NATIONAL HEALTH MISSION

 
Programme
 
  • Reproductive & Child Health (RCH-II)
  • Goals and Objectives
The overall goal of RCH programme is to reduce infant and maternal morbidity and mortality in the state. These goals will be achieved through improvement in quality, enhancing accessibility and availability, and coverage with the reproductive and child health services, including family welfare. The programme emphasizes empowerment of women and communities for enhancing health service utilization to achieve reproductive goals and population stabilization.

OUTCOMES
Goal of Rajasthan upto 2011-12
Infant Mortality Rate (IMR)
32
Maternal Mortality Ratio (MMR)
148
Total Fertility Rate (TFR)
2.1
Crude Birth Rate (CBR)
21
Crude Death Rate (CDR)
7
  • Key Strategies

There are twelve key strategies identify for RCH II

1. Strengthening Project Management Structure at state and district levels

  • Re-organizing of Medical Directorate.
  • Renovation of Medical Directorate and NRHM/RCH-II cell .
  • Setting up, of the PMU at state & district levels .
  • Induction of newly appointed professionals done on programme management and interventions.
  • Support for communication , equipments and mobility to DPMUs.

2. Strengthening Infrastructure at various levels of health service delivery

  • Upgrading of PHCs as BemOCs.
  • Provision of blood storage at 26 identified CEmOCs of IPD districts to make them fully functional.
  • Support for equipment and labor tables at 25% PHCs.(10000.00 Rs. Per Institution)
  • Support for minor repair and renovation of public facilities at 50% PHCs. .(25000.00 Rs. Per Institution)
  • Facility survey of all PHC and CHCs.

3. Human resource development and capacity building

  • Development of annual training calender.
  • Strengthening of ANMTCs.
  • Support medical colleges for Anaesthesia trainings.
  • Library at SIHFW & Medical Directorate.
  • Orientation of AYUSH Doctors on National Programmes.

4. Improving quality of care and Strengthening Referral System

  • Study on referral system by RHSDP
  • 7 days Mobility support to PHC MOs
  • Installation of new telephone connection at all PHC/CHCs.
  • Work shops for developing standards and protocols for quality of care.

5. Strengthening and improvement of logistics and supply systems

  • Feasibility study to setting up of the drugs and logistics warehousing has been done under European Commission SIP programme. A committee to finalize the modalities behind the setting up of Drug Corporation has been set up at the state level.
  • Support for the repair of workshop for cold chain equipment has been provided for Jaipur.
  • Support for hiring 12 new refrigerator mechanics has been provided to district where such positions are vacant.

6. Strengthening Health Management information system (HMIS), monitoring and evaluation

  • Support for CNNA format, ECS has been provided from state level.
  • Integration of RCH-II/NRHM reporting format in existing HMIS software.
  • Baseline and concurrent evaluation.

7. Behaviour Change Communication for increasing demand for RCH and contraceptive services

  • Intensive IEC for RCH-II and NRHM interventions.
  • Provision for hiring of IEC van in all districts.
  • Implementation of Integrated Media Plan.
  • IEC for “Panchmrit programme done by printing of booklet, Banners, cards.

8. Specific Interventions

Maternal Health:

  • RCH camps target:
  • Dai training target:
  • Night delivery facility at all PHCs and CHCs.
  • Hiring of contractual staff (PHN & LT) at CEmOCs.
  • Provision of 1321 additional ANMS at 10 desert and tribal districts.
  • STD/RTI drugs for PHCs.
  • Jannani Suraksha Yojna

Child Health:

  • IMNCI launched in 9 districts.
  • Mal nutration corner at all 237 blocks.
  • Purchase of ORS packets.

Adolescent Health

  • AFHS training at 25% PHCs

Family Planning

  • Improving quality of fix camps.
  • Compensation scheme for stearlization.
  • Blood donation camps.
  • NSV mega camps

9. Strengthening Networking and Partnership with the civil society

  • Collaboration with IMA & FOGSI to build partnership to improve assess and quality of health care service in services.
  • Accreditation of Private nursing home for JSY.
  • MNGO scheme in all districts.
  • Annual consultation with stakeholders on NRHM.
  • Social marketing of contraceptives and other health services.

10. Innovative schemes and pilot projects

  • Pilot Project on Population stabilization initiated at Jhalawar & Tonk.
  • PARINCHE project for five districts.
  • A help line proposed at medical directorate for improving communication between field level functionaries, districts and state level officers.
  • Campaign on Age at Marriage.
  • Medical Mobile unit for all districts.
  • VCTC at 16 CHCs.


11. Improving and strengthening RCH Services in Tribal population

  • Six districts, namely, Baran, Banswara, Chittorgarh Dungarpur, Sirohi and Udaipur will be included as non-primitive tribal group districts under the project in addition to the tribal population in the adjoining blocks of Jhalawar and Kota district.
  • Process for developing PIP for six urban district is under process.

