District Health Action Plan District Year 2011-12

Office of Chief Medical Officer Dehradun 105, Chandar Nagar Dhradun

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Acknowledgements

The commitment to bridge the gaps in the public delivery system, has led to the formulation of District Health Action Plans. The collaboration of different departments that are directly or indirectly related to determinants of health, such as water, hygiene and sanitation, will lead to betterment of health care delivery, and to make this collaboration possible actions are to be outlined in the District Health Action Plan. Thus this assignment is a shared effort between the departments of Health and Family Welfare, ICDS, PRI, Water and Sanitation, Education and NGOs/CBOs to draw up a concerted plan of action.

District Action Plan for of entailed a series of Consultative Meetings with stakeholders at various levels (District/Block/Village), collection of primary/secondary data from various departments and analyzed at District level.

The present acknowledgement would be incomplete without mentioning the participation of representatives and officials from department of Integrated Child Development Services, Panchayati Raj Institution, Education, Water and Sanitation and various NGOs who actively participated in consultations with great enthusiasm. Without their inputs it would not have been possible to formulate the strategic health action plan for the district. The formulation of this plan being a participatory process, with inputs from the bottom up, the participation of community members at village level proved very helpful. These consultations at grassroots level supplemented the deliberations at block and district levels, adding value to the planning process.

Finally, we would like to appreciate the efforts of all those who were associated with the team for accomplishment of this task and brought the effort to execution.

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List of Abbreviations AIDS Acquired Immune Deficiency Syndrome ANC Ante Natal Care ANM Auxiliary Nurse Midwife APHC Additional Primary Health Centre APL Above Poverty Line ARSH Adolescent Reproductive and Sexual Health ASHA Accredited Social Health Activist AWC Centre AWH Anganwadi Helper AWW Anganwadi Worker AYUSH Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homeopathy BCC Behaviour Change Communication BDC Block Development Committee BPL Below Poverty Line BPMU Block Programme Management Unit CBO Community Based Organization CDPO Child Development Project Officer CHC Community Health Centre CMO Chief Medical Officer CPS Chikitsa Prabhandan Sammittee DDC Drug Distribution Centre DAP District Action Plan DF Deep Freezers DH District Hospital DHAP District Health Action Plan DLHS District Level Household Survey DOTS Directly Observed Treatment Short-course DPMU District Programme Management Unit DRHM District Rural Health Mission EmOc Emergency Obstetric Care FGD Focus Group Discussion FRU First Referral Unit FTD Fever Treatment Depot GP Gram Panchayat HMS Health Management Society ICDS Integrated Child Development Services IDSP Integrated Disease Surveillance Project IEC Information Education And Communication ILR Ice-lined Refrigerators IOL Intra-Ocular Lens IUD Intra-uterine Devices IPHS Indian Public Health Standards LHV Lady Health Visitor MDT Multi Drug Therapy MMU Medical Mobile Unit MOIC Medical Officer In-Charge MPW Multi Purpose Worker MSG Mission Steering Group NBCP National Blindness Control Programme

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NGO Non Government Organization NICO Neo Natal Intensive Care Unit NLEP National Leprosy Eradication Programme NRHM National Rural Health Mission NSSK Navjat Shisu Suraksha Karyakram NVBDCP National Vector Borne Disease Control Programme PHC Primary Health Centre PIP Programme Implémentation Plan PPC Post Partum Centres PRI Panchayati Raj Institution RCH Reproductive And Child Health RKS Rogi Kalyan Samiti RNTCP Revised National Tuberculosis Control Programme RTI Reproductive Tract Infections SC Sub-centre SC/ST Scheduled Caste/ Scheduled Tribe SHG Self Help Group SNP Supplementary Nutrition Programme STI Sexually Transmitted Infections TB Tuberculosis TOT Training of Trainers UFWC Urban Family Welfare Centre VHC Village Health Committee VHSC Village Health and Sanitation Committee ZP Zila Panchayat

