NRHM_Flagship Report_GUNA_MP

FLAGSHIP REPORT - NRHM

Submitted to:

Tata Institute of Social Sciences

July 2008

This Flagship study of NRHM in Guna

District of Madhya Pradesh was a part of

Training by TISS and supported by

UNICEF

Abhishek Singh

Dr. Anoop Tripathi

Arun Kumar

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ACKKNOWLEDGEMENT

We are grateful to TISS and UNICEF for providing us the opportunity to spend five weeks to

understand the administration of the district, block, panchayat and village in the state of MP.

These five weeks also provided the opportunity to develop a detailed understanding of NRHM

as a flagship programme and one Village in Guna District of Madhya Pradesh.

Our Sincere thanks goes to UNICEF Bhopal team. We cannot forget to mention Ms. Anita

Dadlani, District Support Officer, UNICEF, Bhopal for her support and special care during

this entire internship period.

Our heartfelt thanks to District Collector, Guna and all the other officials at the State, Guna

District and Chachaura Block; without whose support this study would not have been

possible. Our thanks to all the other stakeholders including Civil Society Organisations who

provided us an in depth understanding of the various development programmes and took us

closer to the community.

Last but not the least; we extend our thanks to the people especially women and children of

Village Umarthana. It was because of them we could stay close to them and fulfil the

purpose of village study.

At the end, our thanks to all the other people whose names may not have found a mention

here. We sincerely thank all of them for helping us in completing this study on time.

Abhishek Singh

Anoop Tripathi

Arun Kumar

3

Abbreviations

NRHM National Rural Health Mission

IMR Infant Mortality Rate

MMR Maternal Mortality Rate

TFR Total Fertility Rate

RKS/HMS Rogi Kalyan Samiti/Hospital Management Society

VHSC Village Health and Sanitation Committee

SC/ST/OBC Scheduled Caste/Scheduled Tribe/Other Backward Caste

NFHS National Family Health Survey

GOI Government of India

PIP Programme Implementation Plan

DHAP District Health Action Plan

MOU Memorandum of Understanding

ANM Auxilary Nurse Midwife

ASHA Accredited Social Health Activist

BEMONC Block Emergency Medical Obstetric and New Born Care

CEOMNC Community Emergency Medical Obstetric and New Born Care

JSY Janani Suraksha Yojna

SNCU Sick New Born Care Unit

NRC Nutrition Rehabilitation Centre

CHC Community Health Centre

PHC Primary Health Centre

SHC Sub Health Centre

AWC/AWW Anganwari Centre/Anganwari Worker

ICDS Integtrated Child Development Scheme

TSC Total Sanitation Campaign

PRI Panchayati Raj Institutions

AYUSH Ayurvedic, Unani, Sidhha and Homeopathy

DH District Health

BMO Block Medical Officer

CMHO Chief Medical Health Officer

CS Civil Surgeon

DPMU District Programme Management Unit

RCH Reproductive and Child Health

HMIS Health Management Information System

BMI Body Mass Index

IMNCI Integrated Management of Neonatal and Childhood Illness

ANC/PNC Ante Natal Care/Post Natal Care

DLHS/NSSO District Level Household Survey/National Sample Survey Organisation

FSW Field Social Worker

IPHS Indian Public Health Standard

LHV Lady Health Volinteer

SBA Skilled Birth Attendant

BPL Bellow Poverty Line

MNGO Mother NGO

BCC Behaviour Change Communication

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Table of Contents INTRODUCTION ............................................................................................................................................................................................................................................... 5

METHODOLOGY .............................................................................................................................................................................................................................................. 5

BACKGROUND OF NRHM ............................................................................................................................................................................................................................... 5

SITUATION IN MP ............................................................................................................................................................................................................................................ 5

Current Status of Health Outcomes and Health Systems in Madhya Pradesh .................................................................................................................................... 6

Status of Health Outcomes ...................................................................................................................................................................................................................... 6

Status of Social determinants of health.................................................................................................................................................................................................. 7

Health Problems in Tribal regions ........................................................................................................................................................................................................... 7

PROFILE OF GUNA DISTRICT ........................................................................................................................................................................................................................... 8

Health Situation in Guna .......................................................................................................................................................................................................................... 9

Health infrastructure in the District ......................................................................................................................................................................................................10

District Hospital at Guna ........................................................................................................................................................................................................................11

HEALTH INFRASTRUCTURE AT THE BLOCK LEVEL .......................................................................................................................................................................................11

Status of Community Health Centres ...................................................................................................................................................................................................11

Status of Primary Health Centres (PHCs) ..............................................................................................................................................................................................13

Status of Sub Health Centres (SHCs) .....................................................................................................................................................................................................13

ROGI KALYAN SAMITI ....................................................................................................................................................................................................................................15

Composition of Rogi Kalyan Samiti (PHC) .............................................................................................................................................................................................15

Role of Rogi Kalyan Samiti .....................................................................................................................................................................................................................16

VILLAGE HEALTH SANITATION COMMITTEE (VHSC)...................................................................................................................................................................................17

Composition of the Village Health Committee ....................................................................................................................................................................................17

Role of Village Health Committee .........................................................................................................................................................................................................18

ASHA- ACCREDITED SOCIAL HEALTH ACTIVIST ...........................................................................................................................................................................................18

Honorarium.............................................................................................................................................................................................................................................19

Selection of ASHA ...................................................................................................................................................................................................................................19

Training of ASHA .....................................................................................................................................................................................................................................20

Drug Kit....................................................................................................................................................................................................................................................20

Coordination with Other Departments.................................................................................................................................................................................................20

JANANI SURAKSHA YOJANA .........................................................................................................................................................................................................................21

Entitlements under JSY ..........................................................................................................................................................................................................................21

National Maternity Benefit Scheme (NMBS) Vs Janani Suraksha Yojana...........................................................................................................................................21

Delivery benefits of JSY ..........................................................................................................................................................................................................................22

Problems with Institutional Birth under JSY .........................................................................................................................................................................................22

Difficult to reach public health facility ..................................................................................................................................................................................................22

Low Quality of Care ................................................................................................................................................................................................................................22

MAINSTREAMING OF AYUSH .......................................................................................................................................................................................................................23

DISTRICT HEALTH SOCIETY ...........................................................................................................................................................................................................................23

CONVERGENCE ..............................................................................................................................................................................................................................................23

ROLE OF NON GOVERNMENTAL ORGANIZATIONS.....................................................................................................................................................................................24

FINANCIAL PERFORMANCE FY-2007-2008 ..................................................................................................................................................................................................24

INNOVATIONS ...............................................................................................................................................................................................................................................25

Nutrition Rehabilitation Centre .............................................................................................................................................................................................................25

Bal Shakti Yojna: .....................................................................................................................................................................................................................................26

Sick New Born Care Unit (SNCU) ...........................................................................................................................................................................................................27

Call Centre ...............................................................................................................................................................................................................................................28

Janani Express Yojna ..............................................................................................................................................................................................................................29

Deendayal Antyodaya Upchar Yojna.....................................................................................................................................................................................................30

CONCLUSION .................................................................................................................................................................................................................................................30

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INTRODUCTION Government of India is implementing different Flagship Programmes to improve the quality

of life of people. Tata Institute of Social Science with support from UNICEF organised a 5

week field internship programme to critically understand the different flagship programmes

across the country. Different teams were assigned one major flagship programme is one of

the integrated districts of UNICEF. National Rural Health Mission is one such ambitious

programme which aims at improving the health status of the populace with a special focus for

people living in rural areas. The progress of implementation of NRHM has been varied across

the country. Though there have been many positive outcomes but there also have been many

critiques of the program at the National & State level.

Guna district in Madhya Pradesh was selected for studying National Rural Health Mission.

The Objectives of the study were:

1. To understand the current health status at State & District level. 2. To understand the delivery structure of the program at the district level

3. To study various components of the program and its implementation in the district. 4. To understand the reasons for success & failures of the program in the district.

5. To examine different innovations, if any, in the district under the program

METHODOLOGY To enable access to complete and factual information about the program different

methodologies were adopted as per the requirement. These included:

1. Formal & Informal Discussions with service providers 2. Desk review of reports & publications

3. Facility visits 4. Unstructured interview of the beneficiaries

5. Observation

BACKGROUND OF NRHM The National Rural Health Mission was launched in 2005, to provide accessible, affordable

and accountable quality health services even to the poorest households in the remotest rural

regions. The difficult areas with unsatisfactory health indicators were classified as special

focus States to ensure greatest attention where needed. The thrust of the Mission was on establishing a fully functional, community owned, decentralized health delivery system with

inter sectoral convergence at all levels, to ensure simultaneous action on a wide range of determinants of health like water, sanitation, education, nutrition, social and gender equality.

Institutional integration within the fragmented health sector was expected to provide a focus on outcomes, measured against Indian Public Health Standards for all health facilities. From

narrowly defined schemes, the NRHM was shifting the focus to a functional health system at all levels, from the village to the district.