12. Establishing and strengthening RCH services in Urban Area

The programme will address the urban slum population in Jaipur, Jodhpur, Kota, Bikaner, Pali, Udaipur, Ganganagar, Hanumangarh, Bhilwara and Tonk cities.
PIP for 8 urban slums is under process.

Immunization

Complete immunization of a child is an important step towards the good health status of the child, hence Immunization has been kept as a major strategy. The complete Immunization in Rajasthan is poor as reported from independent surveys.

Comparison of Reported and Evaluated Coverage 2005-06 (%)

Antigen

Reported Coverage 2005-06

NFHS-III 2005-06

RCES
2006

Reported Coverage
2006-07

Fully Vaccinated

92.16

26.50

48.30

88.89

BCG

102.09

68.50

84.50

98.90

DPT3

100.06

38.70

61.40

95.52

Measles

96.85

42.70

51.60

93.53

Drop-out BCG-Measles

5.13

NA

NA

5.45

TT2+ Booster

88.71

NA

NA

91.30

Summary of Recent Initiatives

1. Service delivery improvements
To enhance Immunization Coverage, MCHN Days are organised as an essential component of Routine Immunization. It is a package of service delivered to the community which involves Maternal, Child and Nutritional components. Mobility support is being provided by different agencies to all the districts for vaccine and logistics supply to the session site. This will be smoothened after coming of RCH 2 budget in which the state has asked the budget for mobility support as alternative vaccine delivery.

2.Financial Support for Social Mobilizers

3. Partnerships with other agencies / organizations (e.g. ICDS, IAP, PP etc.)
In immunization activities, lot of support is being provided by different agencies like ICDS, UNICEF, WHO, CARE etc. These agencies are providing the technical & managerial support in different immunization components. Financial support is being provided by UNICEF in certain areas. A good coordination of the health department with Women and Child department through ICDS is well established. WCD Director is Co-Chairperson in State immunization Steering committee. State is planning to involve NGOs working at district level to support in improving the social mobilization which is a need of the programme. State also needs support from IAP, IMA and other Private Practitioners to be actively involved in immunization programme.

Bottlenecks for full Coverage

  • State needs a State vaccine depot at Jodhpur, which can supply vaccine to Jodhpur region. At present the Jodhpur region is procuring vaccines from the Udaipur State Depot. Also WIF at Udaipur & Jodhpur have been demanded by state.
  • GOI has not supplied DFs & Spares (for non-CFC equipments) since last 3 years.should be supplied this financial year
  • MCHN days microplans need further microplan Monitoring and supervision needs strengthening

Accessibility

· Difficult Terrain (Desert Areas & hilly Tribal Areas).
· Poor Infrastructure & manpower in Urban areas to cater the urban population.

The main strategies for Immunization in RCH II are outlined below:
1. Initiatives for immunization in the state for Programme coordination with partners
A State Level Steering Committee has been formed which will finalize the annual action plan and review the same on a monthly basis. Members will be Director (FW) as Chairperson, Director (WCD) as Co-chairperson, Joint Director (RCH), DD Immunization (member secretary), ICDS, Demographer, Statistical Officer, Representatives of WHO, UNICEF,CARE and others.

A State Task Force has been formed which will review the immunization programme six monthly chaired by Principal Health Secretary.A State Immunization cell has been formed which will review the activities on a weekly basis.District Task forces have been formed to review the Immunization activities in the districts.

2. Strengthening the State officials and RCHO through additional mobility support

3. Improved Vaccine / Supply Logistics : Expanding the Cold Chain Reach and Improved Performance throughAlternative vaccine delivery system (mobility support to PHCs for vaccine delivery) and Polythene bags to keep Vaccine in good condition

4. Ensuring that all children in all villages/towns covered with regular (monthly/quarterly) immunization sessions according to village size through mobilization of children by ASHA for which a sum of Rs.150 per month has been kept for mobilization of children to the immunization session site. For Immunization in the Urban area/slums provision of hiring ANMs for each session, and provision of social mobilizers to mobilize the children to the session site

5. Improved injection safety by introducing AD Syringes

6. Ensuring accurate record keeping / monitoring with improved supervision and Availability of various Formats

  • Reporting & Monitoring formats
  • Monitoring charts
  • Cold chain modules
  • Cold chain Reporting formats
  • Temperature Record books
  • Immunization Cards
  • Tracking Bags

7. Trained Immunization Staff – ANMs, Mid level Managers training for RCHOs, Cold chain handlers, statistical assistants

8. Strengthening Immunization and Cold chain through Major & Minor Repair, Provision for the running costs of WICs & WIF, ILRs & Deep Freezers and POL & maintenance of vaccine delivery van.

