RCH II STATE HEALTH SECRETARIES MEETING 15 th

RCH II STATE HEALTH SECRETARIES MEETING 15 th January, 2010 Amit Mohan Prasad Jt. Secy

ISSUES & SUGGESTED INTERVENTIONS INFRASTRUCTURE AVAILABILITY n Huge offtake of JSY, but facility strengthening slow n n n Full complement of services not available in FRUs / 24 x 7 PHCs, e. g. Trained staff, equipment, adequate beds, quality of care, availability of blood No prioritisation of high load facilities for strengthening Existing staff not placed rationally, and selection of staff for skill-based training and their subsequent posting not adequate Prioritise high load facilities for strengthening, ensuring rational posting of staff, equipment, bed strength etc. TRAINING (LSAS, Em. OC, SBA, IMNCI, NSSK, Sterilisation, MTP, IUD) n Overall progress on various skill-based training needs to pick up n n Calculation of total training load; assessment of training capacity; steps to augment existing capacity through, e. g. PPP; linking training to facility operationalisation, ensuring adequate equipment and drugs/ supplies to trained personnel Monitoring utilisation of trained personnel

ISSUES & SUGGESTED INTERVENTIONS (contd. ) MICROBIRTH PLANNING n n Rolling out of name based tracking system Ensuring full antenatal care Identification of appropriate facility for delivery Ensuring referral arrangements, including transport back to the woman’s home after delivery QUALITY OF ANC, INC, PNC n n VHNDs still heavily focussed on immunisation, with inadequate provision of the full complement of services envisaged; microplanning and monitoring of sessions is essential Monitoring of quality of training, including post training adherence to protocols, e. g. Labour room protocols (maintenance of partographs, etc. ) Ensuring trained providers at all deliveries (SBA, Em. OC, NSSK, etc. ) and available equipment, drugs, etc. Post delivery stay to ensure essential newborn care , and care of post partum complications

ISSUES & SUGGESTED INTERVENTIONS (contd. ) NEONATAL MORTALITY n n NMR continues to remain high, and has declined only by 1 point, from 37 (SRS 2004) to 36 (SRS 2007), contributing to nearly 2/3 rd (65. 5%) of IMR. Early NMR has in fact increased from 26 (SRS 2004) to 29 (SRS 2007), and accounts for 81% of NMR n n Strengthen facilities through provision of newborn baby corners in all labour rooms; adequate beds and hygienic environment and food to ensure 2 -day stay. Ensure post natal care visits in homes through trained providers MALNUTRITION n Greater linkages with the ICDS system at the ground level for early identification / referral of children to the NRCs and follow-up of the children in the community after treatment/ discharge from the facility

ISSUES & SUGGESTED INTERVENTIONS (contd. ) PROGRAM MANAGEMENT & MONITORING n n n Institutionalise facility and community based maternal death review Ensure timely payment to JSY beneficiaries Involvement of community in monitoring of payments, e. g. VHSCs, RKS, public disclosure of JSY beneficiaries at facilities Ensure responsibilities of different levels of personnel for monitoring, eg. Prescribed percentage of physical and financial monitoring by CMO, PHC MO i/c , etc. Strengthening supervision through, e. g. Trained public health nurses Strengthening HMIS systems for better reporting

OTHER COMMON ISSUES ACROSS STATES n n n Low institutional delivery rates in states like Chhattisgarh, Jharkhand, UP High neo natal mortality in all the states; 2/3 rd of the IMR Anaemia during pregnancy and in early childhood is a problem across all states Physical reporting on the HMIS needs attention Delays in financial reporting from “spending centres”, e. g. Training, Urban Local Bodies, NGOs, infrastructure agencies, etc.

STATE-SPECIFIC ISSUES

BIHAR (Rs. Crores) Budget Head Maternal Health JSY Child Health Family Planning (including compensation) Training Others Total RCH II Expenditure (Apr-Sep 09) Amount % 0. 85 50. 3 88. 48 38. 5 0. 58 3. 6 Approved Budget 2009 -10 1. 69 229. 96 16. 11 58. 15 7. 99 13. 7 21. 25 89. 69 416. 85 1. 19 26. 95 126. 03 5. 6 30. 1 30. 2 Opening balance 2009 -10 (Rs. crores) : 34. 33 Release till December 2009 (Rs. crores) : 226. 60 Total available (Rs. crores) : 260. 93 Expenditure / Available % : 48. 3

BIHAR (CONTD. . ) MATERNAL HEALTH §DLHS-3: § 1 st trimester ANC – 24%; At least 3 ANC – 26%; TT injection – 58%; BP taken – 17%; Full ANC – 5% § Institutional delivery 28% and Safe delivery 32% § Post natal visit within 2 weeks – 26% §Anaemia during pregnancy – 60% (NFHS-3) Activity FRU 24 X 7 PHC LSAS TRG EMOC TRG SBA TRG Target till 2008 -09 Achievement 75 76 493 533 75 56 75 40 2432 639 % Target till 2011 -12 101 125 108 821 75 125 53 125 26 4053 § Only 3 FRUs reported to be fully functional in June 09. §Sub-optimal utilisation of trained personnel (LSAS, Em. OC and SBA)