SITUATION IN MP MP is one of the poorer states of the country with more than 37% of its population (22

million) living below poverty line. SCs and STs constituting 35% of the population, account

for the majority of the poor. State has low sex ratio (920 as compared to 933 for the country)

and low female literacy (50% as compared to 54% for the country). Health status is

characterized by high maternal and child mortality (MMR of 498 as compared to 409 for the

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country, IMR of 79 as compared to 64 for the country), high fertility (TFR of 3.3 as

compared to 2.9 for the country), high burden of vector borne and communicable diseases

and weak public health system with extremely low per capita public expenditure (Rs 132 as

compared to Rs 207 for the country).

State has taken many steps in the recent past to improve the functioning of the health system

and facilities. These efforts have acquired a new focus and thrust with the launch of the National Rural Health Mission that has become the umbrella programme for all vertical

disease control programmes, including RCH. State has already signed MOU with the GOI committing itself to increasing public expenditure on health, increased decentralization and

community participation, provision of community level health worker (ASHA) and granting functional autonomy to local health facilities. State has also prepared a Programme

Implementation Plan (PIP) for NRHM and RCH covering the period up to 2012. These PIPs outline the operational plans of the government to reform the health systems for providing

equitable and quality health care to its people.

Current Status of Health Outcomes and Health Systems in Madhya Pradesh

State has made significant progress in reduction in MMR, IMR and CMR over the last few

years. However, these are still worse than national averages and quite poor as compared to

better performing states. Inequities in access and health outcomes extremely low expenditure on health and that too largely as out of pocket and high incidence of communicable diseases

like TB and Malaria characterise the health status of the state.

Status of Health Outcomes The salient health indicators are detailed in the following table:

Sl.

No. MP MP All India Kerala UP

(NFHS 3) (NFHS 2) (NFHS 2) (NFHS 3) (NFHS 3)

1 MMR (SRS 1998) 498 407

2 IMR 70 88 68 15 73

3 Under 5 mortality rate 142 95

4 TFR 3.1 3.4 2.9 1.9 3.8

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Women receiving 3 Antenatal

Check ups 40% 27% 20% 94% 26%

6 % of children fully immunized 40% 22% 42% 75% 23%

7 Institutional Deliveries 30% 22% 33% 100% 22%

8 % of child malnourished 60% 54% 50% 29% 47%

9 Unmet need for FP 12% 17% 16% 9% 22%

Based on the above, the major highlights of the health outcomes and key intermediate

indicators are:

• High MMR and IMR with significant rural-urban, socio-economic group wise and inter-district variation both in health outcomes and utilisation of health services.

• High level of malnutrition amongst children and anaemia amongst women.

• High Gender disparity – CMR for girl child is 87.5 as compared to 49.2 for boys.

• IMR is double and CMR is more than five times in poor families as compared to well

off families. Similarly, 12% of children in poor families were vaccinated as compared to 50% of well off.

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• Only 11% of ST children were fully immunized as compared to 22.4% for the state as

a whole.

• Poor awareness of ORS therapy, while 28% of the state’s IMR was due to diarrhoea.

• MP contributes 24% of malaria cases, 40% of PF cases and 20% of malaria deaths in

the country.

• Poor coverage of sanitation facilities in rural areas.

• Increasing prevalence of TB with poor detection as well as cure rates in majority of

districts.

Status of Social determinants of health

Madhya Pradesh is one of the India’s poorer states, with a per capita income in 2003-04 of

Rs. 8,284 compared to the all-India average of Rs. 11,799. More than 37% of its population

live in poverty. For Scheduled Tribes (20% of the population) and Scheduled Castes (15%),

the poverty levels are higher, at 57% and 40% respectively. Gender inequalities are reflected

in the low sex ratio (920/1,000, against a national average of 933), female literacy of 50%

and lower Human Development Indices for women. Within the state, there are significant

regional inequalities, with extremely high poverty levels in southern and south-western

districts compared to northern districts. High levels of poverty and gender inequalities impact

on key social determinants of health:

• 53% of women are married before the legal age of marriage (18 years) with this indicator as high as 72% for women with no education.

• 13.6% of the women in the age group of 15-19 years were either pregnant or were mothers.

• IMR (125) of youngest mothers was twice that of mothers aged 30-35 (64).

• Prevalence of high anaemia (57.6%) and nutritional deficiency (40% women have

BMI <18) amongst women in reproductive age.

• 70% of ST women are anaemic.

• More than 60% children are malnourished; 40% are stunted and 33% are wasted.

• Only 15% of children were breastfed within one hour of birth and only 21% of children (0-5 months) were exclusively breastfed.

• 86% of habitations are covered by safe drinking water sources. However, inadequate

arrangements for preventive maintenance of hand pumps contribute to poor

availability of safe drinking water.

• Rural sanitation is still a concern as less than 8% of all rural households are estimated to have an IHL. This situation is likely to improve with implementation of ‘Swajal

Dhara’ scheme. However, attitudinal awareness and constraints due to non-

availability of water for flushing need to be tackled.

Health Problems in Tribal regions

• MP has a large tribal population, majority of who reside in 8 tribal districts. These tribal districts are characterised by extreme poverty (more than 57% tribal population

is poor), remoteness, inaccessibility and extremely weak public health infrastructure.

The health outcomes in these areas are, understandably, extremely poor as compared

to other regions and groups:

• CMR was 87 for ST children as compared to 57 for the state (NFHS 2).

• TFR was 3.9 for SC, 3.7 for ST against 3.3 for the state (NFHS 2).

• More than 70% ST women were anaemic as compared to 54% for the state (NFHS 2).

• 60% of ST children were anaemic as compared to 51% for the state (NFHS 2).

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• 91% tribal women delivered at home as compared to 78% for the state as a whole.

• Special strategies for improving access and availability of services and health

outcomes in tribal areas will be devised as a part of the health reform programme.

PROFILE OF GUNA DISTRICT Guna , district of Madhya Pradesh, is the gateway of Malwa. Chambal is located on the

north-eastern part of Malwa Plateau. The western boundary of the District is well defined by the river Parbati. Parbati is the main river flowing along the western boundary touching

Rajgarh District of M.P. and Jhalawarh and Kota District of Rajasthan. Shivpuri & Kota are located in north where as Vidisha, Bhopal, and Rajgarh lies to the South. The total area

of District is 6307.66.63 sq. km. with a population of 977827 (Census 2001).

-

S. No Indicator Year Guna Source

1 Population (thousands) 2001 1667 Census

2 Population (thousands) 2005 1801 Population Projection

Report 2001-2026,

Census 2001

3 Child population (0-6 years) (thousands) 2001 327 Census

4 Sex ratio (Females per 1000 males) 2001 885 --do--

5 Child sex ratio

(0-6 years; girls per 1000 boys)

2001 931 --do--

6 Scheduled Castes (thousands) 2001 294 --do--

7 Scheduled Tribes (thousands) 2001 204 --do--

8 Annual number of births (thousand) 2005 57.8 Population Projection

Report 2001-2026,

Census 2001 and SRS

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The district is divided into 5 blocks which are: Guna, Chachaura, Raghogarh, Aron and Bamori. The blocks are further sub divided into 425 Gram Panchayats. The total number of

revenue villages in the district is 1260. Total number of ICDS centres in the district is 1011

which are located across 1260 villages covering the 0-6 child population. The total number of

schools in the district is 2658 which constitute of all the government, aided and private

schools. The majority of the schools at the primary level and nearly 80 percent at the upper

primary level are comprised by government and government aided schools.

Nearly three fourth of the total population of the district resides in the rural area thus making

it a predominantly rural district. The population density of the district is low (155 persons per

sq. km.) when compared to the other neighbouring states such as Bihar and Uttar Pradesh.

The sex ratio of the district is 885 females per thousand male which is much below the

national average of 933. However the district fares slightly better off in the child sex ratio

which is 931 as per census 2001.

The tribal population of the district is 15 percent and the scheduled caste population is 16%.

Combined together nearly one third of the population comprises of the deprived section. The population of such groups is not evenly distributed and some areas have high proportion of

the tribal population. Incidentally, these areas are the bordering blocks of the district and are extremely backward. The DLHS 2002 – 04 round shows that nearly 60 percent of the

population has low standard of living.

The overall literacy rate of the district is sixty percent out of which the male literacy is 75

percent and the female literacy is 43 percent. The literacy gap in the district is more than 30

percent. It is evident from the fact that in the district the overall ST female literacy is less

than 18 percent and the rural female literacy is 25 percent.

Health Situation in Guna Guna district had some very poor health indicators particularly related to child survival and

safe motherhood. The DLHS round 2002 -04 indicated that the institutional delivery was only

30 percent. The complete immunisation among children in the age group 12 – 35 months was

as low as 11%. Only 16 percent children were receiving ORS during an episode of diarrhoea

and the use of iodised salt in households was less that 50 percent. The IMR of the district was

98 (census estimates) and exclusive breastfeeding (including colostrum feeding) to children

was only 40 percent. One third of the children were born with low birth weight and the

Vitamin A supplementation among children was 5 percent.