9. Review Meetings

Two days six monthly review meetings will be conducted at state for district wise review of immunization programme.Monthly meetings of State Steering committee will also be held. State task force meeting will be organized to review the immunization status.Six monthly meetings of State Task Force will be conducted under the chairmanship of Principal Health Secretary to overall review the situation of Routine Immunization in the stateZonal level review meetings will be organized at seven zones of state to review the immunization activities in the districts.

10.Contingency fund at district levelRs. 40/ month per district has been budgeted as contingency fund for communication cost (sending reports through internet and for buying floppy disks) if needed from Districts to State.

11.Disposal of AD SyringesFor proper disposal of AD syringes after vaccination, hub cutters will be provided to cut out the needles (hub) from the syringes. Plastic syringes will be separated out and will be treated as plastic waste. For the disposal of needles, pits will be formed at PHCs as per CPCB guideline.

12.VPDSurveillanceSentinel Surveillance Units: Hospitals and some other major Govt. and private hospitals will be taken up for VPD surveillance:

  • Strengthening the system already present in the state for VPD surveillance.
  • Orientation of the medical officers of these units in standard-case definitions
  • A software to analyze and present the data (RIMS)
  • Review of data by JD RCH on a regular basis
  • The analyzed data would also be fed back to the districts monthly, suggesting follow-up action
  • Outbreak investigation for which dissemination of guidelines and workshops to train district officials (Rapid Action Team for epidemics) for investigating outbreaks.

13.Hepatities B/Never vaccine will be introduced

14. IEC & Social Mobilization plans

Disease Control Programmes
The National Disease Control Programmes are being implemented in state under NRHM with a view to achieve the MDG goals to halt the spread of major diseases and reverse the trend by 2015 so as to reduce the mortality and morbidity and increase life expectancy and quality of life. The NDCP encompasses: Revised National TB Control Programme (RNTCP), National Vector Borne Disease Control Programme (NVBDCP), and National Programme for control of Blindness (NPCB), The National Leprosy Eradication Programme (NLEP), Integrated Disease Surveillance Programme (IDSP), and Iodine Deficiency Disorder Control Programme (IDDCP).

The National Vector Borne Disease Control Programme (NVBDCP)

NVBDCP include major vector borne diseases of public Health importance, such as Malaria, Filariasis, Japanese Encephalitis, Dengue, and Kala azar. As per the National Health Policy 2002 the goal is to reduce morbidity and mortality by 50% by 2010. In Rajasthan only Malaria and Dengue are prevalent the strategy for control of vector borne diseases includes:
· Enhanced Surveillance with support of community based volunteers (ASHA) and grass root level workers.
· Early diagnosis and proper case management through strengthening Primary and Secondary Health institutions.
· Integrated vector management using bio-friendly methods and limiting use of insecticides.
· Epidemic preparedness and rapid response.
· Institutional strengthening and Capacity building of Health personnel.
· Behavior change communication
· Intersectoral Collaboration
· Computerized Management information system.

The National Leprosy Eradication Programme

Leprosy is a disease of public health concern in India. It is a disease of medico-social concern .Current prevalence is 1.8/10000. Rajasthan has achieved prevalence elimination level (prevalence below 1/10000) in 2000. Current prevalence Rate is 0.24/10000. Under the NRHM the strategies drawn under the National Leprosy Eradication Project to be continued. The fie component include Decentralization and institutional development , strengthening and integration of service delivery, disability care and prevention , IEC and training. Services will be continued to be provided at CHC, PHC, Additional PHC, and hospitals with support from the district nucleus. The sub-centers will be involved in delivery of second and subsequent doses of MDT. NGO will continue to be involved in reconstructive surgery, disability care and prevention and IEC. Village and district Health plans will enable identification and ensure referral of cases requiring disability treatment to the appropriate facility. CMHOs and medical officers will continue to be trained on Leprosy Programme management.

Integrated Disease Surveillance Programme (IDSP)

Objective of IDSP is to establish a state based system of surveillance through Information and communication technology (ICT) for communicable and non-communicable diseases so that a timely and effective public health action can be initiated in response to the health challenges. IDSP will also improve the efficiency of the existing surveillance activities of the different disease control Programs. Surveillance system will be strengthened through Capacity building of medical officers and health workers and technicians, strengthening of laboratory network and reporting system through ICT. This would p[provide a string foundation to the disease control Programmes under NRHM. ASHA being the link between community and public health system will strengthen the community based surveillance system.