BIHAR (CONTD. . ) CHILD HEALTH §NMR at 31 accounts for 53% of the IMR, while early NMR at 27 accounts for 47% of the IMR (SRS 2007). § JSY evaluation (December 2008) – only 16% beneficiaries surveyed stayed for at least two days in the health facility after delivery. §DLHS-3 results: Early initiation of breastfeeding - 16%; Exclusive breastfeeding 12%; ORS use in diarrhoea – 22% §NFHS-3: Childhood anaemia – 88%; and 58% children <3 underweight FAMILY PLANNING §DLHS-3 results: Total unmet need – 37%; use of modern contraceptives – 28% §IUD insertions consistently decreasing: 1. 00 lakh in 05 -06 to 0. 42 lakh in 08 -09 §Distt. Training centres / DHs lack facilities for skill based training (JRM-6) §Lack of overall strategy to increase coverage of spacing methods (CRM-3)

CHHATTISGARH (Rs. Crores) Budget Head Maternal Health JSY Child Health Family Planning (including compensation) Training Others Total RCH II Expenditure (Apr-Sep 09) Amount % 0. 03 2. 2 10. 37 18. 1 0. 15 2. 4 Approved Budget 2009 -10 1. 54 57. 40 5. 95 21. 21 2. 57 12. 1 2. 88 18. 90 107. 89 0. 15 3. 91 17. 18 5. 2 20. 7 15. 9 Opening balance 2009 -10 (Rs. crores) : 8. 86 Release till December 2009 (Rs. crores) : 57. 84 Total available (Rs. crores) : 66. 70 Expenditure / Available % : 25. 8

CHHATTISGARH (CONTD. . ) MATERNAL HEALTH n DLHS-3 results: 1 st trimester ANC – 39%; BP taken – 39%; 100 IFA consumption – 38%; Full ANC – 14%; Institutional delivery – 18%. n JSY platform not sufficiently promoted and utilised to generate pressure on the system to strengthen the facilities (JRM-6) n Anaemia in pregnancy – 63% (NFHS-3) Activity FRU 24 X 7 PHC LSAS TRG EMOC TRG SBA TRG • • Target till 2008 -09 91 424 91 91 2548 Achievement 55 418 44 0 1329 % Target till 2011 -12 60 152 99 707 48 152 0 152 52 4246 Only 14 FRUs reported to be fully functional in June 09. Certification of the LSAS trained MOs, as per GOI protocol, to be prioritised. Establishing Blood storage units, and training of MOs and LTs not planned. Poor quality of care in delivery rooms; with lack of protocols and training of staff, poor infection prevention practices (JRM-6)

CHHATTISGARH (CONTD. . ) CHILD HEALTH § NMR at 41 accounts for 70% of the IMR, while early NMR at 36 accounts for 61% of the IMR (SRS 2007) § DLHS-3: ORS use in diarrhoea – 37% § NFHS-3: Childhood anaemia – 81%; and 52% children <3 underweight § Essential newborn care lacking, with lack of counselling leading to early discharge and poor newborn care practices (JRM-6) § Equipment for neonatal management such as resuscitators and warmers mostly out of order or not in use (CRM-3) FAMILY PLANNING § DLHS-3: Total unmet need – 21% § Fixed day services not available; FP outreach needs to be strengthened (JRM -6)

JHARKHAND (Rs. Crores) Budget Head Maternal Health JSY Child Health Family Planning (including compensation) Training Others Total RCH II Expenditure (Apr-Sep 09) Amount % 0. 17 6. 6 16. 21 28. 1 0. 07 4. 6 Approved Budget 2009 -10 2. 57 57. 69 1. 52 19. 06 3. 73 19. 5 7. 05 32. 87 120. 77 1. 09 3. 06 24. 33 15. 4 9. 3 20. 1 Opening balance 2009 -10 (Rs. crores) : -40. 25 Release till December 2009 (Rs. crores) : 89. 53 Total available (Rs. crores) : 49. 28 Expenditure / Available % : 49. 4

JHARKHAND (CONTD. . ) MATERNAL HEALTH §DLHS-3: at least 3 ANC – 32%; BP taken – 22%; Full ANC – 9%; Institutional delivery – 18% (down from 21% in DLHS-2). §Anaemia in pregnancy – 68% (NFHS-3) Activity Target till 200809 Achievement % Target till 2011 -12 FRU 131 19 15 218 24 X 7 PHC 150 194 129 250 LSAS TRG 131 11 8 218 EMOC TRG 131 29 22 218 SBA TRG 416 242 58 693 §Rational use of existing personnel , especially specialists, a key issue. §Posting of LSAS and Em. OC trained MOs needs to be done in FRUs. §Pace of setting up blood storage units (BSUs) needs to pick up - only procurement of equipments done for a few BSUs

JHARKHAND (CONTD. . ) CHILD HEALTH §NMR at 28 accounts for 58% of the IMR, while early NMR accounts for 57% of the NMR (SRS 2007). at 16 § Post-delivery stay of at least two days not being ensured, and the concept of neonatal care as a planned intervention was missing (JRM-6). §DLHS-3: ORS use in diarrhoea – 21%; care seeking in diarrhoea – 52%; care seeking in ARI – 56% §NFHS-3: Childhood anaemia – 78% §IMNCI - only 5634 persons trained FAMILY PLANNING §No improvement between DLHS 2 -3: Total unmet need – 35%; use of modern contraceptives – 31% §Significant decrease FP performance between 07 -08 and 08 -09: § Total number of sterilisation cases from 1. 06 to 0. 68 lakhs (36% decrease) § IUD insertions from 0. 85 to 0. 72 lakhs (16% decrease)

