Short Programme Review - South-East Asia Regional...
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Short Programme Review
Child Health Programme in Rajasthan
2010
Presentations during inaugural session
Shri BN Sharma, Principal Secretary
Health and Family Welfare, addressing
the workshop on the closing day.
Preliminary Facilitator Meeting
Dr ML Jain lighting the lamp to formally inaugurate the proceedings on 21 Sep 2010
Plenary Sessions
REPORT
ON
SHORT PROGRAMME REVIEW ON CHILD HEALTH
IN
RAJASTHAN
Directorate of Health & Medical Services, Government of Rajasthan
Institute of Health Management Research (IIHMR), Jaipur
Norway India Partnership Initiative (NIPI)
World Health Organization, Country Office for India
2010
Contents
Abbreviations ................................................................................................................................................. i
Executive summary ...................................................................................................................................... iii
1. BACKGROUND .................................................................................................................................. 1
1.1 Background information of Rajasthan State ....................................................................................... 1
1.2 Child health situation in Rajasthan ..................................................................................................... 2
1.3 Child health programmes in Rajasthan ............................................................................................... 2
2. The Short Programme Review .................................................................................................................. 3
2.1 Objectives ......................................................................................................................................... 3
2.2 Proposed Participants ....................................................................................................................... 4
2.3 Methods Used ................................................................................................................................. 4
2.3.1 Preliminary data collection and adaptation of Worksheets .......................................................... 4
2.3.2 Data Sources: ............................................................................................................................... 4
2.3.4 Period of Review .......................................................................................................................... 5
2.3.5 Formation of review team ............................................................................................................ 5
2.3.6 Preliminary Workshop ................................................................................................................. 6
2.4 Steps of SPR ..................................................................................................................................... 6
2.5 Inaugural Session .............................................................................................................................. 7
3. Goals and Objectives of the Child Health Programme ............................................................................. 7
4. Neonatal and Child Health Status ............................................................................................................. 8
5. Intervention Coverage ............................................................................................................................... 9
5.1 Interventions and delivery of packages ............................................................................................... 9
5.1 Coverage Indicators .......................................................................................................................... 10
6. Summary of status of the child health programme ................................................................................. 12
6.1 Summary of technical areas along the continuum of care: ............................................................... 12
6.1.1 Status of Implementation ............................................................................................................... 13
6.2 Summary of Strengths and Weaknesses ........................................................................................... 20
6.2.1 Maternal Group .............................................................................................................................. 20
6.2.2 Newborn Group ............................................................................................................................. 21
6.2.3 Child Group ................................................................................................................................... 22
6.3. Identifying the main problems ............................................................................................................. 24
7. Core problems, Solutions and Recommendations .................................................................................. 24
7.1 Listing the Core Problems ................................................................................................................ 24
7.2 Reorganization of Small groups ........................................................................................................ 24
7.3 Group Activity: Completing Worksheet 7 ........................................................................................ 25
7.4 Decide on next steps ......................................................................................................................... 25
7.5 Presentation of findings and finalization of recommendations ......................................................... 25
7.6 Final Recommendations .................................................................................................................... 26
7.6.1 Group I. Policy, Planning and Management / Monitoring and Evaluation .................................... 26
7.6.2 Group II. Human Resources, Training and Strengthening Health Systems ................................... 29
7.6.3 Group III. Health Communication / IEC and Development of Community Supports ................... 32
7.6.4 Core Group: Scaling up of existing interventions for Child Health ............................................... 35
Annexure I: Day wise summary of Steps completed
Annexure II: Worksheet 1
Annexure III : Worksheet 2
Annexure IV: Worksheet 3
Annexure V : Worksheet 4
Annexure VI : Worksheet 5
Annexure VII: Worksheet 6 (Consolidated)
Annexure VIII: Worksheet 7
Annexure IX : List of Participants
Annexure X : List of Documents Reviewed
Annexure XI : Timetable
References
Acknowledgement
It was indeed a great pleasure to host the Short Programme Review on Child Health in Rajasthan, the first
workshop on the SPR CH package in India.
On behalf of the entire organizing team, I express my sincere thanks to Shri BN Sharma, Principal Secretary Health
and Family Welfare, Government of Rajasthan for his keen interest, support and involvement in the programme
which got the entire process rolling.
I wish to thank the World Health Organization for taking the initiative to organize the Short Programme Review in
Rajasthan. Special thanks are due to Dr Samira Aboubaker, Dr Mikael Ostergren, Dr Harish Kumar,
Dr Rajesh Mehta and Dr Paul Francis, for their expert role and guidance throughout the programme. My special
thanks to Dr Subodh S Gupta for his excellent efforts in coordinating the programme on behalf of WHO.
I acknowledge the active participation and contribution of Dr Kaliprasad Pappu, National Coordinator, NIPI and
overall support provided by UNOPS-NIPI for organizing this workshop.
I thank Dr ML Jain, Director RCH, Directorate of Medical and Health Services, Government of Rajasthan for his
unflinching support, active participation and valuable inputs. The success of this workshop owes much to his pivotal
role in constituting the team participants representing the state government in this review. I also acknowledge the
efforts of Dr Anuradha Aswal, Nodal Officer Training and Child Health, Directorate of Medical and Health
Services, Government of Rajasthan for coordinating the state team of participants and helping in data review. I wish
to thank Dr Avatar Singh Dua, UNICEF State Office, Jaipur, Dr Karanveer Singh, Programme Officer Child
Health, NIPI; Dr SP Yadav, Senior Programme Officer, NIPI , Rajasthan; Dr Shiv Chandra Mathur, Executive
Director, RHSRC and Dr Akhilesh Bhargava, Director SIHFW, Jaipur, for sparing time to provide key information
on State programmes during interviews before this workshop.
Much of the success of this workshop goes to the active involvement and participation shown by all the participants.
Inputs given by the state programme managers and the field experience brought in by the district level officials and
programme coordinators were vital to this review. Inputs and active participation by faculty from departments of
Preventive and Social Medicine and Paediatrics, SMS Medical College, Jaipur and representatives from NIHFW
(New Delhi), UNICEF India (New Delhi), , CARE India (Rajasthan), Save the Children (Rajasthan) and Vatsalya
(Jaipur), IIHMR Bangaluru, is gratefully acknowledged.
I must specially mention the contribution of Dr Suresh Joshi, Professor, and IIHMR Jaipur, whose overall guidance,
expertise and lead facilitation were crucial for the success of this workshop.
I take this opportunity to compliment the local organizing team from IIHMR led by Dr Vinod Kumar SV,
Assistant Professor IIHMR for their flawless conduct of the event. I acknowledge the efforts of Mr Gowtham Ghosh
Research Officer, IIHMR Jaipur whose efforts and dedication were evident in the data review. I appreciate the
efforts of Dr Vivek Lal, Assistant Professor, IIHMR Jaipur in the preparations and conduct of the workshop. The
Institute’s administration, finance and computer department deserve special thanks for extending valuable logistic
and other support in facilitating the programme.
Shiv Dutt Gupta, MD,FAMS,Ph.D [Johns Hopkins University]
Director
Institute of Health Management Research
Jaipur
i
Abbreviations
AIDS Acquired Immunodeficiency Syndrome
ANC Ante Natal Care
ANM Auxiliary Nurse Midwife
ARI Acute Respiratory Infection
ASHA Accredited Social Health Activist
AWC Anganwadi Centre
AWW Anganwadi Worker
AYUSH Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homeopathy
BEmOC Basic Emergency Obstetric Care
CEmOC Comprehensive Emergency Obstetric Care
CHC Community Health Centre
CHW Community Health Worker
DLHS District Level Household Survey
DMHS Directorate of Medical and Health Services
EmOC Emergency Obstetric Care
F-IMNCI Facility based Integrated Management of Neonatal and Childhood Illness
FRU First Referral Unit
FWS Family Welfare Statistics
HBPNC Home Based Post natal Care
HIV Human Immunodeficiency Virus
HMIS Health Management Information System
HW Health Worker
ICDS Integrated Child Development Services Scheme
IEC Information, Education and Communication
IIHMR Institute of Health Management Research
IMNCI Integrated Management of Neonatal and Childhood Illness
IMR Infant Mortality Rate
IVR Interactive voice response
JSY Janani Suraksha Yojana
LHV Lady Health Visitor
LSAS Life Saving Anesthesia Skills
MCHN Maternal Child health and Nutrition Day
MD Mission Director
MDG Millennium Development Goals
ii
MMR Maternal Mortality Rate
MNCH Maternal Newborn and Child Health
MO Medical Officer
MoHFW Ministry of Health and Family Welfare
MTC Malnutrition Treatment Centre
NFHS National Family Health Survey
NGO Non-governmental Organization
NIHFW National Institute of Health and Family Welfare
NIPI Norway India Partnership Initiative
NMR Neonatal Mortality Rate
NRHM National Rural Health Mission
NSSK Navjat Shishu Suraksha Karyakram
PCTS Pregnancy and Child Health Tracking System
PHC Primary Health Centre
PHS Principal Health Secretary
PIP Program Implementation Plan
PNC Post Natal Care
PPTCT Prevention of Parent to Child Transmission
RCH Reproductive and Child Health
RHS Rapid Household Survey
RHSDP Rajasthan Health Systems Development Project
RI Routine Immunization
ROP Record of Proceedings
SBA Skilled Birth Attendant
SC Sub Centre
SEARO South East Asia Regional Office
SHSRC State Health Systems Resource Centre
SIHFW State Institute of Health and Family Welfare
SPR Short Program Review
SPR-CH Short Program Review- Child Health
SRS Sample Registration System
UBR Universal Birth Registration
UNICEF United Nations Children Fund
VHND Village Health and Nutrition Day
VHSC Village Health and Sanitation Committee
WCD Women and Child Health Department
WHO World Health Organization
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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
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NGOs (Save the Children , Vatsalya, CARE) and UN Agencies (WHO, UNICEF and UNOPS)
also participated in the review process.
A one day workshop was held on 20th September, 2010 for reviewing overall preparations,
finalizing the worksheets ( filled in by reviewing and gathering information from different
published documents & other sources) and training of facilitators. The workshop on „Short
program review of Child health in Rajasthan‟ was held from 21st September to 25
th September,
2010 at IIHMR, Rajasthan – India.
SPR-CH adopted a systematic participatory approach consisting of 7 sequential steps which the
team completed in a week. Participants reviewed the available data on maternal and child health
and decided the implementation status of the child health interventions. The review team was
divided into three smaller groups viz Maternal Health, Newborn Health and Child Health
Groups. Participants worked on sequential worksheets of the SPR review process, discussing and
reviewing available data gathered from data review as well as from the policy/programme
documents. Lists of documents used in the data review as well as during the SPR is appended
vide Annexure X.
In addition group discussions enabled sharing of views, experiences and individual discussion
with selected individuals provided more insights. Findings from group discussions were later
presented in the plenary for finalization. Based on the findings, participants defined the main
problems for further analysis. The participants were then regrouped into three thematic groups
policy/planning, management and monitoring & evaluation; Human Resources and Training;
Community supports and IEC, based on the activity areas forming part of the implementation.
Thematic groups discussed and reviewed the problems and identified possible solutions, which
were used as the basis for developing detailed recommendations about what the program should
do in major activity areas.
The recommendations developed by thematic groups were presented before the officials of the
state government and various stakeholders. The feedbacks were recorded and the
recommendations were forwarded to a core team for finalization and prioritization. The core
team had representation from all the stakeholders including the state government, UN agencies
(WHO, UNOPS-NIPI, UNICEF). Representatives from IIHMR were also part of the core team.
The final recommendations were prioritized into two categories - immediate and successive,
taking into consideration their relative importance and feasibility of incorporation in the next or
successive PIPs. The core team also decided to organize a meeting to formally disseminate the
findings of the report to all key stakeholders. The recommendations which merit immediate
priority are enumerated below:
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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.
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Health communication, IEC and development of community supports
Ensure provision of IEC materials as well as AV aids at facility level (CHC and 24X7
PHC level)
Strengthen relevant section on health communication in the state PIP with an activity
plan including R and D with budget allocations.
IEC Activities for child health focusing on the Key Messages
Complete the ongoing training of VHSCs within one year followed by hand holding
support through allocation of a set of villages to PHC level supervisors
Capacity building of supervisors to be completed in the next six months.
Expedite the process of training of ASHA on module 5.
Core Group: Scaling up of existing interventions for Child Health
Scale-up of IMNCI in all districts; Ensure supplies for IMNCI drugs at all levels
Rapid scale-up of F-IMNCI in high-focus districts on priority basis
Strengthening of community-based management of newborn and childhood illnesses
through ASHA and Anganwadi Workers
Strengthening of infra-structure and services for Facility-based Newborn Care in high-
focus districts (includes Special Care Newborn Unit, Neonatal Stabilization Unit and
Newborn Care Corners)
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1. BACKGROUND
India is a signatory to Millennium Development Goals. However, as per the Countdown report
2010, India is unlikely to achieve MDG 4 of reducing the under-five mortality rate by two-third.
According to SRS 2009, Rajasthan has an infant mortality rate of 63 per 1000 live births which is
10 points higher than the national figure. There is thus an urgent need to improve intervention
coverage and reduce child deaths to come on track towards achieving MDG 4.
SPR-CH has been developed at global level to help decision- making at national or state level.
SPR-CH package helps programme managers to identify which areas need strengthening – based
on previous experiences and to set new priorities if necessary. SPR-CH reviews all the
interventions for child health directed anywhere along the continuum of care for the mother and
child- pregnancy, delivery, the post-natal period, infancy and older childhood. Interventions may
be facility- based (first-level or referral facilities); outreach; or related to behavior change
communication or community mobilization directed at the level of home or community. It also
reviews activities in all the areas which are part of process of implementation of child health
programmes; including policy, planning and financing, human resources and training, systems
supports (drug, delivery, supervision, referral etc.), communication, community supports and
monitoring and evaluation.
As health is a state subject in India, strategic directions for health programs are mostly decided at
this level. Moreover, there are lots of variations between different states in India. Therefore, it
was decided to conduct Short Program Review for Child Health at state level in India. Rajasthan,
being one of the focus states for Norway India Partnership Initiatives and having supportive
environment for new initiatives in health sector, was chosen for the first Short Program Review
in India.
1.1 Background information of Rajasthan State
Covering an area of 342,239 sq km (132,150 sq mi) Rajasthan is the largest state in the Republic
of India. Jaipur is the capital of the State. The population of the state is 56.5 million according to
2001 census, which is 5.49 percent of the national population. The ratio of the rural and urban
population is 77:23. The growth rate of population in the state at 28.41 % was higher than that of
the country 21.34 %. Rajasthan has one of the largest concentrations of SC (17.15%) and ST
(12.56%) population in the country. Socio-economic indicators are, in general lower than the
country average. 60.41% and 43.85% of its total urban and rural female population respectively
is literate, the corresponding figures for India being 64.8% and 53.7% respectively. The sex ratio
is 921 (per thousand males) compared to the country average of 933. The health indicators
particularly IMR and MMR have shown downward trends in the recent surveys (18, 25). Moreover
the Crude Birth Rate is also steadily coming down. This is a positive indication that state is moving in the
direction to achieve goals set for health sector.
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1.2 Child health situation in Rajasthan
Out of about 26.1 million children born every year in India, 9.38 lakh newborns die before one month of
life. Rajasthan alone contributes to 8.4% of country‟s total new born mortality even though it has just 6%
of country‟s population. In Rajasthan nearly 1.6 million children are born every year while a hundred
thousand die before they are one year old (1)
.
NFHS surveys showed a decreasing trend in IMR, declining from 80 (infants deaths per thousand live
births) in 1998 – 99(20)
to 65 in 2005 -06(18).
Registrar general of India has released the latest estimates of
Infant Mortality Rate (IMR), Crude birth rate (CBR), Crude Death Rate(CDR) for India and all
States/Union Territories, according to which IMR of Rajasthan has declined from 65 to 63/1000 live
births in 2008(25)
. IMR in rural areas has declined from 72/1000 in 2007 to 69/1000 in 2008 and in urban
areas it has declined from 40/1000 in 2007 to 38/1000 in 2008(25)
. Neonatal mortality rate in Rajasthan is
44/ 1000 live births (India -- 36/1000 live births), contributing to about 50% of all deaths in childhood.
Despite massive investments under RCH-II Programme and NRHM, and visible improvements in health
system, the decline in IMR has been inadequate: much less than what would be required to reach the XIth
plan goals of reducing IMR to 32/1000 live births by the year 2012. While there has been some decline in
the mortality among infants from one month to one year of life, the Newborn mortality has remained
almost static for past seven years.
The nutritional status of children in Rajasthan has improved substantially since NFHS-2(20)
, but 44% of its
children under age five years are still underweight (NFHS-3) (18)
. The problem of anemia requires radical
changes in prophylactic measures as 79.6% of the children under-3 years in rural Rajasthan are still
anaemic (NFHS-3) (18)
. According to DLHS-3(14)
(2007-08) 69.8% of children of ARI/fever and 59.7% of
children with diarrhoea had access to treatment. The usage of ORS among children suffering from
Diarrhoea was 30.6% in 2007-8 (DLHS-3) (14)
.
Access to health care and care seeking for sickness among children has definitely improved. Latest data
on care seeking for ARI in any health facility among children <2 years of age was 89.9 percent for the
state. More needs to be done to improve routine immunization coverage. The coverage of complete
immunization in Rajasthan was 53.8% (CES-2009) (28)
1.3 Child health programmes in Rajasthan
As in most of the states of the country Reproductive and Child Health Programme (RCH II) and
Integrated Child Development Services Scheme (ICDS) constitute the two major programmes of the state
directed at child health and nutrition.
RCH II under the NRHM is the state government‟s flagship programme for maternal and child health.
Conceived with a broad perspective the programme caters for the health of mothers and children bundling
the child health interventions across the prenatal to 5 year continuum and has been in action since 2005.
Integrated Child Development Services Scheme (ICDS) by Department of Women and Child (WCD) is
another major programme in the state catering to the health and nutrition interventions for children under
six years.
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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.
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2.2 Proposed Participants
For conducting SPR, a review team of close to 50 members was conceived and was proposed to include
State level programme managers and consultants, District Programme Managers, Divisional MCH
coordinators and block level service delivery personnel. In addition, Academic and Research Institutions
(IIHMR, NIHFW, SIHFW, SMS Medical College), Local and international NGOs (VATSALYA, Save
the Children and CARE India) and UN Agencies (WHO, UNICEF and UNOPS) also participated in the
review process.
2.3 Methods Used
2.3.1 Preliminary data collection and adaptation of Worksheets
The Data Review Team from IIHMR, Jaipur did the preliminary data collection and interview of key
personnel to gather background data on child health situation in Rajasthan.
Worksheets of SPR-CH package were used for the purpose. Some of the items/indicators which were not
found relevant in context of India were removed and new ones were incorporated wherever found
necessary.
Worksheets were filled in by reviewing and collecting information from published documents of various
health surveys as well as state programme implementation plans of the past three years.
Apart from reviewing the documents, some key officials and experts were interviewed to assess the
coverage of various intervention packages and their implementation and performance. Information about
relevant programmes from the experience and views of experts who had been associated with the
programmes for a long time was also incorporated in the worksheets. Various child health programmes
delivered by the Department of Medical and Health services at the state level, were covered in the
worksheets.
2.3.2 Data Sources:
In India health services and morbidity data are derived from three main sources:
(a) The National Family Health Survey (NFHS)
It is a large scale nationwide multiround household survey conducted on a representative sample
of households throughout India. The survey provides state wise as well as national information on
Fertility, Infant and Child Mortality, Maternal and Child Health, Reproductive Health, Nutrition
Anaemia, practice of Family Planning, Utilization and quality of health and family planning
services. Three rounds of NFHS have been conducted since 1992– NFHS I (1992 – 93) , NFHS II
(1998 – 99 ), NFHS III (2005 – 06)
(b) District Level Household Survey (DLHS)
It is a nationwide district level survey designed to provide information on health care and
utilization indicators on Maternal and child health, reproductive health and family planning.
Three rounds of DLHS have been conducted since 1998 – DLHS I (1998 – 99), DLHS II (2002 –
04) and DLHS III (2007 – 2008)
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(c) The report of the Registrar General of India (RGI):
Office of the Registrar General, India, initiated the scheme of sample registration of births and
deaths in India popularly known as Sample Registration System (SRS) in 1964 65 on a pilot basis
and on full scale from 1969 70. The SRS since then has been providing data on regular basis.
Based on a dual record system the SRS System in India consists of continuous enumeration of
births and deaths in a sample of villages/urban blocks by a resident part time enumerator, and an
independent six monthly retrospective survey by a full time supervisor. The data obtained through
these two sources are matched. SRS bulletins published annually provide up-to-date data on
Birth Rate, Death Rate, Growth Rate and Infant Mortality Rates at National and State Levels.
Apart from above sources, the team also incorporated findings from recent coverage evaluation
survey (28)
and state HMIS. Family Welfare Statistics of India(22)
(2009) published by the
Ministry of Health and Family Welfare , GoI and relevant research papers pertaining to Maternal
and Child Health in Rajasthan were also reviewed for reference and data collection. The complete
list of documents reviewed is appended vide Annexure X.
2.3.4 Period of Review
Since the last set of comprehensive data on various indicators relevant to this review is provided by
NFHS III (2005 – 06), it was decided to keep NFHS-III as the baseline and any data on corresponding
indicators obtained subsequently (including SRS, DLHS-III,CES-2009, HMIS, other sources) was
included in the most recent data.
2.3.5 Formation of review team
In accordance with the composition of the proposed review team mentioned earlier , representatives from
various stakeholders including State Government, International Organizations, NGOs working in the field
of maternal and child health, academic institutions were included to make the 51 member review team.
