNC) Newborn (PNC, FBNC) Child (IMNCI, UIP, Facility based interventions) 1 Plan to ensure adequate staffing at each level, which includes incentives Partially 2 In-service training strategy available Fully 3 In-service training conducted for health staff Status of Implementation (Fully, Partially or not at all) Partially (Not adequate for FBNC) Partially (Not adequate for FBNC) Partially Partially Partially Partially Partially 4 In-service facilitators trained Partially Partially Partially 5 6 Follow-up after in-service training conducted Quality of in-service training are: types of staff trained, materials used, time allocated, amount of clinical practice adequate? Partially Partially Partially Partially Partially No information available 14

31 Human Resources / Training (Pre Service) Short programme Review Status of implementation was inadequate or not at all implemented in most of the activity areas under this head and all the three groups marked them as partially implemented or not implemented. (Table 6.3) Table 6.3 Groupwise summary of activity areas and status of implementation (Activity Head: Human Resources / Training -Pre Service) Groups (Intervention Packages) S No Activity Area Maternal (ANC, SBA, EmOC, PNC) Newborn (PNC, FBNC) Status of Implementation (Fully, Partially or not at all) Child (IMNCI, UIP, Facility based interventions) 1 Pre-service training strategy available No Partially Fully (Partially for F IMNCI) 2 Pre-service training incorporated into curricula of medical and other schools Partially Partially (only IMNCI) Partially (Only IMNCI) 3 Pre-service trainers trained No Partially Partially 4 Quality of pre-service training materials used (including textbooks), time allocated, amount of clinical practice adequate? No information Inadequate No Information 15

32 Child Health in Rajasthan Health Communication / IEC In case of the Maternal health Group, most of the activity areas were in a state of partial implementation (Table 6.4) although the status of development and distribution of messages and materials seemed to be adequate. It was heartening to note that under this head, barring few; most of the activity areas were considered fully implemented by the newborn and child health groups. Newborn health group concluded that focus on reaching low level populations was an area of partial implementation. Child health group felt that implementation status of development and distribution of messages and materials as well as the quality of the messages in terms of adaptation to local context and pretesting remains inadequate. Table 6.4 Groupwise summary of activity areas and status of implementation (Activity Head: Health Communication/IEC ) S No Activity Area Maternal / Child health communication strategy or plan available Focus on reaching low level populations Communication activities conducted: mass media, printed materials, training for local groups/volunteers in inter-personal communication; training for health workers Messages and materials developed and distributed Maternal (ANC, SBA, EmOC, PNC) Groups (Intervention Packages) Newborn (PNC, FBNC) Status of Implementation (Fully, Partially or not at all) Child (IMNCI, UIP, Facility based interventions) Partially Fully Fully Partially Partially (Separate plan from Desert & tribal areas) Fully Partially Fully Fully Fully Fully Partially 5 Quality: Key Maternal / Child health messages used; messages and materials pre-tested and adapted for local context Partially Fully Partially (no field testing) 16

33 Development of Community Supports Short programme Review This activity head again had many activity areas which were considered to be partially implemented by all the groups. Availability of trained community volunteers and the quality were two such areas where all the three groups felt that more need to be done to achieve full implementation. In comparison, Availability of implementation plan for community level activities as well as that of trained community health workers were better implemented (Table 6.5). Table 6.5 Groupwise summary of activity areas and status of implementation (Activity Head: Development of Community Supports ) S No 1 Activity Area Implementation plan for community-level activities available Maternal (ANC, SBA, EmOC, PNC) Groups (Intervention Packages) Newborn (PNC, FBNC) Status of Implementation (Fully, Partially or not at all) Child (IMNCI, UIP, Facility based interventions) Fully Fully Partially 2 Community health workers trained and available Fully (ASHA, AWWA) Partially Fully (ANMs, LHV, AWW) 3 4 Community groups or volunteers trained and available Quality: Developed collaboratively; use local staff and volunteers; supervision or oversight plan Included Partially Partially Partially Partially Partially Partially 17

34 Child Health in Rajasthan Strengthening Health Systems This activity head is an area of concern as almost all the activity areas under it were thought to be in a partial state of implementation by all the three groups. Availability of essential drugs and equipment at first and referral levels in respect of the child health group was the only activity area considered to be adequate. Table 6.6 Groupwise summary of activity areas and status of implementation (Activity Head: Strengthening Health Systems ) S No Activity Area Maternal (ANC, SBA, EmOC, PNC) Groups (Intervention Packages) Newborn (PNC, FBNC) Status of Implementation (Fully, Partially or not at all) Child (IMNCI, UIP, Facility based interventions) 1 Quality of case-management No Partially Partially Services available Essential drugs and equipment available at first and referral levels Routine supervision conducted using checklists, and observation of practice Systems for timely referral for maternal complications in place Partially (EmOC partially available, remaining fully available) Partially Partially Partially Partially Fully Partially Partially Partially Partially Partially Partially 18

35 Short programme Review Monitoring and Evaluation Activity areas under this head are in a mixed state of implementation, with GroupWise differences. (Table 6.7). Functional status of vital registration systems and use of monitoring data for routine planning at various levels was considered to be incomplete by all the three groups. In contrast, availability of population and health facility data for monitoring and evaluation was considered adequate by all groups. Remaining activity areas had varied implementation status across the three groups, being partial with regard to some while being full in the others. Table 6.7 Groupwise summary of activity areas and status of implementation (Activity Head : Monitoring and Evaluation ) S No Activity Area Plan for routine monitoring and periodic evaluation of the maternal health programme included in strategic plan and work plans Standard international indicators used Short and long term targets set Maternal (ANC, SBA, EmOC, PNC) Groups (Intervention Packages) Newborn (PNC, FBNC) Child (IMNCI, UIP, Facility based interventions) Status of Implementation (Fully, Partially or not at all) Fully for Monitoring, Partially for Fully Partially evaluation Partially Fully Fully Fully Partially Fully 4 5 Population- and health facility-based data available for monitoring and evaluation Fully Fully Fully Monitoring data used for routine planning by all levels Partially Partially Partially 6 Vital registration systems working Partially Partially Partially 19

36 Child Health in Rajasthan 6.2 Summary of Strengths and Weaknesses After identifying the Activity areas for each of the activity heads each group discussed the strengths and weaknesses for every activity area. Policy and plan documents as well as field experience of the participants yielded the necessary inputs to required making the consensus. The strengths and weaknesses identified by the groups are summarized under the sequentially below: Maternal Group Maternal group considered ANC, SBA, EmOC and PNC packages and identified the following strengths and weaknesses: Strengths: Systems and mechanisms are in place to enable updating of practice standards and guidelines District plans contribute to making of State level Budgeted Plans Essential drug lists uploaded on website connectivity up to block level HMIS availability online block level and upwards Provision of contractual hiring and rural health cadre Presence of autonomous training institutes Availability of adequate number of trained in service facilitators Provision of supervisory checks for in service training Availability of adequate budget for Health communication / IEC activities along with special budget for low level areas. Support from donor partners in development of IEC/communication materials and use of standard set of materials across the state. Budget for community level activities and creation of Village Health and Sanitation committees in all villages Concurrent monitoring system Trained Health workers and ambulance attendants for managing and transferring emergencies Weaknesses: Limited awareness of policies at field level Essential Drug lists not displayed at facility level District plans not developed in time State proposed budget is usually slashed by the center. Non availability of specialists Attrition among contractual staff In service training : Non compliance by candidates identified for training; Inadequate capacity and frequent transfers of training staff ; limited training sites ; limited capacity to follow up in service training; Injudicious utilization of facilitators Lack of orientation of medical / nursing education according to the need of medical programmes IEC weak for EmOC and PNC 20

37 Short programme Review Lack of coordination between NRHM and RHSDP for IEC/Health Communication All relevant messages are not covered under IEC VHSCs : Formation of VHSCs took longer than planned; all VHSCs are not active; only 30 40% VHSC members are trained Shortage of medicines Emergency transport and referral mechanisms available in some blocks only Newborn Group Newborn group considered PNC and FBNC packages and identified the following strengths and weaknesses: Strengths: Commitment from Government Partnerships with collaborating agencies / donors Availability of resources Adequate funds for maintaining essential drugs Development of plans done in participatory manner with involvement of important stakeholders Strong partnership for FBNC training Adequate facilitators available for NSSK Plan for monitoring FBNC through State Level Newborn cell ICDS involved for supportive supervision of community based newborn care Systems for timely referral : Refrral card/availability of funds/ambulance services HMIS Online system Pregnancy and Child Health tracking system (PCTS) established Indicator based monitoring Vital Registration System : Maternal and Infant Death Inquiry and being scaled up Weaknesses : Essential drug list not updated regularly Template based planning lack of flexibility Less involvement of ICDS Underutilization of Budget and complicated financial processes Vacancy of ASHA Inservice training :Handholding supervision after training is poor; Inadequate number of facilitators for IMNCI/FBNC; Training protocols not followed in training institution; Less number of facilities for conducting training; Lack of quality assurance mechanism for training Pre Service training : not started in all medical colleges; New Born component is inadequate IEC : Distribution and dissemination of IEC materials is inadequate; Content and impact evaluation is not done; weak monitoring; operational and managerial issues Post training support and handholding of community health workers is not adequate. All community workers not covered in training 21

38 Child Health in Rajasthan Training of ASHA completed only for a few modules Quality issues in ASHA training Poor training and follow up Lack of infrastructure and supportive supervision Lack of awareness and acceptance of services Lack of feedback and accountability for community based services Poor referrals despite having referral system and services Poor quality of data Lack of proper system for analysis of data and feedback to providers No system for monitoring quality of care Targets not available for all indicators Exact data required for planning is not always available Training of managers in planning process is weak Vital Registration System : Home deliveries and deaths at home not being registered Child Group Child Group considered IMNCI, UIP/RI and FBI packages and identified the following strengths and weaknesses: Strengths: Good policies, guidelines updated regularly Existence of implementation plans; availability of multi level plans for monitoring and supervision of child health services Participation of districts through District action plans(bottom up Approach) Joint Planning undertaken at State Level. Increasing involvement of Medical Colleges and training Institutions Hiring of contractual staff Mainstreaming of AYUSH personnel In Service Training : Specific training packages for each intervention group; Training plan/calendar ; Two Designated Sites for providing trainings; Entry in service book of candidate IEC : Special directorate at State level; District IEC coordinators; Adequate budget for IEC activities; Inclusion of IEC in all major training packages; development of variety of materials pertaining to major interventions; presence of technical committee to ensure correctness and local adaptation of messages. Placement of ASHA; trainings of ASHA; availability of funds at community level; dedicated training packages for various community groups Mechanism of providing services through village health and nutrition days (VHND) Regular supplies of drugs and equipment through partner support Availability of Ambulance services Online system of sending and receiving reports; Facility level surveys and HMIS to monitor facilities and services 22

39 Short programme Review Use of standard indicators for planning; Targets based on community surveys and determined bottom up and validated by demography cell Availability of disaggregated data even at peripheral levels Monthly review meetings for progress in implementation Weaknesses: Lack of some critical operational elements like supportive supervision mechanisms Most plans and policies are either centrally determined or adopted from National guidelines. Frequent change of directives and circulars Matching of drug list with the intervention packages has not been done IMNCI planning confined to training plan only Convergence with ICDS inadequate. Collaboration with other divisions and donors not uniform at all levels Underutilization of funds Delays in filling vacancies In service Trainings: Lack of coordination and integration of trainings; Frequent disruptions in trainings; Multiplicity of trainings; Training calendar not adhered to; Frequent transfers and lack of reorientation training of facilitators Pre Service Training : National strategy not endorsed at state level; No set plan for pre service training; IMNCI training not present in Nursing colleges IEC : Strategy does not have a comprehensive plan on using appropriate media mix; Implementation and reach are suboptimal; Loss of materials developed in the past; Slow pace of trainings of IPC/BCC packages; Field testing aspect often ignored; Evaluation of materials not undertaken Community Supports : Involvement of community not as per desire, non formal leaders are not involved;. Timeliness of training and quality of training is variable especially those given through NGOs; Weak supportive supervision Manpower not appropriately trained to use equipment Maintenance of equipment not streamlined Inadequate supervisory manpower for field level supportive supervision Inadequate monitoring at lower levels Analysis of computerized data at block level is inadequate Review mechanisms are more administration oriented rather than programme oriented. Use of HMIS data and triangulation is limited Standard international indicators are not internalized by system on regular basis Lack of techno managerial skills to set realistic targets; Unrealistic targets Proper analysis and use of available data on population and health facilities is limited Lack of demand of astute data by decision makers; Very limited data is used in planning Vital registration not yet universalized 23

40 6.3. Identifying the main problems Child Health in Rajasthan Worksheet 5 provided specific set of strengths and weaknesses for various cross cutting activity areas of intervention packages for all the three levels along the continuum of care. (Pregnancy, Newborn and Child groups ). Next logical step was to identify the main problems by reviewing and summarizing the weakness listed in Worksheet 5 which was done by completing Worksheet 6. Continuing to work in small groups through the second half of Day 3, participants picked up the important weaknesses from worksheet 5 and summarized them as the most important problems, picking 4-5 from each activity area. The problems were then presented and discussed in the large group. 7. Core problems, Solutions and Recommendations 7.1 Listing the Core Problems A final list of the most important problems from each activity area across the continuum of care was discussed in the large group in the first session of Day 4. Common problems across the groups were clubbed together and the most critical ones were selected for inclusion in the final list. The main problems were summarized as per the six activity areas (a) Policy, planning and Management; (b) Human Resources and Training; (c) Communication/IEC ;(d) Development of Community Supports; (e) Strengthening Health Systems and (f) Monitoring and Evaluation. The final list of problems formed the basic input for Step 5 which was conducted on Day 4, to develop solutions and recommendations by completing worksheet Reorganization of Small groups The small groups were reorganized in accordance with the activity areas : Group I : Policy, Planning, Financing and Management; Monitoring and evaluation. Group II : Health Communication/IEC; Development of Community Supports Group III : Strengthening Health Systems; Human Resources and Training Each group had its facilitator and a rapporteur. The groups were given copies of adapted Worksheet 7 and the final list of problems identified. Each group then discussed the main problems faced in their respective thematic areas. 24

41 Short programme Review 7.3 Group Activity: Completing Worksheet 7 The groups started by taking each problem in turn. The selected problem was entered in the first column of the worksheet. In the facilitator guided discussion the groups then identified and discussed the possible causes to the problem. Consensus was taken and the causes were listed in the second column on the worksheet. Possible solutions were explored keeping in view the main categories of programme activities and by reasoning how these could be strengthened to overcome the causes of the problem. The possible solutions were written down in the column succeeding the listed causes. Based on the solutions the groups formulated recommendations. Groups aimed at developing clear and concise recommendations which would be action oriented and practically feasible. Each group developed its set of recommendations in respective thematic areas. Completed worksheet 7 was then presented in plenary session. 7.4 Decide on next steps Immediately after completion of the worksheet 7, the core group consisting of the representatives from the state health department, UN organizations (WHO, UNOPS-NIPI, UNICEF) and IIHMR met to decide on the future steps on ensuring the incorporation of recommendations into the state PIP. It was decided that the recommendations would be formally presented to the Principal Secretary Health, Government of Rajasthan on day 5 and subsequently finalized by incorporation of important feedback. It was also decided that the finalized set of recommendations would then be prioritized in consultation with the members of the core group for incorporation in the next and subsequent PIPs. 7.5 Presentation of findings and finalization of recommendations The groupwise findings of SPR were formally presented to Shri BN Sharma, Principal Secretary Health, Department of Health and Family Welfare, Government of Rajasthan in the closing meeting on 25 September He assured full support from the Health department with regards to the incorporation of the recommendations in the upcoming PIP. The feedback on the presentation was recorded for subsequent prioritization and finalizing of the recommendations. The findings were then forwarded to the members of the core team for prioritization. Final recommendations are presented in the subsequent section below. 25

42 Child Health in Rajasthan 7.6 Final Recommendations Group I. Policy, Planning and Management / Monitoring and Evaluation Core problems and recommendations: (a) There is a gap in communication, uniform interpretation and follow up of directives from State HQ to grass root level. Recommendations: Priority for Action Immediate 1. To ensure that result based monitoring of performance is operational along the monitoring cascade whereby the state officials monitor the performance of districts, district officials monitor the performance of the blocks and so on till the sub centre level. 2. (a) A Checklist for ensuring clarity, consistency and completeness of directives and operational guidelines, and their follow-up to be developed by Health Directorate Successive 2. (b) Originating units/ departments use the checklist to ensure that the directives and guidelines are clear, comprehensive and self explanatory 2. (c) The district and block units to ensure that the guidelines reach the intended user in time and an action taken report is sought 3. Explore the use of s, Video-conferencing, Gramsat and other alternative means of communication to improve interactions. (b) Planning not need based but driven by template and budget Recommendations: Priority for Action Immediate 1. State Health Department to organize Capacity Building workshops on Programme Planning and Management for block, district and state level officials to promote data based and need based planning. 2. Health Directorate to ensure that specific and appropriate plans for improving access to services are developed by the desert/ tribal districts and other districts for their difficult to reach areas and support provided for implementation 26