MADHYA PRADESH (Rs. Crores) Budget Head Maternal Health JSY Child Health Family Planning (including compensation) Training Others Total RCH II Expenditure (Apr-Sep 09) Amount % 0. 33 4. 8 77. 64 31. 3 5. 16 42. 3 Approved Budget 2009 -10 6. 78 248. 32 12. 19 59. 00 4. 29 7. 3 11. 16 49. 20 386. 66 2. 05 14. 70 104. 17 18. 4 29. 9 26. 9 Opening balance 2009 -10 (Rs. crores) : -80. 1 Release till December 2009 (Rs. crores) : 145. 55 Total available (Rs. crores) : 65. 45 Expenditure / Available % : 159. 2

MADHYA PRADESH (CONTD. . ) MATERNAL HEALTH §DLHS-3: 1 st trimester ANC – 34%; at least 3 ANC – 34%; BP taken – 30%; Full ANC – 9%; Safe delivery – 50%. §Anaemia in pregnancy – 58% (NFHS-3) Activity FRU 24 X 7 PHC LSAS TRG EMOC TRG SBA TRG Target till 2008 -09 Achievement 180 87 358 182 180 7 180 48 6400 2145 % Target till 2011 -12 48 300 51 596 4 300 27 300 34 10667 § SBA Training: Quality needs attention (CRM-3), including monitoring and supervision and practice of standard protocols. § LSAS Trg has not been initiated in the state, in spite of approval of 4 MCs long back and TOTs conducted twice. § No of private accredited institutions under Janani Sahayogi Yojana in 2009 -10 and 2010 -11 PIP – Figures have decreased from 206 to 15 needs clarification.

MADHYA PRADESH (CONTD. . ) CHILD HEALTH §Highest IMR in the country (70, as per SRS 2008) §NMR at 49 accounts for 68% of the IMR, while early NMR at 39 accounts for 54% of the IMR (SRS 2007). § JSY evaluation (December 2008) – only 68% of the beneficiaries surveyed stayed for at least two days in the health facility after delivery. §DLHS-3: Exclusive breastfeeding – 31%; ORS use in diarrhoea – 30% §NFHS-3: Childhood anaemia – 83%; 60% children <3 underweight §State may look at quality milk being supplied in their NRCs instead of focusing on commercial RUTF FAMILY PLANNING §CRM-3: IUD insertion training, especially post partum, and counselling skills needs strengthening

ORISSA (Rs. Crores) Budget Head Maternal Health JSY Child Health Family Planning (including compensation) Training Others Total RCH II Expenditure (Apr-Sep 09) Amount % 2. 85 18. 6 47. 74 45. 7 1. 42 17. 1 Approved Budget 2009 -10 15. 32 104. 44 8. 29 18. 28 2. 17 11. 9 11. 09 46. 32 203. 75 2. 71 10. 46 67. 35 24. 5 22. 6 33. 1 Opening balance 2009 -10 (Rs. crores) : 45. 34 Release till December 2009 (Rs. crores) : 53. 66 Total available (Rs. crores) : 99. 00 Expenditure / Available % : 68. 0

ORISSA (CONTD. . ) MATERNAL HEALTH §DLHS-3: 1 st trimester ANC – 48%; at least 3 ANC – 55%; BP taken – 42%; Full ANC – 23%; Safe delivery – 51%. §Anaemia in pregnancy – 68% (NFHS-3) Activity FRU 24 X 7 PHC LSAS TRG EMOC TRG SBA TRG Target till 2008 -09 158 769 158 5366 Achievement 48 64 22 23 1143 % Target till 2011 -12 30 8 14 15 21 § Sub-optimal utilization of training centers §Inadequate knowledge/ availability of GOI technical guidelines. 263 1282 263 8943

ORISSA (CONTD. . ) CHILD HEALTH §IMR (SRS 2008) at 69 is the 2 nd highest in the country; however, a rapid decline in IMR in recent years §NMR at 49 accounts for 69% of the IMR, while early NMR at 37 accounts for 52% of the IMR. § JSY evaluation (December 2008) - only 27% of the beneficiaries surveyed, stayed for at least two days in the health facility after delivery (similar observation by the CRM-3 team in November 2009), clearly a missed opportunity to address early NMR §NFHS-3: Childhood anaemia – 74% FAMILY PLANNING §DLHS 2 to 3: Unmet need increased from 20% to 24%; and use of modern contraceptives decreased from 40% to 38% §Significant decrease FP performance between 07 -08 and 08 -09: § Total number of sterilisation cases from 1. 21 to 0. 91 lakhs (25% decrease) § IUD insertions from 1. 61 to 1. 40 lakhs (15% decrease) §CRM-3: Condom and OCP supply issues; low IUD awareness and retention.

RAJASTHAN (Rs. Crores) Budget Head Maternal Health JSY Child Health Family Planning (including compensation) Training Others Total RCH II Expenditure (Apr-Sep 09) Amount % 0. 78 28. 3 77. 50 55. 4 0. 51 24. 8 Approved Budget 2009 -10 2. 75 140. 01 2. 05 40. 90 14. 04 34. 3 10. 40 92. 22 288. 33 3. 11 20. 87 116. 81 29. 9 22. 6 40. 5 Opening balance 2009 -10 (Rs. crores) : 24. 17 Release till December 2009 (Rs. crores) : 181. 50 Total available (Rs. crores) : 205. 67 Expenditure / Available % : 56. 8

RAJASTHAN (CONTD. . ) MATERNAL HEALTH §DLHS-3: 1 st trimester ANC – 33%; at least 3 ANC – 28%; BP taken – 30%; Full ANC – 7%; Safe delivery – 53%. §Anaemia in pregnancy – 61% (NFHS-3) Activity FRU 24 X 7 PHC LSAS TRG EMOC TRG SBA TRG Target till 2008 -09 Achievement 229 100 514 500 229 89 229 39 2735 1236 % 44 97 39 17 45 Target till 2011 -12 382 857 382 4558 § 55 FRUs reported to be fully functional in June 09. §Quality of LSAS and Em. OC training, and post training utilisation of skills, need monitoring. §Establishing blood storage centers needs priority attention at the FRUs. §State needs to prioritize the areas such as difficult, most difficult and inaccessible and make facility-wise strategies for such areas keeping the case load in mind.