In the case of some of the critical maternal health indicators the district does not fare well

either. The MMR estimated for the district is close to 7 per 1000 live births. As per NSSO estimates, nearly 70 percent of the women get married before attaining legal age in the rural

areas. Less than 40 percent of the pregnant women received at least one ANC and IFA tablets. Deliveries attended by skilled professional were less than 30 percent and out of this

only 24 percent were institutional deliveries in the rural areas. Some of the other institutional difficulties included lack of adequate infrastructure at the block level and higher travel time

9 Annual number infant deaths (thousand) 2005 4.7 --do--

10 Households with low standard of living (%) 2002-04 59.9 DLHS

11 Household using iodized salt (> 15 ppm)

(%)

2002-04 43.5 DLHS

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to reach to the facility and congestion at the facility to render immediate delivery related

services.

Against this backdrop, UNICEF piloted integrated approach to improve the maternal and

child health indicators in the district. A set of activities were initiated simultaneously to

combat the health challenge and improve services. Some of these initiatives included training

the local health workers (ANM, AWW) in Integrated Management of Neonatal and Childhood Illness (IMNCI), strengthening of Routine Immunisation, Improved diarrhoea

management and establishing call centre for 24x7 referral transport. To support such efforts existing institutions such as SHCs, PHCs and CHCs have been strengthened and new

facilities have been set up such as Nutrition Rehabilitation Centre (NRC), Sick New Born Care Unit (SNCU) and some of the sub health centres and primary health centres have been

upgraded to provide 24x7 delivery facilities and referral services. The details of these initiatives are discussed in the later section of this report.

Due to such concerted efforts the district has shown progressive trends in last 2 – 3 years. As

per the data provided by the District Health Society, the institutional delivery has gone up to

95 percent with more than 70, 000 deliveries being conducted in the last three years. Out of

this more than 47000 mothers got the benefit under Janani Suraksha Yojna. The district

administration has also accredited two private hospitals for promoting institutional delivery

under public private partnership. The immunisation coverage has also improved considerably

with complete immunisation being more than 85 percent. The district has not reported any

polio case in the last year.

However, family planning efforts seem to be bearing very limited results in the district. The

use of any modern method of contraception is very low. Though some progress can be

observed with female sterilisation being promoted under National Maternity Benefit Scheme, but the male sterilisation rates are abysmally low being reported at less than 5 percent of the

target spelt out for the current year. This clearly indicates that family planning is still the prerogative of females and male participation is very poor. The government has started Deen

Dayal Antyodaya Upchar Yojna which provides a onetime cash benefit of Rs.20000 per household to BPL families for in patient admission. Under this scheme more than 2200

households have benefitted in the current year.

The progress on the other national programmes which have been integrated under the

umbrella can be found to be satisfactory. Though this is a very generic statement as the

estimates of denominator of beneficiaries is not available. But mainstreaming of AYUSH into

the umbrella programme is another area of concern. The AYUSH practitioners have not yet

been placed at the facility level. Neither they have been included in the Rogi Kalyan Samitis

or Health Society or as master trainers of ASHA.

Health infrastructure in the District The district has one district hospital at Guna and one civil hospital situated at Chachaura.

Guna has five Community Health Centres (CHCs), 14 Primary Health Centres (PHCs) and 119 Sub Health Centres (SHCs) catering to the 10 lakh population of the district. 150 Village

Health and Sanitation Committees (VHSCs) have been constituted and are operational in the district. 20 Hospital Management Societies (Rogi Kalyan Samitis) have been registered and

are operational. The Rogi Kalyan Samitis (RKS) have been constituted up to the PHC level as

per the NRHM guidelines and the state PIP.

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District Hospital at Guna

The district hospital at Guna is a 280 bedded hospital located at the district headquarters. The hospital provides health services to the 10 lakh population of the state. The hospital is

equipped with state of art facilities including blood storage and transfusion facilities and is the only facility in the public sector to provide specialised and emergency services to the

people. The outpatient load of the hospital is 600 on an average per day.

The district hospital has a blood bank with blood storage facility, maternity ward with

emergency and obstetric care, sick and new born care unit, TB ward, immunisation ward, eye

care ward, burn unit, trauma centre, OT, physiotherapy unit and facilities such as x-ray, CT

scan and sonography facilities. Thus the hospital is well equipped to deliver all types of

health care services as has been designated by IPHS under NRHM.

However, due to lack of human resource, the hospital is not able to function at its full

capacity and only 50-60 percent of the beds are occupied. The facility has sanctioned position

of 41 doctors out of which only 23 doctors are in position. Out of the 20 sanctioned positions

for specialist doctors only 7 were occupied at the time of observation. Similar is the case for

other key staff positions such as anaesthetists, radiologists, sonographers, paramedics etc. Overall, nearly 50 percent of the staff positions are only in position.

HEALTH INFRASTRUCTURE AT THE BLOCK LEVEL Chachaura has 1 Community Health Centre at Beenaganj, which is the block headquarter.

This facility acts as the first referral unit and the centre for specialised treatment to the people

of the block. Under NRHM, this CHC is proposed to be converted into CEmONC for

conducting complicated deliveries and provide other high end treatment to the patients. Other

health facilities include 1 Civil Hospital at Chachaura, CHC at Kumbhraj which is a BEmONC providing basic emergency obstetric and new born care, 1 primary Health Centre

at Mrigwas, 1 PHC at Teligaon (SHC converted into PHC, notified a month back) and 31 Sub

Health Centres.

Status of Community Health Centres

The secondary level of health care essentially includes Community Health Centres(CHCs), constituting the First Referral Units(FRUs) and the district hospitals. The CHCs are designed

to provide referral health care for cases from the primary level and for cases in need of specialist care approaching the centre directly. Approximately 4 -6 PHCs are included under

each CHC thus catering to approximately 80,000 population in tribal / hilly areas and 1,

20,000 population in plain areas. CHC is a 30- bedded hospital providing specialist care in

medicine, Obstetrics and Gynaecology, Surgery and Paediatrics.

NRHM envisages bringing up the CHC services to the level of Indian Public Health

Standards. Under the NRHM, the Accredited Social Health Activist (ASHA) is being

envisaged in each village to promote the health activities. With ASHA in place, there is

bound to be a groundswell of demands for health services and the system needs to be geared

to face the challenge. Not only does the system require upgradation to handle higher patient

load, but emphasis also needs to be given to quality aspects to increase the level of patient

satisfaction. In order to ensure quality of services, the Indian Public Health Standards are

being set up for CHCs so as to provide a yardstick to measure the services being provided

there.

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Under NRHM, the state has planned to provide all the Community Health Centres into 24x7

Community level Emergency Medical Obstetric and New Born Care (CEmNOC) by year

2009. These centres are to be well equipped to provide specialist services along with delivery

through caesarean section and new born care. For ensuring this, certain guidelines have been

laid out such as positioning of doctors (obstetric/gynaecologist), anaesthetist and essential

medicines, blood storage facility and consumables. The detailed checklist is provided in the

IPHS document for CHCs.

Though the CHC has been given the status of CEmONC, it was observed that the facility does not even fulfil the basic criteria of provision of adequate staff. The position of specialist

doctor and anaesthetist is vacant. Though in the facility 5-6 normal deliveries are being conducted every day, complicated delivery cases are being referred to District hospital in the

absence of adequate facilities. Blood storage facility is also not currently available at the CHC. Other key staff position such as staff nurse (only 4 out of 9 are in position), ANM,

LHV, ultrasonographer and radiocardiologist which are essential positions for emergency

care are also vacant. Other consumables such as proper availability of gloves, supply of water

(no tap water) and adequate back up of electricity (one CFL bulb) is also missing at the

centre.

In the CHC a provision of 30 beds has been made under Bureau of Indian Standards and

IPHS but due to lack of space, only 20 beds are available for inpatient admission. The

delivery rooms had only 2 beds which seemed to be inadequate considering the case load of

the facility. The hygiene condition (foul smell) in the delivery room was also not proper. The

two delivery tables in the delivery room did not have cushions.

NACO has developed Universal Precaution and Safety guidelines under which all the

deliveries have to be considered as risk deliveries with respect to HIV and adequate precautions have to be ensured. This is one of the strongest convergence points between the

SACS and NRHM. However, no training of such sort has been imparted to the staff and the staff is not aware about any such programme. The staff nurse have been trained on IMNCI

and SBA and no other training such as on family planning methods, EmOC etc has been imparted. Training appears to be a weak component in the implementation NRHM in the

district.

One of the important other purpose of the CEmONC is to increase institutional delivery and

safe delivery with adequate provisioning of staff and consumables. In this facility, all the

complicated cases of pregnancy are referred to Guna, which is the district hospital. In case,

complications such as post partum haemorrhage, retained placenta etc arise at the centre,

management of such cases is not possible. These cases are referred to the district hospital

which is at a distance of 60 kilometres and the travel time is one and half hours. Such cases

get more complicated by the time the patient reaches to the district hospital.

Essential new born care is also an important and integrated component of NRHM. The

district has done well by making novel and innovative provisions of Nutrition Rehabilitation

Centre (NRC) and Sick New Born Care Unit (SNCU) at the district as well as at the block

level. Chachaura block has one 10 bedded NRC and 2 bedded SNCU for treatment and care

of extremely malnourished children (Grade III and IV) and underweight new born children, premature birth having birth complications such as birth asphyxia and neonatal jaundice and

ARI.