Representatives from the state Government were finalized in consultation with the Department of Medical
& Health services, Government of Rajasthan, and included state level programme managers and
consultants, district programme managers, divisional MCH coordinators and block level service delivery
personnel.
The team members comprised of nodal persons, experts working in the area of child health and
programme managers concerned with child health interventions and had the following affiliations:
Department of Medical & Health Services , Government of Rajasthan
State Programme Managers and consultants including
- Maternal Health
- IMNCI
- Immunization
- Nutrition
- Health Communication
- HMIS/ Statistics
Health Professionals including Medical Officers/Programme Managers/Coordinators
form District/Block and PHC levels
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International Organizations :
WHO (Headquarters / SEARO/India Country Office)
NIPI ( India and State Offices)
UNICEF (India and State Offices)
Academic / Research / Training Institutions :
IIHMR (Jaipur and Bengaluru)
NIHFW, New Delhi
SMS Medical College and Hospital, Jaipur
SIHFW, Jaipur
RSHRC
NGOs working in the field of Maternal and Child Health
CARE India State Office
Save the Children State Office
Vatsalya, Jaipur
2.3.6 Preliminary Workshop
A one day preliminary workshop was held on 20th September, 2010 for reviewing overall preparations,
finalizing the worksheets and training of facilitators. Representatives from the Department of Medical &
Health services - Govt. Rajasthan, Institute of Health Management Research (IIHMR), Norway India
Partnership Initiative (NIPI), WHO and UNICEF participated.
2.4 Steps of SPR
Short programme Review
7
2.5 Inaugural Session
The workshop was formally inaugurated on 20 Sep 2010 by Dr ML Jain, Director RCH, Directorate of
Medical and Health Services, GoR amidst the presence all the participants of the 5 day programme. The
inaugural session comprised of a presentation on the status of child health in Rajasthan by Dr ML Jain.
Dr Paul F Francis, National Professional Officer and Cluster Focal Point, FHR, WHO SEARO, briefed
the participants on the objectives of SPR. Dr Kaliprasad Pappu, National Coordinator NIPI and Dr SD
Gupta, Director IIHMR, Jaipur also spoke on the occasion.
3. Goals and Objectives of the Child Health Programme
As part of Step 1 of the SPR, goals and objectives of the child health programme were discussed in the
first technical session on Day 1. Working in a plenary the group discussed the programme goals and
objectives as per filled Worksheet 1 which included the programme goals and objectives from the two
major programmes on child health – RCH II and ICDS. In addition goals / objectives of relevance to child
health from disease control and other programmes were also included. Participants discussed whether
goals and objectives were written clearly and whether they were realistic and measurable. It was agreed
upon that though most of the child health related goals and objectives are clearly laid out, some of them
were either too general or were not measurable.
Goals:
The participants concluded that the Goals laid out under various programmes were satisfactory except the
one for “Reducing Newborn Deaths” which was felt to be too general and lacking clarity as to what
reduction to achieve.
Objectives :
The review team concluded that program implementation plans of the state as described in Worksheet 1,
does have many objectives which are clear and measurable but there were certain others which were
either not measurable or were not really framed as objectives. The objectives like “strengthening IEC
activities”, and “strengthening of newborn facilities at tertiary level hospitals” were not measurable while
some activities like “setting up of level II neonatal ICUs” were put under program objectives.
Child Health in Rajasthan
8
4. Neonatal and Child Health Status
Continuing in the afternoon session on Day 1, the group worked in plenary to review and discus the
indicators for maternal, newborn and child health status. In the facilitator guided discussion, the group
reviewed worksheet 2 (which was prefilled). Each indicator was reviewed by asking the following
questions:
Are data available?
Has the target been met? (if a target has previously been established)
How has it changed over time? Is it going up or going down?
Does it differ between different regions or groups?
Are there any problems with the validity or reliability of the data – are new or different methods
needed?
Consensus was arrived at for each indicator and the status was marked by: (a) Ticking for indicators with
positive results; (b) crossing those with negative results and (c) shading those with need for more data.
Summary of Key Findings :
The group reviewed available data and discussed trends to identify areas where the programme has been
doing well and those where the programme is off track and needs to do more. In addition the discussion
also focussed on finding data gaps and identified indicators with need for data collection.
The program has been doing well for improving coverage of delivery by skilled birth attendants mainly
by the marked increase in institutional delivery under Janani Suraksha Yojana. This is likely to reduce
maternal mortality.
There were a number of indicators where the progressive trends were either not on track, static or had no
set targets. Neonatal Mortality rate was identified as a key area where significant efforts would be
required. Moreover, there was no set target in the state plan for this indicator. Infant Mortality and under
five mortality rates had shown decline but the group concluded that going by the present trends,
achievement of MDG targets was unlikely. Review of data on childhood morbidity showed that
comparable data was available only for the prevalence of ARI/Pneumonia and Diarrhoea. It was found
that there was a declining trend in childhood morbidity represented by these conditions. Decline in
prevalence of anaemia among children had been insufficient and prevalence of low birth weight babies
had been relatively static.
Data on causes of death in infants and mothers were limited to few research papers and there was no
available data on causes on child mortality. It was concluded that there was a definite need to have more
data on state specific causes of death among these groups. More data was required on the prevalence of
micronutrient deficiencies, especially Vitamin A.
Short programme Review
9
5. Intervention Coverage
Step 2 of the SPR aimed at assessing the interventions included in the child health programme, delivery
mechanisms and review of the intervention coverage indicators. The participants were divided in three
smaller groups – maternal, newborn and child. Each group had a facilitator and rapporteur for the session.
In accordance with the SPR guidelines (29)
, worksheets were first discussed within the small groups, each
group covering its respective area. Updates and conclusions were finalized by the rapporteur in consensus
with members of the group. Updates were then shared in a plenary with the rapporteurs of each group
making their presentations followed by discussion and further update of the worksheets. This process was
done in sequence for worksheets 3 and 4.
5.1 Interventions and delivery of packages
The group reviewed and discussed worksheet 3 considering the following aspects
Interventions that are currently delivered
Levels at which the interventions are currently delivered
Description of packages under which the interventions are delivered
Extent of implementation : whether complete or partial
Accordingly the findings were discussed and summarized under the three heads:
(a) Availability and levels of delivery of interventions.
Interventions available were appropriate in terms of requirement and the levels at which they are being
delivered. The groups did not identify any such intervention which is lacking and needs to be introduced
afresh except IYCF, which is already being planned to be implemented.
(b) Description of packages under which the interventions are delivered :
Maternal: ANC, BEmOC, CEmOC, PPTCT, Safe Delivery Package, PNC/HBPNC
Newborn: NSSK, FBNC, IMNCI, Yashoda, PNC/HBPNC, RI, Control of Malnutrition, PPTCT
Child: IMNCI, RI, ICDS, IYCF (under planning),
(c) Extent of Implementation:
There was considerable variation in the extent of implementation of various intervention packages.
Packages which have been implemented throughout the state include ANC, PNC, BEmOC, CEmOC,
NSSK, RI, Control of Malnutrition, Supplementary Nutrition (Under ICDS), Control of ARI / Diarrhoea.
Packages with limited implementation include:
IMNCI : Currently implemented in 9 districts. Being expanded to all districts.
Yashoda : Implemented in 3 NIPI focus districts. Taken up for implementation in all districts.
HBPNC : Only in 3 NIPI action districts.
PPTCT : Currently implemented in 10 districts.
Child Health in Rajasthan
10
5.1 Coverage Indicators
Participants split again into the small groups to review worksheet 4 (Prefilled) to review the coverage
indicators. Each indicator was reviewed by asking the following questions:
Are data available?
Has the target been met? (if a target has previously been established)
How has it changed over time? Is it going up or going down?
Does it differ between different regions or groups?
Are there any problems with the validity or reliability of the data – are new or different methods
needed?
Consensus was arrived at for each indicator and the status was recorded by rapporteur by : (a) Ticking
for indicators with positive results; (b) crossing those with negative results and (c) shading those with
need for more data.
Summary of Key Findings:
The groups reviewed available coverage data and discussed trends to identify areas where the programme
has been doing well; those where the programme is off track and needs to do more and areas where there
were major issues. In addition the discussion also focussed on data gaps and identified indicators with
need for data collection.
(a) Coverage indicators with positive trends and realistic targets
Programme was found to be doing well with regards to the intranatal and immediate post natal care, being
reflected in positive trends in the data on Appropriate Cord care and Hygiene for Deliveries at Home and
Immediate Postnatal Visit. NFHS III data showed that 89.5% of babies delivered at home had the cord
cut with a clean instrument. Similarly the proportion of mothers/ newborns receiving a care contact
within first two days of delivery increased from 7.7% in 1998 – 99(20);
to 37.3 % in 2007 – 08 (14)
. With
the current rise of institutional deliveries to above 70% (28)
and universal PNC visit in case of institutional
deliveries; the target of achieving 80% immediate PNC visit mentioned in the State PIP appears realistic .
Micronutrient supplementation (except in case of Vitamin A) was another area where the indicators have
shown a healthy trend. Proportion of mothers who received iron supplementation during pregnancy has
gone up steadily from 29.2 % in 1992 – 93 to 39.3% in 1998 – 99 (20)
and was 57.7% in 2005 – 06(18)
.
Proportion of children living in household using iodized salt has also increased from 35.1% in 2005 – 06 (18)
to 58% in 2009.(28)
Care seeking for pneumonia has also risen promisingly. Proportion of children with suspected pneumonia
taken to appropriate provider has increased from 64.7% in 2005 – 06 (18)
to 89.9% in 2009 (28)
which is
sync with the set target of 90% access in the State PIP for 2010 – 11(4)
.
Short programme Review
11
(b) Coverage indicators with positive trends but programme needs to do more
Proportion of institutional deliveries has increased steadily from 22.5% in 1998 – 99 (9)
to being 31.4% in
2002 – 04 (11)
to 45.4% in 2007 – 08 (14)
. The impact of JSY was visible in significant further increase in
the proportion of institutional deliveries shown to be close to 70% as per the CES by UNICEF in 2009(28)
.
But the figure is still far from the desired target of 90% by 2011 kept under the state PIP 2010 – 11(4)
.
There are disparities in terms of rural urban differences and inter-district variations and although the
trends are good, achievement of target is unlikely.
Appropriate complimentary feeding for children in the age group of 6 -9 months has been quite low and
the proportion of infants aged 6-9 months who received appropriate breast feed and complimentary
feeding stood at 43.7% in 2007 – 08 (14)
.
Management of diarrhoeal diseases in children has also shown a positive trend. Proportion of children
with diarrhea who received ORT rose from 4.7% in 1998 – 99 (14)
to 30.6% in 2007 – 08 (14)
and the latest
data puts the figure at 45% (28)
. Though has been a progress in improving access of such children to ORT
but it falls short of the target of increasing it to 60% by 2010(4)
.
(c) Coverage indicators with negative results – major issues; programme needs to do more
The review team identified a number of coverage indicators for priority interventions showing negative
results, ie, with downward or static trends. Additionally, there were some which have fallen short of
achieving the targets or with widespread disparity in coverage among sub-groups.
Considering the intervention of adequate antenatal care, coverage measure reviewed was the proportion
of mothers who received at least 3 antenatal visits. The latest coverage figure stood at 55.2% in 2009(28)
which is far short of the target of 80% by 2010-11(4)
Moreover there were wide regional and subgroup
differences.
Proportion of mothers who received 2 doses of Tetanus Toxoid had risen from 28.3% in 1998 – 99(9)
to
59.1% in 2002 – 04(11)
and then declined to 50.9% in 2007 – 08(14)
. There were significant rural urban and
subgroup variations too.
Identification and treatment of maternal emergencies such as eclampsia and obstructed labour was
reviewed by looking at the proportion of rural pregnancies having a caesarian; which was 2.2% in 2005
– 06 (18)
. This is less than one fourth of the corresponding figure of 9.9 % in urban areas.
Prevention of hypothermia as assessed by reviewing the data on babies delivered at home; who were
dried, wrapped (and not bathed) immediately after birth shows that the proportion was 34.2%(18)
of the
total babies born at home.
Immediate initiation of breastfeeding as seen from the trends in proportion of mothers who initiated
breast feeding within one hour of birth did show an increase from 14.5 % in 2002 – 04(11)
to 41.4 % in
2007 – 08(14)
but the findings from the Coverage Evaluation Survey 2009 show an alarmingly low figure
of 27.7%(28)
. Moreover, there are widespread regional differences in the practice. The proportion of
babies who received a prelacteal feed was 71.6 % in 2005 – 06(18)
.
Proportion of infants under 6 months exclusively breastfed continues to be relatively low at 65.4 % .(18)
Child Health in Rajasthan
12
Routine Immunization coverage is another area of major concern. Coverage of 0 dose OPV has dipped
from 33.8% in 2002 – 04 (11)
to 33.1% in 2007 – 08. (14)
Most recent HMIS data also reports coverage of
40% for 0 OPV. Percentage of children aged 12 – 23 months who received measles vaccine increased
from 35.9% in 2002 – 04(11)
to 67.3% in 2007 – 08(14)
. CES 2009 however, revealed coverage of
65.6 %( 28)
. State target of achieving coverage of 80% by 2010(4)
thus seems unlikely.
Vitamin A supplementation has not kept pace with the laid down targets. Proportion of children who
received a dose of Vitamin A increased from 22.4% in 2002 – 04(11)
to 52.5% in 2007 – 08(14)
and 60.5%
in 2009(28)
which falls short of the target of 90% by 2009 -10 as laid down under the XI Five Year Plan
Goals for Rajasthan.
Considering the proportion of children who received appropriate antimalarials, the figure of 9.0 % for
2005 – 06(18)
is in fact less than that of 13.9 % in 1998 – 99.(20)
6. Summary of status of the child health programme
Step 3 of the SPR was to critically review the activity areas in the field of child health Programme along
the continuum of care, find the status of implementation, reasons for the observed performance and
identify the strengths and weaknesses of the programme using worksheet 5. The Worksheet had 6 cross
cutting areas as heads under which the review was to be undertaken – namely (a) Policy, Planning and
Management; (b) Human Resources and Training (further divided into In-service and Pre Service
Training);(c) Health Communication/IEC; (d) Development of Community Supports; (e) Strengthening
Health Systems and (f) Monitoring and Evaluation. Day 3 was fully dedicated to discussion and review of
worksheet 5. The participants continued in smaller groups i.e, maternal, newborn and child health groups.
Customized worksheets for each small groups were used. Each group had a facilitator and rapporteur for
the session. As in Step 2, the worksheet was first discussed within the small groups, each group covering
its respective area. Some supporting data filled in the worksheets along with the plan documents were
utilized for assistance. In addition, field experience of the participants helped to guide the discussion.
Updates and conclusions were finalized by the rapporteur in consensus with members of the group.
Updates were then shared in a plenary with the rapporteurs of each group making their presentations
followed by discussion and further update of the worksheets.
6.1 Summary of technical areas along the continuum of care:
Each group started by reviewing the activity areas in their respective areas as applicable in the continuum
of care. Discussion initially sought to identify the activity areas delivering the intervention packages and
then proceeded to decide the status of implementation.
Short programme Review
13
6.1.1 Status of Implementation
Policy, Planning and Management
Status of implementation was complete in most of the activity areas under this head for all the three
groups (Table 6.1). Maternal group had all activity areas being fully implemented except No 5 (Annual
budget adequate to complete all activities in the last plan). Activity area No 4 (Planning done
collaboratively with other divisions and with donors) was considered to be partially implemented with
regards to the packages under the New Born group . For the child group, activity area No1 (Practice
standards and guidelines updated and being used) was in a partial state of implementation for F-IMNCI
excepting which all others were considered to have a full status of implementation.
Table 6.1 GroupWise summary of activity areas and status of implementation
(Activity Head: Policy, Planning and Management)
S
No Activity Area
Groups
(Intervention Packages)
Maternal
(ANC, SBA, EmOC,
PNC)
Newborn
(PNC, FBNC)
Child
(IMNCI, UIP,
Facility based
interventions)
Status of Implementation
(Fully, Partially or not at all)
1 Practice standards and guidelines
updated and being used Fully Fully
Fully (Partially for
F – IMNCI)
2 Essential drug list available Fully Fully Fully
3 Budgeted plans developed annually
– at the state and district levels Fully Fully Fully
4 Planning done collaboratively with
other divisions and with donors Fully Partially Fully
5 Annual budget adequate to complete
all activities in the last plan Partially Fully Fully
Child Health in Rajasthan
14
Human Resources / Training (In Service)
Status of implementation was mostly inadequate in majority of the activity areas under this head and all
the three groups marked them as partially implemented.(Table 6.2)
Table 6.2 Groupwise summary of activity areas and status of implementation
(Activity Head : Human Resources / Training (In Service))
S
No Activity Area
Groups
(Intervention Packages)
Maternal
(ANC, SBA, EmOC,
PNC)
Newborn
(PNC, FBNC)
Child
(IMNCI, UIP,
Facility based
interventions)
Status of Implementation
(Fully, Partially or not at all)
1
Plan to ensure adequate staffing at
each level, which includes
incentives
Partially
Partially (Not
adequate for
FBNC)
Partially
2 In-service training strategy available Fully
Partially (Not
adequate for
FBNC)
Partially
3 In-service training conducted for
health staff Partially Partially Partially
4 In-service facilitators trained Partially Partially Partially
5 Follow-up after in-service training
conducted Partially Partially Partially
6
Quality of in-service training – are:
types of staff trained, materials
used, time allocated, amount of
clinical practice adequate?
Partially Partially No information
available
Short programme Review
15
Human Resources / Training (Pre Service)
Status of implementation was inadequate or not at all implemented in most of the activity areas under this
head and all the three groups marked them as partially implemented or not implemented. (Table 6.3)
Table 6.3 Groupwise summary of activity areas and status of implementation
(Activity Head: Human Resources / Training -Pre Service)
S
No Activity Area
Groups
(Intervention Packages)
Maternal
(ANC, SBA, EmOC,
PNC)
Newborn
(PNC, FBNC)
Child
(IMNCI, UIP,
Facility based
interventions)
Status of Implementation
(Fully, Partially or not at all)
1 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
Child Health in Rajasthan
16
Health Communication / IEC
In case of the Maternal health Group, most of the activity areas were in a state of partial implementation
(Table 6.4) although the status of development and distribution of messages and materials seemed to be
adequate. It was heartening to note that under this head, barring few; most of the activity areas were
considered fully implemented by the newborn and child health groups. Newborn health group concluded
that focus on reaching low level populations was an area of partial implementation. Child health group
felt that implementation status of development and distribution of messages and materials as well as the
quality of the messages in terms of adaptation to local context and pretesting remains inadequate.
Table 6.4 Groupwise summary of activity areas and status of implementation
(Activity Head: Health Communication/IEC )
S
No Activity Area
Groups
(Intervention Packages)
Maternal
(ANC, SBA, EmOC,
PNC)
Newborn
(PNC, FBNC)
Child
(IMNCI, UIP,
Facility based
interventions)
Status of Implementation
(Fully, Partially or not at all)
1
Maternal / Child health
communication strategy or plan
available
Partially Fully Fully
2 Focus on reaching low level
populations Partially
Partially (Separate
plan from Desert &
tribal areas)
Fully
3
Communication activities
conducted: mass media, printed
materials, training for local
groups/volunteers in inter-personal
communication; training for health
workers
Partially Fully Fully
4 Messages and materials developed
and distributed Fully Fully Partially
5
Quality: Key Maternal / Child
health messages used; messages and
materials pre-tested and adapted for
local context
Partially Fully Partially (no
field testing)
Short programme Review
17
Development of Community Supports
This activity head again had many activity areas which were considered to be partially implemented by all
the groups. Availability of trained community volunteers and the quality were two such areas where all
the three groups felt that more need to be done to achieve full implementation. In comparison,
Availability of implementation plan for community level activities as well as that of trained community
health workers were better implemented (Table 6.5).
Table 6.5 Groupwise summary of activity areas and status of implementation
(Activity Head: Development of Community Supports )
S
No Activity Area
Groups
(Intervention Packages)
Maternal
(ANC, SBA, EmOC,
PNC)
Newborn
(PNC, FBNC)
Child
(IMNCI, UIP,
Facility based
interventions)
Status of Implementation
(Fully, Partially or not at all)
1
Implementation plan for
community-level activities
available
Fully Fully Partially
2 Community health workers trained
and available
Fully (ASHA,
AWWA) Partially
Fully (ANMs,
LHV, AWW)
3 Community groups or volunteers
trained and available Partially Partially Partially
4
Quality: Developed collaboratively;
use local staff and volunteers;
supervision or oversight plan
Included
Partially Partially Partially
Child Health in Rajasthan
18
Strengthening Health Systems
This activity head is an area of concern as almost all the activity areas under it were thought to be in a
partial state of implementation by all the three groups. Availability of essential drugs and equipment at
first and referral levels in respect of the child health group was the only activity area considered to be
adequate.
Table 6.6 Groupwise summary of activity areas and status of implementation
(Activity Head: Strengthening Health Systems )
S
No Activity Area
Groups
(Intervention Packages)
Maternal
(ANC, SBA, EmOC,
PNC)
Newborn
(PNC, FBNC)
Child
(IMNCI, UIP,
Facility based
interventions)
Status of Implementation
(Fully, Partially or not at all)
1 Quality of case-management No Partially Partially
2
Services available
Partially (EmOC
partially available,
remaining fully
available)
Partially Partially
3 Essential drugs and equipment
available at first and referral levels Partially Partially Fully
4
Routine supervision conducted
using checklists, and observation of
practice
Partially Partially Partially
5 Systems for timely referral for
maternal complications in place Partially Partially Partially
Short programme Review
19
Monitoring and Evaluation
Activity areas under this head are in a mixed state of implementation, with GroupWise differences. (Table
6.7). Functional status of vital registration systems and use of monitoring data for routine planning at
various levels was considered to be incomplete by all the three groups. In contrast, availability of
population and health facility data for monitoring and evaluation was considered adequate by all groups.