RAJASTHAN (CONTD. . ) CHILD HEALTH §NMR at 44 accounts for 68% of the IMR, while early NMR at 34 accounts for 52% of the IMR (SRS 2007). § JSY evaluation (December 2008) – only 43% of the beneficiaries surveyed stayed for at least two days in the health facility after delivery. §DLHS-3: Exclusive breastfeeding – 25%; ORS use in diarrhoea – 31% §NFHS-3: Childhood anaemia – 80% FAMILY PLANNING §CRM-3: § Family planning services are not fixed day but camp based. Very few providers available in the system. § The training, esp. Minilap, needs to be up scaled. § Post-delivery FP needs to be strengthened esp. IUD services

UTTAR PRADESH (Rs. Crores) Budget Head Maternal Health JSY Child Health Family Planning (including compensation) Training Others Total RCH II Expenditure (Apr-Sep 09) Amount % 0. 87 12. 0 165. 49 53. 3 1. 51 17. 9 Approved Budget 2009 -10 7. 22 310. 28 8. 44 84. 81 8. 73 10. 3 40. 80 218. 38 669. 93 3. 88 36. 60 217. 07 9. 5 16. 8 32. 4 Opening balance 2009 -10 (Rs. crores) : 78. 29 Release till December 2009 (Rs. crores) : 533. 68 Total available (Rs. crores) : 611. 97 Expenditure / Available % : 35. 5

UTTAR PRADESH (CONTD. . ) MATERNAL HEALTH §DLHS-3: 1 st trimester ANC – 25%; at least 3 ANC – 22%; BP taken – 11%; Full ANC – 3%; Institutional delivery – 25%. Activity FRU 24 X 7 PHC LSAS TRG EMOC TRG SBA TRG Target till 2008 -09 309 1098 309 8965 Achievement 121 648 31 31 40 % Target till 2011 -12 39 515 59 1830 10 515 0 14942 § Establishment of BSUs in designated FRUs needs attention. NIL FRUs reported functional in June 09, due to non-availability of blood (BSU, assured linkages to blood bank, etc. ) § Slow Progress of skill based trainings (LSAS/ Em. OC/ SBA) § No clear plan for operationalization of services/ training on safe abortion / RTI/STI § No progress on implementation of new training initiatives e. g. BEm. OC for PHC MOs

UTTAR PRADESH (CONTD. . ) CHILD HEALTH §NMR at 48 accounts for 70% of the IMR, while early NMR at 36 accounts for 52% of the IMR (SRS 2007) §JSY evaluation (December 2008) – only 27% of the beneficiaries surveyed stayed for at least two days in the health facility after delivery. §CRM-3: § 48 hour stay after delivery was seen only in the DH. § At the HSC and PHC level, adequate facilities for patients staying - not available, women leave with their families after a few hours of delivery; § No emergency transport system, with ambulances seen to be used for transport of drugs & supplies §DLHS-3: Early initiation of breastfeeding – 15%; exclusive breastfeeding – 8%; ORS use in diarrhoea – 17%; at least one dose of Vit A supplementation in children 9 months or above – 32% §NFHS-3: Childhood anaemia – 85%

UTTAR PRADESH (CONTD. . ) FAMILY PLANNING §DLHS-3: Total unmet need – 34%; use of modern contraceptives – 27% §Significant decrease FP performance between 07 -08 and 08 -09: § Total number of sterilisation cases from 4. 72 to 3. 94 lakhs (17% decrease) § IUD insertions from 19. 43 to 13. 42 lakhs (31% decrease) §JRM-6: § No focus on IUD insertion; service not even available at the Medical College § Post partum counselling and contraception not provided in most of the facilities

UTTARAKHAND (Rs. Crores) Budget Head Maternal Health JSY Child Health Family Planning (including compensation) Training Others Total RCH II Expenditure (Apr-Sep 09) Amount % 0. 18 41. 7 5. 70 42. 2 0. 25 12. 0 Approved Budget 2009 -10 0. 43 13. 50 2. 06 3. 65 0. 56 15. 3 2. 00 20. 10 41. 74 0. 28 1. 78 8. 74 14. 2 8. 9 20. 9 Opening balance 2009 -10 (Rs. crores) : -6. 89 Release till December 2009 (Rs. crores) : 31. 45 Total available (Rs. crores) : 24. 56 Expenditure / Available % : 35. 6

UTTARAKHAND (CONTD. . ) MATERNAL HEALTH §DLHS-3 results: 1 st trimester ANC and at least 3 ANC – 34%; BP taken – 25%; 100 IFA consumption – 34%; Full ANC – 16%; Institutional delivery – 30%. Activity FRU 24 X 7 PHC LSAS TRG EMOC TRG SBA TRG Target till 2008 -09 Achievement 48 72 48 48 302 72 92 7 8 184 % Target till 2011 -12 150 128 15 17 61 80 120 80 80 504 § 37 FRUs reported to be fully functional in June 09. §CRM-3 visit: Many of the DHs even do not fulfill FRU criteria. §Sub-optimal deployment of specialists / trained personnel at DH / CHCs. § 20 doctors have been trained in LSAS; however as per Go. I records only 7 doctors are trained. Are 20 doctors trained as per GOI norms? If yes are they posted at designated FRUs?