Revised National Tuberculosis Control Programme (RNTCP)


The RNTCP is the vehicle through which through which the WHO recommended DOTS (Directly Observed Therapy Short course) is implemented in India. All the districts of Rajasthan are being covered. As part of the Programme Designated Microscopy centers (DMCs) have been established at PHC, CHC and district hospitals. RNTPC supports the salary of laboratory technicians, laboratory supplies and consumables. All medical officers are trained under RNTCP for diagnosis management and referral. All SCs, PHCs, CHCs and district hospitals function as DOTS centres. Community level DOTS providers are also trained in delivery of drugs. Para medical staff is trained in monitoring consumption of ant TB drugs. The RNTCP also involves the civil society organizations in its outreach of communication efforts. Under NRHM the ASHA will be the facilitator for early access to the diagnosis, referral and follow-up as a community DOTS provider.

National Blindness Control Programme (NPCB)

The National Blindness Control Programme aims at reducing prevalence of blindness from the current level of 1.5% to 0.34% by the 2010. Rajasthan state has set a target of about 3 lac cataract operations every year to achieve the goal. Under NPCB apart from providing surgical treatment through IOL (Intraocular lens) implant for cataract, which is major cause of blindness, the other causes of blindness such as childhood blindness, glaucoma and retinal disorders are also dealt. School health check up is also one of the major components of the Programme. ASHA would play an important role in creating awareness of the Programme and motivate people to seek treatment. NRHM would also seek to create synergy between the NPCB and Vitamin A supplementation Programme.

Additional Interventions under NRHM ASHA

Accredited Social Health Activits

The Government of India and Government of Rajasthan have launched a National Rural Health Mission to address the health needs of rural population, especially the vulnerable sections of the society. The sub center is the most peripheral level of contact with the community under the public health infrastructure. This caters to the population norm of 3000 - 5000. The worker in sub center is an ANM who is directly involved in all the health issues of this population, which is spreaded over the wide area of many kilometers and covering 5 to 8 villages. Many a times the villages are not connected by public or private transport system making her more difficult to achieve the objectives and goals of providing quality health care for the poor and oppressed sections of the society. So the new band of community based functionaries, named as Accredited Social Health Activist (ASHA) is proposed in the NRHM who will serve the population of 1000 and 500 in hilly and desert terrene.

ASHA is the first port of call for any health related demands of deprived sections of the population, especially women, children, old aged, sick and disabled people. She is the link between the community and the health care provider.

Department of Medical and Health at State and at Center is looking at ASHA as a change agent who will bring the reforms in improving the health status of oppressed community of India. The investment on ASHA will definitely result in to better health indicators of state and at large the country.

ASHA Sahayogini

Convergence of DWCD and NRHM
In each Anganwadi Center apart from Anganwadi Worker and Sahayoka one additional worker named 'Sahyogini' is envisaged to provide door to door information and services of Nutrition, Health, preschool education. Her role is quite similar to the role of ASHA under NRHM. So to avoid duplication of workers providing same types of services in the same area, the decision was taken at State level, that there will be only one worker coterminous with Anganwadi, who will work with DWCD and DMHS. This worker is called as 'ASHA Sahyogini', selected by the community through Gram Panchayat and responsible to the community.

Criteria for selection

  • One ASHA Sahyogini for each Anganwadi Center.
  • Woman resident of that area, Married/ Widow/ Divorcee
  • Age between 21 to 45 years
  • ASHA Sahyogini should have effective communication skills, leadership qualities and be able to reach out to the community.
  • ASHA Sahyogini should be literate woman with formal education up to eighth class, In tribal and desert areas the educational qualification may be relaxed if the 8th pass candidate is not available. This is permitted only after the approval of State level Committee.
  • Adequate representation from disadvantaged population groups

Roles and Responsibilities of ASHA Sahayogini

  • Create awareness

Health, Nutrition, basic sanitation, hygienic practices, healthy living and working conditions, information on existing health services and need for timely utilization of health, nutrition and family welfare services.

  • Counseling

Birth preparedness, importance of safe and institutional delivery, breast-feeding, immunization, contraception, prevention of RTI/STI. Nutrition and other health issues.

  • Mobilization

Facilitate to access and avail the health services available in the public health system at Anganwadi Centers, Sub Center, PHC , CHC and district hospitals.

  • Village health plan

Work with the village Health and sanitation Committee to develop the village health plan

  • Escorts/ Accompany

Escorts the needy patients to the institution for care and treatment. She will accompany the woman in labor to the institution and promote institutional delivery

  • Provision of Primary Medical Health Care

Minor ailments such as fever, first aid for minor injuries, diarrhea. A drug kit will be provided to ASHA

  • Provider for DOTS
  • Depot Holder ORS, IFA, DDK, chloroquine, oral pills and condoms
  • Care of new born and management of a range of common ailments
  • Inform Births, deaths and unusual health problem or disease out break
  • Promote Construction of household toilets

Training

Capacity building of ASHA is critical in enhancing her effectiveness. It has been envisaged that training will help to equip her with necessary knowledge and skills. Training of ASHA Sahyogini is a continuous process. Considering her range of functions and task to be performed, her induction training is planned for 23 days in 4 rounds (10+4+4+5 days). The trainings are planned in cascade model. The non governmental organizations are involved in the training of ASHA Sahyoginis at grass root level.