13

When observed, the NRC had only 4 beds occupied out of the 10 beds which seemed to be

inadequate considering the fact that in the last Bal Sanjeevan Campaign (held in the month of

January 2008) the number of Grade III and Grade IV children was 229. It is important here to

note the fact that the NRC in Guna is overloaded with such beneficiaries and in some cases

some wards are not admitted.

The SNCU with 2 beds at the Chachuara CHC was not occupied. It is clear that since all the complicated delivery cases are referred to the District SNCU children are not being admitted.

One of the other reason could be the fact that the incharge of the SNCU was away for training, the beds were not occupied. However, the district SNCU has higher caseload

indicating to the fact that provision of such a state of the art facility at the block level is not helping the cause by reducing the case load at the district facility.

Status of Primary Health Centres (PHCs)

PHCs are organised on the basis of one PHC for every 30,000 rural population in the plains

and one PHC for every 20,000 population in hilly, tribal and backward areas for more

effective coverage. PHCs are the cornerstone of rural health services- a first port of call to a

qualified doctor of the public sector in rural areas for the sick and those who directly report or

referred from Sub-centres for curative, preventive and promotive health care. It acts as a

referral unit for nearly 6 sub-centres and refers out cases to Community Health Centres (CHCs-30 bedded hospital) and higher order public hospitals at sub-district and district

hospitals. It has 6 indoor beds for patients.

The nomenclature of a PHC varies from State to State that include a Block level PHCs (located at block HQ and covering about 100,000 population and with varying number of

indoor beds) and additional PHCs/New PHCs covering a population of 20,000-30,000. The

standards prescribed as per GOI norms is PHC covering 20,000 to 30,000 populations

with 6 beds, as all the block level PHCs are ultimately going to be upgraded as Community

Health Centres with 30 beds for providing specialized services.

In the district 14 PHCs are located at different places and providing services to the rural

population of the district. On an average one PHC is catering to nearly 75000 population in

the district which is far above the GOI norm and the Indian Public Health Standard (IPHS)

prescribed under NRHM. Going by the population norm there is a requirement of 35 PHCs in

the district (considering the 30000 population norm).

As PHCs are the first port of call for health services, servicing a population of 75000 with

only 6 indoor beds seems to be a huge challenge.

Status of Sub Health Centres (SHCs)

In the public sector, a Sub-health Centre (Sub-centre) is the most peripheral and first contact

point between the primary health care system and the community. As per the population norms, one Sub-centre is established for every 5000 population in plain areas and for every

3000 population in hilly/tribal/desert areas.

A Sub-centre provides interface with the community at the grass-root level, providing all the primary health care services. Of particular importance are the packages of services such as

immunization, antenatal, natal and postnatal care, prevention of malnutrition and common childhood diseases, family planning services & counselling and in time referrals

of EMoC cases. It also provides elementary drugs for minor ailments such as Acute

Respiratory Infection (ARI), diarrhoea, fever, worm infestation etc. and carries out

14

community needs assessment. Besides the above, the government implements several

national health and family welfare programmes which again are delivered through these

health centres.

A Sub-centre is staffed by one Female Health Worker commonly known as Auxiliary Nurse

Midwife (ANM) and one Male Health Worker commonly known as Multi Purpose Worker

(Male). One Health Assistant (Female) commonly known as Lady Health Visitor (LHV) and one Health Assistant (Male) located at the PHC level are entrusted with the task of

supervision of all the Sub centres (roughly six sub centres) under a PHC.

In Guna district, the number of SHCs is 119. These SHCs are catering to nearly 9000 population which is almost double the population norms. The total requirement for the district

is 212 SHCs considering 5000 population norm for plain areas and discounting the norm of 3000 population for hilly/tribal areas. Though in certain pockets there is high concentration of

tribal population in the district.

As per the Programme Implementation Plan (PIP) target of the state, it was planned to have at

least 25% SHCs with 2 ANMs by the end of year 2008. The district has currently 35 SHCs

with 2 ANMs which fulfils the above target set by the state. All the other SHCs have one

ANM. In 97 of the Sub Health Centres joint account with the Sarpanch has been opened. This

account is used to remit the untied fund of Rupees ten thousand for the purpose of upkeep

and maintenance of the SHCs.

However, owing to the operational difficulties, from the current year Sarpanch has been

removed from the joint account and the Medical Officer in charge of the SHC has been added

as a signatory to the account. It was found out that under the previous arrangement some

malpractices at the level of Sarpanch were occurring. Therefore, this new system has been worked out to streamline the utilisation of untied funds provided to the SHC.

The village, Umarthana, which was the selected village for study, has one sub health centre

(SHC) located within the boundaries of the village. The SHC covers 10 villages with the farthest village being at a distance of 8 kilometres. The sub health centre provides OPD,

immunisation, counselling for FP services, referral and other requisite services as per the guidelines of IPHS. This SHC is staffed with one FSW and one ANM. The FSW is staying in

the sub centre for the last 13 years whereas the ANM has recently shifted her base. The ANM

has received training in IMNCI organised by UNICEF.

As per the records available with the sub health centre, currently 8 women are pregnant in the

village. Five births have been recorded since the beginning of this year and 4 women are

under post natal care. As informed, the SHC has been able to promote institutional delivery

and all the births in the last two years have occurred in the Beenaganj CHC or district

hospital at Guna. This has been successful after the implementation of the JSY and the Janani

Suraksha Express schemes in the district. Immunisation status of children was also observed

to be good as verified by the records available with the AWC and the SHC. It is important

here to note that there is considerable focus of the government for promoting complete

immunisation and institutional delivery.

Other important services such as home visits for ANC and PNC, essential new born care,

vitamin A supplementation, ARI and Diarrhoea care etc were also emerged to be of satisfactory level during interactions with the community members of the village. However,

15

counselling for promoting the use of FP methods, counselling to adolescents for reproductive

and sexual health care and convergence with schools and on issues of water and sanitation

was found to be weak. Waste disposal was another area where guidelines for disposal of

waste were not being followed and it requires immediate attention.

The supply component was also found to be satisfactory. The SHC had all the essential

medicines available with it. The supply as verified from the stock register has been regular except for two occasions when the supply was delayed by two weeks after placing the indent.

However, as the SHC has the flexibility to use the untied fund, in case of such delays, this fund is used with discretion in such cases. Convergence with the ASHA and the AWW was

also found to be extremely good reflecting in the high institutional delivery and high immunisation rates. During the discussion with ASHA and ANM it came out that adequate

handholding to them is being done.

The SHC has used the untied fund to renovate the centre and build toilet so that the ANM

could stay at the centre. Overall, the SHC at Umarthana was observed to delivering services

better than what had been expected. However, one of the weak link was the lack of adequate

IEC material at the Centre. Display of not much IEC material could be observed neither such

materials were present in the stock despite the fact the there has been ever increasing

emphasis on this. Also, since the SHC is located within the village people of all castes, class,

power and gender are getting the benefits. But one needs to verify the reach of these services

to the other nine villages the SHC caters.

ROGI KALYAN SAMITI Madhya Pradesh is the pioneering state where hospital management societies (Rogi Kalyan

Samitis) were established and operationalized at all health institutions up to the level of

primary health centres. Rogi Kalyan Samiti are the registered societies constituted in the

hospitals as an innovative mechanism to involve the peoples representatives in the

management of the hospital with a view to improve its functioning through levying user

charges.

The RKS/HMS does not function as a Government agency, but as an NGO as far as

functioning is concerned. It may utilize all Government assets and services to impose user charges and is free to determine the quantum of charges on the basis of local circumstances.

It also raises funds additionally through donations, loans from financial institutions, grants from government as well as other donor agencies. Moreover, funds received by the RKS /

HMS are not be deposited in the State exchequer but are available to be spent by the Executive Committee constituted by the RKS/HMS. Private organizations offering high tech

services like pathology, MRI, CAT SCAN, Sonography etc. are permitted to set up their units within the hospital premises in return for providing their services at a rate fixed by the RKS/

HMS.

Composition of Rogi Kalyan Samiti (PHC)

General Body

Janpad Panchayat member of area Chairman

President Gram Panchayat

President of Health Committee of Gram Panchayat

Gram Panchayat female Member Sub Eng.. PWD & MPEB

All Donors ( donated Rs.10,000)

Member

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Tehsildar (SDM)

I/C MO Hosp.. Member Secretary

For managing day to day functioning of the Rogi Kalyan Samiti Executive committee have been constituted. The composition of executive Body is as following:-

Executive Body

Tehsildar (SDM) Chairman

President of Health Committee of Gram Panchayat Sub Eng.. PWD & MPEB

Member

I/C MO Hosp.. Two Donors who are member of General Body and

nominated by President.

Member Secretary

Role of Rogi Kalyan Samiti

• Ensure compliance to minimal standard for facility and hospital care and protocols of

treatment as issued by the Government.

