Recommendations of June 19, 2008 Ayia la Aerie iaRecommendations of Health Sector Reforms Workshop 1.The State level Health sector reforms workshop was convened on June 19, 2008 at SIHFW, Jaipur to identify policy measures needed to improve the health indicators and implementation gaps identified in the NFHS-III survey findings. The concerted policy response for improving Rajasthan's health indicators is necessary for timely and effective implementation of the National Rural Health Mission Programs. List of participants is placed at annex 02. 2. The salient findings of NFHS-II] are as follows: Key indicators NFHS-III findings ‘Total Fertility Rate (TFR) B21 Total Unmet need 147 3 ANC visits At2 Institutional Births O22 Mother Received Post Natal Care from Health Staff within 2 days of delivery 28.9 Children (12-23) Fully Immunized 26.5 Children age 12-35 months who received a Vitamin A dose in last 6 months 13.2 Children under 3 years who are under weight 44.0 The detailed key indicators for Rajasthan from NFHS-I] are atannex 01.3. The workshop deliberated the NFHS-III findings. The year- wise NRHM goals for Rajasthan are the following: Indicators 2007-08, Current 2008-09 2009-10 2010-11 2011-12 Status | Maternal Mortality 285 445, 248 213 180 148 Ratio (MMR) | SRS-03 Infant Mortality Rate 51 65 46 41 3 32 | (IMR) NFHS-I11| Total Fertility Rate 2.6 32 24 |, 23 | 22) | 24 (TER) NFHS-IIT Institutional Deliveriey 60.87 32.2 70.65 | 80.43 90.22 | 100 aD) NFHS-II Crude Birth Rate B56 | 283, | 244 | 233 | 224 | 21 (CBR) SRS-06 Full Immunization 26.5 | | NFHS-IIL 85 4.The Participants felt that NRHM goals appear difficult to achieve, unless policy corrections are made. The following policy recommendations were made; NRHM/RCH-IL Immunization The objective is to achieve 100 percent Immunization envisaged under the NRHM goals. For this purpose the following actions are recommended; (1) Computerisation of Service Delivery Registers at CHC level. (2) A person with data and computer should be deployed for tracking. Immunization camps in Schools. Need to address dropouts of immunization. Specially tread back immunization of girls left behind.(5) Performance based service guarantee for MCHN days. Immunization reporting to improve. (6) ASHAas Social Mobiliser should have a due list prepared for each session to track all children in the village. The objective is to reduce IMR from 67 to 32 per 1000 live births and MMR from 445 to 148 per 100000 live births by 2012. For this purpose the following actions are recommended; (7) NRHM needs to focus on the big picture-Infant Mortality /Maternal Mortality /Malnutrition on annual basis. (8) Monitoring of deaths for Still Births and deaths in transit. (9) Medical college should conduct a study of the reasons for still births. Sikar districts should be taken in first phase.(10) Maternal death audits/ verbal autopsy should be conducted on regular basis. Janani Suraksha Yojana-JSY ‘The objective is to achieve 100 % institutional deliveries by 2012 envisaged under the NRHM goals. For this purpose the following actions are recommended; (11) Concurrent Evaluation of JSY for impact assessment of improvement in IMR/MMR. (12) Payment record should be kept properly and payments should be made within 7 days. (13) Functionality of health facilities and 24X7 services should be ensured. (14) Mobile numbers of all Medical Officer's should be displayed at the front view of PHCs/CHCs. (15) ANC/PNC care should be improved and mandatory for the JSY benefits. (16) Patient Counsellors-Rogi Mitras should be strengthened.Trainings ‘The objective is to do capacity building of the medical staff under NRHM. For this purpose the following actions are recommended; (17) Enhance trainings of Medical officers. Focus on training health administrators. (18) Health sector reform workshop to be held on annual basis. (19) Evaluation