Remaining activity areas had varied implementation status across the three groups, being partial with
regard to some while being full in the others.
Table 6.7 Groupwise summary of activity areas and status of implementation
(Activity Head : Monitoring and Evaluation )
S
No Activity Area
Groups
(Intervention Packages)
Maternal
(ANC, SBA,
EmOC, PNC)
Newborn
(PNC, FBNC)
Child
(IMNCI, UIP,
Facility based
interventions)
Status of Implementation
(Fully, Partially or not at all)
1
Plan for routine monitoring and
periodic evaluation of the maternal
health programme included in
strategic plan and work plans
Fully for
Monitoring ,
Partially for
evaluation
Fully Partially
2 Standard international indicators used
Partially Fully Fully
3 Short and long term targets set
Fully Partially Fully
4
Population- and health facility-based
data available for monitoring and
evaluation
Fully Fully Fully
5
Monitoring data used for routine
planning by all levels
Partially Partially Partially
6 Vital registration systems working
Partially Partially Partially
Child Health in Rajasthan
20
6.2 Summary of Strengths and Weaknesses
After identifying the Activity areas for each of the activity heads each group discussed the strengths and
weaknesses for every activity area. Policy and plan documents as well as field experience of the
participants yielded the necessary inputs to required making the consensus. The strengths and weaknesses
identified by the groups are summarized under the sequentially below:
6.2.1 Maternal Group
Maternal group considered ANC, SBA, EmOC and PNC packages and identified the following strengths
and weaknesses:
Strengths:
Systems and mechanisms are in place to enable updating of practice standards and guidelines
District plans contribute to making of State level Budgeted Plans
Essential drug lists uploaded on website
Email connectivity up to block level HMIS availability online block level and upwards
Provision of contractual hiring and rural health cadre
Presence of autonomous training institutes
Availability of adequate number of trained in service facilitators
Provision of supervisory checks for in service training
Availability of adequate budget for Health communication / IEC activities along with special budget
for low level areas.
Support from donor partners in development of IEC/communication materials and use of standard set
of materials across the state.
Budget for community level activities and creation of Village Health and Sanitation committees in
all villages
Concurrent monitoring system
Trained Health workers and ambulance attendants for managing and transferring emergencies
Weaknesses:
Limited awareness of policies at field level
Essential Drug lists not displayed at facility level
District plans not developed in time
State proposed budget is usually slashed by the center.
Non availability of specialists
Attrition among contractual staff
In service training : Non compliance by candidates identified for training; Inadequate capacity and
frequent transfers of training staff ; limited training sites ; limited capacity to follow up in service
training; Injudicious utilization of facilitators
Lack of orientation of medical / nursing education according to the need of medical programmes
IEC weak for EmOC and PNC
Short programme Review
21
Lack of coordination between NRHM and RHSDP for IEC/Health Communication
All relevant messages are not covered under IEC
VHSCs : Formation of VHSCs took longer than planned; all VHSCs are not active; only 30 – 40%
VHSC members are trained
Shortage of medicines
Emergency transport and referral mechanisms available in some blocks only
6.2.2 Newborn Group
Newborn group considered PNC and FBNC packages and identified the following strengths and
weaknesses:
Strengths:
Commitment from Government
Partnerships with collaborating agencies / donors
Availability of resources
Adequate funds for maintaining essential drugs
Development of plans done in participatory manner with involvement of important stakeholders
Strong partnership for FBNC training
Adequate facilitators available for NSSK
Plan for monitoring FBNC through State Level Newborn cell
ICDS involved for supportive supervision of community based newborn care
Systems for timely referral : Refrral card/availability of funds/Ambulance services
HMIS – Online system
Pregnancy and Child Health tracking system (PCTS) established
Indicator based monitoring
Vital Registration System : Maternal and Infant Death Inquiry and being scaled up
Weaknesses :
Essential drug list not updated regularly
Template based planning – lack of flexibility
Less involvement of ICDS
Underutilization of Budget and complicated financial processes
Vacancy of ASHA
Inservice training :Handholding supervision after training is poor; Inadequate number of facilitators
for IMNCI/FBNC; Training protocols not followed in training institution; Less number of facilities
for conducting training; Lack of quality assurance mechanism for training
Pre Service training : not started in all medical colleges; New Born component is inadequate
IEC : Distribution and dissemination of IEC materials is inadequate; Content and impact evaluation
is not done; weak monitoring; operational and managerial issues
Post training support and handholding of community health workers is not adequate.
All community workers not covered in training
Child Health in Rajasthan
22
Training of ASHA completed only for a few modules
Quality issues in ASHA training
Poor training and follow up
Lack of infrastructure and supportive supervision
Lack of awareness and acceptance of services
Lack of feedback and accountability for community based services
Poor referrals despite having referral system and services
Poor quality of data
Lack of proper system for analysis of data and feedback to providers
No system for monitoring quality of care
Targets not available for all indicators
Exact data required for planning is not always available
Training of managers in planning process is weak
Vital Registration System : Home deliveries and deaths at home not being registered
6.2.3 Child Group
Child Group considered IMNCI, UIP/RI and FBI packages and identified the following strengths and
weaknesses:
Strengths:
Good policies, guidelines updated regularly
Existence of implementation plans; availability of multi level plans for monitoring and supervision
of child health services
Participation of districts through District action plans(Bottom up Approach)
Joint Planning undertaken at State Level. Increasing involvement of Medical Colleges and training
Institutions
Hiring of contractual staff
Mainstreaming of AYUSH personnel
In Service Training : Specific training packages for each intervention group; Training plan/calendar ;
Two Designated Sites for providing trainings; Entry in service book of candidate
IEC : Special directorate at State level; District IEC coordinators; Adequate budget for IEC
activities; Inclusion of IEC in all major training packages; development of variety of materials
pertaining to major interventions; presence of technical committee to ensure correctness and local
adaptation of messages.
Placement of ASHA; trainings of ASHA; availability of funds at community level; dedicated training
packages for various community groups
Mechanism of providing services through village health and nutrition days (VHND)
Regular supplies of drugs and equipment through partner support
Availability of Ambulance services
Online system of sending and receiving reports; Facility level surveys and HMIS to monitor facilities
and services
Short programme Review
23
Use of standard indicators for planning; Targets based on community surveys and determined bottom
up and validated by demography cell
Availability of disaggregated data even at peripheral levels
Monthly review meetings for progress in implementation
Weaknesses:
Lack of some critical operational elements like supportive supervision mechanisms
Most plans and policies are either centrally determined or adopted from National guidelines .
Frequent change of directives and circulars
Matching of drug list with the intervention packages has not been done
IMNCI planning confined to training plan only
Convergence with ICDS inadequate. Collaboration with other divisions and donors not uniform at all
levels
Underutilization of funds
Delays in filling vacancies
In service Trainings: Lack of coordination and integration of trainings; Frequent disruptions in
trainings; Multiplicity of trainings; Training calendar not adhered to; Frequent transfers and lack of
reorientation training of facilitators
Pre Service Training : National strategy not endorsed at state level; No set plan for pre service
training; IMNCI training not present in Nursing colleges
IEC : Strategy does not have a comprehensive plan on using appropriate media mix; Implementation
and reach are suboptimal; Loss of materials developed in the past; Slow pace of trainings of
IPC/BCC packages; Field testing aspect often ignored; Evaluation of materials not undertaken
Community Supports : Involvement of community not as per desire, non formal leaders are not
involved; . Timeliness of training and quality of training is variable especially those given through
NGOs; Weak supportive supervision
Manpower not appropriately trained to use equipment
Maintenance of equipment not streamlined
Inadequate supervisory manpower for field level supportive supervision
Inadequate monitoring at lower levels
Analysis of computerized data at block level is inadequate
Review mechanisms are more administration oriented rather than programme oriented.
Use of HMIS data and triangulation is limited
Standard international indicators are not internalized by system on regular basis
Lack of techno managerial skills to set realistic targets; Unrealistic targets
Proper analysis and use of available data on population and health facilities is limited
Lack of demand of astute data by decision makers; Very limited data is used in planning
Vital registration not yet universalized
Child Health in Rajasthan
24
6.3. Identifying the main problems
Worksheet 5 provided specific set of strengths and weaknesses for various cross cutting activity areas of
intervention packages for all the three levels along the continuum of care. (Pregnancy, Newborn and
Child groups ). Next logical step was to identify the main problems by reviewing and summarizing the
weakness listed in Worksheet 5 which was done by completing Worksheet 6 .
Continuing to work in small groups through the second half of Day 3, participants picked up the
important weaknesses from worksheet 5 and summarized them as the most important problems, picking
4-5 from each activity area.
The problems were then presented and discussed in the large group.
7. Core problems, Solutions and Recommendations
7.1 Listing the Core Problems
A final list of the most important problems from each activity area across the continuum of care was
discussed in the large group in the first session of Day 4. Common problems across the groups were
clubbed together and the most critical ones were selected for inclusion in the final list. The main problems
were summarized as per the six activity areas – (a) Policy, planning and Management; (b) Human
Resources and Training; (c) Communication/IEC ;(d) Development of Community Supports; (e)
Strengthening Health Systems and (f) Monitoring and Evaluation . The final list of problems formed the
basic input for Step 5 which was conducted on Day 4, to develop solutions and recommendations by
completing worksheet 7.
7.2 Reorganization of Small groups
The small groups were reorganized in accordance with the activity areas :
Group I : Policy, Planning, Financing and Management; Monitoring and evaluation.
Group II : Health Communication/IEC; Development of Community Supports
Group III : Strengthening Health Systems; Human Resources and Training
Each group had its facilitator and a rapporteur. The groups were given copies of adapted Worksheet 7 and
the final list of problems identified. Each group then discussed the main problems faced in their
respective thematic areas.
Short programme Review
25
7.3 Group Activity: Completing Worksheet 7
The groups started by taking each problem in turn. The selected problem was entered in the first column
of the worksheet. In the facilitator guided discussion the groups then identified and discussed the possible
causes to the problem. Consensus was taken and the causes were listed in the second column on the
worksheet. Possible solutions were explored keeping in view the main categories of programme activities
and by reasoning how these could be strengthened to overcome the causes of the problem. The possible
solutions were written down in the column succeeding the listed causes. Based on the solutions the groups
formulated recommendations. Groups aimed at developing clear and concise recommendations which
would be action oriented and practically feasible.
Each group developed its set of recommendations in respective thematic areas. Completed worksheet 7
was then presented in plenary session.
7.4 Decide on next steps
Immediately after completion of the worksheet 7, the core group consisting of the representatives from
the state health department, UN organizations (WHO, UNOPS-NIPI, UNICEF) and IIHMR met to
decide on the future steps on ensuring the incorporation of recommendations into the state PIP. It was
decided that the recommendations would be formally presented to the Principal Secretary Health,
Government of Rajasthan on day 5 and subsequently finalized by incorporation of important feedback. It
was also decided that the finalized set of recommendations would then be prioritized in consultation with
the members of the core group for incorporation in the next and subsequent PIPs.
7.5 Presentation of findings and finalization of recommendations
The groupwise findings of SPR were formally presented to Shri BN Sharma, Principal Secretary Health,
Department of Health and Family Welfare, Government of Rajasthan in the closing meeting on 25
September 2010. He assured full support from the Health department with regards to the incorporation of
the recommendations in the upcoming PIP. The feedback on the presentation was recorded for
subsequent prioritization and finalizing of the recommendations. The findings were then forwarded to the
members of the core team for prioritization. Final recommendations are presented in the subsequent
section below.
Child Health in Rajasthan
26
7.6 Final Recommendations
7.6.1 Group I. Policy, Planning and Management / Monitoring and Evaluation
Core problems and recommendations:
(a) There is a gap in communication, uniform interpretation and follow up of directives from State HQ to
grass root level.
Recommendations:
Priority for Action
Immediate
1. To ensure that result based monitoring of performance is operational along the
monitoring cascade whereby the state officials monitor the performance of districts,
district officials monitor the performance of the blocks and so on till the sub centre level.
Successive
2. (a) A Checklist for ensuring clarity, consistency and completeness of directives and
operational guidelines, and their follow-up to be developed by Health Directorate
2. (b) Originating units/ departments use the checklist to ensure that the directives and
guidelines are clear, comprehensive and self explanatory
2. (c) The district and block units to ensure that the guidelines reach the intended user
in time and an action taken report is sought
3. Explore the use of E-mails, Video-conferencing, Gramsat and other alternative means
of communication to improve interactions .
(b) Planning not need based but driven by template and budget
Recommendations:
Priority for Action
Immediate
1. State Health Department to organize Capacity Building workshops on ‘Programme
Planning and Management’ for block, district and state level officials to promote data
based and need based planning.
2. Health Directorate to ensure that specific and appropriate plans for improving access
to services are developed by the desert/ tribal districts and other districts for their
difficult to reach areas and support provided for implementation
Short programme Review
27
(c) Underutilization of AYUSH practitioners in MNCH services
Recommendations:
Priority for Action
Successive
1. State government to utilize AYUSH practitioners for monitoring of MNCH services
2. State government to take a policy decision to enable AYUSH practitioners to deliver
IMNCI through training and ensuring health system support for practicing IMNCI
(d) Lack of coordinated and inadequate attention to address Nutrition and Development in Children
Recommendations:
Priority for Action
Immediate
1. State government to develop joint planning and joint review mechanisms for ICDS
and Child Health Programmes at district and sub-district level to address Malnutrition,
anaemia and child development in under 3 children.
2. Joint Supervision by supervisors of Health and ICDS should be done.
(e) Lack of quality in data capture at field level
Recommendations:
Priority for Action
Immediate 1. HMIS department to develop a plan for orientation of frontline workers and
managers to improve data quality.
Successive
2. HMIS department should also develop a ward wise reporting system in urban areas
for PCTS.
3. Sensitization of private practitioners for reporting morbidity,mortality and service
utilization data.
Child Health in Rajasthan
28
(f) Inadequate data analysis, feedback and reviews at district and sub-district level
Recommendations:
Priority for Action
Immediate
1. State Demographic Cell and HMIS department to plan and conduct
orientation/training of block and district level officials to improve data analysis and
provision of appropriate feedback
Successive
2. Conduct short programme reviews at district level annually before development of
District PIPs
3. Reinstate statisticians at block level
(g) Difficulty in monitoring neonatal care and PNC interventions
Recommendations:
Priority for Action
Immediate 1. State to introduce Neonatal and PNC indicators in the monitoring system
(h) No systematic evaluation plan for MNCH services in place
Recommendations:
Priority for Action
Immediate 1. State to develop a systematic plan to periodically evaluate implementation of IMNCI,
New born care and PNC interventions
Short programme Review
29
(i) Limited data on Quality of care of MNCH services
Recommendations:
Priority for Action
Immediate
1. State to assign responsibility to individual officials and programme managers of
SPMU at State level for specific areas of child health programmes with regard to
monitoring of progress, data collections, analysis and feedback.
2. Departments of Maternal and Child health and ICDS to periodically evaluate quality
of care at health facilities and community level
Successive 3. Develop/adapt tools to assess key elements of quality of care (facility infrastructure,
case management process, satisfaction of beneficiaries)
7.6.2 Group II. Human Resources, Training and Strengthening Health Systems
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.
Child Health in Rajasthan
30
(b) Quality of training is not optimal
Recommendations:
Priority for Action
Immediate 1. Director RCH to develop a procedure to get quality assurance of trainings
conducted
Successive
2. Director RCH to lead development of comprehensive need based training strategy for
MNCH and implementation plans by adopting the following approaches :
Develop and maintain adequate pool of trainers. May have to look beyond
traditional trainers and sharing trainers across programmes
Innovative training approaches such as distance learning, technology based
trainings to be explored. Develop and maintain adequate number of appropriate
training site for competency based trainings like IMNCI, SBA ,EmOC etc.
Innovative training approaches such as distance learning, information
technology based trainings
Ensure the prescribed clinical hands-on training
(c) Pre-service training
Recommendations:
Priority for Action
Successive
1. Principal Secretary Medical Education to formulate a policy to strengthen pre-service
education in medical and nursing institutions.
2. Health Directorate to organize training of teaching staff in MNCH packages and
develop implementation plans for teaching of the same in medical and nursing
institutions
3. Develop a plan for introducing and implementing pre-service IMNCI.
Short programme Review
31
(d) Shortage of drugs ; Mismatch between requirements and supply of drugs and consumables as per
intervention packages
Recommendations:
Priority for Action
Immediate 1. MD NRHM to lead Review of existing drug supply management to identify specific
gaps and state specific solutions
Successive 2. Develop and circulate guidelines on rational use of drugs
(e) Poor supportive Supervision of MNCH services
Recommendations:
Priority for Action
Immediate 1. MD NRHM to issue directives for urgent prioritization and integration of supportive
supervision for MNCH services
Successive 2. Director RCH to identify and train pool of supervisors in each block for integrated
supportive supervision
(f) Poor Maintenance of equipment
Recommendations:
Priority for Action
Immediate 1. Director RCH to explore implementation of similar mechanisms as it is followed by
immunization division for maintenance of equipments and apply lessons learned
Child Health in Rajasthan
32
7.6.3 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.
Short programme Review
33
(c) Poor quality of IEC materials
Recommendations:
Priority for Action
Immediate 1. IEC Activities for child health focusing on the Key Messages
Successive
2. Strengthen Skill up-gradation of State and District IEC coordinators on development
of IEC materials
3. Consider outsourcing for IEC materials and skills development of staff
(d) Poor communication skills of health and nutrition service providers
Recommendations:
Priority for Action
Successive 1. Organize communication skills training programme for service providers in low
coverage areas
(e) Lack of monitoring and evaluation
Recommendations:
Priority for Action
Successive 1. State Directorate to develop a plan of monitoring and evaluation for IEC.
2. State Directorate to develop a system of concurrent evaluation (may be outsourced)
Child Health in Rajasthan
34
(f) Limited capacity of Village Health Sanitation Committee (VHSC)
Recommendations:
Priority for Action
Immediate 1. Complete the ongoing training of VHSCs within one year followed by hand holding
support through allocation of a set of villages to PHC level supervisors
Successive
2. Develop five model VHSCs per block. Explore role of NGOs to establish model
VHSCs
3. Develop a recognition mechanism and reward good performance for VHSC
4. Plan a Quarterly newsletter for VHSC with success stories from the field
(g) VHSC not able to perform its functions like community monitoring and thematic community
meetings
Recommendations:
Priority for Action
Immediate 1. Capacity building of supervisors to be completed in the next six months
Successive 2. The best practices of community monitoring to be explored and adopted for the state
(h) Inadequate quality of training for ASHA and Jan Mangal Couple on MNCH issues
Recommendations:
Priority for Action
Immediate 1. Expedite the process of training of ASHA on module 5
Successive 2. Develop database of Jan Mangal couples and complete trainings within an year
3. Develop a mechanism for QA of trainings
Short programme Review
35
7.6.4 Core Group: Scaling up of existing interventions for Child Health
Based on the discussion held within groups, the Core Review Group added the following
recommendations regarding technical interventions for newborn and child health. The technical
interventions were not covered in the theme-based group work.
Recommendations:
Priority for Action
Immediate
1. Scale-up of IMNCI in all districts; Ensure supplies for IMNCI drugs at all levels
2. Rapid scale-up of F-IMNCI in high-focus districts on priority basis
3. Strengthening of community-based management of newborn and childhood illnesses
through ASHA and Anganwadi Workers
4. Strengthening of infra-structure and services for Facility-based Newborn Care in
high-focus districts (includes Special Care Newborn Unit, Neonatal Stabilization Unit
and Newborn Care Corners)
ANNEXURES
Annexures
Annexure I: Day wise summary of Steps completed
Day Steps Summary of Activities
1 -
Formal Inauguration
1 1
2 Plenary sessions were held.
Prefilled worksheets 1 & 2 were discussed
Goals and Objectives were reviewed with regard to Clarity, measurability and realism.
Trend of Neonatal and Child Health Indicators of the State were reviewed to identify areas of
poor performance, adequate / good performance and data gaps.
Preparatory activity for Step 2 was completed – Participants were allocated into three smaller
groups – Maternal, Newborn and Child.
Worksheets 3 & 4 were customized.
2 2
Participants were divided into three smaller groups: maternal, newborn and Child.
Each group had its own facilitator and rapporteur.
Worksheets 3 and 4 were discussed and reviewed.
Small group discussions were followed by presentation of findings by respective rapporteurs
in plenary sessions.
3 3,4
Worksheet 5 was reviewed and discussed
Participants continued in the three smaller groups : maternal, newborn and Child.
Each group 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
4 5
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
5 6,7
Discussion with key stakeholders on future steps for ensuring the incorporation of
recommendations into the State PIP
Presentation of findings before the representatives of the State Health Department
Recording of feedback.