Compensation package (Incentives)

Under NRHM ASHA Sahyogini is a voluntary worker who will get performance linked incentives. The honorarium is linked with the performance indicators of ASHA Sahyogini. The generic Compensation package made for ASHA Sahyogini by linking her with different health programmes.

The detailed compensation package is worked out at state level. If she works as per the expected standards she would earn approximate Rs. 1067 per month. ASHA will get the package on
Apart from the above package she may get prizes for extraordinary performance in cash or kind from the untied funds. Some of the selected ASHA Sahyoginis will visit different places in the State and outside State during exposure visits.

Drug Kit for ASHA Sahyogini - The drug Kit is provided to ASHA Sahyogini to provide primary Health Care to the community like minor elements like fever, pain, First Aid etc. The replenishment of medicines is made from PHC /Subcenter stocks.

Monthly Meetings - The joint monthly meetings are conducted at PHCs by DWCD and DMHS. ASHA Sahyoginis are interacting with service providers in this monthly meeting. The replenishment of Medicines and payment of incentives are ensured during these meetings.

ASHA Mentoring Group

For strengthening ASHA- Sayogini Programme in the State a State Level Mentoring Group is constituted under the Chairpersonship of Mission Director, NRHM. This group will oversee the implementation of the scheme and facilitate in developing the policy guidelines. Mentoring Group will act as a think - tank for the programme. The mentoring group will provide technical inputs and support mechanism. The members of ASHA Mentoring Group are Director DWCD, PHED, RD,PRI, IEC, RCH, PH, AIDs, representatives from development partners and NGOs.

The Mentoring Group will meet once in three months to review and to provide inputs for the ASHA- Sahyogini Intervention. ASHA Resource Center is the Nodal Agency to organize the meetings and do the follow ups with the support of SPMU- NRHM.

ASHA Resource Center for providing support to ASHA Programme at State level

Need for ASHA Resource Center - ASHA is at the base of NRHM pyramid and National Rural Health Mission is looking at ASHA as a change agent in Health Sector Reform. She will play a vital role in improving the health indicators of the State especially IMR and MMR. She will also facilitate the improvement in service off take of the healthcare institutions.

The State of Rajasthan is spread over a large geographic area with religious, social, cultural, economic variations, so implementation of ASHA component in the state is a challenging task. In this context it is very important to provide technical inputs and strong supportive mechanism to the programme so that expected results can be achieved. State Project Management Unit is established at state level under Director NRHM. SPMU is working as a technical and administrative body to implement the activities of NRHM in the State. ASHA Resource Center (ARC) is conceptualized to improve the quality of the programme. This Center will be established at state level and will work under direction of Mission Director of NRHM