UTTARAKHAND (CONTD. . ) Child Health §DLHS-3: Exclusive breastfeeding – 37%; ORS use in diarrhoea – 44% §NFHS-3: Childhood anaemia – 62% §CRM-3: Inadequate attention to neonatal care FAMILY PLANNING §DLHS-3: Total unmet need – 21% §Sharp decrease in IUD insertions – 1. 41 lakh in 06 -07 to 0. 81 lakh in 08 -09.

HIMACHAL PRADESH (Rs. Crores) Budget Head Maternal Health JSY Child Health Family Planning (including compensation) Training Others Total RCH II Expenditure (Apr-Sep 09) Amount % 0. 13 35. 4 0. 45 44. 3 0. 91 34. 9 Approved Budget 2009 -10 0. 38 1. 01 2. 61 4. 02 0. 29 7. 2 0. 67 5. 53 14. 22 0. 12 1. 64 3. 53 17. 1 29. 6 24. 8 Opening balance 2009 -10 (Rs. crores) : 15. 17 Release till December 2009 (Rs. crores) : 11. 97 Total available (Rs. crores) : 27. 14 Expenditure / Available % : 13. 0

HIMACHAL PRADESH (CONTD. . ) MATERNAL HEALTH §DLHS-3: Institutional deliveries – 48% Activity FRU 24 X 7 PHC LSAS TRG EMOC TRG SBA TRG Target till 2008 -09 51 132 51 51 596 Achievement 51 95 19 0 73 % Target till 2011 -12 100 85 72 220 37 85 0 85 12 994 § LSAS training for MBBS doctors has been initiated since the last 2 years but the state has not yet been able to provide details of their posting & service utilization. § No clear Training plan for interventions on Safe Abortion and RTI/STI. CHILD HEALTH § DLHS-3: Exclusive breastfeeding – 40% § NFHS-3: Childhood anaemia – 59% FAMILY PLANNING § DLHS-3: Total unmet need increased to 15% (from 12% in DLHS-2) § Regular decline in IUD users between 05 -06 and 08 -09 (0. 30 lakh to 0. 28 lakhs)

JAMMU & KASHMIR (Rs. Crores) Budget Head Maternal Health JSY Child Health Family Planning (including compensation) Training Others Total RCH II Expenditure (Apr-Sep 09) Amount % 0. 27 26. 4 7. 12 25. 6 0. 02 2. 7 Approved Budget 2009 -10 1. 02 27. 81 0. 66 2. 70 0. 22 8. 0 2. 74 7. 26 42. 19 0. 14 1. 04 8. 80 5. 0 14. 3 20. 9 Opening balance 2009 -10 (Rs. crores) : 24. 31 Release till December 2009 (Rs. crores) : 30. 44 Total available (Rs. crores) : 54. 75 Expenditure / Available % : 16. 1

JAMMU & KASHMIR (CONTD. . ) MATERNAL HEALTH Activity FRU 24 X 7 PHC LSAS TRG EMOC TRG SBA TRG Target till 2008 -09 Achievement 59 58 112 105 59 9 59 0 471 48 % Target till 2011 -12 98 99 94 187 15 99 0 99 10 785 §Slow progress of LSAS; sub-optimal utilisation of training institute capacity. § State has not shared training plan for Em. OC Training, even though master trainers have been trained. §No details shared on quality certification/accreditation of health facilities as reflected in 2009 -10 PIP. §Maternal deaths reported from facilities are negligible as complicated cases are being referred, often verbally and no documentation of the same exists in registers.

JAMMU & KASHMIR (CONTD. . ) CHILD HEALTH §J&K’s IMR (SRS 2008) at 49 is lower than the national average of 53, yet the IMR has increased by 4 points over the past five years §NMR at 39 accounts for 77% of the IMR, while Early NMR at 31 accounts for 61% of the IMR. Further, Early NMR has steadily increased from 23 (SRS 2004). § CRM-3: Most delivery cases do not stay in the facility beyond a few hours post delivery FAMILY PLANNING §DLHS-3: Total unmet need – 22% §Decline in number of sterilisations and IUD insertions, in the past 3 years. §CRM-3: Any systematic efforts to improve performance of terminal methods (especially post partum sterilization) and spacing methods were nonexistent; Counselling for family planning by ANMs & clinical providers, appears to be lacking.

ANDHRA PRADESH (Rs. Crores) Budget Head Maternal Health JSY Child Health Family Planning (including compensation) Training Others Total RCH II Expenditure (Apr-Sep 09) Amount % 5. 99 29. 9 13. 55 29. 8 0. 51 25. 6 Approved Budget 2009 -10 20. 00 45. 50 2. 00 62. 82 14. 46 23. 0 5. 45 20. 78 156. 55 0. 07 3. 89 38. 47 1. 3 18. 7 24. 6 Opening balance 2009 -10 (Rs. crores) : 71. 14 Release till December 2009 (Rs. crores) : 125. 13 Total available (Rs. crores) : 196. 27 Expenditure / Available % : 19. 6

ANDHRA PRADESH (CONTD. . ) MATERNAL HEALTH Activity Target till 2008 -09 Achievement % Target till 2011 -12 FRU 180 194 108 300 24 X 7 PHC 600 800 133 1000 LSAS TRG 180 0 0 300 EMOC TRG 180 0 0 300 4431 2950 67 7385 SBA TRG § Only 87 FRUs reported to be fully functional in June 09. §Training of MOs in LSAS Training not initiated despite TOT of Master trainers 2 years back. §Inadequate knowledge/ availability of GOI technical guidelines CHILD HEALTH §NFHS-3: Childhood anaemia – 79%