5 - Formal Thanksgiving and conclusion
Annexures
Annexure II: Worksheet 1
Goals and Objectives of the Child Health Program
Program Goal Program Objectives
Maternal Health
RCH II
- Reduce Maternal mortality to
213 by 2010 (State PIP RCH II)
- Reduce Maternal mortality to
148 by 2012 (State PIP RCH II
& 11th Five-year Plan)
ICDS
- To bring down anemia among
women from current level to 40%
by 2010 and 27% by 2012
State Program Implementation Plan
To increase coverage with Antenatal Care to 80% in 2010 – 11
from the level of 60% in 2009-10 (State PIP 2010-11) (ICDS
targets 100%)
Increase coverage of administering 2 TT injections during
Ante natal period from 80%(2009-10) to 100% in 2010-11
Increase the proportion of pregnant women receiving IFA
tablets from 30% (2009-10)to 50% by 2011
Strengthening of IEC to increase awareness on these issues
Increase delivery by skilled birth attendant (doctor, ANM,
Nurse) from 80% (2009-10) to 100% by 2011 (State PIP 2010-
11).
Increasing institutional deliveries from 65% (2009-10) to 90%
by 2011 through Janani Suraksha Yojana.
(ICDS targets 100%)
Increasing access to CEmOC by operationalizing FRUs
Increasing access to postnatal care to 60% in 2009 – 10 to
80% in 2010-11
Urban RCH Program (brief note on urban RCH 2008-09)
Achieving 80% ANCs for pregnant.
Achieving 80% institutional deliveries
Annexures
Newborn Health
RCH II
- Reduce Newborn Deaths
- To reduce the percent of low
birth weight babies by 10% by
2012 (from ICDS)
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)
Reducing NMR by providing immediate care at birth to every
newborn through NSSK
Child Health
RCH II
- Reduce Infant Mortality Rate
to 37 by 2011 (State PIP RCH II
2010-11)
- Reduce Infant Mortality Rate
to 32 by 2012 (State PIP RCH II
& 11th Five Year Plan)
- Reduce the prevalence of
malnutrition among children
under 3 years to 25.3% by 2011
(11th 5-year Plan)
NVBDCP
- Proportionate reduction in
Malaria Mortality among under
-five children by 50%. (State
PIP NVDBCP 2010-11)
State Program Implementation Plan
To increase coverage with complete immunization to 85 % by
2010 (State PIP 2010 -2011)
(ICDS targets 90%)
Complete coverage of IMNCI across the state with
implementation in all districts except Chittorgarh as it is the
control district (State PIP 2010-11)
Improving access to clinical care among children with
diarrhea, ARI and Childhood illness (90% by 2010)
Increasing the proportion of ORS use among children with
Diarrhoea (60% by 2010)
Increasing the proportion of Children getting Vitamin A
Supplementation (90% by 2010)
To Increase IFA administration among children to at least
50% by 2010(State PIP 2010 – 2011)
Urban RCH Program (brief note on urban RCH 2008-09)
Increase in the coverage of fully immunized children by 25%
in 6 months of start of program and 50% by one year of start
of service in the selected slum
100% immunization in the slum.
Annexures
ICDS
- To bring down percentage of
severe and moderate
malnutrition among 0 – 6 years
of age to 10% and 15 %
respectively by 2012
- To reduce the prevalence of
mild malnutrition among
children 0 – 6 years to 20% by
2012
- To bring down anemia among
children from current status to
60% by 2010 and 39% by 2012
ICDS
To promote exclusive breastfeeding and increase the number
of mothers initiating early breastfeeding to 50% by 2010 and
75% by 2012
To increase the quality complementary feeding rate and
feeding care to 45% by 2010 and to 75% by 2012
To ensure 100% coverage of children aged 6 months to 6
years for availing age appropriate supplementary nutrition
To expand the availability of age appropriate micronutrient
enriched – RTE foods to the beneficiaries by up-scaling
successful and cost effective interventions
Annexures
Annexure III : Worksheet 2
Indicators of maternal, newborn and child health status
Data
Required Measures
Back ground data
(Year and source)
Baseline data
(year and source)
Most recent data
(year and source) Target
Differences
by region or
group
(highest/low
est)
Neonatal
deaths
Neonatal death rate
37.2
(P.136 NFHS-1 Rajasthan state
report)* 43.9
(P.56 NFHS-3,(2005-06)
Rajasthan state)
43
(SRS Statistical
Report -2008, P.79)
Urban: 23
Rural: 48
(SRS Statistical
Report -2008,
P.79)
X
- Need to
work
signif -
icantly
Difference
in rural and
urban
49.5
(P. 122 NFHS-2 Rajasthan state
report)**
Neonatal mortality
as a proportion of
IMR and U5MR
Neonatal mortality as a proportion of
IMR :51.2%
(Neonatal death rate-37.2/IMR-72.6)
Neonatal mortality as a proportion of
UMR: 36.3%
(Neonatal death rate-37.2/U5MR-
102.6)*
** Neonatal mortality as a proportion
of IMR : 61.6%
(Neonatal death rate-49.5/IMR-80.4)
Neonatal mortality as a proportion of
UMR: 43.1%
(Neonatal death rate-49.5/U5MR-
114.9)
Neonatal mortality as a
proportion of IMR : 67.2%
(Neonatal death rate-
43.9/IMR-65.3)
Neonatal mortality as a
proportion of UMR: 51.4%
(Neonatal death rate-
43.9/U5MR-85.4)
Causes of death No data No data No data
-Data
needed
-Need to
work
significant-
ly
Annexures
Data
Required Measures
Back ground data
(Year and source)
Baseline data
(year and source)
Most recent data
(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
year1997-98)
501/1,00,000 live
births
P. A-68 FWS-2009
(Data represents for
the year 1999-2001)
388/1,00,000 live
births
P. A-68 FWS-
2009
(Data represents
for the year 2004-
06
( By 2010
– 213
(State PIP
RCH II)
(By 2012
– 148
(State PIP
RCH II in
accordanc
e with XI
FYP)
Trends
are
down-
wards,
sustain
efforts
Causes of death
Hemorrhage
:37.0%
Sepsis:11.0%
Abortion: 10.0%
Obstructed labour
& Hypertensive
disorder: 9.0%
(SRS, 2009)
Low birth
weight
Prevalence of
low birth weight
21.9 %
(RCH-RHS,1998-99
P. 54,India report)
(Data represents Rajasthan)
28.3%
ICDS-state PIP IV,2008-
12,P.81
(Data represents Base line
survey-2000)
27.5%
(NFHS-3,2005-
06,P.226, India report)
(Data represents
Rajasthan state)
X
Static
Annexures
Data
Required Measures
Back ground data
(Year and source)
Baseline data
(year and source)
Most recent data
(year and source) Target
Differences
by region or
group
(highest/low
est)
Infant
deaths
Infant mortality
rate
72.6
(NFHS-1, 1992-93,P. 136,
Rajasthan report)*
65.3
(NFHS-3,2005-06,
P. 56 ,Rajasthan report)
63 - (SRS- 2009)
By 2011 –
37
(State PIP
RCH II
2010-11)
By 2012 –
32
(State PIP
RCH II in
accordance
with XI
FYP)
Urban: 66.0
Rural: 65.1
SRS
Urban – 39
Rural 68
Differences
across
different
regions
Decline
not
sufficient
to reach
goals
80.4
(NFHS-2 , 1998-99, P. 122,
Rajasthan report)**
Infant mortality as
a proportion of all
child mortality
70.8 %
(Infant deaths-72.6/U5MR-102.6)* 76.5%
(Infant deaths-
65.3/U5MR-85.4)
70%
(Infant deaths-80.4/U5MR-114.9)**
Causes of death
Pneumonia: 25.8% Diarrhoea: 14.5%
Severe Malnutrition: 19.4%
Rashes/Fever: 16.1% Prematurely/LBW:12.9%
Asphyxia: 9.7%
Birth injury: 1.6% Congenital anomalies:0.0
(Data represents for the year of 1980)
(Health and Population: Perspectives and Issues
Vol. 32 (2), 105-111, 2009- Changes in
IMR in Rajasthan over 25 years-2009)
Perinatal conditions:42.9%
Respiratory infections:24.5%
Diarrheal diseases: 10.4% Other infectious and parasitic
diseases: 10.3%
Malaria: 1.3% Nutritional deficiencies: 2.3%
Symptoms signs and ill-
defined conditions: 2.7% Unintentional injuries-
Other:1.2%
Congenital anomalies:1.9% Fever of unknown origin: 0.7%
(Report on Causes of death in
India,2001-03,P.26) (Data of EAG states)
Pneumonia: 27.8%
Diarrhoea: 8.3%
Severe Malnutrition: 8.3%
Rashes/Fever: 5.6%
Prematurely/LBW: 19.4%
Asphyxia: 19.4%
Birth injury: 5.6% Congenital anomalies:
5.6%
(Health and Population: Perspectives and Issues
Vol. 32 (2), 105-111,
2009- Changes in IMR in
Rajasthan over 25 years-
2009)
Annexures
Data
Required Measures Back Ground
Baseline data (year
and source)
Most recent data (year and source)
Target
Differences
by region or
group
(highest/lowe
st)
Child deaths
Under 5
mortality
rate
102.6
(NFHS-1,1992-93, P. 136
Rajasthan report)
85.4
(NFHS-3,2005-06
P. 56 ,Rajasthan
report)
80
(SRS-Statistical
Report 2008,P.84)
34.2
MDG
Goal
Urban: 49
Rural: 88
Male: 72
Female:88
(SRS-
Statistical
Report
2008,P.84)
Decline
not
sufficient
to
achieve
MDG 114.9
(NFHS-2,1998-99
P. 120, Rajasthan report)
Causes of
death
Perinatal conditions: 29.9%
Respiratory
infections:24.4%
Diarrheal diseases:14.8%
Other infectious and
parasitic diseases:12.3%
Malaria: 3.3%
Nutritional
deficiencies:3.1%
Ill-defined conditions:2.6%
Unintentional injuries:2.6%
Congenital anomalies:1.6%
Fever of unknown
origin:1.3%
(Report on Causes of death
in India,2001-03,P.26)
(Data of EAG states)
Annexures
Data
Required Measures
Back
ground data
(Year and
source)
Baseline data
(year and source)
Most recent
data
(year and
source)
Target Differences by region or group
(highest/lowest)
Child
morbidity
Prevalence
of childhood
illnesses:
pneumonia,
diarrhea,
malaria
(fever),
measles (2
week
prevalence)
Pneumonia/A
RI: 21.2%
Diarrhea:
33.1%
(RCH-RHS-
1998-
99,P.52,Rajast
han report)
Fever: 10.7%
(NFHS-
1,1992-
93,P.168,Rajas
than report)
Fever: 11.9%
(NFHS-3,2005-
06,P.68,Rajasthan
report)
Pneumonia/AR
I: 7.7%
Diarrhea: 8.4%
(DLHS-
3,2007-
08,P.92,Rajast
han report)
ARI Diarrhea
No targets
available.
Rural: 7.9%
Urban: 6.6%
8.5%
7.7%
Lowest: 0.8%
(Barmer)
Highest:
18.9%(Bharatp
ur)
(DLHS-3,2007-
08,P.92,Rajasth
an report)
Lowest: 0.5%
(Hanuman
garh)
Highest: 25.3%
(Bharatpur)
(DLHS-3,2007-
08,P.92,Rajasth
an report)
Pneumonia/A
RI: 13.2%
Diarrhea:
15.9%
(DLHS-
2,2002-
04,P.106,Rajas
than report)
Fever: --
25.8%
(NFHS-
2,1998-
99,P.140,Rajas
than report)
Prevalence
of HIV –
among
children who
are tested
No data No data No data
Annexures
Data
Required Measures
Back
ground data
(Year and
source)
Baseline data
(year and source)
Most recent
data
(year and
source)
Target Differences by region or group
(highest/lowest)
Under
nutrition
Prevalence of
low weight
for height (z-
score -2 or
less)
19.5%
(NFHS-
1,1992-
93,P.186,
Rajasthan
report) 22.5%
(NFHS-3,2005-
06,P.76, Rajasthan
report)
Urban: 20.8%
Rural: 20.3%
Shows
increase in
wasting
Male: 20.8%
Female: 20.1%
SC: 22.0%
ST: 27.8%
OBC: 16.0%
Others: 23.8%
(NFHS-3,2005-06,P.75, Rajasthan)
16.2%
(NFHS-
3,2005-
06,P.76,
Rajasthan
report)
Data
represents
NFHS-2
Prevalence of
low height for
age (z-score -
2 or less)
43.1%
(NFHS-
1,1992-
93,P.186,
Rajasthan
report) 40.1%
(NFHS-3,2005-
06,P.76, Rajasthan
report)
Urban: 33.9%
Rural: 46.3%
Marginal
decline in
Stunting
Male: 44.3%
Female:43.1%
SC: 48.2%
ST:48.8%
OBC:42.5%
Others:37.3%
(NFHS-3,2005-06,P.75, Rajasthan
report)
59.0%
(NFHS-
3,2005-
06,P.76,
Rajasthan
report)Data
represents
NFHS-2
Annexures
Data
Required Measures
Back
ground data
(Year and
source)
Baseline data
(year and source)
Most recent
data
(year and
source)
Target Differences by region or group
(highest/lowest)
Under
nutrition
Prevalence of
low weight for
age (z-score -2
or less)
41.6%
(NFHS-1,1992-
93, P.186,
Rajasthan
report) 36.8%
(NFHS-3,2005-06,P.76,
Rajasthan report)
20%
(ICDS)
– find
out the
source
Urban: 30.1%
Rural:42.5%
Marginal
decline in
underweight
Male: 40.3%
Female:39.5%
SC: 44.5%
ST:46.8%
OBC:36.7%
Others:37.1%
(NFHS-3,2005-06,P.75, Rajasthan
report)
46.7%
(NFHS-3,2005-
06,P.76,
Rajasthan
report)
Data represents
NFHS-2
Micronutrient
deficiencies
Prevalence
of
xerophthalm
ia
No data No data No data Need to
collect
informa-
tion Prevalence
of low serum
retinol
No data No data No data
Prevalence
of anemia
(Hb 10g/dl)
82.3%
(NFHS-
2,1998-
99,P.175,
Rajasthan
report)
79.9%
(NFHS-3,2005-
06,P.82,Rajasthan
report)
27%
(2012)
Urban: 62.9 %
Rural: 71.4%
Insufficient
decline Male: 69.9%
Female:69.3%
(NFHS-3,2005-06,P.81,
Rajasthan)
Annexures
Summary of Worksheet 2 – Health impact indicators
Health status indicators - program is doing enough now
Maternal Mortality: Trends are downwards, sustain efforts
Under nutrition: Marginal decline in Stunting and Underweight
Health status indicators - program needs to do more
Neonatal Mortality: Need to work significantly. Difference in rural and urban
Infant Mortality Rate: The declining rate is not sufficient to reach the MD Goals
U5 Mortality: Declining rate is not sufficient to reach the MD Goals.
Child Morbidity: There are no targets
Under nutrition: Shows increase in wasting
Prevalence of Anaemia: Insufficient decline.
Annexures
Annexure IV: Worksheet 3
Child health interventions and how they are delivered
PREGNANCY
Interventions
Included
in
program?
Tick if yes
Level at which intervention is
delivered
Tick levels
Implemented in a
training package
with 1 or more
other
interventions?
specify package
(s)
Implemented
in all areas or
selected areas
- specify
Home and
Communit
y
First
level
facility
Referral
facility
Tetanus toxoid
immunization ANC All
Birth and emergency
planning ANC All
Detection of problems
complicating pregnancy
(e.g. hypertensive
disorders, bleeding,
anaemia)
ANC
Management of problems
complicating pregnancy
(e.g. hypertensive
disorders, bleeding,
malpresentations, multiple
pregnancy, anaemia)
24X7
PHC
BEmOC,
CEmOC All
Detection and treatment of
syphilis (RTI/STI)
RTI/STI All
Intermittent prophylactic
treatment for malaria - - - - - -
Information and counseling
on self-care, nutrition, safer
sex, breastfeeding, family
planning
ASHA
All
Insecticide treated bed nets - - - - - -
Prevention of mother to
child transmission of HIV
PPTCT
(RSACS) Selected
Other : (specify) Blood
Storage CEmOC
All DH and
Functional
FRU
Other : (specify)
Anemia Prophylaxis ANC All
Other: (specify) ________
Annexures
BIRTH AND IMMEDIATE POST-NATAL PERIOD
Interventions Included in
program?
Tick if yes
Implemented at which levels?
Tick levels
Implemented in a
training package
with 1 or more
other
interventions? –
specify package (s)
Implemented
in all areas or
selected areas?
- specify
Home and
Community
First level
facility
Referra
l
facility
Monitoring progress of
labour, maternal and
foetal well being with
partograph
Safe delivery
package All
Active management of
the third stage of labour
Safe delivery
package All
Social support
(companion) during birth
24X7
Safe delivery
package
Yashoda
All
YASHODA
Being
expanded to
all districts
Immediate newborn care
(Resuscitation if required,
Thermal care, Hygienic
cord care, Early initiation
of breastfeeding)
ENC
NSSK
All
Emergency obstetric and
neonatal care for
complications
BEmOC
NSSK All
Antibiotics for preterm
premature rupture of
membranes
BEmOC All
Antenatal corticosteroids
for preterm labour
- - - - - -
Prevention of mother to
child transmission of HIV PPTCT
Selected
districts (10)
MC Colleges
and DH
Other : (specify) Blood
transfusion
CEmOC
DH,
Functional
FRU
Other : (specify) _______
Other : (specify) ______
Annexures
NEWBORN PERIOD
Interventions Included
in
program?
Tick if
yes
Level at which intervention is
delivered
Tick levels
Implemented in a
training package with
1 or more other
interventions? –
specify package (s)
Implemented
in all areas or
selected areas
– specify
Home and
Community
First level
facility
Referra
l
facility
Exclusive breastfeeding
IMNCI*
Yashoda*
HBPNC*
ICDS
All (IMNCI/
Yashoda)
HBPNC :
NIPI focus
districts
Thermal care
NSSK
Yashoda*
IMNCI*
HBPNC*
*
Hygienic cord care
NSSK
Yashoda*
IMNCI*
HBPNC*
*
Prompt care seeking for
illness
IMNCI*
ASHA
HBPNC*
Yashoda*
*
Extra care of LBW
infants
FBNC*
Yashoda*
IMNCI*
HBPNC*
*
Management of newborn
illness
IMNCI*
NSSK
FBNC*
*
Prevention of mother to
child transmission of
HIV
PPTCT* *
Other : (specify) Early
initiation of breast
feeding
IMNCI*
Yashoda*
HBPNC*
ASHA
*
Other : (specify)
Referral transport
Untied Funds
HBPNC *
Other : (specify)
Immunization
Routine
Immunization
IMNCI/ASHA
*
Annexures
INFANTS AND CHILDREN
Interventions Name of
Package
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
Exclusive breastfeeding
(<6 months)
IMNCI
9 districts almost
saturated; 24
districts have 30-50
% coverage
Facility Based
Care
Counseling
(Yashoda,
IMNCI)
Yashoda (27 DH +
42 CHCs) and
IMNCI-9 Districts;
40% coverage
PNC
Rolled out in 3
districts with
almost saturation;
9 districts
(IMNCI) ; One
third districts
covered
ICDS
(Health
Education/MC
HN Sessions)
Universal
Coverage
Safe and appropriate
complementary feeding
with continued
breastfeeding (at least
up to 2 years)
ICDS
(Health
Education/MC
HN Sessions)
Universal
Coverage
IMNCI
9 districts almost
saturated; 24
districts have 30-50
% coverage
IYCF
IYCF not yet
implemented
Insecticide treated nets
- - - - - -
Immunization (BCG,
Hepatitis B, DPT, OPV,
Measles, Hib)
Routine
Immunizatio
n (BCG,
DPT, OPV,
RI All Districts
Annexures
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)
All
Safe Water
(PHED)
All
Total
Sanitation
Campaign
Limited
coordination
between Health
and TSC
Birth spacing by > 24
months
Family
Planning
Package
(Jan
Mangal
Scheme)
Other : (specify)
_________
Annexures
INFANTS AND CHILDREN
Interventions Name of
Package
Level at which intervention is
delivered
Tick levels
Implemented in a
training package
with 1 or more
other interventions?
