Activities

Interventions listed
Institutional strengthening

The institutional strengthening component is sub-divided in following parts.

Physical infrastructure strengthening
Human Resource (HR) & Capacity Building
Developing management systems

Physical infrastructure strengthening

	Repairs/ Renovations to existing health institutions
	Construction of delivery room at sub center level
	Construction of warehouses for logistics management at Regional Level.
	Provision of Blood Storage facilities at First Referral Units (FRU)
	Developing a center of excellence
	Establishment of new born care corner at Community Health Center (CHC) / Primary Health Center (PHC)
	Establishment of neo natal intensive care unit
	Improvement of Pediatric ward at District Hospitals
	Strengthening of State Reproductive and Child Health (RCH) Society
	Strengthening of District Reproductive and Child Health (RCH) society

HR and Capacity Building

Staff benefits / incentives for working in remote / tribal areas

State has identified difficult and tribal areas for providing suitable benefits/ incentives to the staff working in these areas. State already has given consideration for Medical Officers and staff working in tribal and difficult areas. Medical Officers are given preference for In-service Post Graduation, enhanced Non Practicing Allowance (NPA) and choice of posting.

Rewarding the work of health teams and institutions

Ensuring availability of human resources at institutional level

Utilization of existing staff
Redeployment of DP project staff
Block Health Officer Scheme

Addition of new staff

Appointment of Auxillary Nurse Midwifes (ANM) on contract basis

In some districts ,few sub centers have population more than 10,000,which affects reach of services. At such places additional ANMs are proposed in rural areas.

Cantonments

These areas will be provided with Contractual ANMs .

Supplementation through private specialists

Contractual Services of Private Gynecologist and Anesthetist:

Operationalization of First Referral Units (FRU) has been a critical action area.

Considering the need for reduction in Infant Mortality Rate (IMR), state desires to utilize the services of private pediatrician at FRUs where their services are not available..

Strengthening of Public Private Partnership:

Reproductive and Child Health (RCH), being a crucial part of public health programmes, Government Of Maharashtra envisages to reach the services to both rural and urban areas. However, the public health services are deficient in most of the urban areas and remote and tribal parts of the state. Hence, Government Of Maharashtra has decided to take concrete steps to overcome these deficiencies through public private partnerships.

Schemes will be :

'Vande Mataram' scheme of Government Of India (GOI).
Subsidized Medical Practitioner (SMP) specialist scheme.
Accreditation scheme :

Private hospitals who wish to join on voluntary basis by developing a criteria and standard of performance.

	scheme of social franchising Involving the interested private practitioners to popularize contraceptives like oral pills, emergency contraceptives and life saving Oral Rehydration Salt (ORS) packets etc.
	Government facilities will be shared with the private doctors on cost basis (e.g. X ray machines, laboratory investigations). The private practitioners will be oriented on government protocols of services through Continues Medical Education(CME).
	Supplementation through private specialists Contractual Services of Private Gynecologist and Anesthetist
	Outsourcing activities like Cleaning, Laundry, Ambulance Services, & Catering Services.

Promotion of entrepreneurship oriented schemes for sustainability

Subsidized Medical Practitioner Scheme in select districts
Availability of Medical and Health services through Govt. or private doctors is a critical issue in difficult and remote areas, To address this problem a scheme for newly passed out Indian System of Medicine (ISM) practitioners has been envisaged under European Commission (EC) -Sector Invensetment Programme (SIP).

Nurse practitioner scheme:
The percentage of Home deliveries in some districts is between 20 to 30%. As it has been noticed that training of TBA will not be sufficient to reduce Infant Mortality Rate (IMR) and Maternal Mortality Rate (MMR). There is a need of Skilled Birth Attendants, i.e. Nurses in areas where population of Sub centers is more than the norm prescribed and the distance from Sub center head quarter, which makes ANM difficult to reach these villages for attending deliveries.

Appointment of Laboratory Technician on contractual basis:
It is proposed to ask the lab. Technician to work on par as mentioned in the scheme of subsidized medical practitioner. It means initial support, for setting up the laboratory, is proposed under the project and honorarium to laboratory technician will be given on tapering basis. Another alternative is the Medical Officer will give the service voucher and the contract will be made with laboratory technician to extend the service against the service voucher, which will be reimbursed in later course by the Medical Officer.