Functions of the ASHA Resource Center-

  1. Technical backstopping in Training - The training of ASHAs is planned for 23 days in a year with refresher trainings every year. ARC will develop user friendly training methodology and the training modules, print the modules in prescribed time, and disseminate the modules in the District. The modules are being developed by MOHFW; GOI .These will be modified in the state context on the basis of functions of ASHA. ARC will also work on the training modalities and will provide the supportive supervision to maintain quality checks and control at District and Block level.
  2. Development of IEC material - ARC will be responsible for developing or collecting the IEC material from different agencies for dissemination during the training. The facilitation kit including flip books, chart, posters etc on different related issues will be developed and disseminated. Need based IEC material will be developed from time to time.
  3. Planning of Monthly Meetings - It is planned to conduct monthly meeting of ASHAs at block level to resolve day -to -day functional problems faced by ASHA and to ensure the progress of the activities conducted by ASHA. It is very important to revise the concepts and contents to improve the learning process .The topics covered during the training will be revised in the monthly meeting. ARC will develop tentative monthly agenda for the monthly meetings; provide required resource material and IEC material. It will develop the monitoring mechanism for the meetings.
  4. Development of Reporting formats and registers - ASHA is envisaged as a voluntary worker and to facilitate her work some very easy and basic reporting formats and registers will be developed. The registers and the formats will be used by ASHA only to streamline her priorities. ARC will develop the formats and will orient ASHA for its utility and use.
  5. Processing of Statistical Data and records- On the basis of reports and registers of ASHA and other sources of data’s. ARC will compile the statistical data, analyze the data and provide the feedback of the programme to the Mission.
  6. Intersectoral Coordination pertaining to ASHA- ASHA is conceptualized as a volunteer responsible for the Health needs of the particular village, Dhani or Mohalla. The credibility of ASHA in the community could be used by other Development Departments to promote their objectives. ARC will coordinate with different departments and facilitate empanelment of ASHAs in various other programmes like Sarva Shiksha Abhiyan, Total Sanitation Programme etc.
  7. Involving NGOs to strengthen the programme- Involvement of NGOs is an important task in the implementation of ASHA programme. NGOs could support the ASHA to work at community level or to develop capacities of ASHA etc. There could be many roles of NGOs and these roles would be identified by the ARC. In consultation of NRHM the NGOs should be involved in the programme.
  8. Provision of Drug Kits- ASHA will provide the basic medical care to the community. The drug kit with basic medicines and supplies will be provided to all the ASHAs under NRHM. The drug Kit will consist of allopathic as well as Ayush medicines. ASHA will charge the user fees from the community. Initially the drug Kits are being provided by GOI. They may need state level modification / supplementation. In such case ARC will facilitate the procurement process and supply it to ASHA. This is not one time activity and regular stocks should be available with ASHA. ARC will develop the mechanism to maintain at least two months stock of medicines with ASHA.
  9. ASHA Sahyoginis role in Village Health Plan - NRHM is promoting the down - up approach for implementation of different health programmes. It is proposed to form Village Health Societies and Village Health Teams to address the health needs of the Village. ASHA Sahyogini will be one of the important members of VHC and VHT. ARC will be responsible for capacity building of ASHA Sahyogini so that she could help in planning and implementation of Health Programmes in the Village.
  10. Organize Quarterly meeting of Mentoring Group - A Mentoring Group is constituted to provide overall guidance to the programme and act as a think - tank for the programme. The mentoring group will provide technical inputs and support mechanism. ASHA Resource Center will conduct the quarterly meetings of the mentoring group and incorporate the valuable inputs provided by the group in the programme.
  11. Provision of services of Helpline - ASHA Sahyogini in near future will work in entire state. There will be more than 45,000 ASHA Sahyoginis in the State. Time to time trainings or monthly meetings may not suffice the need of the ASHA Sahyogini. So the ARC will form the helpline for the ASHA Sahyogini and associated functionaries. ARC will respond to the queries or clarifications needed in the field. ARC will ensure that the prompt help is provided to ASHA.
  12. Organizing ASHA Sammelan, Exposure visits- There will be Sammelans at State level, Zonal level and District level to share the experiences of ASHA Sahyogini and for cross learning’s. ARC will organize such events with the help of State Health Society and District Health Society. ARC will also organize the exposure visits with in the state and outside the state.
  13. Other issues related to the functioning of ASHA - Some of the functions of ARC is mentioned above. The role of ARC is multifaceted and visualized in broader sense. The functions of ARC could be revised as per the need and requirement of the programme. Some new roles could also be incorporated.
  14. Linkages of ASHA Resource Center- ASHA Resource Center is a Hub for ASHA Component under NRHM, which will work in close association with Mission Director. The administrative control on the ARC will be of the outsourced agency, but the Mission Director will be involved in major decisions like recruitment of professionals, budget etc. However day to day functioning will be the responsibility of outsourced agency. ARC will provide support to the districts through NRHM and all the administrative guidelines will be issued through NRHM.
Janani Surakha Yojana (JSY)
Janani Surakha Yojana(JSY) is a centrally sponsored scheme under NRHM umbrella to benefit pregnant women & certified poor families.

Objective

  1. To decrease maternal mortality rate & infant mortality rate.
  2. To increase Institutional deliveries amongst BPL & poor families.

Beneficiary

  • Women of BPL / APL families

Eligibility Criteria (New Guidelines)

OFFICE ORDER

GUIDELINE

Duties of ASHA - Sahyogini:

  1. Registration of eligible beneficiary.
  2. Antenatal checkup (3 times)
  3. Arrange referral transport, Escort her to health facility & facilitate cash assistance from PHC/CHC/DH.
  4. Post natal checkup (2 times).

A Nodal officer has been appointed in each district to implement this scheme effectively.

Untied Funds
There was an urgent need to strengthen the Subcentres and to also decentralize its functioning to improve the quality of services and make it community friendly. For the first time in the history of the FW programme it was proposed to provide untied funds.
  1. As part of the National Rural Health Mission, it is proposed to provide each sub center with Rs.10,000 as an untied fund to facilitate meeting urgent yet discrete activities that need relatively small sums of money
  2. The fund shall be kept in a joint bank account of the ANM and the Sarpanch.
  3. Decisions on activities for which the funds are to be spent will be approved by the Village Health Committee (VHC) and be administered by the ANM. In areas where the sub center is not co-terminus with the Gram Panchayat (GP) and the sub center covers more than one GP, the VHC of the Gram Panchayat where the SC is located will approve the Action Plan. The funds can be used for any of the villages, which are covered by the sub center.
  4. Untied Funds will be used only for the common good and not for individual needs, except in the case of referral and transport in emergency situations.
  5. Suggested areas where Untied Funds may be used include:
  • Minor modifications to sub center- curtains to ensure privacy, repair of taps, installation of bulbs, other minor repairs, which can be done at the local level
  • Ad hoc payments for cleaning up sub center, especially after childbirth.
  • Transport of emergencies to appropriate referral centers
  • Transport of samples during epidemics.
  • Purchase of consumables such as bandages in sub center
  • Purchase of bleaching powder and disinfectants for use in common areas of the village.
  • Labour and supplies for environmental sanitation, such as clearing or larvicidal measures for stagnant water.
  • Payment/reward to ASHA for certain identified activities.