of BCC trainings should be carried out. Additionalties under NRHM PPP Initiatives The participation of private sector to meet public health goals has been envisaged under NRHM to provide effective health care to the rural population, especially the disadvantaged groups including women and children. For effective use of PPP initiatives following actions are recommended; (20) Operationlize EMRI ambulance service/Urban RCH/Medical Mobile Unit. (21) Chiranjivi Scheme of Gujarat should be experimented in pilot mode. (22) Equality in accreditation norms for JSY between public/ Private Institutions. (23) Private sector participation in RCH services to be encouraged to achieve NRHM targets. (24) PPP model for providing family health services. Accreditation of private institutions should be increased. (25) Evolve policies for greater private investment-NGOs role in running PHC/Sub centres.ASHAs ASHA as a change agent are expected bring the reforms in improving health status of the community under NRHM. ‘To strengthen ASHAs the following actions are recommended; (26) Every village a health worker should exist. (27) Strengthening linkages with nearest health facility. (28) Identity cards for ASHAs should be ensured. (29) Payments to ASHAs by cheque only. (30) Villages with less than 500 populations should have at least one health functionary in the village. If the AWW or ASHA/ Sahyogini doesn't identify a person; Health Department will identify an ASHA with relaxed qualification (Specially for Barmet and Jaisalmer district). (31) AWW's to take up early pregnancies; symptoms to be picked up. Village Health Sanitation Committee The NRHM framework supports decentralized planning & monitoring up to grass root level. It has been decided to entrust to village level committees planning monitoring & implementation of NRHM activities in 41000 revenue villages of the State. VHSCs would be the first check on Health institutions. For this purposethe following actions are recommended; (32) Village level committee should provide Untied assistance to take up any activity of their choice not necessarily health activity to promote cohesiveness. (33) Self Help Group representatives should be members of the VHSC. (34) Functional VHSCs to be formed- 182 VHSCs in pilot phase should be studied. Mother NGOs to be involved for the operationalisation of VHSCs. (35) Task force should be formed for creation of VHSCs. Strengthening of DataManagement M&E The core strategy of the NRHM is to strengthen capacities for data collection, assessment and review for evidence based planning, monitoring and supervision. ‘To enhance the competence of State to monitor activities under NRHM with special focus on RCH programme following actions are recommended; (36) Creation of a Dungarpur model for data validation (pilot study). (37) Health Management systems of RHSDP to be adopted for sealing up. (38) Preparation of Health cards. (39) Data triangulation method to be adopted. (40) Formation of Health Monitoring and Planning Committees at CHC/DH Levels. (41) HEALING to be provided general web areas. (42) Evaluation studies should be carried out through external agencies such as IHMR, IDS etc.(43) Civil registration system needs to pickup. (44) Tamil Nadu Model of M&E, to be adopted-Monitoring ‘Teams of Blocks CMO/CDPO. Other Recommendations ‘The other recommendations for achieving NRHM goals are as follows; (45) Vertical Programs in Health Care are not working so Inter Sectoral convergence is necessary between (a) AIDS society & NRHM (b) RHSDP & NRHM (c) WCD & NRHM(d) PRI & NRHM. (46) Specific additional allocations for functional MTCs. (47) Field tours by SPMU consultants for greater collaboration with NGOs. (48) Preventive aspects of Malnutrition to be closely pursued. For adolescent girl child mid day meal till class 'X' so that malnutrition can be better