Training and Capacity Building

Infrastructure Strengthening

	Strengthening of Training institutions
	Clinical Training package
	Institutional linkages
	Exposure visits & study tours
	Continuing Medical Education Bulletin

Innovative strategies under training were initiated under externally aided projects.

Continuing Medical Education (CME) : Bulletin for Professionals.
Organization of seminars / hands on training with the help of private sector.
Discussions are going on with Federation of Obstetric and Gynaecological Societies of India (FOGSI) to develop the training course for basic Emergency Obstetric Care and Comprehensive Emergency Obstetric Care, which will be at par with the competency-based training organized at Vellore.
Comprehensive Training Policy
Training organization and management

Improving Management Systems

Financial Management System

The Programme Management Unit (PMU) proposes to establish a separate section for Finance and Accounts by pooling resources of other DP projects and developing a common Finance Section at state Level. The staff of Finance and audit section will be trained to fulfill the needs. Similar trainings and arrangement will be done at districts level. The state PMU will prepare and furnish financial reports on a quarterly basis.
Similarly District Level PMU having Manegerial & Accounts Staff as Contractual basis.

Procurement and Distribution System for drug and equipment

	Provision for drugs kits supplies
	Provision of Equipment kits
	Provision Of Vaccines, Cold Chain Equipments And Contraceptives.
	Improving Logistics Manegement at Divisional & District Level.

Safe Motherhood Services

Maharashtra is one of the four States implementing Integrated Financial Envelope by including need based special interventions/ innovative schemes under the Reproductive and Child Health (RCH) program.

The various initiatives started to strengthen MCH components are:

	Dai (Traditional Birth Attendant (TBA)) Training :
	Promotion of institutional delivery : (24 Hour delivery scheme) - Janani Suraksha Yojana.
	Referral Transport Scheme : Dept. of Referral plan at village level.
	Reproductive and Child Health (RCH) Camps : At selected 5 - 6 Primary Health Center (PHC)s per district twice a year.
	Contractual services of Gynecologist and Anesthetist

New Initiatives

State proposes to implement following new initiatives during Reproductive and Child Health (RCH) II

a Nutrition demonstration:
Considering the importance of nutritional status of women and children in reducing morbidity and mortality, the activity of nutritional demonstration will be taken up on priority during Reproductive and Child Health (RCH) II. It is planned to implement this activity with the help ofIntegrated Child Development Services(ICDS) functionaries and like Self Help Groups (SHG), who will be taking up this activity on a regular basis considering the local customs and availability of food articles. Especially the concept of providing formula F-75 and F-100 to the grade III and grade IV children

b. Comprehensive EmOC Training (CEmOC):

Medical officers will be trained to get confidence for performing the skills like, tubectomy, Medical Termination of Pregnancy (MTP), General and Emergency Obstrective Care (EmOC) / Emergency EmPC at selected institutions. Postgraduates in DGO/ MO Gyn. / MS (G.S) will be trained in Laproscopic Sterilisation & Lower Section Cesarian Section(LSCS).

c. 'Dada-Dadi' (Ajoba-Aaji) scheme:

Under this scheme, state proposes to identify and recognize the senior citizens as 'Dada' or 'Dadi', who will be joining voluntarily in the scheme to create awareness and demand generation. They will be given orientation especially about need of ANC, Neonatal care and child care as well as mother and child nutrition. Publicity will be given to this scheme.
These 'Dada' and 'Dadis' will be recognized by govt. They will be working voluntarily in their own area at the time, which is convenient for them.

d. 40 Plus Services:

Care of 40 Plus population is an important component under Reproductive and Child Health (RCH).Hypertension, Diabetes, Cancer (preventive oncology), Cataract, Rerpoductive Tract Infection /Sexually Transmitted Infenction (RTI/STI) are the problems commonly observed in this population. Fornightly clinics at District Hospital & identified Rural Hospitals will be initiated in a phased manner.

e. EmOC / EmPC protocols:

UNICEF has developed Protocols for management of EmOC, and EmPC. These will be adopted and monitored for the state.

f. Provision of Tab. Vitamin C Tab Calcium to Pregnant Women

To improve Hemoglobin level and reducing incidence of hyper- tensive disorders (Pre - eclampcia and Eclampcia) during pregnancy. Various reseaReproductive and Child Health (RCH) initiatives have indicated utility of supplementing Vitamin C and Calcium.