6. Untied funds shall not be used for any salaries, vehicle purchase, and recurring expenditures or to meet the expenses of the Gram Panchayat.

IPHS

Under National Rural Health Mission Strengthening of CHCs as per the norms of Indian Public Health Standards (IPHS) is an important component. Under this component all the CHCs of the State will be up graded in phases. Under this component 64 CHCs have been selected for up gradation in the year 2005-6. In the year 2006-07 64 more CHCs has been seleceted for up gradation. Now total number of CHCs selected for upgradation to IPHS is 325.

  • Selection of 64 CHCs has been done after avoiding duplicity with other programme specially the RHSDP. For the year 2006-2007, 64 institutions will be selected. It is proposed that the institution selected by RHSDP will be selected under NRHM and support for construction of quarters will be undertake in this year as under RHSDP there is not any provision for construction of staff quarters. It is expected that by providing support of construction of staff quarters all the 64 CHCs being strengthening under RHSDP will be functional fully with in a year as other facilities and support is being done under RHSDP in these institutions.
  • Facility survey of the 64 CHCs of first phase has been completed. Data regarding man power position, at CHCs, requirement of equipments, furniture, drugs and supplies collected through the facility survey. The facility survey regarding the civil works is being done by RHSDP. For the institutions of phase –II facility survey will be done by NRHM. Facility survey for civil works has already been done by RHSDP.
  • Procurement of equipment and furniture- Requirement of CHCs for the first phase has been obtained through Facility survey. As per decision process of procurement has been initiated. So far purchase orders of the 21 items with cost of Rs.18810078.00 have been placed. Procurement rest items under process. The supplies of equipment and furniture for the CHCs of II phase will is being ensured by RHSDP.
  • Manpower status - Manpower status of CHCs for the phase -I prepared and request has been send to Director, PH for posting of required staff on vacant positions and also facilitate the process for creating new posts on CHCs as per IPHS norms. For the CHCs of second phase same pattern will be obtained.
  • Civil Works - The process of hiring the consultant agencies for supporting operationalization of civil/repair and renovation work under NRHM at CHCs to upgrade as per IPHS norms was initiated and two agencies AVL and PWD selected to provide support in civil works under NRHM as per IPHS.
Building plan for the quarters has been approved. Actual construction work is started. RHSDP will work on 193 CHCs and PWD will work on 132 CHCs.
Health Facilities
Strengthening of Public Institutions for health Delivery

The Rural Health Care System forms an integral part of the National Health Care System. Provision of Primary Health Care is the foundation of the rural health care system. For developing vast public health infrastructure and human resources of the country, accelerating the socio-economic development and attaining improved quality of life, the Primary health care is accepted as one of the main instrument of action. Primary health care is the essential health care made universally available and accessible to individuals and acceptable to them through their full participation and at a cost the community and the country can afford.

Although vast network of this infrastructure looks impressive, accessibility, availability of manpower and quality of services, and their utilization have been major issues in the Public health care delivery system. Adequacy of coverage is an important issue. The number of facilities is not adequate when we consider the current population.

The primary Health Care structure in the country has been established as
per the following norms:
Centre Population Norms
Facility Plain areas Hilly/Tribal areas
Sub-centre 5000 3000
Primary Health Centre 30,000 20,000
Community Health Centre 1, 20,000 80,000

Sub-Centre
Sub Centre is the first peripheral contact point between community and health care delivery system. A Sub Centre is manned by one Female Health Worker (ANM) and one Male Health Worker (MPW). One Lady Health Visitor (LHV) for six sub-centres is provided for supervision at the PHC level.

Primary Health Centre (PHC)
PHC is the first contact point between village community and the Medical Officer. Manned by a Medical Officer and 14 other staff, it acts as a referral unit for 6 Sub-Centres and has 4-6 beds for patients. It performs curative, preventive, promotive and family welfare services. These are established and maintained by the State Governments. Currently there are 23109 Primary Health Centres in the country.

Community Health Centres (CHCs)
CHCs are established and maintained by the State Governments. Manned by four specialists i.e. Surgeon, Physician, Gynecologist and pediatrician and supported by 21 paramedical and other staff, a CHC has 30 indoor beds with one OT, X ray facility, a labour room and laboratory facility. It serves as a referral centre for 4 PHCs. Currently there are 3222 Community Health Centres in the country.