43 Short programme Review (c) Underutilization of AYUSH practitioners in MNCH services Recommendations: Priority for Action Successive 1. State government to utilize AYUSH practitioners for monitoring of MNCH services 2. State government to take a policy decision to enable AYUSH practitioners to deliver IMNCI through training and ensuring health system support for practicing IMNCI (d) Lack of coordinated and inadequate attention to address Nutrition and Development in Children Recommendations: Priority for Action Immediate 1. State government to develop joint planning and joint review mechanisms for ICDS and Child Health Programmes at district and sub-district level to address Malnutrition, anaemia and child development in under 3 children. 2. Joint Supervision by supervisors of Health and ICDS should be done. (e) Lack of quality in data capture at field level Recommendations: Priority for Action Immediate 1. HMIS department to develop a plan for orientation of frontline workers and managers to improve data quality. Successive 2. HMIS department should also develop a ward wise reporting system in urban areas for PCTS. 3. Sensitization of private practitioners for reporting morbidity,mortality and service utilization data. 27

44 Child Health in Rajasthan (f) Inadequate data analysis, feedback and reviews at district and sub-district level Recommendations: Priority for Action Immediate 1. State Demographic Cell and HMIS department to plan and conduct orientation/training of block and district level officials to improve data analysis and provision of appropriate feedback Successive 2. Conduct short programme reviews at district level annually before development of District PIPs 3. Reinstate statisticians at block level (g) Difficulty in monitoring neonatal care and PNC interventions Recommendations: Priority for Action Immediate 1. State to introduce Neonatal and PNC indicators in the monitoring system (h) No systematic evaluation plan for MNCH services in place Recommendations: Priority for Action Immediate 1. State to develop a systematic plan to periodically evaluate implementation of IMNCI, New born care and PNC interventions 28

45 Short programme Review (i) Limited data on Quality of care of MNCH services Recommendations: Priority for Action Immediate 1. State to assign responsibility to individual officials and programme managers of SPMU at State level for specific areas of child health programmes with regard to monitoring of progress, data collections, analysis and feedback. 2. Departments of Maternal and Child health and ICDS to periodically evaluate quality of care at health facilities and community level Successive 3. Develop/adapt tools to assess key elements of quality of care (facility infrastructure, case management process, satisfaction of beneficiaries) Group II. Human Resources, Training and Strengthening Health Systems Core problems and recommendations: (a) There is inadequate number of staff and expertise for maternal, newborn and child health Recommendations: Priority for Action Immediate 1. PHS to lead strengthening of Human Resource Development Strategy/policy (with adequate reflection of requirement forecasting, skills set mix required for MNCH, including policy for induction training development and transfers ) Successive 2. MD NRHM to get evaluation done of focus district approach and based on experience decide next steps. 29

46 Child Health in Rajasthan (b) Quality of training is not optimal Recommendations: Priority for Action Immediate 1. Director RCH to develop a procedure to get quality assurance of trainings conducted 2. Director RCH to lead development of comprehensive need based training strategy for MNCH and implementation plans by adopting the following approaches : Develop and maintain adequate pool of trainers. May have to look beyond traditional trainers and sharing trainers across programmes Successive Innovative training approaches such as distance learning, technology based trainings to be explored. Develop and maintain adequate number of appropriate training site for competency based trainings like IMNCI, SBA,EmOC etc. Innovative training approaches such as distance learning, information technology based trainings Ensure the prescribed clinical hands-on training (c) Pre-service training Recommendations: Priority for Action 1. Principal Secretary Medical Education to formulate a policy to strengthen pre-service education in medical and nursing institutions. Successive 2. Health Directorate to organize training of teaching staff in MNCH packages and develop implementation plans for teaching of the same in medical and nursing institutions 3. Develop a plan for introducing and implementing pre-service IMNCI. 30

47 Short programme Review (d) Shortage of drugs ; Mismatch between requirements and supply of drugs and consumables as per intervention packages Recommendations: Priority for Action Immediate 1. MD NRHM to lead Review of existing drug supply management to identify specific gaps and state specific solutions Successive 2. Develop and circulate guidelines on rational use of drugs (e) Poor supportive Supervision of MNCH services Recommendations: Priority for Action Immediate 1. MD NRHM to issue directives for urgent prioritization and integration of supportive supervision for MNCH services Successive 2. Director RCH to identify and train pool of supervisors in each block for integrated supportive supervision (f) Poor Maintenance of equipment Recommendations: Priority for Action Immediate 1. Director RCH to explore implementation of similar mechanisms as it is followed by immunization division for maintenance of equipments and apply lessons learned 31

48 Child Health in Rajasthan Group III. Health Communication / IEC and Development of Community Supports Core problems and recommendations: (a) No Comprehensive Communication Plan Recommendations: Priority for Action Successive 1. MD/ Director IEC to create a Task Force at the State level headed by a health communication professional (involving technical persons) to develop MNCH communication strategy and implementation plan 2. Identify a resource pool of health communication professionals at State and District Level to support and monitor implementation of plan (b) Improper media mix Recommendations: Priority for Action Immediate 1. Ensure provision of IEC materials as well as AV aids at facility level (CHC and 24X7 PHC level) 2. Strengthen relevant section on health communication in the state PIP with an activity plan including R and D with budget allocations. Successive 3. Explore and expand use of latest technologies, e.g. Mobile phones, Interactive voice response (IVR) system, rejuvenate use of Gramsat system; Video conferencing etc. 4. Ensure provision of operational guidelines for implementing and monitoring IEC activities. 32

49 Short programme Review (c) Poor quality of IEC materials Recommendations: Priority for Action Immediate 1. IEC Activities for child health focusing on the Key Messages Successive 2. Strengthen Skill up-gradation of State and District IEC coordinators on development of IEC materials 3. Consider outsourcing for IEC materials and skills development of staff (d) Poor communication skills of health and nutrition service providers Recommendations: Priority for Action Successive 1. Organize communication skills training programme for service providers in low coverage areas (e) Lack of monitoring and evaluation Recommendations: Priority for Action Successive 1. State Directorate to develop a plan of monitoring and evaluation for IEC. 2. State Directorate to develop a system of concurrent evaluation (may be outsourced) 33

50 Child Health in Rajasthan (f) Limited capacity of Village Health Sanitation Committee (VHSC) Recommendations: Priority for Action Immediate 1. Complete the ongoing training of VHSCs within one year followed by hand holding support through allocation of a set of villages to PHC level supervisors 2. Develop five model VHSCs per block. Explore role of NGOs to establish model VHSCs Successive 3. Develop a recognition mechanism and reward good performance for VHSC 4. Plan a Quarterly newsletter for VHSC with success stories from the field (g) VHSC not able to perform its functions like community monitoring and thematic community meetings Recommendations: Priority for Action Immediate 1. Capacity building of supervisors to be completed in the next six months Successive 2. The best practices of community monitoring to be explored and adopted for the state (h) Inadequate quality of training for ASHA and Jan Mangal Couple on MNCH issues Recommendations: Priority for Action Immediate 1. Expedite the process of training of ASHA on module 5 Successive 2. Develop database of Jan Mangal couples and complete trainings within an year 3. Develop a mechanism for QA of trainings 34

51 Short programme Review Core Group: Scaling up of existing interventions for Child Health Based on the discussion held within groups, the Core Review Group added the following recommendations regarding technical interventions for newborn and child health. The technical interventions were not covered in the theme-based group work. Recommendations: Priority for Action 1. Scale-up of IMNCI in all districts; Ensure supplies for IMNCI drugs at all levels Immediate 2. Rapid scale-up of F-IMNCI in high-focus districts on priority basis 3. Strengthening of community-based management of newborn and childhood illnesses through ASHA and Anganwadi Workers 4. Strengthening of infra-structure and services for Facility-based Newborn Care in high-focus districts (includes Special Care Newborn Unit, Neonatal Stabilization Unit and Newborn Care Corners) 35

52

53

54

55 ANNEXURES

56 Annexure I: Day wise summary of Steps completed Day Steps Summary of Activities 1 - Formal Inauguration , ,7 5-2 Plenary sessions were held. Prefilled worksheets 1 & 2 were discussed Goals and Objectives were reviewed with regard to Clarity, measurability and realism. Trend of Neonatal and Child Health Indicators of the State were reviewed to identify areas of poor performance, adequate / good performance and data gaps. Preparatory activity for Step 2 was completed Participants were allocated into three smaller groups Maternal, Newborn and Child. Worksheets 3 & 4 were customized. Participants were divided into three smaller groups: maternal, newborn and Child. Each group had its own facilitator and rapporteur. Worksheets 3 and 4 were discussed and reviewed. Small group discussions were followed by presentation of findings by respective rapporteurs in plenary sessions. Worksheet 5 was reviewed and discussed Participants continued in the three smaller groups : maternal, newborn and Child. Each group had its own facilitator and rapporteur. Each group identified respective Activity areas for intervention packages of relevance followed by assessing their status of implementation. The groups discussed and identified specific strengths and weaknesses for each activity area. Small group discussions were followed by presentation of findings by respective rapporteurs in plenary session to finalize the worksheet 5. This completed Step 3 Step 4 consisted of filling up the Worksheet 6 identifying the main problems faced by the program. Worksheet 6 was again completed working in small groups, and presented and discussed in the large group Reorganization of small groups. Worksheet 7 was completed based on the final list of problems. Each group had its own facilitator and rapporteur. Each group went sequentially taking one problem at a time, to identify the causes, suggest solutions and make action oriented feasible recommendations. GroupWise Worksheet 7 was presented in plenary and recommendations were finalized Discussion with key stakeholders on future steps for ensuring the incorporation of recommendations into the State PIP Presentation of findings before the representatives of the State Health Department Recording of feedback. Formal Thanksgiving and conclusion

57 Annexure II: Worksheet 1 Goals and Objectives of the Child Health Program Program Goal Maternal Health RCH II - Reduce Maternal mortality to 213 by 2010 (State PIP RCH II) - Reduce Maternal mortality to 148 by 2012 (State PIP RCH II & 11 th Five-year Plan) ICDS - To bring down anemia among women from current level to 40% by 2010 and 27% by 2012 Program Objectives State Program Implementation Plan To increase coverage with Antenatal Care to 80% in from the level of 60% in (State PIP ) (ICDS targets 100%) Increase coverage of administering 2 TT injections during Ante natal period from 80%( ) to 100% in Increase the proportion of pregnant women receiving IFA tablets from 30% ( )to 50% by 2011 Strengthening of IEC to increase awareness on these issues Increase delivery by skilled birth attendant (doctor, ANM, Nurse) from 80% ( ) to 100% by 2011 (State PIP ). Increasing institutional deliveries from 65% ( ) to 90% by 2011 through Janani Suraksha Yojana. (ICDS targets 100%) Increasing access to CEmOC by operationalizing FRUs Increasing access to postnatal care to 60% in to 80% in Urban RCH Program (brief note on urban RCH ) Achieving 80% ANCs for pregnant. Achieving 80% institutional deliveries

58 Newborn Health RCH II - Reduce Newborn Deaths - To reduce the percent of low birth weight babies by 10% by 2012 (from ICDS) State Program Implementation Plan Strengthening of tertiary level newborn care facilities at Medical Colleges Setting up 36 Level II Neonatal ICUs (FBNC Facility Based Newborn Care Centers) across the state at District Hospitals and all Medical Colleges. Setting up the level I care units called Newborn Stabilizing Units (NSUs) at each FRU to link & strengthen the referral from Home Based (IMNCI) / PHC to tertiary level Phased training of all Medical Officers at PHC/CHCs on basic newborn care and resuscitation under Navjat Shishu Suraksha Karyakram (NSSK) Child Health RCH II - Reduce Infant Mortality Rate to 37 by 2011 (State PIP RCH II ) - Reduce Infant Mortality Rate to 32 by 2012 (State PIP RCH II & 11th Five Year Plan) - Reduce the prevalence of malnutrition among children under 3 years to 25.3% by 2011 (11 th 5-year Plan) NVBDCP - Proportionate reduction in Malaria Mortality among under -five children by 50%. (State PIP NVDBCP ) Reducing NMR by providing immediate care at birth to every newborn through NSSK State Program Implementation Plan To increase coverage with complete immunization to 85 % by 2010 (State PIP ) (ICDS targets 90%) Complete coverage of IMNCI across the state with implementation in all districts except Chittorgarh as it is the control district (State PIP ) Improving access to clinical care among children with diarrhea, ARI and Childhood illness (90% by 2010) Increasing the proportion of ORS use among children with Diarrhoea (60% by 2010) Increasing the proportion of Children getting Vitamin A Supplementation (90% by 2010) To Increase IFA administration among children to at least 50% by 2010(State PIP ) Urban RCH Program (brief note on urban RCH ) Increase in the coverage of fully immunized children by 25% in 6 months of start of program and 50% by one year of start of service in the selected slum 100% immunization in the slum.

59 ICDS ICDS - To bring down percentage of severe and moderate malnutrition among 0 6 years of age to 10% and 15 % respectively by 2012 To promote exclusive breastfeeding and increase the number of mothers initiating early breastfeeding to 50% by 2010 and 75% by 2012 To increase the quality complementary feeding rate and feeding care to 45% by 2010 and to 75% by To reduce the prevalence of mild malnutrition among children 0 6 years to 20% by 2012 To ensure 100% coverage of children aged 6 months to 6 years for availing age appropriate supplementary nutrition To expand the availability of age appropriate micronutrient enriched RTE foods to the beneficiaries by up-scaling successful and cost effective interventions - To bring down anemia among children from current status to 60% by 2010 and 39% by 2012

60 Annexure III : Worksheet 2 Indicators of maternal, newborn and child health status Data Required Measures Back ground data (Year and source) Baseline data (year and source) Most recent data (year and source) Target Differences by region or group (highest/low est) Neonatal death rate 37.2 (P.136 NFHS-1 Rajasthan state report)* 49.5 (P. 122 NFHS-2 Rajasthan state report)** 43.9 (P.56 NFHS-3,( ) Rajasthan state) 43 (SRS Statistical Report -2008, P.79) Urban: 23 Rural: 48 (SRS Statistical Report -2008, P.79) X - Need to work signif - icantly Difference in rural and urban Neonatal deaths Neonatal mortality as a proportion of IMR and U5MR Neonatal mortality as a proportion of IMR :51.2% (Neonatal death rate-37.2/imr-72.6) Neonatal mortality as a proportion of UMR: 36.3% (Neonatal death rate-37.2/u5mr )* ** Neonatal mortality as a proportion of IMR : 61.6% (Neonatal death rate-49.5/imr-80.4) Neonatal mortality as a proportion of UMR: 43.1% (Neonatal death rate-49.5/u5mr ) Neonatal mortality as a proportion of IMR : 67.2% (Neonatal death rate- 43.9/IMR-65.3) Neonatal mortality as a proportion of UMR: 51.4% (Neonatal death rate- 43.9/U5MR-85.4) Causes of death No data No data No data -Data needed -Need to work significantly

61 Data Required Measures Back ground data (Year and source) Baseline data (year and source) Most recent data (year and source) Target Differences by region or group (highest/low est) Maternal deaths Maternal mortality ratio 670 /1,00,000 live births P. A-68 FWS-2009 (Data represents for the year ) 501/1,00,000 live births P. A-68 FWS-2009 (Data represents for the year ) 388/1,00,000 live births P. A-68 FWS (Data represents for the year ( By (State PIP RCH II) (By (State PIP RCH II in accordanc e with XI FYP) Trends are downwards, sustain efforts Causes of death Hemorrhage :37.0% Sepsis:11.0% Abortion: 10.0% Obstructed labour & Hypertensive disorder: 9.0% (SRS, 2009) Low birth weight Prevalence of low birth weight 21.9 % (RCH-RHS, P. 54,India report) (Data represents Rajasthan) 28.3% ICDS-state PIP IV, ,P.81 (Data represents Base line survey-2000) 27.5% (NFHS-3, ,P.226, India report) (Data represents Rajasthan state) X Static