Child Survival Services

The state IMR and NMR are 45 and 29 (SRS 2002) respectively, which are better than national average. However, it is observed that, these rates have not improved since last 5 to 6 years.

The activities for reduction of IMR, NMR revolve around -

	Increasing awareness up to grassroots level for home based care
	Increasing reach and availability of items for home based care such as ORS and Septran etc.
	Improving nutritional status of pregnant women and children including promotion of early and exclusive breast feeding, weaning, nutrition demonstrations
	Developing village level referral plans and provisions for referral transport for EmPC
	Establishing Neonatal Intensive Care Unit (NICU), at District Hospitals & selected tribal First Referral Unit (FRU) New born care units and new born care corners at appropriate levels, improving the environment of pediatric wards at district hospitals etc.

Capacity building and trainings are other important action areas covering

	Trainings IMNCI with priority to tribal area.
	MCHN training & New Born Care.
	TBA training
	Promotion on Early and exclusive breast feeding
	Orienting community members and CBOs on identification of danger signs for EmPC in diarrhea, Acute Respiratory Tract Infection (ARI), etc.
	Provision of training equipments and models (to be procured under EC component)

Various incentive schemes exist in tribal areas state which promote maternal care, new born care and care of child illness including diet for parent and compensation for loss of wages for parent/guardian are promoted by the state government apart from the national maternity benefit scheme for Below Poverty Line (BPL) families.

Reproductive and Child Health (RCH) II proposes to allocate special resources for the tribal areas like Innovative schemes of Subsidized Medical Practitioners, and Nurse practitioners to give thrust on IMR related activities.In addition to these, major thrust will be given on promoting joint working of ICDS and Health functionaries through better convergence and close monitoring at all levels.

Technical Aspects

	Promotion of early and exclusive breast-feeding
	Health checkup of malnourished children by Medical Officer (MO), Primary Health Center (PHC) at Aanganwadi .Though the ICDS functionaries
	New Born Care (NBC) & Maternal and Child Health Nurse (MCHN) training
	Integrated Management of Neonatal and Child Illnesses (IMNCI)

High Neo natal, Infant and under % mortality is the most important challenge in child health in tribal and urban areas of the state.Most neo natal deaths occur at home because of home delivery conducted by untrained persons who do not practice aseptic procedures during deliveries. There are difficulties in transporting of sick neonates to hospitals.

Specific interventions

Monitoring of growth records:
UNICEF & ICDS along with health department has developed innovative growth and health checkup cards for mothers and under five children. (-9 to 5 years)


Healthy Baby Competition
To create awareness about good nutritional practices and maintaining child in good health, state proposes to take this initiative in selected districts by organizing Healthy Baby Competition on periodic basis after good publicity along with prizes to children.

Social franchising:

Providing easy access to contraceptives, ORS Packets etc

Adolescent Health Services
Adolescent issues will be incorporated in all the Reproductive and Child Health (RCH) training programmes and all Reproductive and Child Health (RCH) materials developed for communication and behaviour change. This will entail that interventions for addressing unmet need for contraception and pregnancy care, prevention of STIs including HIV/AIDS
Adolescent Health initiative.

The activity will be in two areas. One being through School based activity for student group and will be implemented through the Education department, similar to program run for HIV/AIDS awareness by State AIDS society.

Second approach is through the ICDS / SHG / NGOs for non-school adolescents. UNFPA and UNICEF are piloting in this direction to evolve an agreeable srategy.

Orientation of health staff:
It is essential to equip the health staff with knowledge and skills so as to enable them to cater to reproductive and sexual health needs of adolescents are critical.

Adolescent Health Clinics:
The controlling / preventing reproductive tract infections in adolescent girls at District Hospital & select Rural Hospitals in phased manner.

Role of SHGs

The State is proposing to undertake an initiative to involve SHGs for local production of low cost sanitary pads which will serve as an economic support to SHG groups.

Family Planning - Reducing Total Fertility Rate

Population stabilization is the mandate of State Family Welfare Bureau. Maharashtra has major regional variation due to socio-cultural groups. Actions are planned to identify need-based districts to focus area specific issues. The broad classification of districts brings forth the division of districts in tribal districts – where age at first pregnancy, ignorance about family planning, traditional beliefs and neonatal mortality are main causes of larger family size.