• Ensure accountability of the public health providers to the community;

• Introduce transparency with regard to management of funds;

• Upgrade and modernize the health services provided by the hospital and any

associated outreach services;

• Supervise the implementation of National Health Programmes at the hospital and

other health institutions that may be placed under its administrative jurisdiction;

• Organize outreach services / health camps at facilities under the jurisdiction of the

hospital;

• Display a Citizens’ Charter in the Health facility and ensure its compliance through

operationalisation of a Grievance Redressal Mechanism;

• Generate resources locally through donations, user fees and other means;

• Establish affiliations with private institutions to upgrade services;

• Undertake construction and expansion in the hospital building;

• Ensure optimal use of hospital land as per govt. guidelines;

• Improve participation of the Society in the running of the hospital;

• Ensure scientific disposal of hospital waste;

• Ensure proper training for doctors and staff;

• Ensure subsidized food, medicines and drinking water and cleanliness to the patients

and their attendants;

• Ensure proper use, timely maintenance and repair of hospital building equipment and

machinery;

As a matter of fact, the concept of the Rogi Kalyan Samiti emerged at the Beenaganj CHC in the year 1994. This was an era when public health care was neglected by the policy makers

and not enough funds were flowing down for improving the health services. In this period of little funding and lesser flexibility, the then Deputy Collector of the district started leasing the

unused hospital space by constructing shops in the premise. The fund generated through this

mechanism was given to a registered society which later came to be known as Rogi Kalyan

Samiti (RKS). The RKS apart from managing this fund also started charging minimal user

fees from the patients visiting this facility. The user charges were fixed as Rs.1/- for

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outpatient registration and Rs. 10/- for inpatient registration. For delivery cases additional

charge of Rs. 25/- was fixed. Later on registration charges for BPL patients and delivery

cases was waived off.

Through this process the RKS started generating additional funds which could be used for

upkeep, maintenance, upgradation and maintenance of the facility. Over the years the RKS at

Beenaganj facility has constructed Delivery rooms and gynae wards, Nutrition Rehabilitation Centre Building, additional OT, a general purpose hall and internal concrete road for better

connectivity. The RKS has also supported the CHC by procuring modern equipments and building office annexe.

The RKS at the Beenaganj CHC has been to set up a model of local community action for

management of a public health facility. This model has been adopted as an important component of NRHM under comunitisation. But, the RKS has not been able to expand its

scope beyond institutional upgradtion of the health facility. Some of the equally important

issues such as increasing outreach services, management of other health programmes such as

TB, Malaria, HIV etc, accreditation and coordination with private health facilities, improving

waste disposal, increasing community awareness through camps etc is not clearly visible. The

district has been able to constitute RKS in all the facilities as per the target set out in the State

PIP. However, the same vigour and empowerment of RKS needs to be verified at other

facilities.

VILLAGE HEALTH SANITATION COMMITTEE (VHSC) The NRHM framework supports decentralized planning & monitoring up to the grass root

level. Therefore it was decided to entrust village level committees of the users group,

community based organization for the planning monitoring & implementation of NRHM

activities upto the village level. The Village Health and Sanitation Committee (VHSC) is be

formed in each village under each Gram Sabha ensuring adequate representation to the

disadvantaged categories like women, SC / ST / OBC /minority communities.

Village Health & Sanitation committee (VHSC) feed such groups, which is the fifth

committee (Development Committee) of the Gram Panchayat. The VHSC is the key agency

for developing Village Health Plan & the entire planning of village Panchayat for NRHM. This committee comprises of Panchayat representatives, ANM, MTW, Aganwari workers,

Teachers, Community health volunteers, ASHA. VHSCs are provided with Rs.10000/- for supporting their efforts in developing Village Health Plans.

Composition of the Village Health Committee

This committee is formed at the level of the revenue village (more than one such villages may

come under a single Gram Panchayat).

Composition: The Village Health Committee consists of:

• Gram Panchayat members from the village.

• ASHA, Anganwadi Sevika, ANM

• SHG leader, the PTA/MTA Secretary, village representative of any community based organization working in the village, user group representative.

• The chairperson would be the Panchayat member (preferably woman of SC/ST member) and the convener would be ASHA; where ASHA is not in position it could

be the Anganwadi worker of the village.

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Role of Village Health Committee

• Create Public Awareness about the essentials of health programmes.

• Discuss and develop a Village Health Plan based on an assessment of the village situation and priorities identified by the village community.

• Analyze key issues and problems related to village level health and nutrition

activities, give feedback on these to relevant functionaries and officials. Present

annual health report of the village in the Gram Sabha.

• Participatory Rapid Assessment: to ascertain the major health problems and health

related issues in the village.

• Maintenance of a village health register and health information board/calendar: The

health register and board put up at the most frequented section of the village will have

information about mandated services, along with services actually rendered to all

pregnant women, new born and infants, people suffering from chronic diseases etc.

• Ensure that the ANM and MPW visit the village on the fixed days and perform the

stipulated activity; oversee the work of village health and nutrition functionaries like ANM, MPW and AWW.

• Get a bi-monthly health delivery report from health service providers during their visit to the village.

• Take into consideration of the problems of the community and the health and nutrition

care providers and suggest mechanisms to solve it.

• Discuss every maternal death or neonatal death that occurs in their village, analyze it

and suggest necessary action to prevent such deaths. Get these deaths registered in the Panchayat.

• Managing the Village health fund.

Up to the time of this observation only 5 village health and sanitation committee have been constituted in the block as against a target of 25 percent villages having such committees by

the end of year 2008. Thus the district has failed in its benchmark of communitising the

process of health planning. All such committees have been entrusted the responsibility of

prepare local and need based village plans, but in the absence of such committees the local

action for health has not happened in the district. The untied grant of Rs. 10,000/- was

provided to the 5 committees but the block has not received the utilisation certification from

these committees. The real empowerment of these 5 VHSCs is also to be seen in the future.

ASHA- ACCREDITED SOCIAL HEALTH ACTIVIST ASHA is envisaged as an activist from the community which is the first port of call for any

health related demands of deprived sections (especially women and children) who find it

difficult to access health services. Her major role being of creating awareness on health and

its social determinants and mobilize the community towards local health planning and increased utilization and accountability of the existing health services. She is a promoter of

good health practices and also provides a minimum package of curative care as appropriate and feasible for that level and makes timely referrals. Following roles by ASHA is envisaged

through continuous training and up gradation of her skills

1. Counsel women on birth preparedness, importance of safe delivery, breast feeding

and complementary feeding, immunizations, contraception and prevention of common

infections including RTI/STI and care of young child.

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2. Mobilize the community and facilitate them in accessing health and health related

services available at the Anganwadi/Sub-centre/primary health centres, being

provided by the Government.

3. Work with the Village health & sanitation committee of the Gram panchayat to

develop a comprehensive village health plan.

4. Accompany pregnant women & children requiring treatment / admission to the

nearest pre-identified health facility i.e. PHC/CHC/FRU. 5. Provide primary medical care for minor ailments such as diarrhoea, fevers, and first

aid for minor injuries, work as provider of DOTS under RNTCP. 6. Act as depot holder for essential provisions being made available to every habitation

like ORS, Iron folic acid tablet, chloroqunine, Disposable delivery Kits, Oral pills & condoms, etc.

7. Providing newborn care and management of a range of Common ailments particularly childhood illnesses and its timely referrals.

8. Inform about the births and deaths in her village

9. Promote construction of household toilets under Total Sanitation Campaign.

It was found in the discussion that there is no clarity on roles and responsibilities of ASHA at

the grassroots level. Even concerned persons like AWWs, ANMs, PRI members, VHC

members, and staff at PHC or CHC do not have a clear idea.

Honorarium ASHAs are visualized as harmony volunteers who are not paid monthly salaries and are

reimbursed on performance based incentives. Previously it was indicated in the JSY guidelines, the package for ASHA (or an equivalent worker) where ASHA has not been

recruited) includes:

♦ The referral transport assistance to go to the nearest health centre (Rs 250)

♦ Compensation of ASHA if she stays with the pregnant women in the health centre

for delivery. (Rs 350)

Against this honorarium, a lot of expectations have been heaped on ASHA - identifying cases for subsidies and compensations (to be made by the ANM), reporting to the health system,

functioning as an activist and facilitating people's access to health service. This according to the officials led to lack of motivation among ASHA. It is only after introduction of new

guidelines of incentives, which has resulted in increased endeavours by ASHA. These

incentives include:

♦ Alternate vaccine delivery – Rs. 50

♦ Immunization – Rs. 150 per session

♦ Nutrition Rehabilitation Centre (NRC) referrals – Rs.100

Selection of ASHA

The selection of ASHA in the district has been conducted as per guidelines. For the selection of ASHA CMHO has been declared as the District nodal officer and at the Block level Block

Medical Officer declared as Block Nodal Officer who facilitates the selection process of ASHA and organizing training for trainers. In Guna, Facilitators (Surakarta) were selected at

each Panchayat level. They were trained after which they facilitated the identification and selection of ASHA with the Panchayat in Gram Sabha. There was no active involvement of

BMO in the selection of ASHA in Chachoda block only the names proposed by panchayat is

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approved by them. Ideally the desired education for ASHA is upto class VIII but

operationally majority of them are educated upto class V.

In the State PIP it was envisaged that selection of ASHA would be made 100% by 2008 as

per the norms of one ASHA at the population of 1000, but only around 723(68%) have been

currently selected. The reasons quoted by the DPM for this shortfall was dropout among the

selected ASHA and expulsion of some ASHAs, whose performance was not satisfactory. Further probing for the reasons of the dropout could not be answered. In the shortage of

required number of ASHA, desired services could not be catered to many villages.