62 Data Required Measures Back ground data (Year and source) Baseline data (year and source) Most recent data (year and source) Target Differences by region or group (highest/low est) Infant mortality rate 72.6 (NFHS-1, ,P. 136, Rajasthan report)* 80.4 (NFHS-2, , P. 122, Rajasthan report)** 65.3 (NFHS-3, , P. 56,Rajasthan report) 63 - (SRS- 2009) By (State PIP RCH II ) By (State PIP RCH II in accordance with XI FYP) Urban: 66.0 Rural: 65.1 SRS Urban 39 Rural 68 Differences across different regions Decline not sufficient to reach goals Infant deaths Infant mortality as a proportion of all child mortality 70.8 % (Infant deaths-72.6/u5mr-102.6)* 70% (Infant deaths-80.4/u5mr-114.9)** 76.5% (Infant deaths- 65.3/U5MR-85.4) Causes of death Pneumonia: 25.8% Diarrhoea: 14.5% Severe Malnutrition: 19.4% Rashes/Fever: 16.1% Prematurely/LBW:12.9% Asphyxia: 9.7% Birth injury: 1.6% Congenital anomalies:0.0 (Data represents for the year of 1980) (Health and Population: Perspectives and Issues Vol. 32 (2), , Changes in IMR in Rajasthan over 25 years-2009) Perinatal conditions:42.9% Respiratory infections:24.5% Diarrheal diseases: 10.4% Other infectious and parasitic diseases: 10.3% Malaria: 1.3% Nutritional deficiencies: 2.3% Symptoms signs and illdefined conditions: 2.7% Unintentional injuries- Other:1.2% Congenital anomalies:1.9% Fever of unknown origin: 0.7% (Report on Causes of death in India, ,P.26) (Data of EAG states) Pneumonia: 27.8% Diarrhoea: 8.3% Severe Malnutrition: 8.3% Rashes/Fever: 5.6% Prematurely/LBW: 19.4% Asphyxia: 19.4% Birth injury: 5.6% Congenital anomalies: 5.6% (Health and Population: Perspectives and Issues Vol. 32 (2), , Changes in IMR in Rajasthan over 25 years- 2009)

63 Data Required Measures Back Ground Baseline data (year and source) Most recent data (year and source) Target Differences by region or group (highest/lowe st) Child deaths Under 5 mortality rate Causes of death (NFHS-1, , P. 136 Rajasthan report) (NFHS-2, P. 120, Rajasthan report) 85.4 (NFHS-3, P. 56,Rajasthan report) Perinatal conditions: 29.9% Respiratory infections:24.4% Diarrheal diseases:14.8% Other infectious and parasitic diseases:12.3% Malaria: 3.3% Nutritional deficiencies:3.1% Ill-defined conditions:2.6% Unintentional injuries:2.6% Congenital anomalies:1.6% Fever of unknown origin:1.3% (Report on Causes of death in India, ,P.26) (Data of EAG states) 80 (SRS-Statistical Report 2008,P.84) 34.2 MDG Goal Urban: 49 Rural: 88 Male: 72 Female:88 (SRS- Statistical Report 2008,P.84) Decline not sufficient to achieve MDG

64 Data Required Measures Back ground data (Year and source) Baseline data (year and source) Most recent data (year and source) Target Differences by region or group (highest/lowest) Child morbidity Prevalence of childhood illnesses: pneumonia, diarrhea, malaria (fever), measles (2 week prevalence) Prevalence of HIV among children who are tested Pneumonia/A RI: 21.2% Diarrhea: 33.1% (RCH-RHS ,P.52,Rajast han report) Fever: 10.7% (NFHS- 1, ,P.168,Rajas than report) Pneumonia/A RI: 13.2% Diarrhea: 15.9% (DLHS- 2, ,P.106,Rajas than report) Fever: % (NFHS- 2, ,P.140,Rajas than report) Fever: 11.9% (NFHS-3, ,P.68,Rajasthan report) Pneumonia/AR I: 7.7% Diarrhea: 8.4% (DLHS- 3, ,P.92,Rajast han report) No data No data No data ARI Rural: 7.9% Urban: 6.6% Lowest: 0.8% (Barmer) Highest: 18.9%(Bharatp ur) (DLHS-3, ,P.92,Rajasth an report) Diarrhea 8.5% 7.7% Lowest: 0.5% (Hanuman garh) Highest: 25.3% (Bharatpur) (DLHS-3, ,P.92,Rajasth an report) No targets available.

65 Data Required Under nutrition Measures Prevalence of low weight for height (zscore -2 or less) Prevalence of low height for age (z-score - 2 or less) Back ground data (Year and source) 19.5% (NFHS- 1, ,P.186, Rajasthan report) 22.5% 16.2% (NFHS- 3, ,P.76, Rajasthan report) Data represents NFHS % (NFHS- 1, ,P.186, Rajasthan report) 59.0% (NFHS- 3, ,P.76, Rajasthan report)data represents NFHS-2 Baseline data (year and source) (NFHS-3, ,P.76, Rajasthan report) 40.1% (NFHS-3, ,P.76, Rajasthan report) Most recent data (year and source) Target Differences by region or group (highest/lowest) Urban: 20.8% Rural: 20.3% Male: 20.8% Female: 20.1% SC: 22.0% ST: 27.8% OBC: 16.0% Others: 23.8% (NFHS-3, ,P.75, Rajasthan) Urban: 33.9% Rural: 46.3% Male: 44.3% Female:43.1% SC: 48.2% ST:48.8% OBC:42.5% Others:37.3% (NFHS-3, ,P.75, Rajasthan report) Shows increase in wasting Marginal decline in Stunting

66 Data Required Measures Back ground data (Year and source) 41.6% Baseline data (year and source) Most recent data (year and source) Target Differences by region or group (highest/lowest) Urban: 30.1% Rural:42.5% Under nutrition Micronutrient deficiencies Prevalence of low weight for age (z-score -2 or less) Prevalence of xerophthalm ia Prevalence of low serum retinol Prevalence of anemia (Hb 10g/dl) (NFHS-1, , P.186, Rajasthan report) 46.7% (NFHS-3, ,P.76, Rajasthan report) Data represents NFHS % (NFHS-3, ,P.76, Rajasthan report) 20% (ICDS) find out the source Male: 40.3% Female:39.5% SC: 44.5% ST:46.8% OBC:36.7% Others:37.1% (NFHS-3, ,P.75, Rajasthan report) Marginal decline in underweight No data No data No data Need to collect information No data No data No data 82.3% (NFHS- 2, ,P.175, Rajasthan report) 79.9% (NFHS-3, ,P.82,Rajasthan report) 27% (2012) Urban: 62.9 % Rural: 71.4% Male: 69.9% Female:69.3% (NFHS-3, ,P.81, Rajasthan) Insufficient decline

67 Summary of Worksheet 2 Health impact indicators Health status indicators - program is doing enough now Maternal Mortality: Trends are downwards, sustain efforts Under nutrition: Marginal decline in Stunting and Underweight Health status indicators - program needs to do more Neonatal Mortality: Need to work significantly. Difference in rural and urban Infant Mortality Rate: The declining rate is not sufficient to reach the MD Goals U5 Mortality: Declining rate is not sufficient to reach the MD Goals. Child Morbidity: There are no targets Under nutrition: Shows increase in wasting Prevalence of Anaemia: Insufficient decline.

68 Annexure IV: Worksheet 3 Child health interventions and how they are delivered PREGNANCY Interventions Included in program? Tick if yes Level at which intervention is delivered Tick levels Home and Communit y First level facility Referral facility Implemented in a training package with 1 or more other interventions? specify package (s) Implemented in all areas or selected areas - specify Tetanus toxoid immunization Birth and emergency planning Detection of problems complicating pregnancy (e.g. hypertensive disorders, bleeding, anaemia) Management of problems complicating pregnancy (e.g. hypertensive disorders, bleeding, malpresentations, multiple pregnancy, anaemia) ANC All ANC All ANC 24X7 PHC BEmOC, CEmOC All Detection and treatment of RTI/STI All syphilis (RTI/STI) Intermittent prophylactic treatment for malaria Information and counseling on self-care, nutrition, safer ASHA sex, breastfeeding, family All planning Insecticide treated bed nets Prevention of mother to PPTCT child transmission of HIV (RSACS) Selected All DH and Other : (specify) Blood CEmOC Functional Storage FRU Other : (specify) Anemia Prophylaxis ANC All Other: (specify)

69 BIRTH AND IMMEDIATE POST-NATAL PERIOD Interventions Included in program? Tick if yes Implemented at which levels? Tick levels Home and Community First level facility Referra l facility Implemented in a training package with 1 or more other interventions? specify package (s) Implemented in all areas or selected areas? - specify Monitoring progress of labour, maternal and foetal well being with partograph Active management of the third stage of labour Social support (companion) during birth Immediate newborn care (Resuscitation if required, Thermal care, Hygienic cord care, Early initiation of breastfeeding) Emergency obstetric and neonatal care for complications 24X7 Safe delivery package Safe delivery package Safe delivery package Yashoda ENC NSSK BEmOC NSSK All All All YASHODA Being expanded to all districts All All Antibiotics for preterm premature rupture of membranes Antenatal corticosteroids for preterm labour Prevention of mother to child transmission of HIV Other : (specify) Blood transfusion BEmOC All PPTCT CEmOC Selected districts (10) MC Colleges and DH DH, Functional FRU Other : (specify) Other : (specify)

70 NEWBORN PERIOD Interventions Included in program? Tick if yes Level at which intervention is delivered Tick levels Implemented in a training package with 1 or more other interventions? specify package (s) Implemented in all areas or selected areas specify Exclusive breastfeeding Thermal care Hygienic cord care Prompt care seeking for illness Extra care of LBW infants Management of newborn illness Home and Community First level facility Referra l facility IMNCI* Yashoda* HBPNC* ICDS NSSK Yashoda* IMNCI* HBPNC* NSSK Yashoda* IMNCI* HBPNC* IMNCI* ASHA HBPNC* Yashoda* FBNC* Yashoda* IMNCI* HBPNC* IMNCI* NSSK FBNC* All (IMNCI/ Yashoda) HBPNC : NIPI focus districts * * * * * Prevention of mother to child transmission of HIV Other : (specify) Early initiation of breast feeding Other : (specify) Referral transport Other : (specify) Immunization PPTCT* * IMNCI* Yashoda* HBPNC* ASHA Untied Funds HBPNC Routine Immunization IMNCI/ASHA * * *

71 INFANTS AND CHILDREN Interventions Exclusive breastfeeding (<6 months) Safe and appropriate complementary feeding with continued breastfeeding (at least up to 2 years) Name of Package Level at which intervention is delivered Tick levels Implemented in package with 1 or more other interventions? specify package (s) Implemented in all areas or selected areas - specify Home and Community First level facility Referral facility Preventive interventions IMNCI 9 districts almost saturated; 24 districts have % coverage Facility Based Care Counseling (Yashoda, IMNCI) Yashoda (27 DH + 42 CHCs) and IMNCI-9 Districts; 40% coverage PNC Rolled out in 3 districts with almost saturation; 9 districts (IMNCI) ; One third districts covered ICDS (Health Education/MC HN Sessions) ICDS (Health Education/MC HN Sessions) Universal Coverage Universal Coverage IMNCI 9 districts almost saturated; 24 districts have % coverage IYCF IYCF not yet implemented Insecticide treated nets Immunization (BCG, Hepatitis B, DPT, OPV, Measles, Hib) Routine Immunizatio n (BCG, DPT, OPV, RI All Districts

72 Interventions Name of Package Level at which intervention is delivered Tick levels Implemented in package with 1 or more other interventions? specify package (s) Implemented in all areas or selected areas - specify Measles) Hepatitis B Hepatitis B only in Jaipur Urban Hib Hib not in the RI package Vitamin A supplementation Routine Immunizatio n Up to 9 months All ICDS Monthly drive twice a year All Water, sanitation, hygiene VHSC VHSC All Primary Health Care (Water Chlorination) Safe Water (PHED) All All Birth spacing by > 24 months Total Sanitation Campaign Family Planning Package (Jan Mangal Scheme) Limited coordination between Health and TSC Other : (specify)

73 INFANTS AND CHILDREN Interventions Oral rehydration therapy for diarrhea Zinc for diarrhea Antibiotics for dysentery Antibiotics for pneumonia Antimalarials Management of severe malnutrition Name of Package Level at which intervention is delivered Tick levels Home and Community First level facility Referral facility Implemented in a training package with 1 or more other interventions? specify package (s) Implemented in all areas or selected areas specify Treatment interventions IMNCI 9 districts almost saturated; 24 districts have % coverage IMNCI 9 districts almost saturated; 24 districts have % coverage IMNCI districts almost saturated; 24 districts have % coverage - IMNCI 9 districts almost saturated; 24 districts have % coverage National Anti Malaria Program MTC ICDS Management of HIVexposed/infected children Other : Anaemia PPTCT All Primary Health Care Other : De-worming Primary Health Care

74 Annexure V : Worksheet 4 Period Intervention Coverage measure Back ground (year and source) Baseline data (year and source) Most recent data (year and source) Target Differences by region or group (highest/lowest) Pregnancy Adequate antenatal care Tetanus Toxoid to all pregnant women Proportion of mothers who received at least 4 ANC visits Available data is for 3 visits Proportion of mothers who received TT2+ during pregnancy Proportion of newborns protected at birth 28.3% (RCH- RHS , Rajasthan report P.32) (>3 visits) 28.3 % (NFHS ,P.154,Rajasthan report) 20.5 % (DLHS-2, , P.61,Rajasthan report) 59.1 % (DLHS-2, , P.61, Rajasthan report) 27.6% No data No data No data (DLHS-3, , P.65 Rajasthan report) 55.2 % (UNICEF- Coverage Evaluation Survey- 2009, National fact sheet) 50.9 % (DLHS-3, , P. 66, Rajasthan report) 80% in (State PIP ) Rural: 23.3 % Urban: 48.0% (DLHS-3, P.65 Rajasthan report) SC: 22.4% ST :19.4% OBC: 27.8% Others: 40.8% (DLHS-3, P.65 Rajasthan report) Highest: 48.4% (Ajmer) Lowest: 7.7% (Dhaulpur) (DLHS-3, P.67 Rajasthan report) 100% Rural: 47.2% Urban: 68.1% (DLHS-3, , P. 66, Rajasthan report) SC: 45.0% ST : 43.0% OBC: 51.6% Others: 63.0% (DLHS-3, , P. 66, Rajasthan report) Highest: 76.8 % (wealth index) Lowest: 38.2% DLHS-3, , P. 66, Rajasthan report) X X

75 Period Intervention Coverage measure Back ground (year and source) Baseline data (year and source) Most recent data (year and source) Target Differences by region or group (highest/lowest) Iron supplementatio n Proportion of mothers women who received iron during pregnancy 29.2 % (NFHS , P.154 Rajasthan report) 39.3 % (NFHS-2, ,P.190, Rajasthan report) 57.7% (NFHS -3, , P.61, Rajasthan report ) 53.7% (DLHS-3, ,P.67, Rajasthan report) Rural: 53.1% Urban: 73.9% (NFHS -3, , P.61,Rajasthan report) SC: 56.8% ST : 54.6% OBC: 56.9% Others: 63.0% Highest: 77.7 % (Bharatpur) Lowest: 32.0% (Pali) (DLHS-3, ,P.67, Rajasthan report) + Trends are good with Disparities Labour and delivery Malaria prevention Voluntary counselling and testing for HIV and PMTCT All deliveries by a skilled birth attendant Proportion of pregnant women who slept under an ITN the previous night Proportion of HIV + mothers who received ART prophylaxis Proportion of deliveries by skilled birth attendants No data No data No data Not introduced in Rajasthan No data No data No data RSACS to be contacted 22.6% (NFHS-1, , P.65, Rajasthan report) 35.8 % (NFHS-2, , P.196, Rajasthan report) 43.2% (NFHS-3, ,P.65, Rajasthan report) 80% ( ) to 100% by 2011 (State PIP ). Rural: 32.5% Urban: 74.2% (NFHS-3, ,P.64, Rajasthan report) SC: 34.2% ST : 29.6% OBC: 43.5% Others: 52.9% (NFHS-3, ,P.64, Rajasthan report) + Trends are good Not likely to meet targets Disparities