Further, in Marathwada and Vidarbha region, the problem is more of having a preference to male child. The decreasing sex ratio of 0-6 years age group indicates a need of stringent actions and implementation of PNDT act.

The state is implementing F.W. activities with top priority since last 2-3 decades. Annual eligible couple survey as a process to identify community needs assessment is carried out to know the current status of target couples for spacing and terminal methods of contraception.

State regularly monitors the performance of sterilization on 2 issues and promotion of No Scalpel Vasectomies (NSV) has been given priority in last 5-6 years.

State also implements a incentive scheme from state resopurses for promoting sterilization of BPL couples with only 1-2 females issues and no male issue, under the auspices of 'Savitribai Phule Kanya Kalyan Yojana'. Such couples are given cash certificates in the name of female issues, which mature at their age of 18 years. State is receiving good response to this scheme.

State will implement following activities in Reproductive and Child Health (RCH) Phase II for reducing TFR.

Implementation of PNDT Act

The sex ratio in Maharashtra is 933 (2001 census) and in 0-6 years age group it is 917. This will have grave social implications for next generation, mainly for women's status and their security.

Considering the tendency for male preference in Indian culture, it has become essential to initiate activities to reduce this tendency. This had lead to more no. of female foeticide cases affecting sex ratio, with special reference to sex ratio in -0-6 years age group.

The PNDT act provides important initiative for reduction of female foeticide and male preference. State has issued notification for implementation of PNDT act. All the centers providing facility of prenatal and pre-concept ional sex diagnosis have been registered under revised PNDT act.

IEC activities through media for community and medical profession are being conducted in the state. Special sensitization of doctors running / operating such facilities are conducted. State, and district level structures for monitoring PNDT activities have been set. Strict vigil over functioning of such facilities through quarterly and surprise monitoring visits are conducted in the state. Punitive action including sealing the machines and court cases has been taken in the state.

MTP Services

MTPs are mainly considered as a means of termination of unwanted pregnancy due to failure of contraception. Currently a large Number of maternal deaths occur due to aseptic abortions and other complications. An illegal abortion carried out at illegal institutes by illegal persons is the main cause. The state has following No. of registered MTP centers both in public and private sector.

Public MTP facilities	473
Private MTP facilities	2324
Total	2797

Safe Abortion Services

Despite a liberal abortion law that encompasses a broader range of indications, illegal abortions far outnumber legal procedures in India. About nine percent of all reported maternal deaths could be attributed to unsafe abortions, which translates to about 12000 - 15000 deaths annually.

The causes of unsafe abortion are numerous and include unavailability of health centers providing these services in rural areas, dearth of trained providers and women who largely remain unaware of availability of service outlets and their rights to legal abortion.

Manual Vacuum Aspiration (MVA) technique

India's National Population Policy 2000 delineates strategies to decentralize abortion services adopting new and easy technologies like Manual Vacuum Aspiration (MVA) and drug induced abortion simplifying "provider certification requirements" increasing the number of training centers and education communities.

Considering the success of the pilot and keeping in line with the policy of making all Reproductive and Child Health (RCH) services available to the people of the state, it is planned to introduce Safe Abortion Services in all health centers in the state.

Manual Vacuum Aspiration and Drug-induced abortion techniques will be introduced in a phased manner in all the health centers in the state. It is planned to initiate these services in all RH and Primary Health Center (PHC)s where 24 hr. EmOC services are to be provided.

Services To The Tribal Population And Underserved Areas

a. Pada worker scheme: :(State funded activity)

In tribal areas the distance between villages and health institutions is more and the terrain is difficult, which leads to difficulty in reaching for medical care. Even the information of epidemics reaches the health institution very late leading to delayed actions. Hence State has initiated a Pada worker scheme (Link worker) in all the 15 tribal districts of the state from tribal funds. The pada worker is a local resident and interested in social work.
She / He is given sensitization in first aid, water disinfections and is expected to inform the nearest Primary Health Center (PHC) of any epidemic of water borne diseases or fever cases. She / He is paid an honorarium of Rs. 300/- per month. These pada worker will be involved in Reproductive and Child Health (RCH) activities, mainly in providing guidance for referral for EmOC, EmPC and helping in MCP sessions and nutrition demonstration. Currently a total of 10091 pada workers are engaged for 6 months during June to December every year.
The State is planning to appoint pada workers throughout the year considering morbidity and mortality of under five children in these areas. This being a state funded activity no budget is requested.