– specify package (s)
Implemented
in all areas or
selected areas
– specify
Home and
Community
First
level
facility
Referral
facility
Treatment interventions
Oral rehydration therapy
for diarrhea
IMNCI
9 districts
almost
saturated; 24
districts have
30-50 %
coverage
Zinc for diarrhea
IMNCI
9 districts
almost
saturated; 24
districts have
30-50 %
coverage
Antibiotics for dysentery
IMNCI - - 9 districts
almost
saturated; 24
districts have
30-50 %
coverage -
Antibiotics for pneumonia
IMNCI
9 districts
almost
saturated; 24
districts have
30-50 %
coverage
Antimalarials
National
Anti Malaria
Program
Management of severe
malnutrition
MTC
ICDS
Management of HIV-
exposed/infected children
PPTCT
All
Other : Anaemia
Primary
Health Care
Other : De-worming
Primary
Health
Care
Annexures
Annexure V : Worksheet 4
Period Intervention Coverage
measure
Back ground
(year and source)
Baseline data
(year and source)
Most recent data
(year and source)
Target Differences by region or
group (highest/lowest)
Pregnancy Adequate
antenatal care
Proportion of
mothers who
received at least 4
ANC visits
Available data is
for 3 visits
28.3%
(RCH- RHS-
1998-99,
Rajasthan report
P.32)
(>3 visits)
20.5 %
(DLHS-2, 2002-
04, P.61,Rajasthan
report)
27.6%
(DLHS-3, 2007-08,
P.65 Rajasthan
report)
55.2 %
(UNICEF-
Coverage
Evaluation Survey-
2009, National fact
sheet)
80% in
2010 – 11
(State PIP
2010-11)
Rural: 23.3 %
Urban: 48.0%
(DLHS-3, P.65 Rajasthan
report)
X
SC: 22.4%
ST :19.4%
OBC: 27.8%
Others: 40.8%
(DLHS-3, P.65 Rajasthan
report)
Highest: 48.4% (Ajmer)
Lowest: 7.7% (Dhaulpur)
(DLHS-3, P.67 Rajasthan
report)
Tetanus Toxoid
to all pregnant
women
Proportion of
mothers who
received TT2+
during pregnancy
28.3 %
(NFHS-1 1992-
93,P.154
,Rajasthan report)
59.1 %
(DLHS-2 ,2002-
04, P.61,
Rajasthan report)
50.9 %
(DLHS-3, 2007-08,
P. 66, Rajasthan
report)
100% Rural: 47.2%
Urban: 68.1%
(DLHS-3, 2007-08, P. 66,
Rajasthan report)
X
SC: 45.0%
ST : 43.0%
OBC: 51.6%
Others: 63.0%
(DLHS-3, 2007-08, P. 66,
Rajasthan report)
Highest: 76.8 % (wealth
index)
Lowest: 38.2%
DLHS-3, 2007-08, P. 66,
Rajasthan report)
Proportion of
newborns
protected at birth
No data No data No data
Annexures
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-1 1992-
93, P.154
Rajasthan report)
39.3 %
(NFHS-2, 1998-
99,P.190,
Rajasthan report)
57.7%
(NFHS -3,2005-06,
P.61,
Rajasthan report )
53.7%
(DLHS-3,2007-
08,P.67, Rajasthan
report)
Rural: 53.1%
Urban: 73.9%
(NFHS -3,2005-06,
P.61,Rajasthan report)
+
Trends are
good with
Disparities SC: 56.8%
ST : 54.6%
OBC: 56.9%
Others: 63.0%
Highest: 77.7 % (Bharatpur)
Lowest: 32.0% (Pali)
(DLHS-3,2007-08,P.67,
Rajasthan report)
Malaria
prevention
Proportion of
pregnant women
who slept under
an ITN the
previous night
No data No data No data Not
introduced
in
Rajasthan
Voluntary
counselling and
testing for HIV
and PMTCT
Proportion of HIV
+ mothers who
received ART
prophylaxis
No data No data No data RSACS to
be
contacted
Labour and
delivery
All deliveries
by a skilled
birth attendant
Proportion of
deliveries by
skilled birth
attendants
22.6%
(NFHS-1, 1992-
93, P.65,
Rajasthan report)
35.8 %
(NFHS-2,1998-99,
P.196, Rajasthan
report)
43.2%
(NFHS-3,2005-
06,P.65, Rajasthan
report)
80%
(2009-10)
to
100% by
2011 (State
PIP 2010-
11).
Rural: 32.5%
Urban: 74.2%
(NFHS-3,2005-06,P.64,
Rajasthan report)
+
Trends
are good
Not likely
to meet
targets
Disparities
SC: 34.2%
ST : 29.6%
OBC: 43.5%
Others: 52.9%
(NFHS-3,2005-06,P.64,
Rajasthan report)
Annexures
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-
1998-99 , P.
30,Rajasthan
report
44.4%
(DLHS-2 ,2002-
04, P.72,
Rajasthan report)
52.6 %
(DLHS-3,2007-08,
P.68, Rajasthan
report)
Rural: 48.1%
Urban: 73.5%
(DLHS-3,2007-08, P.68,
Rajasthan report)
SC: 47.0%
ST :44.3%
OBC: 52.8%
Others: 66.2%
Highest: 69.4% (Sikar)
Lowest: 30.6 %(Barmer )
(DLHS-3,2007-08, P.68, Raj
report)
Proportion of
home births/
proportion of
institutional
births
Home births:
77.2%
Inst. Births:
22.5%
(RCH-RHS-
1998-99 ,P. 30,
Rajasthan report)
Home Births:
68.0%
Inst. Births:
31.4%
(DLHS-2, 2002-
04, P.70,
Rajasthan report)
Home births: 53.8%
Institutional Births:
45.4%
(DLHS-3,2007-08
P. 68,Rajasthan
report)
70%
institutional delivery
(UNICEF-Coverage
evaluation survey-
2009)
90% by
2011
through
Janani
Suraksha
Yojana.
Home Institution +
Trends
are good
Not likely
to meet
targets
Disparities
Rural:58.5%
Urban: 32.0%
40.6%
67.5%
SC: 59.5%
ST : 59.3%
OBC: 54.3%
Others:40.9%
39.6%
39.9%
44.8%
58.5%
Highest: 78.7
%(Barmer)
Lowest : 34.1%
( Kota)
(DLHS-3,2007-
08 P. 70, Raj
report)
65.0%
(Kota)
21.3 %
(Barmer)
(DLHS-
3,2007-08
P. 70, Raj
report) Identification and
treatment of
maternal
emergencies such
as eclampsia and
obstructed labour
Proportion of
rural pregnancies
having a C-
section
0.3% (Rural)
(NFHS-1,1992-
93, P.159,
Rajasthan report)
2.1% (Rural)
(NFHS-2,1998-99,
P.197,Rajasthan
report)
2.2% (Rural)
(NFHS-3,2005-06,
P.63, Rajasthan
report)
Total: 3.8%
Urban :9.9%
Rural : 2.2%
(NFHS-3,2005-06, P.63,
Rajasthan report)
X
Annexures
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 Proportion of
babies who were
dried, wrapped
(and not bathed)
immediately
after birth
Data not available Data not available 34.2 %
(Data represents for
deliveries held at
Home)
(NFHS-3,2005-06,
P.63 ,Rajasthan
report)
Urban : 40.5%
Rural : 33.4 %
(NFHS-3,2005-06, P.63,
Rajasthan report)
Appropriate cord
care and hygiene Proportion of
babies who had
the cord cut with
a clean
instrument
Data not available Data not available 89.5%
(Data represents for
deliveries held at
Home)
(NFHS-3,2005-06,
P.63 ,Rajasthan
report)
Urban : 93.7%
Rural : 89.0%
(NFHS-3,2005-06, P.63,
Rajasthan report)
Annexures
Period Intervention Coverage measure Back ground
(Year and
Source)
Baseline data
(year and
source)
Most recent data
(year and source)
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-1998-
99, P. 43,
Rajasthan
report)
7.9%
(NFHS-1, 1992-
93,
P.178, Rajasthan
report
14.5 %
(within two
hours)
(DLHS-2, 2002-
04,P.88,
Rajasthan report)
14.1%
NFHS 3
Rajasthan report
41.4 %
(DLHS-3,2007-08
P.82, Rajasthan
report)
27.7%
(UNICEF-Coverage
evaluation survey-
2009)
60% by
2010-11
SPIP
Rural: 39.6%
Urban: 49.5%
(DLHS-3,2007-08
P.82, Rajasthan report)
SC: 38.7%
ST: 39.2%
OBC: 41.6%
Other: 45.6%
(DLHS-3,2007-08
P.82, Rajasthan report
Lowest: 24.2 % (Jaisalmer)
Highest: 54.8% ( Bundi)
(DLHS-3,2007-08
P.84, Rajasthan report)
Proportion of
babies who
received a pre-
lacteal feed
Data not available Data not available 71.6%
(NFHS-3,2005-06,P.
77, Rajasthan report)
Rural: 74.7%
Urban: 60.5%
(NFHS-3,2005-06,P. 77,
Rajasthan report)
SC: 71.6%
ST:78.3%
OBC:70.9%
Other: 67.5%
(NFHS-3,2005-06,P. 77,
Rajasthan report)
Annexures
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-2,1998-
99,P.199,
Rajasthan report
32%
(NFHS 3, 2005-
06, Rajasthan
report, P. 63)
37.3%
(DLHS-3,2007-08,P.
74, Rajasthan report )
80% in
2010-11
SPIP-2010-
11
Rural: 33.1%
Urban: 56.9%
SC: 31.0%
ST: 33.0%
OBC: 36.4%
Other: 50.7%
(DLHS-3,2007-08,P. 74,
Rajasthan report )
Immuni-zation 0 dose OPV/BCG No data 0 dose OPV
33.8% (DLHS-2)
0 dose- OPV
33.1%
(DLHS -3,2007-08,
P.85)
0 dose OPV 40%
(HMIS 2009-10)
Exclusive
breastfeeding Proportion of
mothers who did
not give anything
other than breast
milk in the first 3
days after birth
No data No data No data
Proportion of
infants 0-28 days
who are exclusively
breastfed
No data No data No data
Annexures
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)
Infants and
children
Exclusive
breastfeeding Proportion of
infants under 6
months exclusively
BF
57 %
(Computed based
on NFHS-1
data Rajasthan
report (P.180,Table
10.2)
33.2%
(NFHS-3,2004-06,
P.78, Rajasthan
report )
65.4%
(DLHS-3,2007-
08,P.83, Rajasthan
report)
34.9%
(UNICEF-CES-
2009)
Rural: 65.0%
Urban: 67.1%
SC: 63.4%
ST: 67.3%
OBC: 66.1%
Other: 63.3% (DLHS-3,2007-08,P.83, Raj report)
Appro-priate
compli-
mentary
feeding
Proportion of
infants 6-9 months
who receive
appropriate BF and
complimentary
feeding
47.8%
NFHS-1
Computed based
on NFHS-1 data,
Rajasthan report (pg.180,Table 10.2)
17.5%
(NFHS-2,1998-
99,P.265,India
report)
(Data represents
Rajasthan state)
43.7%
(DLHS-3,2007-08,
P. 83,Rajasthan
report)
49%
(UNICEF-CES 2009)
Micro-nutrient
supple-
mentation
Proportion of
children who
received a dose of
vitamin A in the
previous 6 m
No data No data 57.2 %
(UNICEF-Coverage
evaluation survey-
2009)
Proportion of
children who
received a dose of
vitamin A
22.2%
(RCH-RHS-1998-
99,P.47,
Rajasthan report)
22.4%
(DLHS-2,2002-
04,P.99, Rajasthan
report)
52.5%
(DLHS-3,2007-
08,P.88, Rajasthan
report)
60.5 %
(UNICEF-Coverage
evaluation survey-
2009)
90% by
2009 – 10
(Chapter 23
XI Five
Year Plan
Rajasthan p
23.3)
Rural: 50.5%
Urban: 61.7%
Male: 54.3%
Female: 50.4%
(DLHS-3,2007-08,P.88,
Rajasthan report)
Lowest: 20.1% (Bharatpur)
Highest: 93.3%
( Dungarpur)
Proportion of
children living in
HH that use iodised
salt (>15 ppm)
No data 35.1%
( NFHS-3,2004-06,P.
83 Rajasthan report)
58%
(UNICEF-Coverage
evaluation survey-
2009)
Urban: 65.1%
Rural: 27.3%
SC: 28.0%
ST: 31.7%
OBC:32.7%
Other: 52.9%
( NFHS-3,2004-06,P. 83
Rajasthan report)
Annexures
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)
Immunization
against
vaccine
prevent-able
diseases
Proportion of children 12-23 months of age
vaccinated against
measles before 12 months
No data No data No data
Percentage of
children aged 12- 23
months who received
Measles vaccine
42.3%
(RCH-RHS-1998-
99,P.47, Rajasthan
report )
35.9%
(DLHS-2,2002-
04,P.99,Rajasthan
report)
67.3%
(DLHS-3,2007-08,P.85
Rajasthan report)
65.6%
(UNICEF-Coverage
evaluation survey-
2009)
80 %
by 2010
(State PIP
2010 -2011)
Rural: 65.5%
Urban: 75.7% (DLHS-3,2007-08,P.85 Rajasthan report)
SC: 64.2% ST: 64.6%
OBC: 66.5% Other:76.8% (DLHS-3,2007-08,P.85 Rajasthan report)
Male: 70.0%
Female : 64.3% (DLHS-3,2007-08,P.85 Rajasthan report)
Lowest: 39.9%( Bharatpur)
Highest: 93.6%(Dungarpur) (DLHS-3,2007-08,P.86 Rajasthan report)
Prevention of
malaria
Proportion of children
who slept under an
ITN the previous
night
No data No data No data
Antimalarial
treatment for
malaria
Proportion of children
with fever who
received appropriate
antimalarials
13.9%
(NFHS-1,1992-93,
P.171, Rajasthan
report )
No data
9.0%
(NFHS-3,2004-06,P. 68
Rajasthan report)
Urban: 7.4%
Rural: 9.5%
SC: 6.5% ST: 11.2%
OBC: 10.4% Other: 5.4%
Male: 8.8%
Female : 9.2% (NFHS-3,2004-06,P. 68 Rajasthan report)
Care seeking
for pneumonia
Proportion of children
with suspected
pneumonia taken to
appropriate provider
No data
64.7%
(NFHS-3,2005-
06,P.68,Rajasthan
report)
89.9%
(UNICEF-Coverage
evaluation survey-
2009)
90% access
by 2010 (
State PIP
2010-11)
Urban: 71.9%
Rural: 62.9%
Male: 66.6%
Female :61.8% (NFHS-3,2005-06,P. 68 Rajasthan report)
Proportion of children
suffered from /
symptoms of ARI
21.2%
(RCH-RHS-1998-
99,P.52, Rajasthan
report )
13.4%
(DLHS-2,2002-
04,P.105, Rajasthan
report)
7.7 %
( DLHS-3,2007-
08,P.91,
Rajasthan report)
Rural: 7.9%
Urban: 6.6%
SC: 7.9%
ST: 7.4%
OBC: 7.8%
Other: 7.5%
Lowest: 0.8% ( Barmer)
Highest: 18.9% (Bharatpur)
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)
Proportion of
children sought
advice /
treatment
35.2%
(RCH-RHS-1998-
99,P.52,Rajasthan
report)
70.5%
(DLHS-2,2002-
04,P.105,Rajasthan
report)
75.7%
(DLHS-3,2007-
08,P.91,Rajasthan
report)
Rural: 73.7%
Urban: 86.5%
SC: 70.1 %
ST: 72.6%
OBC: 77.2%
Other: 80.8% (DLHS-3,2007-
08,P.91,Rajasthan report)
Lowest: 62.2% (Dhaulpur)
Highest:
100%(Hanumangarh) (DLHS-3,2007-
08,P.92,Rajasthan report)
Antibiotic
treatment for
suspected
pneumonia
Proportion of
children with
suspected
pneumonia who
received
appropriate
antibiotics
No data No data 18.2% (NFHS-3,2005-
06,P.68,Rajasthan
report)
Urban: 12.5%
Rural: 19.6% (NFHS-3,2005-
06,P.68,Rajasthan report)
Male:20.6 %
Female: 14.3% (NFHS-3,2005-
06,P.68,Rajasthan report)
Oral rehydration
for diarrhea
Proportion of
children with
diarrhea who
received ORT
4.7% (RCH-RHS-1998-
99,P.52,Rajasthan
report)
29.4% (DLHS-2, 2002-
04,P.102,Rajasthan
report)
30.6% (DLHS-3,2007-
08,P.90,Rajasthan
report)
45%
(UNICEF-Coverage
evaluation survey-
2009)
increase to
60% by
2010,ensuri
ng 100%
availability
of ORS at
sub centre
level.(SPIP-
2010-11)
Urban: 52.7%
Rural: 26.5%
SC: 25.9%
ST: 26.7%
OBC: 31.0%
Other: 40.3% (DLHS-3,2007-
08,P.90,Rajasthan report)
Use of zinc for
the treatment of
diarrhea
Proportion of
children with
diarrhea who
received ORT and
a course of zinc
No data No data No data
Annexures
Summary of Worksheet 4 – Coverage Indicators
Coverage indicators - programme is doing enough now
Iron supplementation: Proportion of mothers women who received iron during pregnancy
Appropriate cord care and hygiene: Proportion of babies who had the cord cut with a clean instrument
Postnatal care visit: Proportion of mothers/newborns who had a care contact in the first 2 days after
delivery
Proportion of children living in HH that use iodised salt (>15 ppm)
Case seeking for pneumonia: Proportion of children with suspected pneumonia taken to appropriate
provider
Coverage indicators – trends are positive, but programme needs to do more
Proportion of Institution deliveries.
Proportion of babies who were dried, wrapped (and not bathed) immediately after birth
Appropriate complimentary feeding: Proportion of infants 6-9 months who receive appropriate BF and
complimentary feeding
Proportion of mothers who initiated BF within 1 hour of birth
Proportion of babies who received a pre-lacteal feed
Proportion of mothers who did not give anything other than breast milk in the first 3 days after birth
Proportion of infants 0-28 days who are exclusively breastfed
Oral rehydration for diarrhea: Proportion of children with diarrhea who received ORT
Coverage indicators – major issues; programme needs to do more
Adequate antenatal care: Proportion of mothers who received at least 4 ANC visits
Tetanus Toxoid to all pregnant women: Proportion of mothers who received TT2+ during pregnancy
Identification and treatment of maternal emergencies such as eclampsia and obstructed labour:
Proportion of rural pregnancies having a C-section
Prevention of hypothermia: Proportion of babies who were dried, wrapped (and not bathed)
immediately after birth
Immediate initiation of breastfeeding: Proportion of mothers who initiated BF within 1 hour of birth;
Proportion of babies who received a pre-lacteal feed
Exclusive breastfeeding: Proportion of infants under 6 months exclusively BF
Immunization – „0‟ dose OPV; Percentage of children aged 12- 23 months who received Measles
vaccine
Micronutrient supplementation: Proportion of children who received a dose of vitamin A
Antimalarial treatment: Proportion of children with fever who received appropriate antimalarials
Coverage indicators - Adequate data not available
Malaria prevention: Proportion of pregnant women who slept under an ITN the previous night
Voluntary counseling and testing for HIV and PMTCT: Proportion of HIV + mothers who received
ART prophylaxis
Annexures
Annexure VI : Worksheet 5
Review how well the programme implemented activities
Pregnancy __Birth and Immediate Post-natal period__ Neonatal period __Infants and children 1-59 months
INTERVENTION PACKAGES BEING DELIVERED: ANC, SBA, EmOC, PNC
Activity area
Status of
implementation
(fully, partly or
not at all)
Reasons for observed
implementation
Performance
Strengths Weaknesses
Policies, planning and management
Practice
standards and
guidelines
updated and
being used
Fully met -Disseminated through
regular mechanisms
-Monitored whether
put into practice
System and
mechanisms in place
-Email up to block level
-Monthly meetings of
staff
Awareness at field level is
limited
Essential drug
list available
Fully met -Disseminated through
regular mechanisms
-EDL gets revised with
the revision of
guidelines
-Posted on website
-Supplied with
regularly provided kits
-No individual memory
among staff
-Not displayed in health
facilities
Budgeted plans
developed
annually – at
the state and
district levels
Partly met Planning units exist at
district and state level
District plans are
supposed to contribute
to state plan
District plans are not
developed in time
Planning done
collaboratively
with other
divisions and
with donors
Fully Technical support from
the donor partners
Exec Committees exist
and meet
The final call is taken by
the state, so some
suggestions from donors
not
Annual budget
adequate to
complete all
activities in the
last plan
Partly Inadequate funds for
civil works and
medicine procurement
-Proposed state budget is
slashed down by the
National government
- State is not able to
generate funds to cover the
shortfall
Annexures
Supporting data: policy and planning
Indicator Current status
Policies for exemption of pregnant women, newborns and
children from health charges available and implemented
Y N Rs 2 for
registration
CRC reporting mechanism established and working Y N (Rajasthan third draft report on
convention on rights of child suggests focused
attention on needs of children at policy and
programme level- Source: p.8 Child Policy Rajasthan
2009)
Costed national plan for ensuring universal access to
newborn and child survival interventions available
Y N
Mechanism for monitoring the International Code for
Marketing of Breast milk substitutes working
Y N
Laws and policies on vital registration adopted
Y N
National child health strategy endorsed and costed
Y N
% of districts implementing intervention package
100%
% of proposed child health budget received on time in the
previous year
Info to be collected
Annexures
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)
Reasons for
observed
implementation
Performance
Strengths Weaknesses
Human resources/training – in-service
Plan to ensure adequate
staffing at each level,
which includes
incentives
Partly Inadequate financial
resources to hire
Contractual hiring
Rural health cadre
Non availability of
specialists
Attrition rates among
contractual staff
In-service training
strategy available
Fully met Training cell in the
ministry
Training institute is
autonomous
State health
resource centre
Postponements
Non compliance by
identified candidates
(MOs)
In-service training
conducted for health
staff
Partly met
LSAS: 28 /
72
completed
Targets partly met -Trainer capacity is limited
-Training sites not
adequate
Trained staff is transferred
In-service facilitators
trained
Partly Adequate numbers
available
Utilization of facilitators
needs to be rationalized
Follow-up after in-
service training
conducted
Partly Policy and
mechanism for SBA
and BEmOC exists
Clear guidelines for
SBA F-up training
Capacity is limited
Quality of in-service
training – are: types of
staff trained, materials
used, time allocated,
amount of clinical
practice adequate?
Partly State monitoring cell
monitoring quality of
training created
-SIHFW provides
supervisory checks
CEmOC: certification
delayed
Annexures
Worksheet 5: Review how well the programme implemented activities
Pregnancy __Birth and Immediate Post-natal period__ Neonatal period __Infants and children 1-59 months
INTERVENTION PACKAGES BEING DELIVERED: ANC, SBA, EmOC, PNC
Activity area
Status of
implementation
(fully, partly or
not at all)
Reasons for observed
implementation
Performance
Strengths Weaknesses
Human resources/training – pre-service
Pre-service
training
strategy
available
No Need to reorient medical
nursing education to the
needs of national
programmes
Pre-service
training
incorporated
into curriculae
of medical and
other schools
Knowledge and
skills are
covered in
normal
curriculum
Pre-service
trainers trained
No
Quality of pre-
service training
– materials
used (including
textbooks),
time allocated,
amount of
clinical practice
adequate?