76 Period Intervention Coverage measure Back ground (year and source) Baseline data (year and source) Most recent data (year and source) Target Differences by region or group (highest/lowest) Labour and delivery All deliveries by a skilled birth attendant Percentage of safe deliveries 33.5% (RCH-RHS , P. 30,Rajasthan report 44.4% (DLHS-2, , P.72, Rajasthan report) 52.6 % (DLHS-3, , P.68, Rajasthan report) Rural: 48.1% Urban: 73.5% (DLHS-3, , P.68, Rajasthan report) SC: 47.0% ST :44.3% OBC: 52.8% Others: 66.2% Highest: 69.4% (Sikar) Lowest: 30.6 %(Barmer ) (DLHS-3, , P.68, Raj report) Identification and treatment of maternal emergencies such as eclampsia and obstructed labour Proportion of home births/ proportion of institutional births Proportion of rural pregnancies having a C- section Home births: 77.2% Inst. Births: 22.5% (RCH-RHS ,P. 30, Rajasthan report) 0.3% (Rural) (NFHS-1, , P.159, Rajasthan report) Home Births: 68.0% Inst. Births: 31.4% (DLHS-2, , P.70, Rajasthan report) 2.1% (Rural) (NFHS-2, , P.197,Rajasthan report) Home births: 53.8% Institutional Births: 45.4% (DLHS-3, P. 68,Rajasthan report) 70% institutional delivery (UNICEF-Coverage evaluation survey- 2009) 2.2% (Rural) (NFHS-3, , P.63, Rajasthan report) 90% by 2011 through Janani Suraksha Yojana. Home Institution + Rural:58.5% Urban: 32.0% SC: 59.5% ST : 59.3% OBC: 54.3% Others:40.9% Highest: 78.7 %(Barmer) Lowest : 34.1% ( Kota) (DLHS-3, P. 70, Raj report) Total: 3.8% Urban :9.9% Rural : 2.2% 40.6% 67.5% 39.6% 39.9% 44.8% 58.5% 65.0% (Kota) 21.3 % (Barmer) (DLHS- 3, P. 70, Raj report) (NFHS-3, , P.63, Rajasthan report) Trends are good Not likely to meet targets Disparities X

77 Period Intervention Coverage measure Back ground (Year and Source) Baseline data (year and source) Most recent data (year and source) Target Differences by region or group (highest/lowest) Immediately after birth Prevention of hypothermia Appropriate cord care and hygiene Proportion of babies who were dried, wrapped (and not bathed) immediately after birth Proportion of babies who had the cord cut with a clean instrument Data not available Data not available 34.2 % (Data represents for deliveries held at Home) (NFHS-3, , P.63,Rajasthan report) Data not available Data not available 89.5% (Data represents for deliveries held at Home) Urban : 40.5% Rural : 33.4 % (NFHS-3, , P.63, Rajasthan report) Urban : 93.7% Rural : 89.0% (NFHS-3, , P.63, Rajasthan report) (NFHS-3, , P.63,Rajasthan report)

78 Period Intervention Coverage measure Back ground (Year and Source) Baseline data (year and source) Most recent data (year and source) Target Differences by region or group (highest/lowest) Immediate initiation of breastfeeding Proportion of mothers who initiated BF within 1 hour of birth 15.8% (within two hours) (RCH-RHS , P. 43, Rajasthan report) 7.9% (NFHS-1, , P.178, Rajasthan report 14.5 % (within two hours) (DLHS-2, ,P.88, Rajasthan report) 14.1% NFHS 3 Rajasthan report 41.4 % (DLHS-3, P.82, Rajasthan report) 27.7% (UNICEF-Coverage evaluation survey- 2009) 60% by SPIP Rural: 39.6% Urban: 49.5% (DLHS-3, P.82, Rajasthan report) SC: 38.7% ST: 39.2% OBC: 41.6% Other: 45.6% (DLHS-3, P.82, Rajasthan report Lowest: 24.2 % (Jaisalmer) Highest: 54.8% ( Bundi) (DLHS-3, P.84, Rajasthan report) Proportion of babies who received a prelacteal feed Data not available Data not available 71.6% (NFHS-3, ,P. 77, Rajasthan report) Rural: 74.7% Urban: 60.5% (NFHS-3, ,P. 77, Rajasthan report) SC: 71.6% ST:78.3% OBC:70.9% Other: 67.5% (NFHS-3, ,P. 77, Rajasthan report)

79 Period Intervention Coverage measure Back ground (Year and Source) Baseline data (year and source) Most recent data (year and source) Target Differences by region or group (highest/lowest) Postnatal / neonatal period Postnatal care visit Proportion of mothers/newborns who had a care contact in the first 2 days after delivery 7.7% (NFHS-2, ,P.199, Rajasthan report 32% (NFHS 3, , Rajasthan report, P. 63) 37.3% (DLHS-3, ,P. 74, Rajasthan report ) 80% in SPIP Rural: 33.1% Urban: 56.9% Immuni-zation 0 dose OPV/BCG No data 0 dose OPV 33.8% (DLHS-2) Exclusive breastfeeding Proportion of mothers who did not give anything other than breast milk in the first 3 days after birth Proportion of infants 0-28 days who are exclusively breastfed No data No data No data No data No data No data 0 dose- OPV 33.1% (DLHS -3, , P.85) 0 dose OPV 40% (HMIS ) SC: 31.0% ST: 33.0% OBC: 36.4% Other: 50.7% (DLHS-3, ,P. 74, Rajasthan report )

80 Period Intervention Coverage measure Back ground (Year and Source) Infants and children Exclusive breastfeeding Appro-priate complimentary feeding Micro-nutrient supplementation Proportion of infants under 6 months exclusively BF Proportion of infants 6-9 months who receive appropriate BF and complimentary feeding Proportion of children who received a dose of vitamin A in the previous 6 m Proportion of children who received a dose of vitamin A Proportion of children living in HH that use iodised salt (>15 ppm) 57 % (Computed based on NFHS-1 data Rajasthan report (P.180,Table 10.2) 47.8% NFHS-1 Computed based on NFHS-1 data, Rajasthan report (pg.180,table 10.2) Baseline data (year and source) 33.2% (NFHS-3, , P.78, Rajasthan report ) 17.5% (NFHS-2, ,P.265,India report) (Data represents Rajasthan state) Most recent data (year and source) 65.4% (DLHS-3, ,P.83, Rajasthan report) 34.9% (UNICEF-CES- 2009) 43.7% (DLHS-3, , P. 83,Rajasthan report) 49% (UNICEF-CES 2009) No data No data 57.2 % (UNICEF-Coverage evaluation survey- 2009) 22.2% (RCH-RHS ,P.47, Rajasthan report) 22.4% (DLHS-2, ,P.99, Rajasthan report) No data 35.1% ( NFHS-3, ,P. 83 Rajasthan report) 52.5% (DLHS-3, ,P.88, Rajasthan report) 60.5 % (UNICEF-Coverage evaluation survey- 2009) 58% (UNICEF-Coverage evaluation survey- 2009) Target 90% by (Chapter 23 XI Five Year Plan Rajasthan p 23.3) Differences by region or group (highest/lowest) Rural: 65.0% Urban: 67.1% SC: 63.4% ST: 67.3% OBC: 66.1% Other: 63.3% (DLHS-3, ,P.83, Raj report) Rural: 50.5% Urban: 61.7% Male: 54.3% Female: 50.4% (DLHS-3, ,P.88, Rajasthan report) Lowest: 20.1% (Bharatpur) Highest: 93.3% ( Dungarpur) Urban: 65.1% Rural: 27.3% SC: 28.0% ST: 31.7% OBC:32.7% Other: 52.9% ( NFHS-3, ,P. 83 Rajasthan report)

81 Period Intervention Coverage measure Back ground (Year and Source) Immunization against vaccine prevent-able diseases Prevention of malaria Antimalarial treatment for malaria Care seeking for pneumonia Proportion of children months of age vaccinated against measles before 12 months Percentage of children aged months who received Measles vaccine Proportion of children who slept under an ITN the previous night Proportion of children with fever who received appropriate antimalarials Proportion of children with suspected pneumonia taken to appropriate provider Proportion of children suffered from / symptoms of ARI Baseline data (year and source) No data No data No data 42.3% (RCH-RHS ,P.47, Rajasthan report ) No data 13.9% (NFHS-1, , P.171, Rajasthan report ) No data 21.2% (RCH-RHS ,P.52, Rajasthan report ) 35.9% (DLHS-2, ,P.99,Rajasthan report) No data No data 64.7% (NFHS-3, ,P.68,Rajasthan report) 13.4% (DLHS-2, ,P.105, Rajasthan report) Most recent data (year and source) 67.3% (DLHS-3, ,P.85 Rajasthan report) 65.6% (UNICEF-Coverage evaluation survey- 2009) No data 9.0% (NFHS-3, ,P. 68 Rajasthan report) 89.9% (UNICEF-Coverage evaluation survey- 2009) 7.7 % ( DLHS-3, ,P.91, Rajasthan report) Target 80 % by 2010 (State PIP ) 90% access by 2010 ( State PIP ) Differences by region or group (highest/lowest) Rural: 65.5% Urban: 75.7% (DLHS-3, ,P.85 Rajasthan report) SC: 64.2% ST: 64.6% OBC: 66.5% Other:76.8% (DLHS-3, ,P.85 Rajasthan report) Male: 70.0% Female : 64.3% (DLHS-3, ,P.85 Rajasthan report) Lowest: 39.9%( Bharatpur) Highest: 93.6%(Dungarpur) (DLHS-3, ,P.86 Rajasthan report) Urban: 7.4% Rural: 9.5% SC: 6.5% ST: 11.2% OBC: 10.4% Other: 5.4% Male: 8.8% Female : 9.2% (NFHS-3, ,P. 68 Rajasthan report) Urban: 71.9% Rural: 62.9% Male: 66.6% Female :61.8% (NFHS-3, ,P. 68 Rajasthan report) Rural: 7.9% Urban: 6.6% SC: 7.9% ST: 7.4% OBC: 7.8% Other: 7.5% Lowest: 0.8% ( Barmer) Highest: 18.9% (Bharatpur)

82 Period Intervention Coverage measure Antibiotic treatment for suspected pneumonia Oral rehydration for diarrhea Use of zinc for the treatment of diarrhea Proportion of children sought advice / treatment Proportion of children with suspected pneumonia who received appropriate antibiotics Proportion of children with diarrhea who received ORT Proportion of children with diarrhea who received ORT and a course of zinc Back ground (Year and Source) 35.2% (RCH-RHS ,P.52,Rajasthan report) Baseline data (year and source) 70.5% (DLHS-2, ,P.105,Rajasthan report) Most recent data (year and source) 75.7% (DLHS-3, ,P.91,Rajasthan report) No data No data 18.2% (NFHS-3, ,P.68,Rajasthan report) 4.7% (RCH-RHS ,P.52,Rajasthan report) 29.4% (DLHS-2, ,P.102,Rajasthan report) No data No data No data 30.6% (DLHS-3, ,P.90,Rajasthan report) 45% (UNICEF-Coverage evaluation survey- 2009) Target increase to 60% by 2010,ensuri ng 100% availability of ORS at sub centre level.(spip ) Differences by region or group (highest/lowest) Rural: 73.7% Urban: 86.5% SC: 70.1 % ST: 72.6% OBC: 77.2% Other: 80.8% (DLHS-3, ,P.91,Rajasthan report) Lowest: 62.2% (Dhaulpur) Highest: 100%(Hanumangarh) (DLHS-3, ,P.92,Rajasthan report) Urban: 12.5% Rural: 19.6% (NFHS-3, ,P.68,Rajasthan report) Male:20.6 % Female: 14.3% (NFHS-3, ,P.68,Rajasthan report) Urban: 52.7% Rural: 26.5% SC: 25.9% ST: 26.7% OBC: 31.0% Other: 40.3% (DLHS-3, ,P.90,Rajasthan report)

83 Summary of Worksheet 4 Coverage Indicators Coverage indicators - programme is doing enough now Iron supplementation: Proportion of mothers women who received iron during pregnancy Appropriate cord care and hygiene: Proportion of babies who had the cord cut with a clean instrument Postnatal care visit: Proportion of mothers/newborns who had a care contact in the first 2 days after delivery Proportion of children living in HH that use iodised salt (>15 ppm) Case seeking for pneumonia: Proportion of children with suspected pneumonia taken to appropriate provider Coverage indicators trends are positive, but programme needs to do more Proportion of Institution deliveries. Proportion of babies who were dried, wrapped (and not bathed) immediately after birth Appropriate complimentary feeding: Proportion of infants 6-9 months who receive appropriate BF and complimentary feeding Proportion of mothers who initiated BF within 1 hour of birth Proportion of babies who received a pre-lacteal feed Proportion of mothers who did not give anything other than breast milk in the first 3 days after birth Proportion of infants 0-28 days who are exclusively breastfed Oral rehydration for diarrhea: Proportion of children with diarrhea who received ORT Coverage indicators major issues; programme needs to do more Adequate antenatal care: Proportion of mothers who received at least 4 ANC visits Tetanus Toxoid to all pregnant women: Proportion of mothers who received TT2+ during pregnancy Identification and treatment of maternal emergencies such as eclampsia and obstructed labour: Proportion of rural pregnancies having a C-section Prevention of hypothermia: Proportion of babies who were dried, wrapped (and not bathed) immediately after birth Immediate initiation of breastfeeding: Proportion of mothers who initiated BF within 1 hour of birth; Proportion of babies who received a pre-lacteal feed Exclusive breastfeeding: Proportion of infants under 6 months exclusively BF Immunization 0 dose OPV; Percentage of children aged months who received Measles vaccine Micronutrient supplementation: Proportion of children who received a dose of vitamin A Antimalarial treatment: Proportion of children with fever who received appropriate antimalarials Coverage indicators - Adequate data not available Malaria prevention: Proportion of pregnant women who slept under an ITN the previous night Voluntary counseling and testing for HIV and PMTCT: Proportion of HIV + mothers who received ART prophylaxis

84 Annexure VI : Worksheet 5 Review how well the programme implemented activities Pregnancy Birth and Immediate Post-natal period Neonatal period Infants and children 1-59 months INTERVENTION PACKAGES BEING DELIVERED: ANC, SBA, EmOC, PNC Activity area Status of implementation Reasons for observed implementation Strengths Weaknesses (fully, partly or not at all) Performance Policies, planning and management Practice standards and guidelines updated and being used Essential drug list available Budgeted plans developed annually at the state and district levels Planning done collaboratively with other divisions and with donors Annual budget adequate to complete all activities in the last plan Fully met Fully met Partly met Fully Partly -Disseminated through regular mechanisms -Monitored whether put into practice -Disseminated through regular mechanisms -EDL gets revised with the revision of guidelines Planning units exist at district and state level Technical support from the donor partners Inadequate funds for civil works and medicine procurement System and mechanisms in place - up to block level -Monthly meetings of staff -Posted on website -Supplied with regularly provided kits District plans are supposed to contribute to state plan Exec Committees exist and meet Awareness at field level is limited -No individual memory among staff -Not displayed in health facilities District plans are not developed in time The final call is taken by the state, so some suggestions from donors not -Proposed state budget is slashed down by the National government - State is not able to generate funds to cover the shortfall

85 Supporting data: policy and planning Indicator Current status Policies for exemption of pregnant women, newborns and children from health charges available and implemented Y N Rs 2 for registration CRC reporting mechanism established and working Y N (Rajasthan third draft report on convention on rights of child suggests focused attention on needs of children at policy and programme level- Source: p.8 Child Policy Rajasthan 2009) Costed national plan for ensuring universal access to newborn and child survival interventions available Y N Mechanism for monitoring the International Code for Marketing of Breast milk substitutes working Laws and policies on vital registration adopted Y N Y N National child health strategy endorsed and costed % of districts implementing intervention package 100% Y N % of proposed child health budget received on time in the previous year Info to be collected

86 Review how well the programme implemented activities Pregnancy Birth and Immediate Post-natal period Neonatal period Infants and children 1-59 months INTERVENTION PACKAGES BEING DELIVERED: ANC, SBA, EmOC, PNC Activity area Status of implementa tion (fully, partly or not at all) Human resources/training in-service Plan to ensure adequate Partly staffing at each level, which includes incentives In-service training Fully met strategy available In-service training conducted for health staff Partly met LSAS: 28 / 72 completed Reasons for observed implementation Performance Inadequate financial resources to hire Training cell in the ministry Targets partly met Strengths Contractual hiring Rural health cadre Training institute is autonomous State health resource centre Weaknesses Non availability of specialists Attrition rates among contractual staff Postponements Non compliance by identified candidates (MOs) -Trainer capacity is limited -Training sites not adequate Trained staff is transferred In-service facilitators trained Follow-up after inservice training conducted Partly Partly Policy and mechanism for SBA and BEmOC exists Adequate numbers available Clear guidelines for SBA F-up training Utilization of facilitators needs to be rationalized Capacity is limited Quality of in-service training are: types of staff trained, materials used, time allocated, amount of clinical practice adequate? Partly State monitoring cell monitoring quality of training created -SIHFW provides supervisory checks CEmOC: certification delayed