In Chachoda block 198 ASHA have been selected so far and 39 places are still to be filled. Most of the ASHA have sustained, but it was shared that the selection in few places was

influenced by the powerful people and ASHA is not delivering. Although BMO is authorized to take action if ASHA is not working with a copy of order marked to CMHO & CEO but

such action has not happened so far.

Training of ASHA

The training of ASHAs also leaves a lot to be desired. In the State PIP it was forseen that

80% of the ASHA would be fully trained by 2008. Owing to the fact that the target for the selection of ASHA could not be met, the no Trained ASHA is also insufficient. Of the

selected ASHA only 540 ASHA have completed their training till module 4, remaining have been trained upto module 2. None of the ASHA has been imparted training upto module 5

(final module). In Chachoda block, all 198 ASHA have been trained. The lack of training was accounted to the lack of adequate infrastructure.

The training includes more of her role as a community mobilizer. The technical issues like

identification of complicated deliveries are not part of the training. This at some places has

resulted in low credibility of ASHA among the community as compared to AWW or DAIs in

the area.

The general impression is that training is being rushed as the government is under pressure to

show results. There has been criticism that civil society organisations were not consulted in

the training process of ASHA. Often, it is just the PHC/CHC staff who are unwilling trainers

and have little time to devote conduct the training for ASHA. Also, they have little pedagogic

orientation. On the other hand, the recipients (ASHAs) have no background or understanding

of health issues, which may result in low level of learning and internalization.

Drug Kit There is a provision to provide ASHA with a drug kit consisting of medicines for routine

health problems like diarrhoea. 240 ASHA have been equipped with drug kit in the State,

though BMO of Chachoda block claimed of having provided drug kit to all 198 ASHA in the block. It is still to be observed that how efficiently this facility is being utilized by ASHA at

the grass-root. Also, there has been a discussion on why the AYUSH doctors involved under NRHM are not legitimatized to provide modern drugs considering the fact of lack of medical

faculty at the centres.

Coordination with Other Departments

As the role of ASHA and AWW overlaps, there have been many incidents of conflict

between the two. This is mostly due to the perceived threat of losing her job in near future by

the AWW. It was also observed that AWW feels that most of the work is done by the ANM

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and herself for organizing immunization day. As it is part of their job responsibility, there is

no extra incentive for them. ASHA on the other hand receives incentive of Rs 150 per session

for bringing children to the site. Also, there have been conflicts for claiming the amount

under JSY for referrals of pregnant women. The current practice to resolve such dispute is

distribution of amount equally among them, which is unfair on part of ASHA as she is not

entitled to receive fixed honorarium. Additionally, ASHA is being pressurised by AWWs and

ANMs to work as their assistants.

JANANI SURAKSHA YOJANA Background

In the past, National Maternity Benefit Scheme (NMBS) came into effect in August 1995 as

part of the National Social Assistance Program (NSAP). It provided 500 Rs in cash assistance

to pregnant women living below the poverty line for her first two births provided she is 19

years or older. The benefit was given several weeks before delivery and was used for

nutrition and other needs.

With the launching of NRHM in April, 2005 Janani Suraksha Yojana (JSY) scheme came

into existence that provisioned cash incentives for pregnant women to seek an institutional

birth.

Entitlements under JSY

Janani Suraksha Yojana provides hiring of specialists of OBGY and Anaesthesia to provide specialist care in managing complicated obstetric cases. Using the similar norms, CEmONC

and BEmONC facilities would be able to hire the services of OBGY and Anaesthesia

specialists on case-to-case basis.

Under Janani Suraksha Yojana (JSY) the government provides a cash incentive for pregnant

mothers to have institutional births as well as pre- and ante-natal care. According to the

October 2006 JSY guidelines, all women in Low Performing States (LPS), like Madhya

Pradesh, receive cash assistance if they have their baby in a government health centre or

accredited private institution. In rural areas they receive 1400 Rs and in urban areas 1000 Rs.

The money is to be dispersed at the time of delivery in the institution.

Under JSY, below poverty line pregnant women older than 19 also receive 500 Rs cash

assistance for their first two births if these deliveries are at home. The cash is to be given at

birth or around 7 days before for “care during delivery or to meet incidental expenses of delivery.”

Few of the critical observations of JSY were as follows:

National Maternity Benefit Scheme (NMBS) Vs Janani Suraksha Yojana As part of the right to food case, the Supreme Court ordered on November 11, 2001 that the

state governments fully implement the National Maternity Benefit Scheme. It was observed that despite the Supreme Court’s orders to the contrary the State government is no longer

implementing the National Maternity Benefit Scheme (NMBS).Instead; NMBS has been replaced with JSY.

Importantly, unlike NMBS which provided cash assistance 8-12 weeks before delivery to

help with nutrition and other expenses the government states that “the cash assistance to the

mother [under JSY] is mainly to meet the cost of delivery.”Although JSY was created to

pursue a worthy goal – the safe delivery of babies – it does not address the nutritional needs

of women during pregnancy like NMBS was designed to do.

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The Integrated Child Development Service (ICDS), operated through local Anganwadi

Centres, is a critical component of the government’s strategy to combat malnutrition in

pregnant women and children by providing supplementary nutrition to pregnant and lactating

women and children under five. However, during our discussion it was revealed that several

ICDS centres could not properly reach out pregnant women majorly due to lack of timely

supply or inadequate quantity of supplementary nutrition. This breakdown of the ICDS system is particularly troubling given the implementation problems surrounding the pre-birth

benefit program and the home delivery benefit of JSY.

Delivery benefits of JSY

It was observed, below poverty line women rarely receive the money for home delivery

actually envisioned under JSY. The state’s own numbers support these field observations

concerning the massive under-utilization of the home delivery benefit of JSY. According to

the government, during 2006-2007 only 1687 women in Madhya Pradesh who had a home

delivery received a benefit from JSY. This is especially troubling since women who have a

home birth are more likely to be poor and malnourished.

Also, in most of the occasions it was husbands, brothers, or fathers who often made most of

the important medical decisions for pregnant women. They decided to take the woman for ante-natal care or not. They decided whether to have the birth at an institution or at home.

They took the money received under JSY and decided what to use it for. It was not that women always had no voice in these decisions, but this voice was often filtered through, or

could be easily vetoed by, men.

Problems with Institutional Birth under JSY While both the pre-birth benefit program and the home-delivery aspect of JSY were

massively under-implemented in the state, JSY benefits are widely received for institutional births. With the implementation of Janani Suraksha Yojana in the State there has been a

remarkable increase in the number of institutional deliveries particularly in the district

hospitals. Although the Government data claimed to have achieved 94% institutional

deliveries in Guna district, there is no concrete data available for the denominator (Actual

number of pregnancies and deliveries in the area).

Difficult to reach public health facility With establishment of call centre, Ambulances and 26 delivery points, there is improved

access to institutional delivery. But Primary Health Centres are still too difficult to reach from many villages making them effectively useless to these villagers.

Low Quality of Care

Most of the infrastructure in much of the state is old and outdated. Additionally, many hospitals, even district hospitals, lack even the most basic equipment. Fear over spreading

HIV/AIDS has rightly increased quality-control measures for blood supplies. This has made it more difficult to have blood banks in remote areas.

Moreover, there is a frightening scarcity of trained medical personnel throughout the public

health system. This shortage is particularly acute for highly trained medical staff. For e.g. in

Chachoda block hospital, although it’s a CMOC there is no gynaecologist and anaesthetist.

There is no facility for caesarians for obstructed labours. In lack of up-to-date public health

facilities staffed by quality medical personnel, JSY is dubious reduce infant and maternal

mortality in the dramatic way that is necessary.

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MAINSTREAMING OF AYUSH Mainstreaming of AYUSH under NRHM is a non- starter in the District as is evident from

the absence of any linkage of the Ayurvedic and Unani activities with the district health

services despite provision of space for Ayurvedic and Unani facilities in the medical

institutions. The Office of the CMHO and the Divisional Ayurvedic and Unani office were

found to be functioning in complete isolation of each other. Despite the fact that a large

number of Ayurvedic and Unani facilities are reportedly active in the District. The AYUSH

division has no communication about NRHM in the District with no allocation of funds for

the same. The infrastructure available to AYUSH institutions is extremely deficient both in

terms of buildings and funds for maintenance and rentals. There are wide gaps between

sanctioned posts and in-position staff. There are no staff nurses and no residential facilities at

Centres. Training of Ayurvedic and homeopathic Officers in NRHM under the District Health services is being conducted by the CMHO without involvement of the respective

departments at the State/ district levels. There are many vacant AYUSH posts in the district health program.

DISTRICT HEALTH SOCIETY The focus of the programme was to improve the impact of the health programmes. One of the

strategies for this was streamlining the delivery structure at the state as well as at the district

level. District level structures were created in the form of District Health Societies and it was planned to merge all the other vertical programme delivery structures such as RNTCP,

NBCP, NVBDCP etc. Professional staffs having key competencies were hired to expedite the process of integration and reach the outcomes as envisaged in the design of the programme.