addressed. (49) Sectoral Interventions for (a) Tribal areas; (b) Slum areas (c) Core desert areas / JJMR/BMR/JDPR. (50) State Level Telephone Line '177' toll free number should be initiated for grievance redresssal with Relief dept. (61) Accreditation of CHCs in 'A'/ 'B'/ 'C' grades and incentives for moving up/down. (62) Concept of unmet need to be better examined and quality of ongoing services should be ensured. (53) Primary health services should be provided by stationary staff. Mobile clinics to visit on a weekly basis. (54) Population criteria for sub centres in tribal and desert arcas should be revised to 1500 because of far distance and low densiy of population In these areas,Pitts Key Indicators for Rajasthan from NFHS-3 Marriage and Fertility 1. Women age 20-24 married by age 18 (9) S71 358 657 725 Oho 440 7.9 683 695 2. Men age 25.29 martied by age 21 (%) 567 354 660 738 619 480 447 na oa 3, Total fertility rate (children per woman) B21 221 362 371 273 242 182 378 363 4, Women age 15-19 who were already smothers of pregnant atthe time oF che survey () 160 81 190 28 193 30 nana 5, Median age at. rt birth for women age 25-49) 196 201 W4 193 192 22 27 194 197 6, Married women with 2 living chikiren wanting no ‘more children (% TAB 853 646 G28 765 S14 930 583 442 6a, Two sons BBO 921 792 765 927 * 956 748 574 6b, One soa, one daughter TIT 905 689 662 838 858 957 Gt 530 Ge, Two daughters 31 514 182-2600 * * 125 67 Family Planning (currently married women, age 15-49) Current use 7. Any method (2) 412 657 405 441 479 569 625 403 319 8. Any modern method (%) MA 620 380 M16 46.1 51.0 577 381 310 8a, Female sterilization (2) M2 96 322 360 331 313 261 308 254 Sb. Male stetilization (7) 08 17 05 05 o4 16 06 15 24 Se. TUD (%) 16 24 13 12 14 18 49 12 12 8d, Pill 4) 20 49 10 08 38 50 55 15 05 Be, Condom (2) 58 133 31 27 77 «10 22 34 18 Unmet need for family planning 9, Towa unmet need (%) 147 98 165 143 160 162 140 176 198 9a, For spacing (%) 73 52 81 59 17 125 81 87 108 9b. For limiting (26) 74 46 84 84 53 37 59 89 90 Maternal and Child Health Maternity cate (for births in the last 3 years) 10. Mothers who had atleast 3 antenatal care visits for theie ast birth (%) M2 747 325 285 56.1 735 86.0 236 18 11, Mothers who consumed IFA for 99 days or more ‘when they were prepnant with their last child @) 28 M7 81 62 154 6 569 na om 12. Births assisted by a doetor/aurse/LHV/ANM/other health, personnel (4) 1432 770 M6 312 580 708 993 388 193 15. Institutional bieths (4) 1322 617 233 206 458 2 789 215 120 14, Mothers who received postnatal ear from a doctor/ snurse/LHV/ANM/other health personnel within 2 days of delivery for their ast birth (4) 28:9 Child immunization and vitamin A supplementation! 15a, Children 12-23 months fully immunized (BCG, measles, and 3 doses each of palio/DPT) (%) 265 443 221 25 286 418 614 173 21d 197 S04 742 ona15b, Children 12-23 months who have received BCG (2) 6885 15e, Childeen 12-23 months who have received 3 doses of polio vaccine ( 652. 15d, Children 12.23 months who have received 3 doses of DPT vaccine ( 387 15e. Children 12-23 months who have received measles vaccine (7) 427 16, Children age 12-35 months who received a vitamin A dose jn last 6 months (4) 2 ‘Treatment of childhood diseases (children under 3 years)! 17. Childeen with diaeehoea in the last 2 weeks who received ORS (8) 160 18, Children with diarthoea in the last 2 weeks taken to a Dealt facility (2) 3606 19. Children with acute espiratory infection or fever inthe lst weeks taken to a health vclty (2) 689 Child Feeding Practices and Nutritional Stats of Children 20. Children under 3 years breastfed within one hour of birth (6) 8 21, Children age 0-5 months exclusively breastfed (4) 382 22. Children age 6-9 months receiving solid or semi-solid food and breastmilk (%) 387 25. Children under 3 years who are stunted (%) 337 24. Chidven under 