b. Matrutava Anudan Yojana for Tribal areas:(State funded activity)

Maharashtra state is implementing 'Matrutava Anudan Yojana' in tribal districts of Maharashtra under the auspices of "Nav Sanjivani"yojana, and is similar to National Maternity Benefit Scheme (JSY) of GOI. Every pregnant mother is provided with Rs. 400/- for improving nutrition and other needs. In addition Rs. 400/- are kept with nearest Primary Health Center (PHC) / Community Health Center (CHC) for necessary medical treatment i.e. cost of drugs.

Tribal Area activities through E.C. supported Sector investment prog.

The state of Maharashtra has a considerable tribal population spread across several district. The tribal people live in remoteareas in hamlets. All these tribals have their own taboos and customs. Usually during the illness of women & children, they approach the Bhagats. They immensely trust in Bhagats for all religious purposes including severely ill children and women.

Interventions for tribal areas

	Dai training
	Dai training in the field
	Provision of Dai kits to trained Dais
	Female Pada Worker scheme

In order to tackle the problem of maternal and child health, a female Pada worker will be selected and they will be suitably trained.

Training of healt staff on human approach regarding tribal issues.

The training will be given to M.O.s and Paramedical staff working in Primary Health Center (PHC)s about the tribal culture and taboos at block level.

Training to Traditional Healers Traditional Medical Prcatitioners(TMPs/Bhagats)

Traditional healers/Bhagats Traditional Medical Practitioner(TMP) are very influential people in tribal population.In order to curb this tradition, it is necessary to involve the traditional healers in Reproductive and Child Health (RCH) Programme

Referral incentives to TMPs

Compentency based training for Specialist MOs of FRUs in these areas.

Basic Emergency Obstretic Care Training by FOGSI initiative to Doctor.

M.O.s working at tribal Primary Health Center (PHC)s are supposed to conduct normal deliveries as well as refer high risk and obstructed labour cases to FRUs or District Hospitals. They are suppose d to handle cases as preacampcia and also PPH cases.Under the circumstances they need to be trained in handling such EmOC cases at Primary Health Center (PHC) level.

	Integrated Management of Neonatal and Child lllnesses(IMNCI) Training
	Sensitization of Panchayat Raj Institutions personnel for supporting referral advocacy and demand generation
	Management of paediatric asthma cases
	Reimbursement of Travel Cost in ITDP Area
	Maintenace & repaiors of vehicles (RH & PHCs)
	Pol for vehicles
	Provision for repairs of opertion theatres and labour rooms at Primary Health Center (PHC)s
	Provision of Motorcycles. / Mopeds to Health Staff to increase mobility in Ttibal districts.
	IEC Activities

Behavioral Change Communication (BCC)

It is a well-known fact that investment in health care improves well-being of the person directly affecting his capacity to work, production and thus helps in improving economic status of the person and community..

a) Health issues needing behavioral change

	Breast feeding
	Complimentary feeding
	Male preference leading to sex determination and female foeticide
	Male sterilization
	Early detection and treatment of RTI/STI
	Responsible sexual behavior related to HIV/ AIDS Immunization

b) Non-health issues needing behavioral change:

There are a number of non-health issues, which cannot be totally dealt by the health staff. However, they have direct bearing on MMR, IMR and TFR. Some of the important non-health issues are listed below:

	Age at marriage, age at first pregnancy,
	Decision for limiting family size by spacing and terminal methods,
	Male child preference, preference for female sterilization
	Male participation in identification/ decision of high-risk issues related
	IMR and MMR and for timely referral.
	Nutritional issues.
	Availing / demanding essential health services linked to status of women
	Involvement of Panchayat Raj Institutes (PRI) / community in monitoring public health services
	Gender issues
	Gender violence
	Women empowerment

Providing humane and sensitive treatment to the beneficiaries is an essential requirement of all health institutions. For this purpose, bringing about attitudinal and behavioral change in the health staff is very critical. A number of initiatives such as social labs, trainings, exposure visits, appreciative inquiry etc will be undertaken to improve the responsiveness of the system.

List of Hospitals selected for IPHS

24 x 7 PHCs Operationalisation - Status & Plan for 2006-07 - Maharashtra State

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List of 162 FRUs