87 Worksheet 5: Review how well the programme implemented activities Pregnancy Birth and Immediate Post-natal period Neonatal period Infants and children 1-59 months INTERVENTION PACKAGES BEING DELIVERED: ANC, SBA, EmOC, PNC Activity area Status of implementation Reasons for observed implementation Strengths Weaknesses (fully, partly or not at all) Performance Human resources/training pre-service Pre-service training strategy available Pre-service training incorporated into curriculae of medical and other schools Pre-service trainers trained Quality of preservice training materials used (including textbooks), time allocated, amount of clinical practice adequate? No Knowledge and skills are covered in normal curriculum No N/A Supporting data: human resources/ training Need to reorient medical nursing education to the needs of national programmes Indicator Baseline data (year and source) Most recent data (year and source) Target Differences by region or group (highest/lowest) % of health staff who have received training in intervention package SBA 53 MO 136(PHN/NT/SN)* up to (P.7, PIP ) 1236ANM/SN/LV up to % ANMs trained in SBA % up to (P.20, ROP ) 57.9 % for (P.20 ROP )

88 Indicator Baseline data (year and source) Most recent data (year and source) Target Differences by region or group (highest/lowest) Doctors trained in EmOC (numbers) 49 up to (P.20, ROP ) Doctors trained in LSAS 117 up to (P.20 ROP ) 89 for (P.20 ROP ) 189 for (P.20 ROP 10-11) % of planned trainings completed in the previous year % of health facilities with at least 60% of health workers caring for children, newborns or pregnant women trained in training package % of all trained staff who receive follow-up visit within 3 months of training % of medical/nursing/midwifery training schools that have incorporated focus intervention or package= % of mothers who receive ANC/PNC from a skilled provider 3 or more ANC Checkups 28.8% (DLHS-2, ) P.4 DLHS-3 Rajasthan Fact sheet) 41.2 % (NFHS-3, ) 27.7% (DLHS-3, ) P.4 DLHS-3 Rajasthan Fact sheet) 80% (P.4 RCH chapter PIP ) Rural: 23.3 % Urban: 48.1% (P.4 DLHS-3, Rajasthan Fact sheet) At least 1 TT injection administration 61.4% (DLHS-2, ) P.4 DLHS-3 Rajasthan Fact sheet) Institutional deliveries 32.2% (DLHS-2, ) P.4 DLHS-3 Rajasthan Fact sheet) 55 % ( DLHS-3, ) P.4 Rajasthan Fact sheet) 32.2% (NFHS-3, ) 45.5% ( DLHS-3, ) P.4 DLHS-3 Rajasthan Fact sheet) 70% in 2009 (p.4 RCH chapter PIP 09-10) Access to PNC % ( DLHS-3, ) P.4 Rajasthan Fact sheet) % of achievement of need assessed- Institutional Deliveries 52.1% (Performance Statistics Table B.4- Maternal Health Institutional deliveries, July 2010) 80% ( P.4 RCH chapter PIP ) Intervention Target: RCH outreach camps (No.) in % was the target for ( P.4 RCH chapter PIP ) 60% was the target for ( P.4 RCH chapter PIP ) Rural: 51.4% Urban: 72.4% (DLHS-3, , P.4, Rajasthan Fact sheet) Rural: 40.7% Urban: 67.7% (DLHS-3, P.4, Rajasthan Fact sheet) Rural: 34.1% Urban: 57.8% (DLHS-3, ,P.4 Rajasthan Fact sheet)

89 Review how well the programme implemented activities Pregnancy Birth and Immediate Post-natal period Neonatal period Infants and children 1-59 months INTERVENTION PACKAGES BEING DELIVERED: ANC, SBA, EmOC, PNC Activity area Status of implementation Reasons for observed implementation Strengths Weaknesses (fully, partly or not at all) performance Maternal health communication strategy or plan available Focus on reaching low level populations Communication activities conducted: mass media, printed materials, training for local groups/volunteers in inter-personal communication; training for health workers Messages and materials developed and distributed Quality: key maternal health messages used; messages and materials pre-tested and adapted for local context Health communication/iec Partly Delay in marriage, ANC registration, institutional delivery, emergency transport Adequate budget Partly Special drives and camps Special budget RHSDP Partly Fully Partly Variable in different districts Independent state and district units Folk groups empanelled and used Donor partners provide support for developing materials Standard set used across the state, Local contexts not used EMOC, PNC component is weak Lack of coordination between NRHM and RHDSP All messages not covered All messages not covered All messages not covered

90 Review how well the programme implemented activities Pregnancy Birth and Immediate Post-natal period Neonatal period Infants and children 1-59 months INTERVENTION PACKAGES BEING DELIVERED: ANC, SBA, EmOC, PNC Activity area Status of implementation Reasons for observed implementation Strengths Weaknesses (fully, partly or not at all) performance Development of community supports Implementation plan for community-level activities available Community health workers trained and available Community groups or volunteers trained and available Quality: Developed collaboratively; use local staff and volunteers; supervision or oversight plan Included Fully AWW, ASHA Sahayogini Partly Partly Village committees formed(vhsc) 90% villages have appointed ASHA Jan-Mangal couples being revived 80% PHCs have ASHA supervisors Supporting data: health communication/ community Funds transferred Budgets ensured VHSC created in all villages ASHA, VHSC selected by local community Took longer than planned 30-40% VHSC members trained Motivation not sustained All VHSC have not been active Difficult to sustain motivation Indicator Baseline data (year and source) Most recent data (year and source) Target Differences by region or group (highest/lowest) % of mothers receiving at least one mass media communication activity (radio, TV, groups etc) which includes the key interventions in the he last 3 months = % of caregivers who know 2 danger signs for seeking care during pregnancy/for their sick child % of villages with trained CHWs for promoting key family and community practices = % of CHWs trained in intervention package = % of caretakers of children 0-59 months who received a home visit and counseling from a community health provider in the previous 3 months = % of villages with trained volunteers for promoting key family and community practices =

91 Worksheet 5: Review how well the programme implemented activities Pregnancy Birth and Immediate Post-natal period Neonatal period Infants and children 1-59 months INTERVENTION PACKAGES BEING DELIVERED: ANC, SBA, EmOC, PNC Activity area Status of implementation Reasons for observed implementation Strengths Weaknesses (fully, partly or not at all) performance Strengthening health systems Quality of casemanagement No system for assessment or assuring quality of care for SBA, EMOC, PNC Services available ANC, SBA, PNC are fully available EMOC is partly available FRUs and 24X7 PHCs not functional Lack of specialists Essential drugs and equipment available at first and referral levels Routine supervision conducted using checklists, and observation of practice Systems for timely referral for maternal complications in place Partly Equipment available Medicine shortage Partly Checklists are not adequate to address Concurrent monitoring system Partly Emergency transport HW and ambulance attendants trained available at some blocks only

92 Supporting data: systems Indicator Baseline data (year and source) Most recent data (year and source) Target Differences by region or group (highest/lowest) % of children who received integrated assessment (10 assessment tasks) - IMNCI % of children attending facilities who need an antibiotic and/or an antimalarial who are prescribed the medicine correctly - IMNCI Data on quality of antenatal care, delivery or newborn care Services available % of hospitals providing comprehensive emergency obstetric and newborn care (24 hours/day, 7 days/week) = % of hospitals or maternity facilities accredited as baby-friendly in the previous 2 years = % of facilities with immunization services available daily = % of facilities providing ANC, delivery, ANC, IMNCI services = % of caretakers receiving PNC/ANC from a skilled provider Essential drugs, equipment and supplies % of health facilities with all essential medicines for managing common newborn childhood illnesses or obstetric emergencies = Quality of case-management % of health facilities with all equipment and supplies for vaccination = % of facilities with all equipment and supplies for managing sick newborns and children % of facilities that manage severely ill children with oxygen/delivery systems available in the paediatric ward = Supervision and referral % of health facilities receiving at least one supervisory visit with observation of casemanagement in the previous 6 months =

93 Worksheet 5: Review how well the programme implemented activities Pregnancy Birth and Immediate Post-natal period Neonatal period Infants and children 1-59 months INTERVENTION PACKAGES BEING DELIVERED: ANC, SBA, EmOC, PNC Activity area Plan for routine monitoring and periodic evaluation of the maternal health programme included in strategic plan and work plans Standard international indicators used Short and long term targets set Population- and health facilitybased data available for monitoring and evaluation Monitoring data used for routine planning by all levels Vital registration systems working Status of implementation (fully, partly or not at all) Fully for monitoring Partly, for evaluation Partly, But All nationally decided indicators are captured Fully at state level Yes Partly Partly About 80 % births registered Maternal death registration are very low Supporting data: monitoring and evaluation Reasons for observed implementation performance Strengths Monitoring and evaluation Monthly reporting system Some components are evaluated each year Five year and annual programme cycles have targets Facility based data at state level Population based data available from national surveys Data is used at state level Awareness programme on birth registration in parts of state HMIS online at block level and upwards Weaknesses Power and internet connectivity Training on data entry required No integrated evaluation plan District specific targets not fixed Quality of data needs to be improved No data on quality of case management collected Data based planning not done at district level and sub-district level Indicator Baseline data (year and source) Most recent data (year and source) Target Differences by region or group (highest/lowest) % of births registered at birth = 61.43% (UBR 2005) % of child deaths registered = % of routine reports from districts received on time 75.27% (UBR-2009) % (Urban) 63.49% (Rural) (UBR -2009)

94 Worksheet 5: Review how well the programme implemented activities Pregnancy Birth and Immediate Post-natal period Neonatal period Infants and children 1-59 months INTERVENTION PACKAGES BEING DELIVERED: PNC & Newborn Care Activity area Status of implementation (fully, partly or not at all) Policies, planning and management Practice Facility-based standards and Newborn Care - guidelines NNF guidelines updated and being utilized being used Essential drug list available Budgeted plans developed annually at the national and sub-national levels Planning done collaboratively with other divisions and with donors Annual budget adequate to complete all activities in the last plan Home-based Newborn Care - Available Available; Drugs are being purchased based on the list Yes; available at state and district level Yes; but not all partners adequately involved Reasons for observed implementation Performance - Interest of the state government in FBNC - Resources available through NRHM Strong partnership NNF, UNICEF, NIPI - Commitment of the government Strengths Commitment from government Partnerships Resources - Adequate funds available - Was done in participatory manner - Done in participatory manner with involvement of important stakeholders Weaknesses - Activity not covered in PIP Although guidelines are available, implementation poor - Not updated regularly - Template based planning lack of flexibility - - Involvement of ICDS is less - Available - Approximately 20% budget not utilized - Complicated processes

95 Supporting data: policy and planning Indicator Current status Policies for exemption of pregnant women, newborns and children from health charges available and implemented Y N CRC reporting mechanism established and working Y N (Rajasthan third draft report on convention on rights of child suggests focused attention on needs of children at policy and programme level- Source: p.8 Child Policy Rajasthan 2009) Costed national plan for ensuring universal access to newborn and child survival interventions available Y N Mechanism for monitoring the International Code for Marketing of Breastmilk substitutes working Laws and policies on vital registration adopted Y N Y N National child health strategy endorsed and costed % of districts implementing intervention package Y N 26 functional FBNC out of 36 planned (source: p.67 NRHM PIP ) % of proposed child health budget received on time in the previous year

96 Worksheet 5: Review how well the programme implemented activities Pregnancy Birth and Immediate Post-natal period Neonatal period Infants and children 1-59 months INTERVENTION PACKAGES BEING DELIVERED: PNC & Newborn Care Activity area Status of implementation (fully, partly or not at all) Human resources/training in-service Plan to ensure - Adequate adequate staffing at staffing at each FBNC not level, which planned includes - incentives In-service training strategy available Yes; not adequate (FBNC & HBNC) Reasons for observed implementation Performance - Shortage of trained manpower Strengths - Strong partnership for FBNC training Weaknesses - Vacancy of ASHA (15%) - Lack of staff nurses at FBNC - Handholding supervision after training is also poor In-service training conducted for health staff Yes; not adequate (FBNC & HBNC) - Strong partnership for FBNC training - Handholding supervision after training is also poor In-service facilitators trained Follow-up after in-service training conducted Yes Not adequate - No mechanism - Adequate facilitators available for NSSK - Inadequate facilitators for IMNCI, FBNC - Protocols not being followed in training institutions Quality of inservice training are: types of staff trained, materials used, time allocated, amount of clinical practice adequate? Need improvement - not adequate clinical practice during training Quality assurance mechanism for training not available - Less number of facilities for conducting training

97 Worksheet 5: Review how well the programme implemented activities Pregnancy Birth and Immediate Post-natal period Neonatal period Infants and children 1-59 months INTERVENTION PACKAGES BEING DELIVERED: PNC & Newborn Care Activity area Status of implementation (fully, partly or not at all) Human resources/training pre-service Reasons for observed implementation Performance Strengths Weaknesses Pre-service training strategy available Pre-service training incorporated into curriculum of medical and other schools Pre-service trainers trained Quality of preservice training materials used (including textbooks), time allocated, amount of clinical practice adequate? - IMNCI MBBS, ANM; Not available for nursing schools - Only IMNCI included Partly Inadequate Supporting data: human resources/ training - Training on newborn care not a priority - Not perceived as priority - Not started in all medical colleges - - Newborn component not adequate Indicator Baseline data (year and source) Most recent data (year and source) Target Differences by region or group (highest/lowest) % of health staff who have received training in intervention package = % of planned trainings completed in the previous year = % of health facilities with at least 60% of health workers caring for children, newborns or pregnant women trained in training package = % of all trained staff who receive follow-up visit within 3 months of training = % of medical/nursing/midwifery training schools that have incorporated focus intervention or package = % of mothers who receive ANC/PNC from a skilled provider = Access to PNC % ( DLHS-3, ) P.4, Rajasthan Fact sheet) 60% ( P.4 RCH chapter PIP ) Rural: 34.1% Urban :57.8% (DLHS , P.4, Rajasthan Fact sheet)

98 Worksheet 5: Review how well the programme implemented activities Pregnancy Birth and Immediate Post-natal period Neonatal period Infants and children 1-59 months INTERVENTION PACKAGES BEING DELIVERED: PNC & Newborn Care Activity area Status of implementation (fully, partly or not at all) Health communication/iec Reasons for observed implementation Performance Strengths Weaknesses Child health communication strategy or plan available Focus on reaching low level populations Communication activities conducted: mass media, printed materials, training for local groups/volunteers in inter-personal communication; training for health workers Messages and materials developed and distributed Quality: key child health messages used; messages and materials pretested and adapted for local context - Part of the state health and ICDS PIP - Separate plan for tribal and dessert areas both in RCH and ICDS PIP - Available (IPC and Print media) Yes Yes - Distribution and dissemination of the IEC materials - Evaluation of the content and impact not done - Operational and managerial issues - Monitoring of IEC

99 Worksheet 5: Review how well the programme implemented activities Pregnancy Birth and Immediate Post-natal period Neonatal period Infants and children 1-59 months INTERVENTION PACKAGES BEING DELIVERED: PNC & Newborn Care Activity area Status of implementati on (fully, partly or not at all) Development of community supports Reasons for observed implementation Performance Strengths Weaknesses Implementation plan for community-level activities available Available Community health workers trained and available Community groups or volunteers trained and available Quality: developed collaboratively; use local staff and volunteers; supervision or oversight plan Included Partly Partly - Mechanism for monitoring by independent agency available - Jan Mangal Couple available for 24 hours - Post-training follow-up and handholding is not adequate - All Community Health Workers not covered - Training of ASHA completed only for a few modules - Quality issues in training of ASHA

100 Supporting data: health communication/ community Indicator Baseline data (year and source) Most recent data (year and source) Target Differences by region or group (highest/lowest) % of mothers receiving at least one mass media communication activity (radio, TV, groups etc) which includes the key interventions in the he last 3 months = % of caregivers who know 2 danger signs for seeking care during pregnancy/for their sick child = Awareness among women about danger signs of ARI 71.7% (DLHS- 2, ) P.5 DLHS-3 Rajasthan Fact sheet) 98.6% ( DLHS- 3, ) P.5, Rajasthan Fact sheet) Rural:98.6% Urban: 98.8% (DLHS-3, ) P.5, Rajasthan Fact sheet) % of villages with trained CHWs for promoting key family and community practices = % of CHWs trained in intervention package = % of caretakers of children 0-59 months who received a home visit and counseling from a community health provider in the previous 3 months = % of villages with trained volunteers for promoting key family and community practices =