3 years who are wasted (4) 197 25. Children under 3 years who are underweight ( wo Nutritional Status of Ever-Married Adults (age 15-49) 26, Women whose Body Mass Index is below normal ( 336 27. Men whose Body Mass Indes is below normal (/ 338 28, Women who are overweight or obese (2) 102 29, Men who are axerweight ci obese 7) Be. Anaemia among Children and Adults 30, Children age 6-35 months who ate anaemic (4) 76 31. Everamarried women age 15-49 who are anaemic (%) 83.1 32, Pregnant women age 15-49 who are anaemic (%) 612 33, Ever-marrried men age 15-89 who are anaemic (6) 203 Knowledge of HIV/AIDS among Ever-Martied Adults (age 15-49) 3d. Women who have heard of AIDS (%) 338 35, Men who have heatd of AIDS () m2 36, Women who know that consistent condom use can reduce the chances of getting HIV/ AIDS (%) 2A 37. Men who know that consistent condom use ean reduce the chances of getting HIV/ AIDS (%) 32 Women’s Empowerment 38, Currently marsied women who usually participate in household Alecisions (%) oe 39, Kivermarried women who have ever experienced spousal violence (4) 46.3 na noc avilable * Not showin; based on fewer than 25 unweighted eases T6L no 36 190 280 192 256 2s BA 193. 75 480 645 164 730 96.3 616 630 326 384 nz 15 657 210 340 364 199 459 308 386 38 a so 54.9 ot 23 193, O45 147 520 43, 166 at 323 404 223 50.0 31 74 30 803 55.0 613 287 1s 417 98 260) 384 504 167 80.7 aut 492 ve 6 488 286 179 355 37 389 13 a 808 542 63 21s 569 BI 433 593 958 44 176 27 10.1 321 329 383 165 94 805 558 2m 872 O18 78 826 406 158 189 ws 254 187 700 340 105, 988 987 583 207 1. Baza om tho last 2 bith in tbe 3 yeors befor the curve; 2. Por children be edcaton refers tothe mother’ education. Ciao 203 253 52.0 Ww 506 3 a 23 485) 514 456 39 296 a3 124 500 48 a8 212 443 BREAnnexure-02 List of Participants in Health Sector Reform Workshop on June 19, 08 S.No.Name rey BD Sh. Narpat Singh Rajvi Sh. Parmesh Chandra Ms. Alka Kala Mr. R. K. Meena Mr. V, Srinivas Ms. Roli Singh Mr. B. Praveen Ms, Sarita Singh Mr. K. K. Gupta Dr. ©. P. Gupta Dr. M. L. Jain Dr. R.N. D. Purohit Dr. Akhilesh Bhargava Dr. Manisha Chawla Dr. S. P. Yadav Ms, Laxmi Bhawani Mr. Nesim Tumkaya Dr. Madhulika Bhattacharya Dr. Dinesh Baswal Prof. Sulbha Parsuraman Dr. Narendra Gupta Designation Hon'ble Medical & Health Minister Additional Chief Secretary (SI) Principal Secretary (WCD) Principal Secretary (Health) Secretary, FW and MD, NRHM Project Director, RHSDP Director, ICDS Director, Women Empowerment Project Director, NRHM Director, Public Heath Director, RCH Director, AIDS Director, SIHFW CARE India, Rajasthan State Program Officer, NIPI UNICEE Jaipur Country Director, UNFPA, New Delhi Prof. NIHFW Asst. Comm. Trg, MoHFW, New Delhi Professor, IIPS, Mumbai Prayas, ChittorgarhDr. PR, Sodani Dr. R.S. Gupta Dr. R.P Jain Dr. R. K. Rai Singhani Mr. J. B. Jat Jai Singh Shekhawat Mr. Sumer Singh Mr. Sunil Sharma Mr. Ram Karan Singh Mr. Ravi Upadhyay Dr. Anuradha Aswal Dr. Vandana Mishra Ms. Vishanti Chauhan Dr. Indra Gupta Ms. Vaidehi Agnihotri Dr. B.S. Babel Dr. Girdhar Gopal Dr. Afifa Zafer Dr. S.S. Yadav Dr. Vishal Singh Dr. Mamta Chauhan Mr. Sanjeev Dham Ms. Manita Jangid Dr. Nupur Dubey Mr. Sharad Iyenger Associate Professor, IIHMR, Jaipur Addl. Director, RCH Joint Director (Gazetted) Joint Director, Plan Demographer & Evaluation Officer, FW State Program Manager, NRHM State Finance Manager, NRHM. State Accounts Manager, NRHM State Data Officer, NRHM. Consultant, HRD. Consultant, Training Consultant, IMNCI Consultant, SBA Consultant, RCH Camp Coordinator, ARSH Consultant, FRU AD AYUSH Faculty, SIHFW Faculty, SIHFW Faculty, SIH FW Faculty, SIHPW PSI Consultant, Urban RCH RSACS. ARTH, UdaipurDirectorate, Medical, Health and Family Welfare (NRHM) (ia Swasthya Bhavan, Tilak Marg, C-Scheme at Rolla ato atc) website: www.nrhmrajasthan.nic.in website: www.rajswasthya.nic.in