Activities to be taken up for strengthening the facilies:

I. Strengthening of the Physical Infrastructure of the existing facilities:

  • Buildings: Provision of proper buildings for the Subcentres with Adequate residential facility, Electricity, water supply system,referral transport, furniture etc.
  • Repair and Maintenance:Repair and maintenance of the centres having their own buildings and ensuring 24 hours water supply and electricity
  • Financial provision: S.No. Facility Amount
    1 Subcentre 10000
    2 PHC 500000
    3 CHC 1000000
  • New Facilities: New centres need to be established in order to cover the entire population of the country as has been discussed before.

II. Manpower

The vacancies need to be filled up. In Rajasthan a decentralized mechanism exists for the appointment of Contractual appointments of MO. ANM, Lab Technician.

III Equipments, Drugs and other supplies:

A list of essential drugs, equipments and other supplies have been prepared by GOI. An Essential Drug list exists for Rajasthan. Streamlining of the Logistics and Warehousing systems needs tro be done for timely supply of quality drugs

IV. Training

NRHM envisages an accountable system for delivery of quality services. For quality services, the skill of the health personnel needs to be improved. The attitudinal changes in the health personnel to be responsive to the health needs of the community will require orientation of health personnel. In this context, the induction training, in-service skill development training, and management training of the health personnel are being planned in.


RCH-Phase-II. The training load of various categories for personnel is as follows:

I. Training of ASHA
II. Orientation and Skill Development Training for ANMs
III. Orientation and Skill Development Training for Male Health Worker
IV. Orientation and Skill Development Training for LHVs / Female Health Supervisor
V. Orientation and Skill Development Training for Health Assistant (Male)
VI. Orientation and Skill Development Training for Medical Officers at PHCs
VII. Other skilled trainings include Anesthesia, Skilled Birth Attendants, MVA, NSV

Emergency obstetric care services

Rajasthan is the state with second highest mother in maternal mortality in India. Approximately total number of deaths of pregnant ladies in Rajasthan in one year is equivalent to total number of deaths of pregnant mothers in five years in Kerala.
World over it has been observed that delays at three levels are the reasons for the deaths of the pregnant mothers. Most of the deaths of pregnant mothers can be averted by addressing these delays.

  1. First delay: - Occurs at house hold levels in taking decision to seek medical help and there is no preparedness for delivery of the baby.
  2. Second delay: - Occurs during the transportation of the pregnant lady to the appropriate place. Many a times either vehicle is not available or the money is not available to hire the vehicle. There is lack of knowledge regarding the right place where the pregnant lady should be transported in case of emergencies
  3. Third delay: - Occurs at the facility level, when a pregnant lady reaches at facility either trained manpower, equipments or drugs are not available. Hence initiation of treatment is delayed .To address all these delays and problems faced by a pregnant lady, in the state has been studied and a multi pronged strategy has been developed .The following activities are planned and are being implemented by the Government of Rajasthan for reducing maternal mortality in the state.
  1. (1) Training of field staff, posted in remote & far flung areas in
    (2) Strengthening of referral transport.
    (3) Awareness generation in the communities for preparedness of delivery of the baby.
    (4) Strengthening of facilities to provide comprehensive and basic emergency obstetric care services round the clock through out the year.

Comprehensive and Basic Emergency Obstetric Care Services (CEmOC/BEmOC)

United Nation has developed certain criteria for labeling any institution as either
CEmOC/BEmOC as well as distribution according the populations of the area.

Basic Emergency Obstetric Care Center (BEmOC)

BEmOC is a center which should cover a population of 1.25 lakhs (four centers for a population of five lakhs) and should provide the following services.

1. Parenteral administration of Antbiotic
2. Parenteral administration of Anticonvulsants
3. Parenteral administration of Oxytocics
4. Assisted Vaginal delivery
5. Manual removal of Placenta.
6. Removal of retained products of conception.


Comprehensive Emergency Obstetric Care Services (CEmOC)

CEmOC is a center to cater the needs of population of around five lakhs and should provide all the above six services along with the following services round the clock through out the year.

1. Availability of blood and blood transfusion facility.
2. Facility for Caesarian section for delivery of foetus in emergency cases.

As per the UN process indicators a total number of 128 CEmOCs and 459 BEmOC are required to provide emergency obstetric care services to all the pregnant ladies, of the state.

In the regard a total number of 187 institutions have been identified to provide comprehensive emergency obstetric care services in the state keeping in view the geographical conditions and population of the state. These institutions will be strengthened in a phased manner, in the first phase 137 institutions will be strengthened and remaining 50 institutions will be strengthened in the second phase.

Similarly a total of 173 institutions are identified to provide basic emergency obstetric care services by the end of this year.