101 Worksheet 5: Review how well the programme implemented activities Pregnancy Birth and Immediate Post-natal period Neonatal period Infants and children 1-59 months INTERVENTION PACKAGES BEING DELIVERED: PNC & Newborn Care Activity area Status of implementation (fully, partly or not at all) Reasons for observed implementation Performance Strengths Strengthening health systems Weaknesses Quality of casemanagement Services available Essential drugs and equipment available at first and referral levels Routine supervision conducted using checklists, and observation of practice Systems for timely referral of sick newborns and children in place Unsatisfactory Inadequate - Services available only at District hospital - Unsatisfactory for Community level - For first level, units to be established - For referrals, equipments and drugs available - The list of essential drugs need to be updated for newborns Not at all for FBNC Partly for Communitybased Available - Training and followup after training - Lack of Quality Assurance system - Poor monitoring - Lack of skilled manpower - Lack of infrastructure - - Lack of skilled manpower - Lack of wellestablished infrastructure -Still in the preliminary stage of planning for FBNC - For communitybased, we have checklists available for supervisors - Acceptance of the public health system - Training of the workers - Follow-up of referral - Plan for monitoring of FBNC through State level Newborn cell - ICDS involved for supportive supervision of Community-based Newborn Care - - Referral card - Funds are available - Ambulance services - Training and follow-up after training - Lack of Quality Assurance system - Poor monitoring - Lack of skilled manpower - Lack of infrastructure - Lack of awareness and acceptance of services (communitybased/facility-based) - Gender bias in care - Lack of supportive supervision - Lack of awareness and acceptance of services (communitybased/facility-based) - Lack of accountability - Although equipments available at referral level, maintenance is a problem Community-based care - Lack of feedback - Lack of accountability - Although system is available, referrals remain poor

102 Supporting data: Health systems Indicator Baseline data (year and source) Most recent data (year and source) Target Differences by region or group (highest/lowest) % of children who received integrated assessment (10 assessment tasks) IMNCI IMNCI (Integrated Management of Neonatal & Childhood Illnesses) Quality of case-management Personnel Trained in IMNCI by (No.) (P.21 ROP ) % of children attending facilities who need an antibiotic and/or an antimalarial who are prescribed the medicine correctly - IMNCI Data on quality of antenatal care, delivery or newborn care To implement IMNCI in 33 districts in next two years. (P.8 NRHM PIP ) up to (P.21 ROP 10-11) Please note : All data on T/t of diarrhea and ARI is for two weeks before the concerned survey. Children with Diarrhea who sought advice or treatment Children with Diarrhea who received treatment with ORS Children who had Diarrhoea 61.7% (DLHS-2, ) P.5 DLHS-3 Rajasthan Fact sheet) 28.9% (DLHS-2, ) P.5 DLHS-3 Rajasthan Fact sheet) 59.7% ( DLHS-3, ) P.5 Rajasthan Fact sheet) 30.6% ( DLHS-3, ) P.5 Rajasthan Fact sheet) 10.3% ( NFHS-3, P.69 State report ) Rural: 58.7% Urban: 64.9% (DLHS-3, ) P.5 DLHS-3 Rajasthan Fact sheet) Rural: 26.4%( Urban: 53.0% (DLHS-3, ) P.5 Rajasthan Fact sheet) % Children taken to Health Provider Treated with ORT 56.7% 21.4%(including16.5% ORS) No Treatment 28.7% (NFHS-3, P.69 State report)

103 Children with Diarrhea who were treated with ORS Children under 5 who had symptoms of ARI Out of these who were taken to the health facility Out of these who received antibiotics % children with ARI and fever who sought advice or treatment % Of Sick children (with Diarrhea/ARI/childhood illnesses) having access to care % of hospitals providing comprehensive emergency obstetric and newborn care (24 hours/day, 7 days/week) = FBNC(facility based new born care) at district hospitals NBSU(newborn stabilizing units) at FRUs New born care services 70.1% (DLHS-2, P.5 DLHS-3 Rajasthan Fact sheet) 11 FBNC functional out of 35 planned in (P.14 RCH chapter PIP ) 16.5%( ) 50% ( ) 60%( ) 80%( ) P.31 NRHM PIP % (NFHS-3, P. 24 State report) 65% 18% 75.6% ( DLHS-3, P.5 DLHS-3 Rajasthan Fact sheet) Services available 26 functional FBNC out of 36 planned (P.67 NRHM PIP ) Since April 2009 a total Newborns were admitted till Nov 09 (p.68 NRHM PIP ) 85% of of neonates cured and treated ( State PIP ) 90% by (P.67 NRHM PIP ) 36 by March 2010 (P.67 NRHM PIP ) 36 in number (A.2.2 excel sheet PIP budget sheet ) 100 in number (A.2.2 excel sheet PIP budget sheet ) Estimates : new born will receive quality care every year( State PIP ) Rural: 73.6% Urban: 86.3% ( P.5 DLHS-3 Rajasthan Fact sheet)

104 % of hospitals or maternity facilities accredited as baby-friendly in the previous 2 years = % of facilities with immunization services available daily = % of facilities providing ANC, delivery, ANC, IMNCI services = FRUs Operational 100 FRUs by were functional (P.4 PIP ) % of caretakers receiving PNC/ANC from a skilled provider % of health facilities with all essential medicines for managing common newborn childhood illnesses or obstetric emergencies = % of health facilities with all equipment and supplies for vaccination % of facilities with all equipment and supplies for managing sick newborns and children % of facilities that manage severely ill children with oxygen/delivery systems available in the paediatric ward = % of health facilities receiving at least one supervisory visit with observation of case-management in the previous 6 months = Essential drugs, equipment and supplies Supervision and referral 237 in number in (P.134 NRHM PIP )

105 Worksheet 5: Review how well the programme implemented activities Pregnancy Birth and Immediate Post-natal period Neonatal period Infants and children 1-59 months INTERVENTION PACKAGES BEING DELIVERED: IMNCI,UIP/RI, MTC Activity area Plan for routine monitoring and periodic evaluation of the child health programme included in strategic plan and work plans Standard international indicators used Short and long term targets set Status of implementation (fully, partly or not at all) Yes Yes Partly Reasons for observed implementation performance Strengths MONITORING AND EVALUATION - Online - Pregnancy and child tracking system established - Indicator based monitoring Weaknesses - Quality of data needs improvement - Proper system for analysis of data and feedback to the providers not available -Monitoring for quality of care - System of verification of data - Targets not available for all indicators (impact and coverage Population- and health facilitybased data available for monitoring and evaluation Monitoring data used for routine planning by all levels Vital registration systems working Yes Partly Partly - - Maternal death enquiry initiated and being scaled up - Birth registration has improved with increase in institutional delivery Supporting data: monitoring and evaluation Indicator Baseline data (year and source) % of births registered at birth = 61.43% (UBR 2005) % of child deaths registered = % of routine reports from districts received on time Most recent data (year and source) 75.27% (UBR 2009) Target - Use of data for decisionmaking needs improvement - Planning process - Training of managers in planning process - Exact data needed for planning may not be available - home delivery and death at home not being registered - Differences by region or group (highest/lowest) % (Urban) 63.49% (Rural) ( UBR 2009)

106 Worksheet 5: Review how well the programme implemented activities Pregnancy Birth and Immediate Post-natal period Neonatal period Infants and children 1-59 months INTERVENTION PACKAGES BEING DELIVERED: IMNCI, UIP, MTC FBI Activity area Status of implementation Reasons for observed implementation Performance Strengths POLICIES, PLANNING AND MANAGEMENT Weaknesses Practice standards and guidelines updated and being used IMNCI Full UIP - Full Facility based Interventions (MTC,Yashoda,F-IMNCI)=Yes except for F-IMNCI; policy decision has been taken, details being worked out Good Policies Guidelines, updated regularly, Implementation Plans Comprehensive guidelines available encompassing several components of program management Some critical operational elements are lacking e.g supportive supervision mechanisms. Centrally determined plans and policies, local needs for certain vaccines may not be met as per requirement.(e.g need for HepB and HiB) Elements of demand side is missing; tackled separately in IEC section Most policies are adoption of National level guidelines; sometimes even the translation in the local language is not undertaken. Frequent change of circulars and directives. Essential drug list available IMNCI -Yes as part of the State Essential Drug List UIP: All vaccines available Facility based Interventions: part of essential drug list One comprehensive drug list for each level of facility has been prepared. Provision to buy materials outside the list if required. Dissemination of the guidelines are not timely: there is also variation in interpretation. Matching of the drug list with the intervention packages has not been done. Vaccines available but supply chain management issues Matching of essential drug list required specially for newer programs such as F IMNCI and MTC.

107 Activity area Status of implementation Reasons for observed implementation Performance Strengths Weaknesses Budgeted plans developed annually at the national and subnational levels Planning done collaborativ ely with other divisions and with donors Annual budget adequate to complete all activities in the last plan Yes, for all as a part of the PIP IMNCI-Yes, UIP; Yes FBI: Yes IMNCI-Yes UIP: Yes FBI: yes Participation of districts which are preparing dist action plans/ sub plans: bottom up approach Joint planning undertaken at state level Medical college/ training institutions involvement is increasing IMNCI Planning confined to Planning for Training Collaboration not uniform at all levels Convergence with ICDS not adequate. Most of the budgeted money remains underutilized.

108 Worksheet 5: Review how well the programme implemented activities Pregnancy Birth and Immediate Post-natal period Neonatal period Infants and children 1-59 months INTERVENTION PACKAGES BEING DELIVERED: IMNCI, UIP, MTC FBI Activity area Status of implementation Reasons for observed implementa tion Performanc e Strengths Weaknesses HUMAN RESOURCES/TRAINING IN-SERVICE Plan to ensure adequate staffing at each level, which includes incentives Partial. plan is available, positions are identified where vacancies are. Hiring of contractual staff where needed. Delays in filling vacancies. Main streaming of AYUSH personnel In-service training strategy available Yes there are a variety of training packages available (21)!! DP also providing /supporting technomanagerial personnel. specific training packages for each intervention group Lack of coordination and integration of trainings. In-service training conducted for health staff Yes Training plan/calendar made Flexibility in training; can change calendar if necessary Frequent disruptions in trainings. multiple trainings in process a burden to time and personnel. Training calendar not adhered to: synchronization of trainings not always evident. budget sometimes not available in time leading, external exigencies prolong duration of trainings. Contingency plans not made.

109 Activity area Status of implementation Reasons for observed implementat ion Performance In-service Yes facilitators trained Strengths Weaknesses lack of reorientation leads to loss of skills Transfer of facilitators leading to loss in manpower. Follow-up after in-service training conducted Quality of inservice training are: types of staff trained, materials used, time allocated, amount of clinical practice adequate? Partial mixed; trainings at block level tend to be of poor quality, at govt venue tend to have other distractions Each candidate's service book would contain the trainings he has undertaken. Two sites designated at training sits to assure quality (for state level trainings) post training deployment is not appropriate the appropriate persons are not sent for the trainings; tendency for the same person to be sent for several trainings.

110 Activity area Status of implementation Reasons for observed implementat ion Performance Strengths HUMAN RESOURCES/TRAINING PRE-SERVICE Pre-service training strategy available Partial; Formal strategy in place for IMNCI, not for all Weaknesses National strategy not endorsed at state level dissemination not done to all levels. No set plan for in service training. Pre-service training incorporated into curriculae of medical and other schools Partial Material not incorporated yet in all relevant text books.(only select;op Ghai) At present, IMNCI training is for medical colleges and not for nursing schools. Pre-service trainers trained Partial: only from medical colleges e.g for IMNCI Quality of preservice training materials used (including textbooks), time allocated, amount of clinical practice adequate? No information available

111 Worksheet 5: Review how well the programme implemented activities Pregnancy Birth and Immediate Post-natal period Neonatal period Infants and children 1-59 months INTERVENTION PACKAGES BEING DELIVERED: IMNCI, UIP, MTC FBI Activity area Status of implementation Reasons for observed implementation Performance Strengths Weaknesses Child health communication strategy or plan available Focus on reaching low level populations Yes, as a part of the the overall IEC plan Yes HEALTH COMMUNICATION/IEC Special directorate at state and IEC coordinators at districts in place Budget available for IEC activity Strategy does not have comprehensive plan using appropriate media mix: more emphasis written messages and not always appropriate Despite availability of plans, implementation and reach are less than optimum. Communication activities conducted: mass media, printed materials, training for local groups/volunteer s in interpersonal communication; training for health workers Messages and materials developed and distributed Quality: key child health messages used; messages and materials pretested and adapted for local context Yes Yes(developed); partial dissemination Partial: field testing part not undertaken Local religious leaders have been used, puppet shows have been organised, video CD materials have been developed, posters and LCD screens with 7 CD sets of IEC materials are being displayed in maternity wards, claender for IMNCI. BCC trainings for HW by RHSDP, IEC training a part of all major training packages. Variety of materials developed pertaining to major interventions. Technical committee ensures correct messages, local context adapted Loss of materials developed in the past, Slow pace of trainings of IPC/BCC packages, often not practiced by HW. materials not always available where required; often not displayed despite availability field testing aspect often ignored Evaluation (output) of material not undertaken

112 Worksheet 5: Review how well the programme implemented activities Pregnancy Birth and Immediate Post-natal period Neonatal period Infants and children 1-59 months INTERVENTION PACKAGES BEING DELIVERED: IMNCI, UIP, MTC FBI Activity area Status of implementation Reasons for observed implementation Performance Strengths Weaknesses Implementati on plan for communitylevel activities available DEVELOPMENT OF COMMUNITY SUPPORTS Partial; ASHAs recruited, lack of ASHA placed; trained, VHSC made; plan for coordination funds available at training PRI members between health community level functionaries and community persons to develop concrete plan Involvement of community is not as per desired, nonformal leaders are not involved. Community health workers trained and available Community groups or volunteers trained and available Full: ANMs, LHV, and AWW Almost complete (ASHA) Partial (VHSC) different training packages for each group timeliness of training, quality of training variable(through NGOs) Conflicting messages in different trainings as understood by trainees. Quality: developed collaborativel y; use local staff and volunteers; supervision or oversight plan included Partial. Models of supportive supervision has been created and tested in Rajasthan(e.g director=district, nursing schools) supportive supervision weak multiplicity of packages; no integration of supportive supervision mechanism

113 Worksheet 5: Review how well the programme implemented activities Pregnancy Birth and Immediate Post-natal period Neonatal period Infants and children 1-59 months INTERVENTION PACKAGES BEING DELIVERED: IMNCI, UIP, MTC FBI Activity area Quality of casemanagement Status of implementation Partial (from given data of diarrhea, pneumonia, mal nutrition) Reasons for Strengths observed implementation Performance STRENGTHENING HEALTH SYSTEMS Logistics issues, training issues Gradual improvement is evident Weaknesses irrational use of antibiotics, IV fluids, feeding counseling weak Services available Essential drugs and equipment available at first and referral levels Routine supervision conducted using checklists, and observation of practice Partial Full Partial IPHS standards available to be followed. Facility level survey carried out periodically HMIS also monitors facilities and services. Mechanism for providing services through VHND Equipment are being supplied by regular and partner support Drug supplies are mostly regular Senior personnel from directorate allotted districts for direct supervision (has a comprehensive common checklist) facilities and services not uniformly available as per IPHS standards manpower not appropriately trained to use equipment Maintenance of the equipment not streamlined Inadequate supervisory manpower for field level supportive supervision. Available supervisors need appropriate training for use of checklists. Systems for timely referral of sick newborns and children in place Partial, 108 mechanism for referral funds available at VHSC for referral when needed Awareness for need for referral increasing. Recent problems with 108 company PPP arrangement; introduced phase-wise at Rajasthan. Timely referral being hindered due delays in identification and decision making ( also information on where to refer) Referral slips not honoured. Availability of doctors at facility level. Need for training processes at facility level.

114 Worksheet 5: Review how well the programme implemented activities Pregnancy Birth and Immediate Post-natal period Neonatal period Infants and children 1-59 months INTERVENTION PACKAGES BEING DELIVERED: IMNCI, UIP, MTC FBI Activity area Plan for routine monitoring and periodic evaluation of the child health programm e included in strategic plan and work plans Status of implementation Reasons for observed implementation Performance Strengths MONITORING AND EVALUATION Partial State has made multi level plans for monitoring and supervision of child health activities. State has tool for validation of monitoring data. Has an online system for receiving reports from the lowest levels; also pregnancy child tracking system in place. CRMs and JRMs also include review of child health packages. Stock taking of CRM and JRM recommendations are undertaken through action taken report. Monthly review meeting for progress in implementation undertaken at the state UIP has a monitoring system including periodic reviews. Weaknesses Monitoring at lower levels inadequate (lack of time, variety of tasks including nonhealth tasks) Analysis of computerized data at block level inadequate, now started at district level. Teams involved in JRMs and CRMs are not apprised of the action and are not involved in the corrective planning process. central initiative rather than the state. Review mechanisms have more focus on administrative processes than program indicators. use of HMIS data and data triangulation limited. UIP reviews are mostly undertaken where DP support is strong.