GUJARAT (Rs. Crores) Budget Head Maternal Health JSY Child Health Family Planning (including compensation) Training Others Total RCH II Expenditure (Apr-Sep 09) Amount % 1. 04 26. 4 10. 44 64. 9 0. 22 2. 0 Approved Budget 2009 -10 3. 94 16. 10 11. 16 23. 32 6. 47 27. 8 13. 09 66. 19 133. 80 2. 41 13. 65 34. 24 18. 4 20. 6 25. 6 Opening balance 2009 -10 (Rs. crores) : 6. 81 Release till December 2009 (Rs. crores) : 112. 23 Total available (Rs. crores) : 119. 04 Expenditure / Available % : 28. 8

GUJARAT (CONTD. . ) MATERNAL HEALTH § Effect of Chiranjeevi Yojana is not visible on indicators (institutional delivery has increased marginally from 52. 2% to 54. 9% between DLH-2 and DLHS-3). § In spite of comprehensive Mamta Diwas in place, full ANC has declined between DLHS-2 (25%) and DLHS-3. (19%) Activity FRU 24 X 7 PHC LSAS TRG EMOC TRG SBA TRG Target till 2008 -09 Achievement 178 148 322 331 178 80 178 50 6016 5775 % Target till 2011 -12 83 296 103 536 45 296 28 296 96 10027 § Quality of care is an issue in Chiranjeevi scheme. Further, no attempts seen to make beneficiaries aware of their entitlements in the scheme (CRM-3) § SBA/ LSAS/ Em. OC Training needs proper monitoring and supervision especially quality parameters.

GUJARAT (CONTD. . ) CHILD HEALTH §State has one of the highest rates of IMNCI & facility based care implementation, in the country, yet reduction in IMR is slow; 1. 4 points per year between SRS 2003 and SRS 2008. §NMR at 37 accounts for 71% of the IMR, while early NMR at 29 accounts for 56% of the IMR (SRS 2007). FAMILY PLANNING §NSV progress remains very slow in 08 -09 (compared to 07 -08); 11530 cases of male sterilisation have been carried out in 08 -09; however, in 07 -08 this was around 21000.

HARYANA (Rs. Crores) Budget Head Maternal Health JSY Child Health Family Planning (including compensation) Training Others Total RCH II Expenditure (Apr-Sep 09) Amount % 0. 07 4. 8 1. 61 26. 8 0. 01 0. 8 Approved Budget 2009 -10 1. 49 6. 00 1. 77 13. 69 2. 57 18. 8 6. 06 35. 04 64. 06 0. 71 6. 10 11. 06 11. 6 17. 4 17. 3 Opening balance 2009 -10 (Rs. crores) : 36. 23 Release till December 2009 (Rs. crores) : 16. 32 Total available (Rs. crores) : 52. 55 Expenditure / Available % : 21. 1

HARYANA (CONTD. . ) MATERNAL HEALTH § Only state besides Punjab where MMR has increased – Steps to address this? § DLHS-3: Full ANC – 13%; Institutional delivery – 47% § Anaemia in pregnancy – 70% (NFHS-3) Activity FRU 24 X 7 PHC LSAS TRG EMOC TRG SBA TRG Target till 2008 -09 90 240 90 90 980 Achievement 104 318 32 45 806 % Target till 2011 -12 116 150 133 400 36 150 50 150 82 1634 § 17 FRUs reported to be fully functional in June 09. §State may share the details of Janani Suvidha Yojana for e. g. payment to the private provider/ Incentive to Sakhi etc, Delivery Hut Scheme/Jaccha Baccha Scheme? §No Training plan for intervention on Safe Abortion and RTI/STI. §BEm. OC Training for MOs not planned §Except in DH, no partographs or baby corner observed by the CRM team

HARYANA (CONTD. . ) CHILD HEALTH § 19 (out of 21) districts of the state implementing IMNCI, Breastfeeding is promoted by establishing counselling centres in each district hospital, 46 FRUs and 160 PHCs are providing newborn care services § Yet one point decline per year in IMR for past five years §NMR at 34 accounts for 62% of the IMR, while early NMR at 23 accounts for 42% of the NMR (SRS 2007). Wherever enquired by the CRM team, mother and baby were kept for 6 hrs only following delivery. §DLHS-3: Early initiation of breastfeeding – 17%; exclusive breastfeeding – 6%; ORS use in diarrhoea – 32% §NFHS-3: Childhood Anaemia – 83% FAMILY PLANNING § Increase in total unmet need between DLHS-2 (15%) and DLHS-3 (16%)

KARNATAKA (Rs. Crores) Budget Head Maternal Health JSY Child Health Family Planning (including compensation) Training Others Total RCH II Expenditure (Apr-Sep 09) Amount % 1. 20 1131. 4 11. 18 40. 8 0. 01 0. 1 Approved Budget 2009 -10 0. 11 27. 40 6. 96 45. 15 5. 11 11. 3 16. 64 89. 72 185. 97 4. 12 27. 06 48. 67 24. 8 30. 2 26. 2 Opening balance 2009 -10 (Rs. crores) : 26. 7 Release till December 2009 (Rs. crores) : 130. 37 Total available (Rs. crores) : 157. 07 Expenditure / Available % : 31. 0

KARNATAKA (CONTD. . ) MATERNAL HEALTH §Highest MMR among the southern states - 213 §Anaemia in pregnancy – 50% (NFHS-3) Activity FRU 24 X 7 PHC LSAS TRG EMOC TRG SBA TRG Target till 2008 -09 Achievement 210 157 1007 974 210 50 210 40 8005 2716 % Target till 2011 -12 75 350 97 1679 24 350 19 350 34 13342 § 71 FRUs reported to be fully functional in June 09. §SBA Training needs to be expedited. §Sub-optimal deployment and utilization of specialists (anesthesia & OBG) already available in the system.