N/A
Supporting data: human resources/ training
Indicator Baseline data (year
and source)
Most recent data
(year and source)
Target Differences by
region or
group
(highest/lowest)
% of health staff who have
received training in intervention
package
SBA 53 MO
136(PHN/NT/SN)* up
to 2006-07
(P.7, PIP 2009-10)
1236ANM/SN/LV
up to
2007-08
% ANMs trained in SBA 36.07 % up to
2009-10 (P.20, ROP 2010-11)
57.9 % for
2010-2011 (P.20 ROP
2010-11)
Annexures
Indicator Baseline data (year and
source)
Most recent data
(year and source)
Target Differences by
region or group
(highest/lowest)
Doctors trained in EmOC (numbers) 49 up to 2009-10
(P.20, ROP 2010-11)
89 for 2010-
2011 (P.20
ROP 2010-
11)
Doctors trained in LSAS 117 up to 2009-10
(P.20 ROP 2010-11)
189 for 2010-
2011 (P.20
ROP 10-11)
% of planned trainings completed in
the previous year
% of health facilities with at least 60%
of health workers caring for children,
newborns or pregnant women trained
in training package
% of all trained staff who receive
follow-up visit within 3 months of
training
% of medical/nursing/midwifery
training schools that have incorporated
focus intervention or package=
% of mothers who receive ANC/PNC
from a skilled provider
3 or more ANC Checkups 28.8% (DLHS-2 ,2002-
04)
P.4 DLHS-3 Rajasthan
Fact sheet)
41.2 % (NFHS-3,
2005-06)
27.7%
(DLHS-3 ,2007-08)
P.4 DLHS-3
Rajasthan Fact sheet)
80%
(P.4
RCH chapter
PIP 2009-10)
Rural: 23.3 %
Urban: 48.1%
(P.4 DLHS-3,
2007-08
Rajasthan Fact
sheet)
At least 1 TT injection administration 61.4% (DLHS-2 ,2002-
04)
P.4 DLHS-3 Rajasthan
Fact sheet)
55 %
( DLHS-3 ,2007-08)
P.4 Rajasthan Fact
sheet)
80% ( P.4
RCH chapter
PIP 2009-10)
Intervention
Target:
RCH
outreach
camps- 2436
(No.) in
2010-2011
Rural: 51.4%
Urban: 72.4%
(DLHS-3,2007-
08, P.4, Rajasthan
Fact sheet)
Institutional deliveries 32.2%
(DLHS-2, 2002-04)
P.4 DLHS-3 Rajasthan
Fact sheet)
32.2%
(NFHS-3, 2005-06)
45.5%
( DLHS-3, 2007-08)
P.4 DLHS-3
Rajasthan Fact sheet)
70% in 2009 (p.4 RCH chapter PIP 09-10)
80% was the
target for
2009-10( P.4
RCH chapter
PIP 2009-10)
Rural: 40.7%
Urban: 67.7%
(DLHS-3
,2007-08
P.4, Rajasthan
Fact sheet)
Access to PNC -
38.2%
( DLHS-3 ,2007-08)
P.4 Rajasthan Fact
sheet)
60% was the
target for
2009-10( P.4
RCH chapter
PIP 2009-10)
Rural: 34.1%
Urban: 57.8%
(DLHS-3,2007-
08,P.4 Rajasthan
Fact sheet)
% of achievement of need assessed-
Institutional Deliveries
52.1%
(Performance
Statistics Table B.4-
Maternal Health –
Institutional
deliveries, July 2010)
Annexures
Review how well the programme implemented activities
__Pregnancy __Birth and Immediate Post-natal period__ Neonatal period __Infants and children 1-59
months
INTERVENTION PACKAGES BEING DELIVERED: ANC, SBA, EmOC, PNC
Activity area
Status of
implementation
(fully, partly or
not at all)
Reasons for observed
implementation
performance
Strengths Weaknesses
Health communication/IEC
Maternal health
communication
strategy or plan
available
Partly Delay in marriage, ANC
registration, institutional
delivery, emergency
transport
Adequate budget EMOC, PNC component is
weak
Focus on reaching
low level
populations
Partly Special drives and camps Special budget
RHSDP
Lack of coordination
between NRHM and RHDSP
Communication
activities
conducted: mass
media, printed
materials, training
for local
groups/volunteers
in inter-personal
communication;
training for health
workers
Partly Variable in different
districts
Folk groups empanelled
and used
All messages not covered
Messages and
materials
developed and
distributed
Fully Independent state and
district units
Donor partners provide
support for developing
materials
All messages not covered
Quality: key
maternal health
messages used;
messages and
materials pre-tested
and adapted for
local context
Partly Standard set used across
the state, Local contexts
not used
All messages not covered
Annexures
Review how well the programme implemented activities
Pregnancy __Birth and Immediate Post-natal period__ Neonatal period __Infants and children 1-59 months
INTERVENTION PACKAGES BEING DELIVERED: ANC, SBA, EmOC, PNC
Activity area
Status of
implementation
(fully, partly or
not at all)
Reasons for observed
implementation
performance
Strengths Weaknesses
Development of community supports
Implementation
plan for
community-level
activities
available
Fully Village committees
formed(VHSC)
Funds transferred Took longer than planned
30-40% VHSC members
trained
Community
health workers
trained and
available
AWW,
ASHA Sahayogini
90% villages have
appointed ASHA
Budgets ensured Motivation not sustained
Community
groups or
volunteers trained
and available
Partly Jan-Mangal couples
being revived
VHSC created in all
villages
All VHSC have not been
active
Quality:
Developed
collaboratively;
use local staff and
volunteers;
supervision or
oversight plan
Included
Partly 80% PHCs have ASHA
supervisors
ASHA, VHSC selected by
local community
Difficult to sustain
motivation
Supporting data: health communication/ community
Indicator Baseline
data (year
and
source)
Most recent
data (year
and source)
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 =
Annexures
Worksheet 5: Review how well the programme implemented activities
__Pregnancy __Birth and Immediate Post-natal period__ Neonatal period __Infants and children 1-59
months
INTERVENTION PACKAGES BEING DELIVERED: ANC, SBA, EmOC, PNC
Activity area
Status of
implementation
(fully, partly or
not at all)
Reasons for observed
implementation
performance
Strengths Weaknesses
Strengthening health systems
Quality of case-
management
No system for
assessment or
assuring quality of
care for SBA,
EMOC, PNC
Services
available
ANC, SBA, PNC
are fully available
EMOC is partly
available
FRUs and 24X7 PHCs
not functional
Lack of specialists
Essential drugs
and equipment
available at first
and referral
levels
Partly Equipment available Medicine shortage
Routine
supervision
conducted using
checklists, and
observation of
practice
Partly Checklists are not
adequate to address
Concurrent monitoring
system
Systems for
timely referral
for maternal
complications in
place
Partly Emergency transport HW and ambulance
attendants trained
available at some blocks only
Annexures
Supporting data: systems
Indicator Baseline data
(year and
source)
Most recent
data (year
and source)
Target Differences by
region or group
(highest/lowest)
Quality of case-management
% of children who received integrated
assessment (10 assessment tasks) - IMNCI
% of children attending facilities who need an
antibiotic and/or an antimalarial who are
prescribed the medicine correctly - IMNCI
Data on quality of antenatal care, delivery or
newborn care
Services available
% of hospitals providing comprehensive
emergency obstetric and newborn care (24
hours/day, 7 days/week) =
% of hospitals or maternity facilities accredited
as baby-friendly in the previous 2 years =
% of facilities with immunization services
available daily =
% of facilities providing ANC, delivery, ANC,
IMNCI services =
% of caretakers receiving PNC/ANC from a
skilled provider
Essential drugs, equipment and supplies
% of health facilities with all essential
medicines for managing common newborn
childhood illnesses or obstetric emergencies =
% of health facilities with all equipment and
supplies for vaccination =
% of facilities with all equipment and supplies
for managing sick newborns and children
% of facilities that manage severely ill children
with oxygen/delivery systems available in the
paediatric ward =
Supervision and referral
% of health facilities receiving at least one
supervisory visit with observation of case-
management in the previous 6 months =
Annexures
Worksheet 5: Review how well the programme implemented activities
Pregnancy __Birth and Immediate Post-natal period__ Neonatal period __Infants and children 1-59 months
INTERVENTION PACKAGES BEING DELIVERED: ANC, SBA, EmOC, PNC
Activity area
Status of
implementation
(fully, partly or
not at all)
Reasons for observed
implementation
performance
Strengths Weaknesses
Monitoring and evaluation
Plan for routine
monitoring and
periodic
evaluation of the
maternal health
programme
included in
strategic plan and
work plans
Fully for
monitoring
Partly, for
evaluation
Monthly reporting
system
Some components are
evaluated each year
HMIS online at block
level and upwards
Power and internet
connectivity
Training on data entry
required
No integrated evaluation
plan
Standard
international
indicators used
Partly, But All
nationally
decided
indicators are
captured
Short and long
term targets set
Fully at state
level
Five year and annual
programme cycles
have targets
District specific targets
not fixed
Population- and
health facility-
based data
available for
monitoring and
evaluation
Yes Facility based data at
state level
Population based data
available from
national surveys
Quality of data needs to
be improved
No data on quality of case
management collected
Monitoring data
used for routine
planning by all
levels
Partly Data is used at state
level
Data based planning not
done at district level and
sub-district level
Vital registration
systems working
Partly
About 80 %
births registered
Maternal death
registration are
very low
Awareness
programme on birth
registration in parts of
state
Supporting data: monitoring and evaluation
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)
75.27%
(UBR-2009)
118.51% (Urban)
63.49% (Rural)
(UBR -2009)
% of child deaths registered =
% of routine reports from districts received on time
Annexures
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 Weaknesses
Policies, planning and management
Practice
standards and
guidelines
updated and
being used
Facility-based
Newborn Care -
NNF guidelines
being utilized
- Interest of the state
government in FBNC
- Resources available
through NRHM
Strong partnership –
NNF, UNICEF, NIPI
Commitment from
government
Partnerships
Resources
Home-based
Newborn Care -
Available
- Activity not covered in
PIP 2010-11
- Although guidelines are
available, implementation
poor
Essential drug
list available
Available;
Drugs are being
purchased based
on the list
- Adequate funds
available
- Was done in
participatory manner
- Not updated regularly
Budgeted plans
developed
annually – at
the national and
sub-national
levels
Yes; available at
state and district
level
- Commitment of the
government
- Done in participatory
manner with
involvement of
important stakeholders
- Template based planning
– lack of flexibility
-
Planning done
collaboratively
with other
divisions and
with donors
Yes; but not all
partners
adequately
involved
- Involvement of ICDS is
less
Annual budget
adequate to
complete all
activities in the
last plan
- Available - Approximately 20%
budget not utilized
- Complicated processes
Annexures
Supporting data: policy and planning
Indicator Current status
Policies for exemption of pregnant women, newborns and
children from health charges available and implemented
Y N
CRC reporting mechanism established and working Y N (Rajasthan third draft report on
convention on rights of child suggests focused
attention on needs of children at policy and
programme level- Source: p.8 Child Policy Rajasthan
2009)
Costed national plan for ensuring universal access to
newborn and child survival interventions available
Y N
Mechanism for monitoring the International Code for
Marketing of Breastmilk substitutes working
Y N
Laws and policies on vital registration adopted
Y N
National child health strategy endorsed and costed
Y N
% of districts implementing intervention package
26 functional FBNC out of 36 planned (source: p.67
NRHM PIP 2010-2011)
% of proposed child health budget received on time in the
previous year
Annexures
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 Weaknesses
Human resources/training – in-service
Plan to ensure
adequate
staffing at each
level, which
includes
incentives
- Adequate
staffing at
FBNC not
planned
-
- Shortage of trained
manpower
- Vacancy of ASHA (15%)
- Lack of staff nurses at
FBNC
In-service
training
strategy
available
Yes; not
adequate
(FBNC &
HBNC)
- Strong partnership for
FBNC training
- Handholding supervision
after training is also poor
In-service
training
conducted for
health staff
Yes; not
adequate
(FBNC &
HBNC)
- Strong partnership for
FBNC training
- Handholding supervision
after training is also poor
In-service
facilitators
trained
Yes - Adequate facilitators
available for NSSK
- Inadequate facilitators
for IMNCI, FBNC
- Protocols not being
followed in training
institutions
Follow-up after
in-service
training
conducted
Not adequate - No mechanism
Quality of in-
service training
– are: types of
staff trained,
materials used,
time allocated,
amount of
clinical practice
adequate?
Need
improvement
- not adequate clinical
practice during training
Quality assurance
mechanism for training not
available
- Less number of facilities
for conducting training
Annexures
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 Weaknesses
Human resources/training – pre-service
Pre-service training
strategy available
- IMNCI – MBBS,
ANM; Not available
for nursing schools
- Training on
newborn care not a
priority
- Not started in all
medical colleges
-
Pre-service training
incorporated into
curriculum of
medical and other
schools
- Only IMNCI
included
- Newborn component
not adequate
Pre-service trainers
trained
Partly - Not perceived as
priority
Quality of pre-
service training –
materials used
(including
textbooks), time
allocated, amount of
clinical practice
adequate?
Inadequate
Supporting data: human resources/ training
Indicator Baseline
data (year
and
source)
Most recent
data (year and
source)
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 =
-
38.2%
( DLHS-3
,2007-08)
P.4,
Rajasthan
Fact sheet)
60% 2009-
10( P.4
RCH
chapter PIP
2009-10)
Rural: 34.1%
Urban :57.8%
(DLHS-3 2007-
08,
P.4, Rajasthan
Fact sheet)
Access to PNC
Annexures
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 Weaknesses
Health communication/IEC
Child health
communication
strategy or plan
available
- Part of the
state health and
ICDS PIP
Focus on reaching
low level
populations
- Separate plan
for tribal and
dessert areas
both in RCH
and ICDS PIP
Communication
activities conducted:
mass media, printed
materials, training
for local
groups/volunteers in
inter-personal
communication;
training for health
workers
- Available (IPC
and Print media)
Messages and
materials
developed and
distributed
Yes
Quality: key child
health messages
used; messages
and materials pre-
tested and adapted
for local context
Yes - Distribution and
dissemination of the IEC
materials
- Evaluation of the
content and impact not
done
- Operational and
managerial issues
- Monitoring of IEC
Annexures
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)
Reasons for
observed
implementation
Performance
Strengths Weaknesses
Development of community supports
Implementation plan
for community-level
activities available
Available
Community health
workers trained and
available
Partly
- Mechanism for
monitoring by
independent agency
available
- Post-training follow-up
and handholding is not
adequate
- All Community Health
Workers not covered
- Training of ASHA
completed only for a few
modules
- Quality issues in training
of ASHA
Community groups or
volunteers trained and
available
Partly - Jan Mangal Couple
available for 24 hours
Quality: developed
collaboratively; use
local staff and
volunteers;
supervision or
oversight plan
Included
Annexures
Supporting data: health communication/ community
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-
2,2002-04)
P.5 DLHS-3
Rajasthan Fact
sheet)
98.6%
( DLHS-
3,2007-08)
P.5,
Rajasthan
Fact sheet)
Rural:98.6%
Urban: 98.8%
(DLHS-3 ,2007-
08)
P.5, Rajasthan
Fact sheet)
% of villages with trained CHWs for promoting key
family and community practices =
% of CHWs trained in intervention package =
% of caretakers of children 0-59 months who
received a home visit and counseling from a
community health provider in the previous 3 months
=
% of villages with trained volunteers for promoting
key family and community practices =
Annexures
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 Weaknesses
Strengthening health systems
Quality of case-
management
Unsatisfactory
- Training and follow-
up after training
- Lack of Quality
Assurance system
- Poor monitoring
- Lack of skilled
manpower
- Lack of infrastructure
-
- Plan for monitoring of
FBNC through State
level Newborn cell
- Training and follow-up
after training
- Lack of Quality
Assurance system
- Poor monitoring
- Lack of skilled
manpower
- Lack of infrastructure
- Lack of awareness and
acceptance of services
(community-
based/facility-based)
- Gender bias in care
Services
available
Inadequate
- Services
available only at
District hospital
- Unsatisfactory
for Community
level
- Lack of skilled
manpower
- Lack of well-
established
infrastructure
- Lack of supportive
supervision
- Lack of awareness and
acceptance of services
(community-
based/facility-based)
- Lack of accountability
Essential drugs
and equipment
available at
first and
referral levels
- For first level,
units to be
established
- For referrals,
equipments and
drugs available - The list of
essential drugs
need to be
updated for
newborns
- Although equipments
available at referral level,
maintenance is a problem
Routine
supervision
conducted
using
checklists, and
observation of
practice
Not at all for
FBNC
Partly for
Community-
based
-Still in the
preliminary stage of
planning for FBNC
- For community-
based, we have
checklists available for
supervisors
- ICDS involved for
supportive supervision
of Community-based
Newborn Care
-
Community-based care
- Lack of feedback
- Lack of accountability
Systems for
timely referral
of sick
newborns and
children in place
Available - Acceptance of the
public health system
- Training of the
workers
- Follow-up of referral
- Referral card
- Funds are available
- Ambulance services
- Although system is
available, referrals remain
poor
Annexures
Supporting data: Health systems
Indicator Baseline
data (year
and source)
Most recent data
(year and source)
Target Differences by
region or group
(highest/lowest)
Quality of case-management
% of children who received integrated
assessment (10 assessment tasks) –
IMNCI
IMNCI (Integrated Management of
Neonatal
& Childhood Illnesses)
To
implement
IMNCI in
33 districts
in next two
years. (P.8 NRHM PIP 2010-11)
Personnel Trained in IMNCI 17000 by 2009-10
(No.)
(P.21
ROP 2010-11)
25250 up
to 2010-11 (P.21 ROP 10-11)
% of children attending facilities who
need an antibiotic and/or an
antimalarial who are prescribed the
medicine correctly - IMNCI
Data on quality of antenatal care,
delivery or newborn care
Please note : All data on T/t of diarrhea and ARI is for two weeks before the concerned survey.
Children with Diarrhea who sought
advice or treatment
61.7%
(DLHS-2
,2002-04)
P.5 DLHS-3
Rajasthan
Fact sheet)
59.7%
( DLHS-3 ,2007-08)
P.5 Rajasthan Fact
sheet)
Rural: 58.7%
Urban: 64.9%
(DLHS-3 ,2007-08)
P.5 DLHS-3
Rajasthan Fact
sheet)
Children with Diarrhea who received
treatment with ORS
28.9%
(DLHS-2
,2002-04)
P.5 DLHS-3
Rajasthan
Fact sheet)
30.6%
( DLHS-3 ,2007-08)
P.5 Rajasthan Fact
sheet)
Rural: 26.4%(
Urban: 53.0%
(DLHS-3,2007-08)
P.5 Rajasthan Fact
sheet)
Children who had Diarrhoea
% Children taken to Health Provider
Treated with ORT
No Treatment
10.3% (
NFHS-3,2005-2006
P.69 State report )
56.7%
21.4%(including16.5%
ORS)
28.7%
(NFHS-3,2005-2006
P.69 State report)
Annexures
Children with Diarrhea who were
treated with ORS
16.5%(2005-06)
50% (2006-07)
60%(2007-08)
80%(2009-10)
P.31 NRHM PIP 2010-2011
Children under 5 who had symptoms of
ARI
Out of these who were taken to the
health facility
Out of these who received antibiotics
7%
(NFHS-3,2005-2006
P. 24 State report)
65%
18%
% children with ARI and fever who
sought advice or treatment
70.1%
(DLHS-2
,2002-04
P.5 DLHS-3
Rajasthan
Fact sheet)
75.6%
( DLHS-3,2007-08
P.5 DLHS-3 Rajasthan
Fact sheet)
Rural: 73.6%
Urban: 86.3%
(2007-08
P.5 DLHS-3
Rajasthan Fact
sheet)
% Of Sick children (with
Diarrhea/ARI/childhood illnesses)
having access to care
90% by
2010-11
(P.67
NRHM
PIP 2010-
11)
Services available
% of hospitals providing
comprehensive emergency obstetric
and newborn care (24 hours/day, 7
days/week) =
FBNC(facility based new born care) at
district hospitals
11 FBNC
functional
out of 35
planned in
2009-10
(P.14 RCH
chapter PIP
2009-10)
26 functional FBNC
out of 36 planned
(P.67 NRHM PIP
2010-2011)
36 by March
2010
(P.67
NRHM PIP
2010-11)
36 in
number (A.2.2 excel sheet PIP
budget sheet
2010-11)
NBSU(newborn stabilizing units) at
FRUs
100 in
number (A.2.2 excel
sheet PIP budget sheet
2010-11)
New born care services Since April 2009 a
total 18452 Newborns
were admitted till Nov
09 (p.68 NRHM PIP
2010-2011)
85% of 19971 of
neonates cured and
treated
( State PIP 2010-2011)
Estimates :
50000 new
born will
receive
quality care
every year(
State PIP
2010-2011)
Annexures
% of hospitals or maternity facilities
accredited as baby-friendly in the
previous 2 years =
% of facilities with immunization
services available daily =
% of facilities providing ANC,
delivery, ANC, IMNCI services =
FRUs Operational 100 FRUs by 2008-09
were functional
(P.4 PIP 2009-10)
237 in
number in
2010-11 (P.134 NRHM PIP 2010-11)
% of caretakers receiving PNC/ANC
from a skilled provider
Essential drugs, equipment and supplies
% of health facilities with all essential
medicines for managing common
newborn childhood illnesses or
obstetric emergencies =
% of health facilities with all
equipment and supplies for vaccination
% of facilities with all equipment and
supplies for managing sick newborns
and children
% of facilities that manage severely ill
children with oxygen/delivery systems
available in the paediatric ward =
Supervision and referral
% of health facilities receiving at least
one supervisory visit with observation
of case-management in the previous 6
months =
Annexures
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
Status of
implementation
(fully, partly or
not at all)
Reasons for observed
implementation
performance
Strengths Weaknesses
MONITORING AND EVALUATION
Plan for routine
monitoring and
periodic
evaluation of the
child health
programme
included in
strategic plan and
work plans
Yes - Online
- Pregnancy and child
tracking system
established
- Indicator based
monitoring
- Quality of data needs
improvement
- Proper system for analysis
of data and feedback to the
providers not available
-Monitoring for quality of
care
- System of verification of
data
Standard
international
indicators used
Yes
Short and long
term targets set Partly - Targets not available for
all indicators (impact and
coverage
Population- and
health facility-
based data
available for
monitoring and
evaluation
Yes - Use of data for decision-
making needs
improvement
Monitoring data
used for routine
planning by all
levels
Partly - Planning process
- Training of managers in
planning process
- Exact data needed for
planning may not be
available
Vital registration
systems working
Partly
- - Maternal death
enquiry initiated and
being scaled up
- Birth registration has
improved with increase
in institutional delivery
- home delivery and death
at home not being
registered
-
Supporting data: monitoring and evaluation
Indicator Baseline data (year
and source)
Most recent data
(year and source)
Target Differences by
region or group
(highest/lowest)
% of births registered at birth =
61.43%
(UBR 2005)
75.27%
(UBR 2009)
118.51% (Urban)
63.49% (Rural)
( UBR 2009)
% of child deaths registered =
% of routine reports from districts
received on time
Annexures
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
POLICIES, PLANNING AND MANAGEMENT
Practice
standards
and
guidelines
updated
and being
used
IMNCI –Full Good Policies
Guidelines, updated
regularly,
Implementation Plans
Some critical
operational elements
are lacking e.g
supportive supervision
mechanisms.