115 Activity area Standard international indicators used Status of implementation Yes Reasons for observed implementation Performance Yearly periodic reports have to be submitted based on the indicators. Strengths In the PIP the standard indicators have been mentioned each year and have been used for planning purposes. Weaknesses Not internalized by the system on a regular basis Not used to drive the programs systematically. Short and long term targets set Yes Need to provide reports with targets. Targets determined following community surveys and determined bottom up. Targets for each intervention related to child health not available. Demography cell validates and finalises these targets. Sometimes targets are unrealistically set due to ambitious requirements of decision makers. Lack of techno managerial skills to set realistic targets. Populationand health facilitybased data available for monitoring and evaluation Yes, through HMIS data and through surveys Disaggregated data (e.g sex wise, rural urban) now available even at peripheral levels Sometimes validation of data carried out by independent agencies. Proper analysis and use is limited. Lack of demand for astute data by decision makers and not appropriately used in planning and review processes. Data of private services not available. Monitoring data used for routine planning by all levels Partial Indicators and information are available. Only limited data (key indicators information) used for planning processes e.g immunization Feedback of data is not usually shared at lower levels, the block review mechanisms vary from block-to-block Vital registration systems working Partial (85%) Being done at village by gram sachivs (85% registration) Maternal death audits started in 14 districts Incentives for reporting maternal and infant death. Computerization of data/ support by DPs e.g maternal death audits. Not yet universal

116 Annexure VII: Worksheet 6 (Consolidated) Identify the main problems Activity Area Policy, planning and management Problems Communication from HQ to grass root level: a. Clarity and completeness b. Timeliness c. F/U on action Lack of Operational Guidelines/ SOPs a. Clarity on program incentives Need based Planning a. Limited Program Planning and Management capacities especially at district level b. Constraints of templates and budget, flexibility not there c. Data not used, equity not considered (RBP) d. Special plans for desert and tribal areas Stronger HR policy and Training strategy to be developed a. Deployment b. Recognitions and incentives c. Involvement of AYUSH practitioners in IMNCI Lack of Convergence with health related departments like ICDS, Water, Sanitation, PRIs Program Implementation challenges a. Feedback system b. Weak supervisory mechanisms c. Logistics management 1. Transmission loss of stated guidelines resulting into ambiguity in understanding guidelines- (Language, Individual interpretation) (M) 2. Frequent changes, time lag in issue to implementation, lack of reference (M) 3. Policies do not explicitly state the operational element /implementation plan e.g. post training programmatic support (needs detailing). (C) 4. The local level adaptation and dissemination of National level guidelines of the guidelines are weak. (C) 5. Delink between the district plans & section plans and hence lack of consistency in district plans and state plans. (M) 6. Facility-based newborn care availability of SCNU beds not decided on the number of deliveries conducted (N) 7. Budget allocation does not often match with plan needs. (M) 8. Procedural delays resulting in poor budget utilization (N) 9. Lack of linkages between program activities planned coverage of key interventions & achieving impact and set goals. (M) 10. Posting of staff far away from their native district. (N) 11. Comprehensive training strategy does not exist. (C) 12. Weak coordination between ICDS and Health Department related with defining the role of ASHA. (N)

117 Human resources and training Communication Development of community supports Lack of Systematic policy of human resource development. (M) - Selection of proper person for trainings. (M) - Delink between available data of PIS (personal information system) and its use. (M) - Proper Utilization of training skills. (M) Weak supportive supervision system, lack of follow-up after training and programmatic support. (M) Pre service education programme does not incorporate training packages of medical & paramedical staff. (M) Vacancies of critical staff at facility and community level (N) Post training Supportive supervision and handholding is weak. (N) Pre service training on IMNCI not being done. (N) Not adequate training of trainers for pre-service courses. (N) Newly recruited field staff (ASHA coordinator) not provided adequate training and mobility support. (C) Attrition of junior doctors high for PG seats. (C) Delays in filling vacancies, recruitment slow. (C) The appropriate participants and facilitators not selected for trainings. (C) No well designed BCC strategy for MCH. (M) Messages do not match with the all services packages. (M) Inappropriate Media mix. (M) Lack of impact assessment of communication materials. (M) Communication skills of health workers. (M) Absence of Integrated communication plan for newborn health, no focus on gender either. (N) Interpersonal communication weak (N) Monitoring and evaluation of IEC activities weak (N) Intensity of IEC is not sustained throughout the year. (C) Slow pace of trainings of IPC/BCC packages (C) Field testing aspect and content analysis often ignored (C) Impact evaluation of material not undertaken (C) Inadequate quality of VHSC, ASHA, Janmangal couple trainings. (M) Un-sustained motivation of support groups. (M) Handholding of Village Health and Sanitation Committee is weak (N) Community Monitoring not being done by Village Health and Sanitation Committee (N) Thematic community meetings involving right community members (on Immunization, breastfeeding: for role in community mobilization, behavior change, community monitoring of activities) not happening. (C) Weak linkages with different community groups and health systems. (C) Lack of timeliness of training for community members, quality of training variable (through NGOs). Conflicting messages in different trainings as understood by trainees. (C)

118 Strengthening health systems Monitoring and evaluation No system for assessment or assuring quality of care for SBA, EMOC, PNC. (M) Lack of specialists (CEmOC), nursing staff, ANMs. (M) Shortage of medicines. (M) Inadequate emergency transport. (M) Lack of skilled manpower; extra positions not created to keep pace with the new facilities; e.g. FBNC (N) Supportive supervision (N) Maintenance of equipments (N) Maintenance of the equipment and training for their appropriate use not streamlined (C) Weak supportive supervision. (C) Referral related delays are a problem. (C) Poor case management (C) Lack of comprehensive analysis of data at district and sub-district level o Some issues in data quality (e.g. morbidity, mortality) o Denominators not considered o In individual tracking, Urban data not covered o Some Private sector data missing e.g. Newborn and Child health data Weak Review and feedback mechanisms at district and sub-district level- more administrative- less programmatic, targets- results should be discussed, need to be more structured, Joint director of respective zones should attend the reviews o Joint reviews with related departments like ICDS, Water, Sanitation and PRIs Need to update monitoring indicators related to MNCH Targets not realistic No systematic evaluation plan Assessment of Quality of care of MNCH services 1. System for analysis of data at district and sub-district level and feedback to the providers not available. (N) 2. No analysis and feedback on HMIS data. (M) 3. Monitoring and feedback at all levels inadequate (lack of time, variety of tasks including non-health tasks) (C) 4. Standard newborn care indicators and targets not included in monitoring system (N) 5. Inadequate Quality of HMIS data. (M) 6. Analysis of computerized data at block level inadequate. (C) 7. Data of private sector services not available. (C) 8. Realistic targets for each intervention related to child health not available. (C) 9. Review mechanisms have more focus on administrative processes than program indicators. (C) 10. No integrated evaluation plan. (M) 11. Quality assurance system of facility based and community based newborn care not included in PIP. (N) 12. Inadequate Use of data for planning. (M) M: Maternal Group, C: Child Health Group, N: New born group

119 Annexure VIII: Worksheet 7 Develop solutions and recommendations: Activity area: Policy, planning and management The Problems are Causes Solutions Recommendations There is a gap in communication,, uniform interpretation and follow-up of directives from State HQ to grass root level. a. Lack of clarity, consistency and completeness b. Delay in communication c. There is no follow up on communication and action taken Checklist to be developed to ensure clarity and completeness and all communications to go through this checklist Action taken report should be obtained and Periodic Follow ups should be done Should be shared verbally and in written during monthly/ quarterly reviews Apart from verbal and written communication, video conferencing and Gramsat platform can be utilized to bring clarity in communication Along with long guidelines, gist in bullets to be included CMHOs & BCMHOs to be made more accountable In the area of addressing Gaps in Communication of guidelines from state HQ to grass root level it is recommended that: 1. Checklist for ensuring clarity, consistency and completeness of guidelines, follow-up is developed by Health Directorate 2. Originating units/ departments use the checklist to ensure that the guidelines are clear, comprehensive and self explanatory 3. The district and block units ensure that the guidelines reaches the intended user in time and an action taken report is sought

120 Activity area: Policy, planning and management The Problems are Causes Solutions Recommendations Planning not need based but driven by template and budget Underutilization of AYUSH practitioners in MNCH services Lack of coordinated and inadequate attention to address Nutrition and Development in Children a. Limited Program Planning and Management capacities especially at district level b. Constraints because of template planning and budget restraints c. Data not used, equity not considered (RBP) d. Desert and tribal areas not given adequate priority e. Targets unrealistic or missing for some interventions a. No clear policy for utilization of services of AYUSH practitioners in MNCH a. Lack of coordination between ICDS and Health departments Building capacities for Program Planning and Management at state and district and block level Decentralized planning based on data and local needs as recommended in NRHM Alternate approaches to be developed for difficult areas Utilization of AYUSH practitioners for IMNCI implementation Monitoring of other MNCH services Better coordination between AWW, ASHA and ANM In the area of Need based Planning it is recommended that: 1. Organize Capacity building workshops on Program Planning and Management for block, district and state level officials to promote data and need based planning 2. Health Directorate to ensure that specific and appropriate plans for improving access to services are developed by desert/ tribal districts and other districts for their difficult areas State government to take a policy decision to enable AYUSH practitioners to deliver IMNCI through training and monitoring of other health services Joint planning and reviews of ICDS and Child Health programme at district and subdistrict level to address Malnutrition, anaemia and development in under 3 children Joint training

121 Activity area: Monitoring and Evaluation The Problems are Causes Solutions Recommendations Lack of quality in data capture at field level Inadequate data analysis, feedback and reviews at district and sub-district level o o o o o o Some issues in data quality like under-reporting, misreporting, definitions not clear (e.g. morbidity, mortality), fear factor high In individual tracking, Urban data not covered Some Private sector data missing e.g. Newborn and Child health data Mechanism for analysis and feedback exists but is inadequate and not target oriented Review is more administrative rather than programmatic Some MNCH targets not realistic 1. Orientations on importance of data for frontline workers to improve data quality 2. Sensitization and Orientation of block and district level officials to address apprehension to report morbidity and mortality data 3. Ward wise reporting system in urban areas to be developed for PCTS 4. Sensitization of private practitioners 1. Orientations of block district and state level officials to improve data analysis and provide appropriate feedback 2. Monthly sector & block meetings to be used for review and data analysis 3. Reviews need to be made more structured, Joint director of respective zones should attend the reviews 4. PHC sector meeting is the most important point where adequacy and quality of data can be discussed at length with the grass root workers. The meeting at PHC level should be organized regularly and a block level officer should attend it State to develop : A plan for orientations of frontline workers and managers to improve data quality Ward wise reporting system in urban areas for PCTS Sensitization of private practitioners for reporting morbidity, mortality and service utilization data State to plan: Orientations/training of block and district level officials to improve data analysis and provide appropriate feedback Conduct short program reviews at district level annually before development of District PIPs Provision of statistician at Block level

122 The Problems are Causes Solutions Recommendations Difficulty in monitoring neonatal care and PNC interventions No systematic evaluation plan in place Indicators related to neonatal care and PNC are not available Need to update monitoring indicators related to neonatal care and PNC Evaluation for priority interventions to be more systematic State to introduce Neonatal and PNC indicators in the monitoring system State to develop a systematic plan to periodically evaluate implementation of IMNCI, New born care and PNC interventions Limited data on Quality of care of MNCH services No system for Assessment of Quality of Care for MNCH services Periodic assessment of Quality of care for sick newborns and children State to: Develop/adapt tools to assess quality of care (facility, case management, satisfaction of beneficiaries) Periodically evaluate quality of care at health facilities and community level

123 Activity area: Human resources/training The Problems are Causes Solutions Recommendations Human resource 1) There is in-adequate number Lack of Systematic policy of human resource placement & development. Short term Use data generated from Personal information system of staff and expertise for Vacancies not filled (PIS) appropriately for maternal, newborn and child (administrative process) placement of critical HR health and as a result inadequate number of critical staff at Acknowledge development of facility and community level Attrition of junior doctors high for PG seats. (C) Mismatch between personal information (health worker Focus District Approach that has just been started and document experiences and lessons learnt for scaling up for improving quality of services. profile) and posting Mismatch between patient load (services) and number of staff needed Long term Have in place a human resource development policy/strategy Rationalization of existing HR available in the system at different levels by appropriate authority Fast track recruitment for vacant posts through online, walk-in-interviews Accessing HR services through PPP model HR policy/ strategy to address HR issues systematically Include succession planning Mapping of facilities of various levels to be done and as per requirement, right HR to be posted. Evaluation of focus district approach and based on experience decide next steps Synchronization of HR as per intervention package wherever possible PHS to lead strengthening of Human Resource Development Strategy/policy (with adequate reflection of number, skills including induction training, transfers )

124 The Problems are Causes Solutions Recommendations Training 2 Quality of training is not optimal A Comprehensive training calendar not made Information regarding training status of personnel not available Same message delivered in various training (integration of training modules on same issues) Lesser no of trainers as compared to no of training programs in place Increase pool of trainers by going beyond traditional trainers and sharing trainers across programmes Innovative training approaches such as distance learning, technology based trainings to be explored All clinical trainings to have adequate hands on components Post training programmatic support to be put in place External agency support for on job/follow up training and supportive supervision Collection of information for impact analysis to be explored Strengthen district training capacity Director RCH to lead development of comprehensive training strategy and implementation plans Increase pool of trainers by going beyond traditional trainers and sharing trainers across programmes Innovative training approaches such as distance learning, technology based trainings to be explored Ensure hands on clinical training and these training sites need to be strengthened further. Supervision/ evaluation of training programmes on routine basis Specialist services to be increased through targeted training Directive need to be issued by appropriate authority to include training like IMNCI in MBBS, nursing and ANM education

125 The Problems are Causes Solutions Recommendations 3) Pre-service training Teaching staff are not fully informed on need to incorporate MNCH guidelines in pre-service Orientation of teaching staff (medical and para- medical schools) Orient and conduct training for teaching staff on MNCH guidelines With teaching staff develop a plan for introducing and implementing MNCH pre-service IMNCI

126 Activity area: Strengthening Health Systems The Problems are Causes Solutions Recommendations Shortage of drugs Mismatch between requirements and supply of drugs and consumables as per intervention package Kit base supply also it s a push system Need base supply system not in place Irrational drug usage Poor Awareness among personnel for resources available for drug procurement at local level Kit supply to match need Essential drug list should include all drugs required for newborn and child health Better quality of training on usage of drugs (as per principles of rational drug use) Create awareness Review and identify gap in drug supply management and utilization of alternative available funds (Untied fund, RKS fund etc.) MD NRHM to lead Review existing drug supply management to identify specific gaps and solutions Strengthen teaching on rational use of drugs At district level, all the supplies received through kits and supply of essential drugs used to be reviewed. Drugs and consumables that are missing to be procured through untied funds and RKS. A clear-cut guidelines and financial directive in this regard need to be issued to all concerned facilities. Poor supportive Supervision Micro planning of supportive supervision action plan is not evident Not getting adequate attention/importance supportive supervision Shortage of adequate human resource, inadequate skills of supervisory cadre Supportive supervision to be given adequate priority Integration of supportive supervision for related activities Urgent prioritization and integration of supportive supervision for various activities Dir.RCH to identify and train pool of supervisors in each block for integrated supportive supervision Checklist and clear guidelines for planning implementation, analysis & feedback for supervision

127 Activity area: Strengthening Health Systems The Problems are Causes Solutions Recommendations Poor Maintenance of equipment Training of staff on handling and maintenance not uniform Mechanism for maintenance of equipments not in place Annual maintenance contract Training of staff Mechanism for repair maintenance Dir. RCH to explore implementation of similar mechanisms as it is followed by immunization division for maintenance of equipments and apply lessons learned Weak referral linkages Ensure availability of transport Referral facilities not prepared adequately to receive patients Transport mechanism to be streamlined. Written protocols need to be made available at all referral facilities Link the existing transport mechanism with F-IMNCI. Further strengthening wherever required Community based services not optimally utilized for increasing coverage of key MNCH services Triaging not done properly

128 Activity area: Communication/IEC The problems are Causes Solutions Recommendations No Comprehensive Communication Plan - Weak linkage between technical and IEC section - IEC for Maternal and Child health is not a priority - Lack of professional approach Develop a comprehensive communication plan with professional input and in participatory manner (involving technical and IEC professionals) Ensure availability of IEC professionals at different levels Director IEC to create a Task Force at the State level headed by a health communication professional (involving technical persons) to develop the communication strategy and implementation plan Identify a resource pool of health communication professional at State and District Level to support and monitor implementation of plan Strengthen relevant section on health communication in the PIP with an activity plan including R and D with budget allocations Explore and expand use of latest technologies, e.g. Mobile, Interactive voice response (IVR) system, rejuvenate use of Gramsat system; Video conferencing (after proper R &D) Provisions of IEC materials as well as AV aids at facility level (CHC and 24X7 PHC level) Provide guidelines Monitor IEC activities Improper media mix - Lack of professional approach - Poor coordination of technical personnel with media (e.g. song and drama division, folk media, TV, radio) - No comprehensive workplan with defined responsibilities and accountabilities Results of R & D to identify media mix Well defined workplan with defined responsibility and accountability Prior planning for campaigns; e.g. Swasthya Chetna Yatra; immunization week Members of VHSC to be utilized for disseminating messages and changing community norms Explore approaches to be used to disseminate health messages during mother s stay in facility after delivery