KARNATAKA (CONTD. . ) CHILD HEALTH § 1 point reduction of IMR per year (52 in 2003 to 45 in 2008 as per SRS) a cause of concern §DLHS-3: Early initiation of breastfeeding – 47%; exclusive breastfeeding – 38%; ORS use in diarrhoea – 46% §NFHS-3: Childhood anaemia – 83% §Home Based Newborn Care, SEARCH model is being implemented in 6 districts, is the Gentamycin injection and asphyxia management part also being implemented, evaluation of the initiative needs to be done

KERALA (Rs. Crores) Budget Head Maternal Health JSY Child Health Family Planning (including compensation) Training Others Total RCH II Expenditure (Apr-Sep 09) Amount % 3. 63 44. 1 5. 36 36. 2 1. 25 25. 0 Approved Budget 2009 -10 8. 23 14. 79 5. 00 5. 20 1. 87 35. 9 12. 92 42. 61 88. 75 0. 85 18. 06 31. 01 6. 6 42. 4 34. 9 Opening balance 2009 -10 (Rs. crores) : 18. 28 Release till December 2009 (Rs. crores) : 62. 84 Total available (Rs. crores) : 81. 12 Expenditure / Available % : 38. 2

KERALA (CONTD. . ) MATERNAL HEALTH Activity FRU 24 X 7 PHC LSAS TRG EMOC TRG SBA TRG Target till 2008 -09 Achievement 73 65 298 178 73 0 2659 0 % Target till 2011 -12 90 121 60 497 0 121 0 4431 § State may clarify its position whether it needs LSAS/Em. OC Trained doctors or it has sufficient number of specialists available in public heath system. § Maternal death review conducted by the State for many years. No sharing of the report with GOI. CHILD HEALTH § Need to introduce initiatives to increase access to care for CH initiatives (ORS use rates declining) improve the nutritional status- continued breastfeeding rates, anaemia management § DLHS-3: exclusive breastfeeding only 22. 3% FAMILY PLANNING § Use of any modern method for family planning has decreased from 54. 7% to 53. 1% (DLHS 2 -3), while total unmet need has increased by 1. 7% points (15. 1% to 16. 8%).

MAHARASHTRA (Rs. Crores) Budget Head Maternal Health JSY Child Health Family Planning (including compensation) Training Others Total RCH II Expenditure (Apr-Sep 09) Amount % 0. 30 8. 7 10. 89 37. 7 0. 55 9. 2 Approved Budget 2009 -10 3. 39 28. 90 5. 99 59. 13 12. 16 20. 6 19. 64 107. 60 224. 64 3. 02 10. 39 37. 30 15. 4 9. 7 16. 6 Opening balance 2009 -10 (Rs. crores) : 112. 04 Release till December 2009 (Rs. crores) : 132. 82 Total available (Rs. crores) : 244. 86 Expenditure / Available % : 15. 2

MAHARASHTRA (CONTD. . ) MATERNAL HEALTH Activity FRU 24 X 7 PHC LSAS TRG EMOC TRG SBA TRG Target till 2008 -09 300 540 300 7454 Achievement 466 663 98 22 2199 % Target till 2011 -12 155 500 123 900 33 500 7 500 29 12424 § 144 FRUs reported to be fully functional in June 09. §SBA Training: Quality needs attention including monitoring and supervision and practice of standard protocols. §Though there is a plan for procuring equipments for BSUs, however there is no holistic plan shared for BSU training.

MAHARASHTRA (CONTD. . ) CHILD HEALTH §NMR at 25 accounts for 74% of the IMR, while Early NMR at 21 accounts for 62% of the IMR. §DLHS-3: ORS use in diarrhoea – 44% §NFHS-3: Childhood anaemia – 72% § Strategy for control of anaemia is missing FAMILY PLANNING § Total unmet need has increased from DLHS-2 (12. 6%) to DLHS-3 (14. 2%) § Decline in number of reported sterilisations between 05 -06 and 08 -09

PUNJAB (Rs. Crores) Budget Head Maternal Health JSY Child Health Family Planning (including compensation) Training Others Total RCH II Expenditure (Apr-Sep 09) Amount % 3. 36 279. 9 3. 44 70. 1 0. 00 0. 0 Approved Budget 2009 -10 1. 20 4. 90 0. 25 11. 17 5. 93 53. 1 6. 54 40. 06 64. 12 0. 73 13. 67 27. 12 11. 1 34. 1 42. 3 Opening balance 2009 -10 (Rs. crores) : 34. 71 Release till December 2009 (Rs. crores) : 37. 05 Total available (Rs. crores) : 71. 76 Expenditure / Available % : 37. 8

PUNJAB (CONTD. . ) MATERNAL HEALTH §MMR has increased – steps to address this? Activity FRU 24 X 7 PHC LSAS TRG EMOC TRG SBA TRG Target till 2008 -09 Achievement 108 123 145 182 108 10 108 0 1185 239 % Target till 2011 -12 114 180 125 242 9 180 0 180 20 1975 §JSY is not being aggressively promoted in the state; more than half the JSY beneficiaries each year are still home deliveries §Inadequate progress in implementing Anaesthesia and SBA Training. §Sub-optimal utilization of training centers. §Em. OC and BEm. OC Training not initiated. §No training plan for intervention s on Safe Abortion and RTI/STI.