The state has done well in creating the District Health Society and merging all the vertical

programme societies which existed prior to implementation of NRHM. However, the funding mechanism of these societies has not changed. The funds are still routed to the individual

societies. The only change which has occurred is that the societies have been converted into

sub committees under the DHS with one nodal officer heading the committee. Thus, the

objective of the merger has not completely been achieved.

CONVERGENCE Under NRHM convergence was sought at two levels: 1. Within the health department

2.convergence with other line departments. The attempt to converge within the health department was aimed at bringing the entire disease control program within NRHM which

would improve delivery and impact. The intention of convergence within the Health

Department was also to reorganize human resources in a more effective and efficient way

under the umbrella of the common District Health Society. Such integration within the Health

Department would make available more human resources with the same financial allocations.

It would also promote more effective interventions for health care. Though the convergence

within the health system seems to have appeared in terms of merger of the disease control

societies, the functioning of these societies is still discrete in nature. HIV and AIDS is still

outside the purview of DHS. Below the district level convergence in form has occurred.

The indicators of health depend as much on drinking water, female literacy, nutrition, early

childhood development, sanitation, women’s empowerment etc. as they do on hospitals and

functional health systems. Realizing the importance of wider determinants of health, NRHM

seeks to adopt a convergent approach for intervention under the umbrella of the district plan. The Anganwadi Centre under the ICDS at the village level is envisaged as the principal hub

24

for health action. Likewise village committees have to be constituted for convergence with

for drinking water, sanitation, ICDS etc. NRHM attempts to move towards one common

Village Health Committee covering all these activities. Panchayati Raj institutions were to be

involved in this convergent approach so that the gains of integrated action can be reflected in

District Plans.

Under the leadership of Collector, weekly time limits meetings are organised at the district level where representatives from the all the above mentioned departments meet and discuss

on the issues of convergence. However, in the absence of village plans which were the starting point of convergence the action gets limited to the district level. The Village Health

and Sanitation Committees have also not been constituted which can take forward the vision of convergence at the village level. The role of PRIs is also a very weak link and the

empowerment of PRIs to converge cannot be established as no efforts have been taken on this front. Thus, convergence, currently is limited at the district level and that too within the

department and on some specific components only.

ROLE OF NON GOVERNMENTAL ORGANIZATIONS The Non-governmental Organizations are established as critical for the success of NRHM.

The role of NGOs was envisaged as improve the reach of the programme and act as eyes and ears of the government and build capacities at all levels for effective implementation of

Programme. For this, Mother NGO scheme was supposed to be strengthened. The Mother NGO scheme is being implemented in the district with identification of MNGO and Field

NGOs completed two years back. However, it was noted during the discussion with MNGO

that that even the first instalment of funds has not been released. Thus, NGOs are yet to be

integrated into the umbrella programme of NRHM.

FINANCIAL PERFORMANCE FY-2007-2008

Intervention / Activity

Budget Planned

Budget Achieved

Balance Budget

%

TOTAL - RCH-II, NRHM,

ADDIONALITIES,

IMMUNIZATION

120768000 92025000 28743000 76.20

Total RCH- II 73347500 68383315 4964185 93.23

TOTAL Maternal Health 58595500 57945595 649905 99

TOTAL Child Health 534000 713055 -179055 134

Running Cost NRCs 384000 254190 129810 66.20

Total Family Planning - Population

Stabilization 8380000 7481101 898899 89

Total Infrastructure & Human

Resource 2944000 659885 2284115 22

Repair and renovation of PHCs

Annual 160000 103373 56627 64.61

Repair and renovation for District

hospital Annual 200000 95028 104972 47.51

TOTAL IEC & BCC 1408000 997516 410484 71

TOTAL PROGRAMME 796000 524003 271997 66

TOTAL NRHM 41354800 19534921 21819879 47.24

Village Health & Sanitation 6250000 15423 6234577 0.25

25

Committee – United Fund to 15462

VHSC’s @ 10,000

TOTAL Strengthening SHC’s 12930500 5638002 7292498 43.60

United Fund @10,000 per SHC’s per year

1190000 178886 1011114 15.03

TOTAL Strengthening CHC’s 750000 1006695 -256695

134.23

Maintenance grant @ Rs.1 Lack per

CHC per year 500000 700000 -200000

140.0

0

United Fund @ Rs.50,000 per CHC

per year 250000 306695 -56695

122.6

8

TOTAL Strengthening PHC’s 8898000 1975175 6922825 22.20

Maintenance grant @ Rs.50,000 per PHC per year

700000 490057 209943 70.01

United Fund @ Rs.25,000 per PHC per year

325000 268513 56487 82.62

District Hospital Rs. 5,00,000 per DH 500000 209192 290808 41.84

Total RKS 3200000 2539853 660147 79.37

One of the important initiatives under NRHM program was combined utilization of RCH II

and NRHM program fund. The analysis of expenditure of budget reveals that though the utilization of RCH fund is substantial, utilization of NRHM fund has been less than 50%.

Also the combined program fund utilization is only 66% which reflects poor management of the finances.

The expenditure on maternal health & child health is quite heartening but at the same time

expenditure on other components of NRHM is inadequate thus confining NRHM to Maternal

& child health defeating the purpose of the program to have comprehensive health

development. Expenditure on strengthening CHC is more than what was budgeted whereas

on the other hand expenditure on strengthening SHC and PHC, which are the door step

services of the community have been poor. Also fund allocated to the grass-root point of

service delivery i.e. SHC & Village Health & sanitation committee has been poorly utilized.

Clearly, overall financial management needs to be fortified.

INNOVATIONS

Nutrition Rehabilitation Centre

The nutritional status of the population is an important indicator of the development of the society. Mortality rates, micronutrient deficiencies and malnutrition status are some of the

important indicators that can be used to assess the health status of a specific area. Overall nutritional status is poor in the state as reflected by the occurrence of 82.6% anaemia in

children aged 6-35 months while about 57.9% women in the reproductive age group were anaemic. Vitamin A supplementation (VAS) efforts in the state could not improve the uptake

and only 16.1% of children aged 12-35 months received a dose of vitamin A during the last 6

months. As well, 44.2 % of the rural women have BMI lower than the normal as against the

national average of 38%.

The state level situation of malnutrition among children is well represented by the Guna

District. The Infant Mortality Rate of the district is 98 per thousand live births. The

malnutrition rate is about 50%. The severity of the situation is captured well in the recently

26

concluded ninth round of Bal Sanjivan Campaign held during the month of January –

February 2008. The details are summarised below in the table:

Sr.

no.

Grade Guna

(R)

Guna

(U)

Bamori Aron Raghogarh Chanchora Total

1. Normal 13560 9137 10733 7584 15311 15953 72278

2. Grade-1 9246 5014 7111 5260 10593 7805 45029

3. Grade-2 4067 2294 2893 4307 5868 4128 23557

4. Grade-3 182 80 161 48 48 97 616

5. Grade-4 37 18 41 19 15 27 157

6. Total 27092 16543 20939 17218 31835 28010 141637

Thus for improving the overall health status of children in the age group 0 -5 years was one of the biggest challenge in the state as well as Guna District.

Bal Shakti Yojna:

(Scheme for Medical Treatment and Nutritional Rehabilitation of Severely

Malnourished Children)

Bal Sanjeevni Campaign is organised in the state of Madhya Pradesh in two rounds every

year. This scheme of Bal Shakti Yojna has been envisioned following the Bal Sanjeevni

Campaigns under which as many as 10913 under-5 children were identified to be suffering

from Grade 4 level of malnutrition and 67352 from Grade 3 level malnutrition and that

majority of these children belong to poor and weaker sections.

Purpose

The scheme aimed at arresting the rate of severe malnutrition seeks to bring about reduction

in Grade 4 and Grade 3 levels of malnutrition among all children by one per cent.

Essential Features

• All children identified as Grade 4 and Grade 3 levels of malnutrition under each round of Bal Sanjeevni Campaign are provided requisite medical treatment.

• Parents/guardians of the identified malnourished children are provided counselling regarding the significance of nutritional diet. Also, they are trained in preparing

nutritional diet from low-cost and locally available foods.

The Scheme is implemented in following stages:

Stage I: Organising of Health Check Camps

One day health check camps are held at block levels wherein all malnourished children. The

camps are organised by CM&HOs in coordination with DWCDOs. Services of 2

pediatricians are made available at these camps and if required private pediatrician's services

are hired @Rs.800/- per day. A provision of Rs. 20,000/- per camp is made for organising

these camps. The amount includes expenditure in respect of mobilizing doctors, camp

arrangements, transport of children from their homes to camp and back, camp to hospital and

back to home and medicines. Children requiring emergency medical attention are admitted in

nearby appropriate hospitals on the same day. Children who are not admitted, their parents

are advised regarding home based care, given medicines and their mothers are included in

training on nutritional rehabilitation.

27

Stage II: Training in Nutritional Rehabilitation

One member of each family of those children who are not admitted, particularly the mother

are given a one day training at the sector level. The training includes care of malnourished

children and preparation of low-cost and local foods based nutritional diet. A provision of

Rs.60/- per participant is made for these trainings.