UIP - Full Comprehensive
guidelines available
encompassing several
components of program
management
Centrally determined
plans and policies,
local needs for certain
vaccines may not be
met as per
requirement.(e.g need
for HepB and HiB)
Elements of demand
side is missing;
tackled separately in
IEC section
Facility based Interventions
(MTC,Yashoda,F-IMNCI)=Yes
except for F-IMNCI; policy
decision has been taken,
details being worked out
Most policies are
adoption of National
level guidelines;
sometimes even the
translation in the local
language is not
undertaken.
Frequent change of
circulars and
directives.
Dissemination of the
guidelines are not
timely: there is also
variation in
interpretation.
Essential
drug list
available
IMNCI -Yes as part of the
State Essential Drug List
One comprehensive drug
list for each level of
facility has been
prepared.
Provision to buy
materials outside the list
if required.
Matching of the drug
list with the
intervention packages
has not been done.
UIP: All vaccines available Vaccines available but
supply chain
management issues
Facility based Interventions:
part of essential drug list
Matching of essential
drug list required
specially for newer
programs such as F
IMNCI and MTC.
Annexures
Activity
area
Status of implementation Reasons for
observed
implementation
Performance
Strengths Weaknesses
Budgeted
plans
developed
annually –
at the
national
and sub-
national
levels
Yes, for all as a part of the
PIP
Participation of districts
which are preparing dist
action plans/ sub plans:
bottom up approach
IMNCI Planning
confined to Planning
for Training
Planning
done
collaborativ
ely with
other
divisions
and with
donors
IMNCI-Yes,
UIP; Yes
FBI: Yes
Joint planning
undertaken at state level
Medical college/ training
institutions involvement
is increasing
Collaboration not
uniform at all levels
Convergence with
ICDS not adequate.
Annual
budget
adequate to
complete all
activities in
the last
plan
IMNCI-Yes
UIP: Yes
FBI: yes
Most of the budgeted
money remains
underutilized.
Annexures
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.
Main streaming of
AYUSH personnel
DP also providing
/supporting techno-
managerial personnel.
Delays in filling
vacancies.
In-service
training strategy
available
Yes there are a variety of
training packages available
(21)!!
specific training
packages for each
intervention group
Lack of coordination
and integration of
trainings.
Frequent disruptions
in trainings.
In-service
training
conducted for
health staff
Yes Training plan/calendar
made
Flexibility in training;
can change calendar if
necessary
multiple trainings in
process a burden to
time and personnel.
Training calendar not
adhered to:
synchronization of
trainings not always
evident.
budget sometimes not
available in time
leading , external
exigencies prolong
duration of trainings.
Contingency plans not
made.
Annexures
Activity area Status of implementation Reasons for
observed
implementat
ion
Performance
Strengths Weaknesses
In-service
facilitators
trained
Yes lack of reorientation
leads to loss of skills
Transfer of facilitators
leading to loss in
manpower.
Follow-up after
in-service
training
conducted
Partial Each candidate's service
book would contain the
trainings he has
undertaken.
post training
deployment is not
appropriate
Quality of in-
service training –
are: types of staff
trained, materials
used, time
allocated, amount
of clinical practice
adequate?
mixed; trainings at block
level tend to be of poor
quality, at govt venue tend
to have other distractions
Two sites designated at
training sits to assure
quality (for state level
trainings)
the appropriate
persons are not sent
for the trainings;
tendency for the same
person to be sent for
several trainings.
Annexures
Activity area Status of implementation Reasons for
observed
implementat
ion
Performance
Strengths Weaknesses
HUMAN RESOURCES/TRAINING – PRE-SERVICE
Pre-service
training strategy
available
Partial; Formal strategy in
place for IMNCI, not for all
National strategy not
endorsed at state level
dissemination not
done to all levels.
No set plan for in
service training.
Pre-service
training
incorporated
into curriculae
of medical and
other schools
Partial Material not
incorporated
yet in all
relevant text
books.(only
select;OP
Ghai)
At present , IMNCI
training is for medical
colleges and not for
nursing schools.
Pre-service
trainers trained
Partial: only from medical
colleges e.g for IMNCI
Quality of pre-
service training
– materials used
(including
textbooks), time
allocated,
amount of
clinical practice
adequate?
No information available
Annexures
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
HEALTH COMMUNICATION/IEC
Child health
communication
strategy or plan
available
Yes, as a part of the the
overall IEC plan
Special directorate at
state and IEC
coordinators at districts
in place
Budget available for IEC
activity
Strategy does not have
comprehensive plan
using appropriate
media mix: more
emphasis written
messages and not
always appropriate
Focus on
reaching low
level populations
Yes Despite availability of
plans , implementation
and reach are less than
optimum.
Communication
activities
conducted:
mass media,
printed
materials,
training for local
groups/volunteer
s in inter-
personal
communication;
training for
health workers
Yes Local religious leaders
have been used, puppet
shows have been
organised, video CD
materials have been
developed, posters and
LCD screens with 7 CD
sets of IEC materials are
being displayed in
maternity wards,
claender for IMNCI.
BCC trainings for HW
by RHSDP, IEC training
a part of all major
training packages.
Loss of materials
developed in the past,
Slow pace of trainings
of IPC/BCC packages,
often not practiced by
HW.
Messages and
materials
developed and
distributed
Yes(developed); partial
dissemination
Variety of materials
developed pertaining to
major interventions.
materials not always
available where
required; often not
displayed despite
availability
Quality: key child
health messages
used; messages and
materials pre-
tested and adapted
for local context
Partial: field testing part
not undertaken
Technical committee
ensures correct
messages, local context
adapted
field testing aspect
often ignored
Evaluation (output) of
material not
undertaken
Annexures
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
DEVELOPMENT OF COMMUNITY SUPPORTS
Implementati
on plan for
community-
level activities
available
Partial; ASHAs recruited,
VHSC made; plan for
training PRI members
lack of
coordination
between health
functionaries and
community
persons to
develop concrete
plan
ASHA placed; trained,
funds available at
community level
Involvement of
community is not as
per desired, non-
formal leaders are not
involved.
Community
health
workers
trained and
available
Full: ANMs , LHV, and
AWW
different training
packages for each group
timeliness of training,
quality of training
variable(through
NGOs)
Conflicting messages
in different trainings
as understood by
trainees.
Community
groups or
volunteers
trained and
available
Almost complete (ASHA)
Partial (VHSC)
Quality:
developed
collaborativel
y; use local
staff and
volunteers;
supervision or
oversight plan
included
Partial. Models of supportive
supervision has been
created and tested in
Rajasthan(e.g
director=district, nursing
schools)
supportive supervision
weak
multiplicity of
packages; no
integration of
supportive supervision
mechanism
Annexures
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
STRENGTHENING HEALTH SYSTEMS
Quality of
case-
management
Partial (from given data
of diarrhea, pneumonia,
mal nutrition)
Logistics issues,
training issues
Gradual improvement
is evident
irrational use of antibiotics,
IV fluids, feeding
counseling weak
Services
available
Partial IPHS standards
available to be
followed.
Facility level survey
carried out periodically
HMIS also monitors
facilities and services.
Mechanism for
providing services
through VHND
facilities and services not
uniformly available as per
IPHS standards
Essential drugs
and equipment
available at
first and
referral levels
Full Equipment are being
supplied by regular
and partner support
Drug supplies are
mostly regular
manpower not appropriately
trained to use equipment
Maintenance of the
equipment not streamlined
Routine
supervision
conducted using
checklists, and
observation of
practice
Partial Senior personnel
from directorate
allotted districts for
direct supervision
(has a comprehensive
common checklist)
Inadequate supervisory
manpower for field level
supportive supervision.
Available supervisors need
appropriate training for use
of checklists.
Systems for
timely referral
of sick
newborns and
children in
place
Partial, 108 mechanism for
referral
funds available at
VHSC for referral
when needed
Awareness for need
for referral
increasing.
Recent problems with 108
company PPP arrangement;
introduced phase-wise at
Rajasthan.
Timely referral being
hindered due delays in
identification and decision
making ( also information
on where to refer)
Referral slips not honoured.
Availability of doctors at
facility level.
Need for training processes
at facility level.
Annexures
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
MONITORING AND EVALUATION
Plan for
routine
monitoring
and
periodic
evaluation
of the child
health
programm
e included
in strategic
plan and
work plans
Partial State has made multi
level plans for
monitoring and
supervision of child
health activities.
State has tool for
validation of monitoring
data.
Has an online system for
receiving reports from
the lowest levels; also
pregnancy child tracking
system in place.
CRMs and JRMs also
include review of child
health packages.
Stock taking of CRM
and JRM
recommendations are
undertaken through
action taken report.
Monthly review meeting
for progress in
implementation
undertaken at the state
UIP has a monitoring
system including
periodic reviews.
Monitoring at lower
levels inadequate (lack
of time, variety of
tasks including non-
health tasks)
Analysis of
computerized data at
block level
inadequate, now
started at district level.
Teams involved in
JRMs and CRMs are
not apprised of the
action and are not
involved in the
corrective planning
process. central
initiative rather than
the state.
Review mechanisms
have more focus on
administrative
processes than
program indicators.
use of HMIS data and
data triangulation
limited.
UIP reviews are
mostly undertaken
where DP support is
strong.
Annexures
Activity
area
Status of implementation Reasons for
observed
implementation
Performance
Strengths Weaknesses
Standard
international
indicators
used
Yes Yearly periodic
reports have to be
submitted based on
the indicators.
In the PIP the standard
indicators have been
mentioned each year and
have been used for planning
purposes.
Not internalized by the
system on a regular basis
Not used to drive the
programs systematically.
Short and
long term
targets set
Yes Need to provide
reports with
targets.
Targets determined
following community
surveys and determined
bottom up.
Demography cell validates
and finalises these targets.
Targets for each
intervention related to
child health not
available.
Sometimes targets are
unrealistically set due to
ambitious requirements
of decision makers.
Lack of techno
managerial skills to set
realistic targets.
Population-
and health
facility-
based data
available for
monitoring
and
evaluation
Yes, through HMIS data and
through surveys
Disaggregated data (e.g sex
wise, rural urban) now
available even at peripheral
levels
Sometimes validation of
data carried out by
independent agencies.
Proper analysis and use
is limited.
Lack of demand for
astute data by decision
makers and not
appropriately used in
planning and review
processes.
Data of private services
not available.
Monitoring
data used
for routine
planning by
all levels
Partial Indicators and information
are available.
Only limited data (key
indicators information)
used for planning
processes e.g
immunization
Feedback of data is not
usually shared at lower
levels, the block review
mechanisms vary from
block-to-block
Vital
registration
systems
working
Partial
(85%)
Being done at
village by gram
sachivs (85%
registration)
Maternal death
audits started in 14
districts
Incentives for reporting
maternal and infant death.
Computerization of data/
support by DPs e.g
maternal death audits.
Not yet universal
Annexures
Annexure VII: Worksheet 6 (Consolidated)
Identify the main problems
Activity Area Problems
Policy, planning
and
management
Communication from HQ to grass root level:
a. Clarity and completeness
b. Timeliness
c. F/U on action
Lack of Operational Guidelines/ SOPs
a. Clarity on program incentives
Need based Planning
a. Limited Program Planning and Management capacities especially at
district level
b. Constraints of templates and budget, flexibility not there
c. Data not used, equity not considered (RBP)
d. Special plans for desert and tribal areas
Stronger HR policy and Training strategy to be developed
a. Deployment
b. Recognitions and incentives
c. Involvement of AYUSH practitioners in IMNCI
Lack of Convergence with health related departments like ICDS, Water,
Sanitation, PRIs
Program Implementation challenges
a. Feedback system
b. Weak supervisory mechanisms
c. Logistics management
1. Transmission loss of stated guidelines resulting into ambiguity in understanding
guidelines- (Language, Individual interpretation) (M)
2. Frequent changes, time lag in issue to implementation, lack of reference (M)
3. Policies do not explicitly state the operational element /implementation plan e.g.
post training programmatic support (needs detailing). (C)
4. The local level adaptation and dissemination of National level guidelines of the
guidelines are weak. (C)
5. Delink between the district plans & section plans and hence lack of consistency in
district plans and state plans. (M)
6. Facility-based newborn care – availability of SCNU beds not decided on the
number of deliveries conducted (N)
7. Budget allocation does not often match with plan needs. (M)
8. Procedural delays resulting in poor budget utilization (N)
9. Lack of linkages between program activities planned coverage of key interventions
& achieving impact and set goals. (M)
10. Posting of staff far away from their native district. (N)
11. Comprehensive training strategy does not exist. (C)
12. Weak coordination between ICDS and Health Department related with defining
the role of ASHA. (N)
Annexures
Human
resources and
training
Lack of Systematic policy of human resource development. (M)
- Selection of proper person for trainings. (M)
- Delink between available data of PIS (personal information system) and its
use. (M)
- Proper Utilization of training skills. (M)
Weak supportive supervision system, lack of follow-up after training and
programmatic support. (M)
Pre service education programme does not incorporate training packages of
medical & paramedical staff. (M)
Vacancies of critical staff at facility and community level (N)
Post training Supportive supervision and handholding is weak. (N)
Pre service training on IMNCI not being done. (N)
Not adequate training of trainers for pre-service courses. (N)
Newly recruited field staff (ASHA coordinator) not provided adequate training
and mobility support. (C)
Attrition of junior doctors high for PG seats. (C)
Delays in filling vacancies, recruitment slow. (C)
The appropriate participants and facilitators not selected for trainings. (C)
Communication
No well designed BCC strategy for MCH. (M)
Messages do not match with the all services packages. (M)
Inappropriate Media mix. (M)
Lack of impact assessment of communication materials. (M)
Communication skills of health workers. (M)
Absence of Integrated communication plan for newborn health, no focus on
gender either. (N)
Interpersonal communication weak (N)
Monitoring and evaluation of IEC activities weak (N)
Intensity of IEC is not sustained throughout the year. (C)
Slow pace of trainings of IPC/BCC packages (C)
Field testing aspect and content analysis often ignored (C)
Impact evaluation of material not undertaken (C)
Development of
community
supports
Inadequate quality of VHSC, ASHA, Janmangal couple trainings. (M)
Un-sustained motivation of support groups. (M)
Handholding of Village Health and Sanitation Committee is weak (N)
Community Monitoring not being done by Village Health and Sanitation
Committee (N)
Thematic community meetings involving right community members (on
Immunization, breastfeeding: for role in community mobilization, behavior
change, community monitoring of activities) not happening. (C)
Weak linkages with different community groups and health systems. (C)
Lack of timeliness of training for community members, quality of training
variable (through NGOs). Conflicting messages in different trainings as
understood by trainees. (C)
Annexures
Strengthening
health systems
No system for assessment or assuring quality of care for SBA, EMOC, PNC.
(M)
Lack of specialists (CEmOC), nursing staff, ANMs. (M)
Shortage of medicines. (M)
Inadequate emergency transport. (M)
Lack of skilled manpower; extra positions not created to keep pace with the
new facilities; e.g. FBNC (N)
Supportive supervision (N)
Maintenance of equipments (N)
Maintenance of the equipment and training for their appropriate use not
streamlined (C)
Weak supportive supervision. (C)
Referral related delays are a problem. (C)
Poor case management (C)
Monitoring and
evaluation
Lack of comprehensive analysis of data at district and sub-district level
o Some issues in data quality (e.g. morbidity, mortality)
o Denominators not considered
o In individual tracking, Urban data not covered
o Some Private sector data missing e.g. Newborn and Child health data
Weak Review and feedback mechanisms at district and sub-district level- more
administrative- less programmatic, targets- results should be discussed, need to
be more structured, Joint director of respective zones should attend the reviews
o Joint reviews with related departments like ICDS, Water, Sanitation
and PRIs
Need to update monitoring indicators related to MNCH
Targets not realistic
No systematic evaluation plan
Assessment of Quality of care of MNCH services
1. System for analysis of data at district and sub-district level and feedback to the
providers not available. (N)
2. No analysis and feedback on HMIS data. (M)
3. Monitoring and feedback at all levels inadequate (lack of time, variety of tasks
including non-health tasks) (C)
4. Standard newborn care indicators and targets not included in monitoring
system (N)
5. Inadequate Quality of HMIS data. (M)
6. Analysis of computerized data at block level inadequate. (C)
7. Data of private sector services not available. (C)
8. Realistic targets for each intervention related to child health not available. (C)
9. Review mechanisms have more focus on administrative processes than
program indicators. (C)
10. No integrated evaluation plan. (M)
11. Quality assurance system of facility based and community based newborn care
not included in PIP. (N)
12. Inadequate Use of data for planning. (M)
M: Maternal Group, C: Child Health Group, N: New born group
Annexures
Annexure VIII: Worksheet 7
Develop solutions and recommendations: Activity area: Policy, planning and management
The Problems are… Causes Solutions Recommendations
There is a gap in communication,,
uniform interpretation and
follow-up of directives from State
HQ to grass root level.
a. Lack of clarity, consistency and
completeness
b. Delay in communication
c. There is no follow up on
communication and action taken
Checklist to be developed to
ensure clarity and completeness
and all communications to go
through this checklist
Action taken report should be
obtained and Periodic Follow
ups should be done
Should be shared verbally and in
written during monthly/
quarterly reviews
Apart from verbal and written
communication, video
conferencing and Gramsat
platform can be utilized to bring
clarity in communication
Along with long guidelines, gist
in bullets to be included
CMHOs & BCMHOs to be
made more accountable
In the area of addressing „Gaps in
Communication‟ of guidelines from
state HQ to grass root level it is
recommended that:
1. Checklist for ensuring clarity,
consistency and completeness of
guidelines, follow-up is
developed by Health Directorate
2. Originating units/ departments
use the checklist to ensure that
the guidelines are clear,
comprehensive and self
explanatory
3. The district and block units
ensure that the guidelines
reaches the intended user in time
and an action taken report is
sought
Annexures
Activity area: Policy, planning and management
The Problems are… Causes Solutions Recommendations
Planning not need based but
driven by template and budget
a. Limited Program Planning and
Management capacities
especially at district level
b. Constraints because of template
planning and budget restraints
c. Data not used, equity not
considered (RBP)
d. Desert and tribal areas not given
adequate priority
e. Targets unrealistic or missing
for some interventions
Building capacities for „Program
Planning and Management‟ at
state and district and block level
Decentralized planning based on
data and local needs as
recommended in NRHM
Alternate approaches to be
developed for difficult areas
In the area of „Need based Planning‟
it is recommended that:
1. Organize Capacity building
workshops on „Program
Planning and Management‟ for
block, district and state level
officials to promote data and
need based planning
2. Health Directorate to ensure that
specific and appropriate plans
for improving access to services
are developed by desert/ tribal
districts and other districts for
their difficult areas
Underutilization of AYUSH
practitioners in MNCH services
a. No clear policy for utilization of
services of AYUSH
practitioners in MNCH
Utilization of AYUSH
practitioners for IMNCI
implementation
Monitoring of other MNCH
services
State government to take a
policy decision to enable
AYUSH practitioners to deliver
IMNCI through training and
monitoring of other health
services
Lack of coordinated and
inadequate attention to address
Nutrition and Development in
Children
a. Lack of coordination between
ICDS and Health departments Better coordination between
AWW, ASHA and ANM
Joint planning and reviews of
ICDS and Child Health
programme at district and sub-
district level to address
Malnutrition, anaemia and
development in under 3 children
Joint training
Annexures
Activity area: Monitoring and Evaluation
The Problems are… Causes Solutions Recommendations
Lack of quality in data capture at
field level
o Some issues in data quality like
under-reporting, misreporting,
definitions not clear (e.g.
morbidity, mortality), fear factor
high
o In individual tracking, Urban
data not covered
o Some Private sector data
missing e.g. Newborn and Child
health data
1. Orientations on importance of
data for frontline workers to
improve data quality
2. Sensitization and Orientation of
block and district level officials
to address apprehension to
report morbidity and mortality
data
3. Ward wise reporting system in
urban areas to be developed for
PCTS
4. Sensitization of private
practitioners
State to develop :
A plan for orientations of
frontline workers and managers
to improve data quality
Ward wise reporting system in
urban areas for PCTS
Sensitization of private
practitioners for reporting
morbidity, mortality and service
utilization data
Inadequate data analysis,
feedback and reviews at district
and sub-district level
o Mechanism for analysis and
feedback exists but is
inadequate and not target
oriented
o Review is more administrative
rather than programmatic
o Some MNCH targets not
realistic
1. Orientations of block district
and state level officials to
improve data analysis and
provide appropriate feedback
2. Monthly sector & block
meetings to be used for review
and data analysis
3. Reviews need to be made more
structured, Joint director of
respective zones should attend
the reviews
4. PHC sector meeting is the most
important point where adequacy
and quality of data can be
discussed at length with the
grass root workers. The meeting
at PHC level should be
organized regularly and a block
level officer should attend it
State to plan:
Orientations/training of block
and district level officials to
improve data analysis and
provide appropriate feedback
Conduct short program reviews
at district level annually before
development of District PIPs
Provision of statistician at Block
level
Annexures
The Problems are… Causes Solutions Recommendations
Difficulty in monitoring neonatal
care and PNC interventions
Indicators related to neonatal
care and PNC are not available
Need to update monitoring
indicators related to neonatal care
and PNC
State to introduce Neonatal and
PNC indicators in the
monitoring system
No systematic evaluation plan in
place
Evaluation for priority interventions
to be more systematic
State to develop a systematic
plan to periodically evaluate
implementation of IMNCI, New
born care and PNC interventions
Limited data on Quality of care of
MNCH services
No system for „Assessment of
Quality of Care for MNCH services
Periodic assessment of „Quality of
care for sick newborns and children‟
State to:
Develop/adapt tools to assess
quality of care (facility, case
management, satisfaction of
beneficiaries)
Periodically evaluate quality of
care at health facilities and
community level
Annexures
Activity area: Human resources/training
The Problems are… Causes Solutions Recommendations
Human resource
1) There is in-adequate number
of staff and expertise for
maternal, newborn and child
health
Lack of Systematic policy
of human resource
placement & development.