129 The Problems are Causes Solutions Recommendations Poor quality of IEC materials - Research and development is weak - Lack of professional approach - Receiver is not in focus rather message is focus - Inter-region disparities never addressed - Results of R& D to be used to develop IEC materials, to disseminate the materials etc. (for interventions with poor coverage and on new knowledge in maternal and child health) - Professional training Skill up-gradation of State and District IEC coordinators on development of IEC materials Outsourcing for materials and skills development Poor communication skills of health and nutrition service providers Lack of monitoring and evaluation - All packages have component of communication, but given the least priority; Skill-based training lacking - Inadequate of facilitators - Weak supportive supervision - improper utilization of mobility support - Improper use of available communication materials at all levels - Indicators, tools and mechanism not available for monitoring - System of concurrent evaluation is lacking - Dedicated training on communication skills (existing training packages to be explored for this purpose) - Revisit existing IEC materials and prepare proper job aids for frontline workers; train them on use of materials Organize communication skills training program for service providers in low coverage areas - Develop a plan of monitoring and evaluation for IEC Develop a system of concurrent evaluation (may be outsourced)

130 Activity area: Community Support The problems are Causes Solutions Recommendations Limited capacity of VHSC VHSC not involved in community monitoring - Training of VHSC not completed - Support mechanism weak - Motivation related issues both for trainees and trainers - Accelerate training and assure quality - Regular support from PHC MO, block and district level authorities - (may be outsourced to NGOs) - Extending role of NGOs for follow-up after training - VHSCs are in development stage - Inclusion of community monitoring in VHSC Complete the training within one year followed by hand holding support through allocation of a set of villages to PHC level supervisors Develop five model VHSCs per block. Explore role of NGOs to establish model VHSCs Quarterly newsletter for VHSC with success stories from the field Develop a recognition mechanism and reward good performance for VHSC The best practices of community monitoring to be explored and adopted for the state Thematic community meetings involving community members not happening Inadequate quality of training for ASHA and Jan Mangal Couple on MNCH issues - Capacity of convener is limited - Weak support from ASHA supervisors - Jan Mangal Couples revived recently - Capacity building of PHC level supervisors for monthly thematic meetings - Accelerate update of listing of Jan Mangal Couple and training Capacity building of supervisors to be completed in the next six months Develop database of Jan Mangal couples and complete trainings within an year Expedite the process of training of ASHA on module Develop a mechanism for QA of trainings

131 Annexure IX : List of Participants Dr. Samira Aboubaker Coordinator country Implementation and support WHO/ HQ Geneva Dr. Mikael Ostergren Medical Officer WHO/HQ Geneva Dr. Rajesh Mehta MO- CAH WHO-SEARO Dr. Harish Kumar M O-CAH WHO/Dhaka Bangladesh Dr. Paul P Francis National Professional Officer and Cluster Focal Point, FHR WHO Country Office for India New Delhi Dr. Subodh Sharan Gupta National Professional Officer - Child Health & Development WHO Country office for India New Delhi Dr. Dhananjoy Gupta Health Specialist - Policy & Planning UNICEF New Delhi Dr. Avtar Singh Dua Health Specialist UNICEF Rajasthan Dr. Kaliprasad Pappu National Co-coordinator UNOPS-Norway India Partnership Initiative New Delhi Dr. Karanveer Singh Programme Officer- Child Health UNOPS-Norway India Partnership Initiative New Delhi Dr.Narottam Pradhan Immunization Officer UNOPS-Norway India Partnership Initiative New Delhi Dr. Satya Pal Yadav Senior Program Officer UNOPS-Norway India Partnership Initiative Rajasthan Mr.Pradeep Choudhary State Program Officer UNOPS-Norway India Partnership Initiative Rajasthan Dr. M. P. Sharma Professor & Head Dept. of Community Medicine SMS Medical college Dr. S Sitaraman Professor of Paediatrics SMS Medical College Dr. Jayanta K Das Professor & Head (Dept. of Epidemiology) National Institute of Health and Family Welfare- New Delhi Dr. Suresh Joshi Professor Institute of Health Management Research Jaipur Dr. Anoop Khanna Associate Professor Institute of Health Management Research Jaipur Dr. Vinod Kumar SV Assistant Professor Institute of Health Management Research Jaipur Dr. Vivek Lal Assistant Professor Institute of Health Management Research Jaipur Ms. Preety Sharma Assistant Professor Institute of Health Management Research Bengaluru Dr.Manisha Chawala State Health & Nutrition Coordinator Save the Children Rajasthan Dr.Vandana Mishra State program Representative CARE-India Rajasthan Dr. Hitesh Gupta CEO VATSALYA- Rajasthan

132 Dr.ML. Jain Director - RCH Directorate of Medical & Health Services[DMHS] Govt. of Rajasthan Dr. J P Dhamija Add. Director - RCH DMHS - Govt. of Rajasthan Dr.Rajendra Singh Rathore Deputy Director Immunization DMHS - Govt. of Rajasthan Mr. J.P. Jat State Demographer DMHS - Govt. of Rajasthan Mr. N.L. Paliwal Social Scientist DMHS - Govt. of Rajasthan Dr. Jal Singh C.O. F.R.U DMHS - Govt. of Rajasthan Dr. Shiv Chandra Mathur Executive Director State Health Systems Resource Centre Rajasthan Dr. Anuradha Aswal Nodal Officer Training & Child Health DMHS - Govt. of Rajasthan Dr. Indra Gupta Nodal Officer SBA DMHS - Govt. of Rajasthan Ms. Vaidehi Agnihotri Coordinator-VHSC DMHS Govt. of Rajasthan Mr.Lalit Kumar Tripathi Consultant-HRHH DMHS Govt. of Rajasthan Dr. Laxman Singh Jadoun Medical Officer- Kanwatia Hospital DMHS Govt. of Rajasthan Dr. Kishor Kumar Medical Officer- CHC- Chomu DMHS- Govt. of Rajasthan Ms. Poonam Srivastava District Maternal &Child Health Coordinator Bharatpur Dr. Sheetal Joshi Consultant DMHS - Govt. of Rajasthan Dr. Madhu Dhamija S.M.O., Govt. Hospital -Sri Ganganagar DMHS - Govt. of Rajasthan Dr. Ragini Agrawal S.M.O. Udaipur DMHS - Govt. of Rajasthan Dr. R.K. Vijayvargiya S.M.O, Govt. Dispensary Ajmer DMHS - Govt. of Rajasthan Dr. Dinesh Kharadi Medical Officer, Udaipur DMHS- Govt. of Rajasthan Mr. Kaushal Kumar District Programme Manager - Churu DMHS - Govt. of Rajasthan Dr. Manoj Vijay Rural Medical Officer CHC- Bhopalsagar- Chittorgarh DMHS - Govt. of Rajasthan Mr. Abid Siraj Divisional Maternal & Child Health Coordinator - Ajmer DMHS - Govt. of Rajasthan Mr. Akhilesh Gupta Divisional Maternal & Child Health Coordinator - Bikaner DMHS - Govt. of Rajasthan Mr. Pawan Kumar District Maternal & Child Health Coordinator Barmer DMHS Govt. of Rajasthan Ms. Renu Yadav District Maternal &Child Health Coordinator Dausa DMHS Govt. of Rajasthan Dr. Sandeep Kumar Aggarwal RCH Medical Consultant State Institute of Health & Family Welfare Rajasthan Dr. Richa Chaturvedy RCH Medical Consultant SIHFW- Rajasthan

133 Annexure X : List of Documents Reviewed 1 Baseline survey on Child Health and related maternal Health Care, 2009, NIPI. 2 Coverage Evaluation Survey- 2009, National Fact sheet- UNICEF. 3 District level House Hold and Facility Survey-III, ; Rajasthan 4 Family Welfare statistics in India- 2009, Ministry of Health & Family Welfare, Govt. of India. 5 Family Welfare statistics in India- 2006, Ministry of Health & Family Welfare, Govt. of India. 6 Fact Sheet of Rajasthan-National Family Health Survey-III, Five Year plan IX, Rajasthan- Chapter 18 8 ICDS: Programme implementation plan- Rajasthan National Family Health Survey-I Rajasthan & India National Family Health Survey-II Rajasthan & India National Family Health Survey-III Rajasthan & India Report on Causes of Death in India ; Office of the Registrar general, Ministry of Home affairs, Govt. of India. 13 Reproductive and Child Health- District level Household Survey-II, ; Rajasthan 14 Reproductive and Child Health Project- Rapid Household survey ,Rajasthan; by IIPS 15 Rajasthan State Program implementation Plan Rajasthan State Program implementation Plan Rajasthan State Program implementation Plan Rajasthan State Report on National Rural Health Mission Sample Registration System -Statistical Report -2008, Office of the Registrar general, Ministry of Home affairs, Govt. of India. 20 Sample Registration System Maternal Mortality in India : Trends, Causes & Risk Factors, Office of the Registrar general, Ministry of Home affairs, Govt. of India. 21 Sample Registration System- Special Bulletin (April 2009) on Maternal Mortality in India ; Office of the Registrar general, Ministry of Home affairs, Govt. of India. 22 Shiv D Gupta et.al ; Maternal mortality ratio and predictors of maternal deaths in selected desert districts in Rajasthan - A community-based survey and case control study; Women s Health Issues 20 (2010) S.D.Gupta et al. Changes In IMR in Rajasthan over 25 Years; Health and Population: Perspectives and Issues Vol. 32 (2), , 2009

134 Annexure XI : Timetable Short Program Review - Child Health Government of Rajasthan Indian Institute of Health Management and Research, Jaipur Sep 20 25, 2010 Supported by: WHO Country Office for India and Norway India Partnership Initiative Agenda: Day 1 Day 1 With all SPR review participants Tuesday; Sep 21, Registration Inaugural session Welcoming remarks Inaugural ceremony Objectives of Short Program Review Round of introduction Opening Remarks and Presentation on Child Health Program in Rajasthan Tea break Overview: how the short programme review will be conducted and background concepts that will be used (from handouts 1 and 2) facilitator Step 1: Where are we going? Work in plenary session to review: goals and objectives; status of maternal and child health. Key data presented and discussed. Review and discuss Worksheets 1 and Lunch break Plenary discussion: review of child health data: summary of findings Tea break Step 2: Are interventions reaching women and children? Introduction to small group work Definition of terms Introduction to use of Worksheets 3 and 4 Small group work: worksheet 3: Groups work through the worksheet. Each group has a different point along the continuum of care pregnancy, delivery, neonatal, infants and children. The First session for Day 2 (Wednesday; Sep 22, 2010) will start at 0900h

135 Short Program Review - Child Health Government of Rajasthan Indian Institute of Health Management and Research, Jaipur Sep 20 25, 2010 Supported by: WHO Country Office for India and Norway India Partnership Initiative Agenda Day 2 5 Day 2 Wednesday; Sep 22, Step 2: Are interventions reaching women and children (continued) Small group work: review of coverage indicators. Complete worksheets 3 and 4. Summarize findings on computer template. Present, discuss and summarize findings in plenary session Tea break Step 3: How well are programme activities being implemented? Introduction to small group work Definition of terms Introduction to use of Worksheet 5 Group work: worksheet 5. Groups work through the worksheet. Each group has a different point along the continuum of care pregnancy, delivery, neonatal, infants and children Lunch break Group work Step 3: continue review and complete worksheet Tea break Group work Step 3: continue review and complete worksheet 5. Summarize findings on computer template Plenary session Step 3: each group summarizes findings from their level of the continuum of care: how well the programme implemented maternal and child health interventions.

136 Day 3 Thursday; Sep 23, Step 4: Identify the main problems the programme has faced Review of previous steps and introduction to worksheet 6 Small group work: identify the main problems identified for each of the main activity areas. Summarize findings on flip charts Tea break Small group work (continued): summarize problems for each activity area Lunch break break Plenary session Step 4: summarize problems identified by all groups into a single list of common problems Tea break Complete plenary session Step 4: summary of problems Day 4 Friday; Sep 24, Step 5: Identify solutions and recommendations to the main problems Introduction to group work and begin group work Summarize findings using standard template Tea Break Small group work (continued) Lunch break Plenary session Step 5: summary and discussion of solutions and possible recommendations Tea break Summary of next steps Feedback from participants Day 5 Saturday ;Sep 25, Step 6: decide on next steps for taking action on recommendations Step 7: Present SPR findings Formal Closing Ceremony Lunch break

137 References 1 BPNI (2008). Infant Survival and Development Report Card Rajasthan: Information Sheet No 25. BPNI, New Delhi 2 Department of Medical, Health and Family Welfare, GoR (2009). National Rural Health Mission(NRHM) State Program Implementation Plan : Volume I 3 Department of Medical, Health and Family Welfare, GoR (2009). National Rural Health Mission(NRHM) State Program Implementation Plan : Volume II 4 Department of Medical, Health and Family Welfare, GoR (2009). National Rural Health Mission(NRHM) State Program Implementation Plan Department of Women and Child Development, GoR (2008). State Child Policy. Jaipur : WCD, GoR 6 Department of Women and Child Development, GoR (2009). ICDS State Programme Implementation Plan. Jaipur : WCD, GoR 7 Gupta SD et al (2009)." Changes In IMR in Rajasthan over 25 Year", Health and Population: Perspectives and Issues. 32 (2): Gupta SD et al (2010). "Maternal mortality ratio and predictors of maternal deaths in selected desert districts in Rajasthan - A community-based survey and case control study", Women s Health Issues 20 : International Institute for Population Sciences (IIPS), 2001.Reproductive and Child Health Project Rapid Household Survey (Phase I & II) : India.Mumbai: IIPS 10 International Institute for population Sciences (IIPS), District Level Household Survey (DLHS-2), : India. Mumbai: IIPS 11 International Institute for population Sciences (IIPS), District Level Household Survey (DLHS-2), : Rajsthan. Mumbai: IIPS 12 International Institute for Population Sciences (IIPS), District Level Household and Facility Survey (DLHS-3), : India.Mumbai: IIPS. 13 International Institute for Population Sciences (IIPS), 2010.District Level Household and Facility Survey (DLHS-3), : India. Rajasthan Fact Sheet. Mumbai: IIPS. 14 International Institute for Population Sciences (IIPS), 2010.District Level Household and Facility Survey (DLHS-3), : India. Rajasthan. Mumbai: IIPS. 15 International Institute for Population Sciences (IIPS),1995.National Family Health Survey (MCH and Family Planning), India : India. Bombay: IIPS. 16 International Institute for Population Sciences (IIPS)and ORC Macro International,2007.National Family Health Survey (NFHS-3), India, : India : Volume I. Mumbai: IIPS.

138 17 International Institute for Population Sciences (IIPS)and ORC Macro International,2007.National Family Health Survey (NFHS-3), India, : India : Volume II. Mumbai: IIPS. 18 International Institute for Population Sciences (IIPS)and ORC Macro International,2008.National Family Health Survey (NFHS-3), India, : Rajasthan. Mumbai: IIPS. 19 International Institute for Population Sciences (IIPS)and ORC Macro,2001.National Family Health Survey (NFHS-1), India, : India. Mumbai: IIPS. 20 International Institute for Population Sciences (IIPS)and ORC Macro,2001.National Family Health Survey (NFHS-2), India, : Rajasthan. Mumbai: IIPS. 21 Lawn JE, Cousens S, Darmstadt GL, et al(2006). "1 year after The Lancet Neonatal Survival Series was the call for action heard?", Lancet. 367: Ministry of Health and Family Welfare, GoI (2009).Family Welfare Statistics in India New Delhi :MoHFW, GoI 23 Planning Commission, Government of India, New Delhi (2006). Report on Health of Women and Children for the Eleventh Five Year Plan ( ) 24 Sample Registration System (2008). Statistical Report Registrar General of India, Vital Statistics Division, New Delhi 25 Sample Registration System (2009). Monthly Report October Registrar General of India, Vital Statistics Division, New Delhi 26 Sample Registration System (2009). Special Bulletin on Maternal mortality in India Registrar General of India, Vital Statistics Division, New Delhi 27 UNICEF (2008). The state of the world's children Available from: 28 UNICEF (2010). Coverage Evaluation Survey National Fact Sheet. UNICEF India Country Office, New Delhi 29 World Health Organization (2010).Using Data for reviewing child health programmes (Short Programme Review) 30 World Health Organization (2010). Countdown to 2015 decade report ( ): taking stock of maternal, newborn and child survival.

139 Small Group Sessions