Stage III: Institutional Medical Care and Nutritional Rehabilitation in NRC This includes hospitalization of children from 7 to 14 days under the care of pediatricians.

Mothers of these children are required to be with the children who are given training in preparation of low cost nutritional diet. Mothers are given an amount of Rs.100/- per child for

expenses in respect of transportation of children to the hospital.

At the time of discharge, a follow up card is given to the mother and the ANM. The children are followed up by the ANM and AWW for 6 months during which 4 visits are made, one in

the first week, second in the first month, third in the third month and fourth in the sixth

month. As per the scheme, the motivator who brings the malnourished grade III or IV child to

the NRC is given an incentive of Rs. 100 per child. As the mother of the child has to stay

with the child at the centre, she is given an amount of Rs. 35 per day towards compensation

of wages for the period of stay. Additionally, Rs. 300 is provided towards transportation cost

and Rs. 700 so that the child can continue with the nutritional diet.

Under this scheme a total of 93 NRCs have been operationalised at District and sub district

level in the premises of the government health facility. In Guna district, 2 NRCs are

operational located at the district hospital and Beenaganj CHC. The NRC at Guna is a 20

bedded facility and the NRC at Beenaganj is a 10 bedded facility. At the time of observation

all the beds were occupied at the Guna NRC. However, only 4 out of 10 beds were occupied

at the Beenaganj NRC. It was observed that the demand for such service is quite high at the community and mostly the deprived sections are getting benefit out of it. At the Guna NRC,

all the 20 beds remain occupied and there are situations when the children have to wait to get admitted. However, in critical case, the children are admitted even if the occupancy is full.

One important component of the scheme is the motivation amount being provided to the

ICDS worker for identification of malnourished children and referral to the NRC. Sometimes in the lure of the incentive amount, some grade I and II children are being referred. There are

some similar operational issues which are cropping up which should not dampen the overall

spirit with which this novel scheme has been designed. Overall, in the longer duration this

scheme will contribute in reducing the malnutrition in the state if it is continued with same

vision and vigour.

Sick New Born Care Unit (SNCU) Sick Newborn Care unit is a State of Art started in Guna on 14th December 2007 with a

motive to bring remarkable improvement in infant mortality rate. It’s a 20 bedded Intensive care unit for the new born (0-1 month) covered in 2000 square feet inside the campus of

District Hospital. The unit is equipped with modern equipments and machines to ensure regulated temperature and intensive care to the sick new born.

Since its inception it has had approx 700 admissions with mortality rate of the admitted

children to approx 20%. When we visited the unit, only 1 bed was vacant i.e. 19 children

were under treatment. Though, the capacity of the unit is low as compared to the demand.

28

Informer

Driver

Delivery Center

Call Center software Call Center

Call Center register

InformsDriverDetails

Callfromvillage

InformspatientDetails

Transportpatient

InformsDeliverydetails

Deliverydetailsare Filled

Patientdetailsare Filled

Sometimes the number of critical children is more and bed has to be shared between 2

children so as not to deny the poor people.

The Unit is divided into three parts.

1. In Born unit – Children with critical condition born in the Hospital are kept in this

unit

2. Out Born unit – Children with critical condition born out of the hospital are kept here 3. Step Down Section - The Children whose condition becomes stable are kept in the

Step Down section for few days and then discharged.

There are 4 Doctors placed in SNCU supported by 14 Nursing Staff and 2 lab technician. UNICEF has extended a financial support of approximately 25 lakhs for the set up of the unit

at the district. UNICEF also supports the salary of the doctors in SNCU. The other running cost of the care unit is covered under NRHM. A similar two bedded set up has been

established at Beenaganj CHC but there is no specialized doctor to run the unit although,

there is one paediatrician who was out for training for the same at the time of our visit. It is

proposed to scale up the initiative to all IMNCI districts. The sustainability of the unit is a

challenge.

Call Centre Call Centre is a 24 hours service established Under Janani Suraksha Yojana on 9th September

2007 to provide free of Cost round the clock Transport Service to Pregnant Mother’s and severely sick children below the age of 6 years. The main objective behind the initiative was:

1. To optimize and regulate the use of Delivery Van’s stationed at District Health

Center’s. 2. To monitor the progress of No. Of Institutional Deliveries month wise in District

Health Center’s.

3. To accumulate the ANS List for all the blocks in the District How it Works

Patients in need of Free Emergency Transport contact Call Centre on a Toll Free number 102 & 251560. 24 vehicles pooled from various sources for emergency transport of pregnant

women and sick children. All vehicles are equipped with Mobile phones for coordination. Besides this UNICEF has given Mobile to Kotwars (Chokidars) under BCC Project earlier in

the villages. These are helpful in informing about expected delivery in remote areas and also

to triangulate information of any call received directly in call centre. These phones are under

BSNL corporate connection so the inter-calling is free.

29

MONTH WISE JSY FREE TRANSPORTATION COMPARISON GRAPH

Call Center, Guna(M.P)

0

62

128 125

234

292

386

771

546

645

602587

648

0

701

767

0

100

200

300

400

500

600

700

800

900

April

may

june

july

Aug

ust

septem

ber

Octob

er

Nov

embe

r

Dec

embe

r

Janu

ary

Febr

uary

Mar

ch

No. of C

ases T

ransport

ed

JSY 2007-08

JSY 2008-09

The details of the delivery are entered into the software available at the call centre. Call

Centre Software is developed to automate and monitor the working of Call Centre. The sole

objective is to accumulate the free transportation details and generate Monthly Free

transportation report for the sectors, block & District. The patients details are filled in a

register maintained at the call centre.

The initial set-up cost was supported by UNICEF which included equipments (2 computer & other furniture) and salary of 3 operators & Coordinator and Telephone & AC Bills. Later the

running cost was booked under NRHM. Only salary of the coordinator is supported by UNICEF. Call centre has made remarkable difference as currently approximately 700-800

deliveries out of approx 2000 deliveries in the district are being conducted through call centre.

Janani Express Yojna

The purpose of Janani Express Yojna is to ensure 24 hours transport availability at field level

in order to bring the pregnant women to CEmONC & BEmONC facility. The objective was

that the number of women missing on the benefits of Institutional delivery in absence of

transport facilities should be brought down to minimum. Transport is hired locally on

contractual basis for a period of one year on the basis of outsource criteria and made available

in the concerned area of Govt. Hospital, CHC, and PHC. 28 such vehicles are in place. All

the drivers have mobile and the process is coordinated through the call centre. All the

subcentres in the catchment area of the vehicle also have the driver’s number. Rogi Kalyan

Samitis play the key role in the all issues related with maintenance & operations of

contractual vehicle. The amount is recovered from the money designated for transport under

Janani Suraksha Yojna. Monthly supervision is done by the ANM in their respective area to

make it sure that the vehicle is made available on call. The patient’s details and the delivery details have to be informed at the call centre, which is entered in software at the call centre.

Linking of these vehicles with the call centre has ensured effective and timely outreach to pregnant women and effective monitoring of the deliveries in the area.

30

Deendayal Antyodaya Upchar Yojna

The Government of Madhya Pradesh has designed and implemented an innovative scheme for socially and economically disadvantaged people of the society for providing access to

quality health care to the needy people like SC, ST and BPL families. The Scheme, known as Deendayal Antyodaya Upchar Yojana was instituted on 25th September 2004. It was further

modified in the month July, 2006 to extend the coverage to all below poverty line (BPL)

people in the state.

The scheme aims to provide access to SC, ST and BPL population to health care services.

Under the scheme free of charge health services upto the maximum limit of Rs. 20000/- in a

financial year in government health institutions is provided to all BPL families of the state.

One family health card is issued to each BPL family. This unique card consists of a

photograph of the head of household with details of all other family members. Hospitalization

and medical checkup details are registered in the card.

CONCLUSION

NRHM has identified communitization, flexible financing, innovations in human resource

management, monitoring against IPH Standards, and building capacities at all levels as the

principal approaches to ensure quality service delivery, efficient utilization of scarce

resources, and most of all, to ensure service guarantees at the doorsteps.

While there have been many positive outcomes like improved institutional delivery,

infrastructure & Neo-natal care under NRHM in Guna, but there has been vital support from

UNICEF at the same time. There are still many start-up activities that need to be initiated.

There is a lack of information and a need for widespread dissemination of information on all aspects of the NRHM, especially ASHA. Community-level stakeholders like the Gram

Pradhan, ASHA and Village Health Committees need to be involved in planning,

implementation and monitoring of the NRHM through systematic inputs and capacity

building.

The institutional platform of Village Health and Sanitation Committees, the Rogi Kalyan

Samitis and the Panchayati Raj Institution committees at various levels is providing a rare

opportunity for convergent action on all determinants of health. Also, the other components

like AYUSH and Communicable/non-communicable diseases need to be strengthened.

The experience of the last three years gives the confidence that the program has the right motive but we need to deepen institutional reforms and effective decentralization. Ultimately,

the success of NRHM will depend on the ability of the Mission interventions to galvanize State Governments into action, pursuing innovations and flexibility in all spheres and

ensuring availability of fully trained and equipped resident health functionaries at all levels and large scale demand side financing.