Vacancies not filled
(administrative process)
and as a result inadequate
number of critical staff at
facility and community
level
Attrition of junior doctors
high for PG seats. (C)
Mismatch between personal
information (health worker
profile) and posting
Mismatch between patient
load (services) and number
of staff needed
Short term
Use data generated from
Personal information system
(PIS) appropriately for
placement of critical HR
Acknowledge development of
Focus District Approach that
has just been started and
document experiences and
lessons learnt for scaling up
for improving quality of
services.
Long term
Have in place a human
resource development
policy/strategy
Rationalization of existing HR
available in the system at
different levels by appropriate
authority
Fast track recruitment for
vacant posts through online,
walk-in-interviews
Accessing HR services
through PPP model
HR policy/ strategy to address
HR issues systematically
Include succession planning
Mapping of facilities of various
levels to be done and as per
requirement, right HR to be
posted.
Evaluation of focus district
approach and based on
experience decide next steps
Synchronization of HR as per
intervention package wherever
possible
PHS to lead strengthening of
Human Resource Development
Strategy/policy (with adequate
reflection of number, skills
including induction training,
transfers )
Annexures
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
Annexures
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
Annexures
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
Annexures
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
Triaging not done properly
Transport mechanism to be
streamlined.
Written protocols need to be
made available at all
referral facilities
Link the existing transport
mechanism with F-IMNCI. Further
strengthening wherever required
Community based services not
optimally utilized for increasing
coverage of key MNCH services
Annexures
Activity area: Communication/IEC
The problems are … Causes Solutions Recommendations
No Comprehensive
Communication Plan
- Weak linkage between technical
and IEC section
- IEC for Maternal and Child
health is not a priority
- Lack of professional approach
Develop a comprehensive
communication plan with
professional input and in
participatory manner (involving
technical and IEC
professionals)
Ensure availability of IEC
professionals at different levels
Director IEC to create a Task Force at
the State level headed by a health
communication professional (involving
technical persons) to develop the
communication strategy and
implementation plan
Identify a resource pool of health
communication professional at State and
District Level to support and monitor
implementation of plan
Improper media mix
- 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
Strengthen relevant section on health
communication in the PIP with an
activity plan including R and D with
budget allocations
Explore and expand use of latest
technologies, e.g. Mobile, Interactive
voice response (IVR) system, rejuvenate
use of Gramsat system; Video
conferencing (after proper R &D)
Provisions of IEC materials as well as
AV aids at facility level (CHC and
24X7 PHC level)
Provide guidelines
Monitor IEC activities
Annexures
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
- All packages have component of
communication, but given the
least priority; Skill-based training
lacking
- Inadequate of facilitators
- Weak supportive supervision
- improper utilization of mobility
support
- Improper use of available
communication materials at all
levels
- Dedicated training on
communication skills (existing
training packages to be explored
for this purpose)
- Revisit existing IEC materials
and prepare proper job aids for
frontline workers; train them on
use of materials
Organize communication skills
training program for service
providers in low coverage areas
Lack of monitoring and
evaluation
- Indicators, tools and mechanism
not available for monitoring
- System of concurrent evaluation
is lacking
-
Develop a plan of monitoring and
evaluation for IEC
Develop a system of concurrent
evaluation (may be outsourced)
Annexures
Activity area: Community Support
The problems are … Causes Solutions Recommendations
Limited capacity of VHSC - Training of VHSC not completed
- Support mechanism weak
- Motivation related issues both
for trainees and trainers
- Accelerate training and assure
quality
- Regular support from PHC MO,
block and district level authorities
- (may be outsourced to NGOs)
- Extending role of NGOs for
follow-up after training
Complete the training within
one year followed by hand
holding support through
allocation of a set of villages
to PHC level supervisors
Develop five model VHSCs
per block. Explore role of
NGOs to establish model
VHSCs
Quarterly newsletter for
VHSC with success stories
from the field
Develop a recognition
mechanism and reward good
performance for VHSC
VHSC not involved in
community monitoring
- VHSCs are in development stage - Inclusion of community
monitoring in VHSC
The best practices of community
monitoring to be explored and
adopted for the state
Thematic community meetings
involving community members
not happening
- Capacity of convener is limited
- Weak support from ASHA
supervisors
- Capacity building of PHC level
supervisors for monthly thematic
meetings
Capacity building of
supervisors to be completed in
the next six months
Inadequate quality of training
for ASHA and Jan Mangal
Couple on MNCH issues
- Jan Mangal Couples revived
recently
- Accelerate update of listing of
Jan Mangal Couple and training Develop database of Jan
Mangal couples and complete
trainings within an year
Expedite the process of
training of ASHA on module
Develop a mechanism for QA
of trainings
Annexures
Annexure IX : List of Participants Dr. Samira Aboubaker
Coordinator country Implementation and support
WHO/ HQ
Geneva
Mr.Pradeep Choudhary
State Program Officer
UNOPS-Norway India Partnership Initiative
Rajasthan
Dr. Mikael Ostergren
Medical Officer
WHO/HQ
Geneva
Dr. M. P. Sharma
Professor & Head
Dept. of Community Medicine
SMS Medical college
Dr. Rajesh Mehta
MO- CAH
WHO-SEARO
Dr. S Sitaraman
Professor of Paediatrics
SMS Medical College
Dr. Harish Kumar
M O-CAH
WHO/Dhaka
Bangladesh
Dr. Jayanta K Das
Professor & Head (Dept. of Epidemiology)
National Institute of Health and Family
Welfare- New Delhi
Dr. Paul P Francis
National Professional Officer and Cluster Focal Point, FHR
WHO Country Office for India
New Delhi
Dr. Suresh Joshi
Professor
Institute of Health Management Research
Jaipur
Dr. Subodh Sharan Gupta
National Professional Officer - Child Health & Development
WHO Country office for India
New Delhi
Dr. Anoop Khanna
Associate Professor
Institute of Health Management Research
Jaipur
Dr. Dhananjoy Gupta
Health Specialist - Policy & Planning
UNICEF
New Delhi
Dr. Vinod Kumar SV
Assistant Professor
Institute of Health Management Research
Jaipur
Dr. Avtar Singh Dua
Health Specialist
UNICEF
Rajasthan
Dr. Vivek Lal
Assistant Professor
Institute of Health Management Research
Jaipur
Dr. Kaliprasad Pappu
National Co-coordinator
UNOPS-Norway India Partnership Initiative
New Delhi
Ms. Preety Sharma
Assistant Professor
Institute of Health Management Research
Bengaluru
Dr. Karanveer Singh
Programme Officer- Child Health
UNOPS-Norway India Partnership Initiative
New Delhi
Dr.Manisha Chawala
State Health & Nutrition Coordinator
Save the Children
Rajasthan
Dr.Narottam Pradhan
Immunization Officer
UNOPS-Norway India Partnership Initiative
New Delhi
Dr.Vandana Mishra
State program Representative
CARE-India
Rajasthan
Dr. Satya Pal Yadav
Senior Program Officer
UNOPS-Norway India Partnership Initiative
Rajasthan
Dr. Hitesh Gupta
CEO
VATSALYA- Rajasthan
Annexures
Dr.ML. Jain
Director - RCH
Directorate of Medical & Health Services[DMHS]
Govt. of Rajasthan
Dr. Sheetal Joshi
Consultant
DMHS - Govt. of Rajasthan
Dr. J P Dhamija
Add. Director - RCH
DMHS - Govt. of Rajasthan
Dr. Madhu Dhamija
S.M.O., Govt. Hospital -Sri Ganganagar
DMHS - Govt. of Rajasthan
Dr.Rajendra Singh Rathore
Deputy Director Immunization
DMHS - Govt. of Rajasthan
Dr. Ragini Agrawal
S.M.O. Udaipur
DMHS - Govt. of Rajasthan
Mr. J.P. Jat
State Demographer
DMHS - Govt. of Rajasthan
Dr. R.K. Vijayvargiya
S.M.O, Govt. Dispensary – Ajmer
DMHS - Govt. of Rajasthan
Mr. N.L. Paliwal
Social Scientist
DMHS - Govt. of Rajasthan
Dr. Dinesh Kharadi
Medical Officer, Udaipur
DMHS- Govt. of Rajasthan
Dr. Jal Singh
C.O. F.R.U
DMHS - Govt. of Rajasthan
Mr. Kaushal Kumar
District Programme Manager - Churu
DMHS - Govt. of Rajasthan
Dr. Shiv Chandra Mathur
Executive Director
State Health Systems Resource Centre
Rajasthan
Dr. Manoj Vijay
Rural Medical Officer
CHC- Bhopalsagar- Chittorgarh
DMHS - Govt. of Rajasthan
Dr. Anuradha Aswal
Nodal Officer – Training & Child Health
DMHS - Govt. of Rajasthan
Mr. Abid Siraj
Divisional Maternal & Child Health Coordinator - Ajmer
DMHS - Govt. of Rajasthan
Dr. Indra Gupta
Nodal Officer SBA
DMHS - Govt. of Rajasthan
Mr. Akhilesh Gupta
Divisional Maternal & Child Health Coordinator - Bikaner
DMHS - Govt. of Rajasthan
Ms. Vaidehi Agnihotri
Coordinator-VHSC
DMHS
Govt. of Rajasthan
Mr. Pawan Kumar
District Maternal & Child Health Coordinator
Barmer
DMHS – Govt. of Rajasthan
Mr.Lalit Kumar Tripathi
Consultant-HRHH
DMHS
Govt. of Rajasthan
Ms. Renu Yadav
District Maternal &Child Health Coordinator
Dausa
DMHS – Govt. of Rajasthan
Dr. Laxman Singh Jadoun
Medical Officer- Kanwatia Hospital
DMHS
Govt. of Rajasthan
Dr. Sandeep Kumar Aggarwal
RCH Medical Consultant
State Institute of Health & Family Welfare
Rajasthan
Dr. Kishor Kumar
Medical Officer- CHC- Chomu
DMHS- Govt. of Rajasthan
Dr. Richa Chaturvedy
RCH Medical Consultant
SIHFW- Rajasthan
Ms. Poonam Srivastava
District Maternal &Child Health Coordinator
Bharatpur
Annexures
Annexure X : List of Documents Reviewed
1 Baseline survey on Child Health and related maternal Health Care, 2009, NIPI.
2 Coverage Evaluation Survey- 2009, National Fact sheet- UNICEF.
3 District level House Hold and Facility Survey-III, 2007-08; Rajasthan
4 Family Welfare statistics in India- 2009, Ministry of Health & Family Welfare, Govt. of India.
5 Family Welfare statistics in India- 2006, Ministry of Health & Family Welfare, Govt. of India.
6 Fact Sheet of Rajasthan-National Family Health Survey-III, 2005-06.
7 Five Year plan – IX, Rajasthan- Chapter 18
8 ICDS: Programme implementation plan- Rajasthan 2009-10
9 National Family Health Survey-I Rajasthan & India-1992-93
10 National Family Health Survey-II Rajasthan & India 1998-99
11 National Family Health Survey-III Rajasthan & India 2005-06
12 Report on Causes of Death in India- 2001-2003; Office of the Registrar general, Ministry of Home
affairs, Govt. of India.
13 Reproductive and Child Health- District level Household Survey-II , 2002-04; Rajasthan
14 Reproductive and Child Health Project- Rapid Household survey -1998-99,Rajasthan; by IIPS
15 Rajasthan State Program implementation Plan – 2008-09
16 Rajasthan State Program implementation Plan – 2009-10
17 Rajasthan State Program implementation Plan – 2010-11
18 Rajasthan State Report on National Rural Health Mission-2009-10
19 Sample Registration System -Statistical Report -2008, Office of the Registrar general, Ministry of
Home affairs, Govt. of India.
20 Sample Registration System –Maternal Mortality in India-1997-2003: Trends, Causes & Risk
Factors, Office of the Registrar general, Ministry of Home affairs, Govt. of India.
21 Sample Registration System- Special Bulletin (April 2009) on Maternal Mortality in India 2004-06;
Office of the Registrar general, Ministry of Home affairs, Govt. of India.
22 Shiv D Gupta et.al ; Maternal mortality ratio and predictors of maternal deaths in selected desert
districts in Rajasthan - A community-based survey and case control study; Women‟s Health Issues
20 (2010) 80–85
23 S.D.Gupta et al. Changes In IMR in Rajasthan over 25 Years; Health and Population: Perspectives
and Issues Vol. 32 (2), 105-111, 2009
Annexures
Annexure XI : Timetable
Short Program Review - Child Health
Government of Rajasthan Indian Institute of Health Management and Research, Jaipur
Sep 20 – 25, 2010
Supported by: WHO Country Office for India and Norway India Partnership Initiative
Agenda: Day 1
Day 1 Tuesday; Sep 21, 2010
With all SPR review participants
0900- 1000 Registration
1000-1100
Inaugural session Welcoming remarks Inaugural ceremony Objectives of Short Program Review Round of introduction Opening Remarks and Presentation on Child Health Program
in Rajasthan 1100-1130 Tea break
1130-1200 Overview: how the short programme review will be conducted and
background concepts that will be used (from handouts 1 and 2) –
facilitator
1200-1300
Step 1: Where are we going? Work in plenary session to review: goals and objectives; status of maternal and child health. Key data presented and discussed.
Review and discuss Worksheets 1 and 2
1300-1400 Lunch break
1400-1530 Plenary discussion: review of child health data: summary of findings
1530-1545 Tea break
1545-1730
Step 2: Are interventions reaching women and children? Introduction to small group work Definition of terms Introduction to use of Worksheets 3 and 4 Small group work: worksheet 3: Groups work through the worksheet.
Each group has a different point along the continuum of care–
pregnancy, delivery, neonatal, infants and children.
The First session for Day 2 (Wednesday; Sep 22, 2010) will start at 0900h
Annexures
Short Program Review - Child Health
Government of Rajasthan Indian Institute of Health Management and Research, Jaipur
Sep 20 – 25, 2010
Supported by: WHO Country Office for India and Norway India Partnership Initiative
Agenda Day 2 – 5
Day 2 Wednesday; Sep 22, 2010
0900-1030
Step 2: Are interventions reaching women and children (continued) Small group work: review of coverage indicators. Complete worksheets 3 and 4. Summarize findings on computer template. Present, discuss and summarize findings in plenary session.
1030-1045 Tea break 1045-1230
Step 3: How well are programme activities being implemented? Introduction to small group work Definition of terms Introduction to use of Worksheet 5 Group work: worksheet 5. Groups work through the worksheet.
Each group has a different point along the continuum of care–
pregnancy, delivery, neonatal, infants and children.
1230-1330 Lunch break 1330-1500 Group work Step 3: continue review and complete worksheet 5.
1500-1515 Tea break 1515-1630 Group work Step 3: continue review and complete worksheet 5.
Summarize findings on computer template.
1630-1730 Plenary session Step 3: each group summarizes findings from their
level of the continuum of care: how well the programme implemented
maternal and child health interventions.
Annexures
Day 3 Thursday; Sep 23, 2010
0900 -1030 Step 4: Identify the main problems the programme has faced Review of previous steps and introduction to worksheet 6 Small group work: identify the main problems identified for each of
the main activity areas. Summarize findings on flip charts.
1030-1045 Tea break 1045-1230 Small group work (continued): summarize problems for each activity
area 1230-1330 Lunch break break 1330-1500 Plenary session Step 4: summarize problems identified by all groups
into a single list of common problems.
1500-1515 Tea break 1515-1730 Complete plenary session Step 4: summary of problems
Day 4 Friday; Sep 24, 2010
0900-1030 Step 5: Identify solutions and recommendations to the main problems Introduction to group work and begin group work Summarize findings using standard template.
1030 - 1045 Tea Break 1030-1230 Small group work (continued) 1230-1330 Lunch break 1330-1500 Plenary session Step 5: summary and discussion of solutions and
possible recommendations
1500-1515 Tea break 1515-1700 Summary of next steps
Feedback from participants
Day 5 Saturday ;Sep 25, 2010
0900-1230 Step 6: decide on next steps for taking action on recommendations Step 7: Present SPR findings
1230-1330 Formal Closing Ceremony 1330-1430 Lunch break
Annexures
References
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 2009 -10 : Volume I
3 Department of Medical, Health and Family Welfare, GoR (2009). National Rural Health
Mission(NRHM) State Program Implementation Plan 2009 -10 : Volume II
4 Department of Medical, Health and Family Welfare, GoR (2009). National Rural Health
Mission(NRHM) State Program Implementation Plan 2010 -11
5 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): 105-111
8 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 : 80–85
9 International Institute for Population Sciences (IIPS), 2001.Reproductive and Child Health Project
Rapid Household Survey (Phase I & II) 1998-99: India.Mumbai: IIPS
10 International Institute for population Sciences (IIPS), 2006. District Level Household Survey
(DLHS-2), 2002-04: India. Mumbai: IIPS
11 International Institute for population Sciences (IIPS), 2006. District Level Household Survey
(DLHS-2), 2002-04: Rajsthan. Mumbai: IIPS
12 International Institute for Population Sciences (IIPS), 2010. District Level Household and Facility
Survey (DLHS-3), 2007-08: India.Mumbai: IIPS.
13 International Institute for Population Sciences (IIPS), 2010.District Level Household and Facility
Survey (DLHS-3), 2007-08: India. Rajasthan Fact Sheet. Mumbai: IIPS.
14 International Institute for Population Sciences (IIPS), 2010.District Level Household and Facility
Survey (DLHS-3), 2007-08: India. Rajasthan. Mumbai: IIPS.
15 International Institute for Population Sciences (IIPS),1995.National Family Health Survey (MCH
and Family Planning), India 1992 - 93 : India. Bombay: IIPS.
16 International Institute for Population Sciences (IIPS)and ORC Macro International,2007.National
Family Health Survey (NFHS-3), India, 2005 -06 : India : Volume I. Mumbai: IIPS.
Annexures
17 International Institute for Population Sciences (IIPS)and ORC Macro International,2007.National
Family Health Survey (NFHS-3), India, 2005 -06 : India : Volume II. Mumbai: IIPS.
18 International Institute for Population Sciences (IIPS)and ORC Macro International,2008.National
Family Health Survey (NFHS-3), India, 2005 -06 : Rajasthan. Mumbai: IIPS.
19 International Institute for Population Sciences (IIPS)and ORC Macro,2001.National Family
Health Survey (NFHS-1), India, 1992 - 93 : India. Mumbai: IIPS.
20 International Institute for Population Sciences (IIPS)and ORC Macro,2001.National Family
Health Survey (NFHS-2), India, 1998 - 99 : 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. 367:1541-7.
22 Ministry of Health and Family Welfare, GoI (2009).Family Welfare Statistics in India - 2009.
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 (2007 - 2010)
24 Sample Registration System (2008). Statistical Report 2008. Registrar General of India, Vital
Statistics Division, New Delhi
25 Sample Registration System (2009). Monthly Report October 2009. Registrar General of India,
Vital Statistics Division, New Delhi
26 Sample Registration System (2009). Special Bulletin on Maternal mortality in India 2004-06.
Registrar General of India, Vital Statistics Division, New Delhi
27 UNICEF (2008). The state of the world's children 2009. Available from:
http://www.unicef.org/publications/index_47127.html.
28 UNICEF (2010). Coverage Evaluation Survey 2009 - 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 (2000–2010): taking stock
of maternal, newborn and child survival.
Small Group Sessions