PUNJAB (CONTD. . ) CHILD HEALTH §Pace of training for IMNCI slow §Absence of focus on all aspects of facility based care for newborns and children (infrastructure strengthening- setting up SNCUs, stabilization units, as well as on trainings like NSSK §Neonatal mortality rate at 29 (SRS 2007) accounts for 67% of the IMR, while early NMR accounts for 47% of the IMR. §DLHS-3: Exclusive breastfeeding – 9% §NFHS-3: Childhood anaemia – 80% FAMILY PLANNING §Total unmet need increased between DLHS-2 (10. 3%) & DLHS-3 (11. 9%). §Decline in the number of sterilisations (1. 08 lakhs in 05 -06 to 0. 89 lakhs in 08 -09) and IUD insertions (3. 41 lakhs in 05 -06 to 2. 65 lakhs in 08 -09)

TAMIL NADU (Rs. Crores) Budget Head Maternal Health JSY Child Health Family Planning (including compensation) Training Others Total RCH II Expenditure (Apr-Sep 09) Amount % 1. 01 37. 9 14. 87 46. 9 0. 12 Approved Budget 2009 -10 2. 66 31. 68 0. 00 31. 21 8. 65 27. 7 19. 18 92. 61 177. 35 1. 25 28. 93 54. 83 6. 5 31. 2 30. 9 Opening balance 2009 -10 (Rs. crores) : 143. 4 Release till December 2009 (Rs. crores) : 153. 55 Total available (Rs. crores) : 296. 95 Expenditure / Available % : 18. 5

TAMIL NADU (CONTD. . ) MATERNAL HEALTH Activity Target till 2008 -09 Achievement % Target till 2011 -12 FRU 210 290 138 350 24 X 7 PHC 900 1215 135 1500 LSAS TRG 210 108 51 350 EMOC TRG 210 8 4 350 4500 3773 84 7500 SBA TRG §Challenges in ensuring availability of specialists and blood storage facilities in FRUs. §Slow progress in Em. OC Training and SBA Training. Need to up-scale the training. Training Plan for BEMOC not shared by the State. FAMILY PLANNING §Reduction in total number of sterilisation and IUD cases by 2. 9% (from 353436 to 343201) and 12. 6% (from 354311 to 310205) respectively, between 07 -08 and 08 -09

WEST BENGAL (Rs. Crores) Budget Head Maternal Health JSY Child Health Family Planning (including compensation) Training Others Total RCH II Expenditure (Apr-Sep 09) Amount % 5. 84 27. 3 18. 95 43. 7 1. 16 7. 2 Approved Budget 2009 -10 21. 42 43. 39 16. 08 41. 13 8. 56 20. 8 9. 06 51. 05 182. 14 0. 92 9. 08 44. 51 10. 2 17. 8 24. 4 Opening balance 2009 -10 (Rs. crores) : 156. 83 Release till December 2009 (Rs. crores) : 93. 13 Total available (Rs. crores) : 249. 96 Expenditure / Available % : 17. 8

WEST BENGAL (CONTD. . ) MATERNAL HEALTH Activity FRU 24 X 7 PHC LSAS TRG EMOC TRG SBA TRG Target till 2008 -09 219 277 219 2100 Achievement 61 168 38 30 1959 % Target till 2011 -12 28 61 17 14 93 365 461 365 3500 §Posting of trained MOs in LSAS and Em. OC needs priority attention as well as rational posting of Anesthesia specialists already available in the system. §Need to upscale operationalization of services and training for interventions of safe abortions and RTI/STI.

WEST BENGAL (CONTD. . ) Child Health §Follow-up monitoring of newborns and their mothers by village health workers needs attention §IMNCI is ongoing in 6 (out of 19) districts of the state, however status of IMNCI training is not known. §Neonatal mortality rate at 28 (SRS 2007) accounts for 75. 7% of the IMR, while early NMR at 23 (SRS 2007) accounts for 82. 1% of the NMR. §During the site visits by CRM team, local workers reported that purported 48 hour post partum stay policy does not appear to be enforced. Follow-up monitoring of newborns and their mothers by village health workers is very weak.

GOA (Rs. Crores) Budget Head Maternal Health JSY Child Health Family Planning (including compensation) Training Others Total RCH II Expenditure (Apr-Sep 09) Amount % 0. 02 11. 3 0. 02 24. 9 0. 00 0. 4 Approved Budget 2009 -10 0. 17 0. 08 0. 05 0. 14 0. 03 22. 4 0. 21 2. 40 3. 03 0. 02 0. 20 0. 29 10. 5 8. 4 9. 7 Opening balance 2009 -10 (Rs. crores) : 2. 10 Release till December 2009 (Rs. crores) : 1. 84 Total available (Rs. crores) : 3. 94 Expenditure / Available % : 7. 4

GOA (CONTD. . ) MATERNAL HEALTH Activity Target till 2008 -09 Achievement FRU % Target till 2011 -12 4 2 50 7 24 X 7 PHC 10 13 130 16 LSAS TRG 4 0 0 7 EMOC TRG 4 0 0 7 60 46 77 100 SBA TRG § State can train some of the MBBS doctors on Em. OC and LSAS to operationalise all the FRUs. CHILD HEALTH § DLHS-3: Exclusive breastfeeding – 30% § NFHS-3: Childhood anaemia – 50% § State should track and supplement IFA to such children through home visits by ASHAs/ ANMs and through VHNDs FAMILY PLANNING § DLHS-3: Total unmet need – 29%; use of modern contraceptives – 36%