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Executive Summary

The Government of Uttarkhand is committed to enhance the health status of population with strong focus on improving health outcomes especially among women, children and vulnerable populations such as scheduled cast, Scheduled tribes and tribal groups. NRHM is projected to operate as an omnibus broadband programme by integrating all vertical health programmes of the Department of Health and Family Welfare including Reproductive and Child Health Programme-II, National Vector Borne Disease Control Programme, Revised National Tuberculosis Control Programme, National Blindness Control Programme National Leprosy Eradication Programme, National Programme for Prevention Control of Deafness, Iodine Deficiency Disorder and Mental Health Programme. The Mission envisions effective integration of health concerns, with determinants of health like hygiene, sanitation, nutrition and safe drinking water through decentralized management at district level. In order to make NRHM fully accountable and responsive, the need for formulation of year wise District Health Action Plan (DHAP) has been recognized, the DHAP intends to provide a guideline to develop a viable public health delivery system through intensive monitoring and ensuring performance standards. It reflects the convergence of different aspects of health like potable water, sanitation, women and child development and school level education.

District Health Plan is a consolidation of Block Health Plan. The Activities proposed to be undertaken under various programmes is based on the district specific needs. The Health plan gives a brief introduction to the health status in the district, background information about the district, followed by situational analysis both in terms of infrastructure and health indicators as assessed by different survey / collection of data. Plan highlights the goals, objectives, strategies and activities drawn up to meet the goals. It also explains the priorities, constraints and actions to overcome the constraints as envisaged in the block action plans.

As a first step towards planning process, identification of performance gaps was attempted by carrying out a situational analysis. The public health infrastructure in the district indicates under- equipped health facilities with vacant staff positions. Out of Seven CHCs in the district, only two (Vikas Nagar & ) is fully functional as FRUs. and Kalsi Blocks are the most vulnerable with inadequate outreach services due to difficult topography. In convergence point of view, involvement of ICDS and PRI within the framework of health is significant. Intervention by PRI through the constitution and activation of Village Health Committees is still in process, and in the meantime, ICDS workers integrate with health workers at village level through Anganwadi centre to ensure better accessibility and availability of health services at door steps.

The formulation of the DHAP envisages a participatory approach at various levels. To make the plan more practicable and to ensure that grass root issues are voiced and heard, the initial stages of process of plan development included consultations at village and block levels. As NRHM emphasizes community participation and need-based service delivery with improved outreach to disadvantaged communities, village and block level consultations provided vital information to guide the district health action plan. The consultations endeavored to reach a consensus on constraints at community level and engender feasible solutions/intervention strategies. Priorities were set based on discussions on both demand and supply side concerns in the blocks. Furthermore, a district level workshop was conducted to share findings of the village and block level process with a larger stakeholder group, and to finalize a strategic action plan.

During district level consultations involving a range of stakeholders from different levels, strategies have been formulated to achieve identified district plan objectives. For effective implementation, specific activities have been identified for each strategy and a time frame assigned for each activity.

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To provide equitable reproductive and child health services with the objective of bridging the spatial variations and achieving the goals of the National Rural Health Mission, a comprehensive approach will be adopted through partnerships with private institutions, initiatives by other departments like ICDS, Education and civil society. Involvement of VHSC member, Panchayat representatives and community participation at large have specified for addressing and reducing gender discrimination issues (viz. advocacy on age at marriage, denial of sex-selection, equality of immunization etc). For enhancing availability, accessibility and acceptability of services, increase in female literacy, improved IEC for behaviour change and strengthening of health services as well as service providers are envisaged as major tools which can mitigate cultural, institutional and functional constraints.

For strengthening of mother & child health care services and immunization activity in the district regular outreach camps, VHND, RCH camps, population week etc. had been organized during the year 2010-11 and the same activity is proposed for the year 2011-12. We have started SMS alert service for immunization in Kalsi block with the help of NIC and plan to extend it in remaining 5 blocks. E-Mamta software activity (Family Health Survey completed and online data entries of mothers started in October, 10) has been completed in the district. In E-Mamta software/Mother and Child Tracking System (MCTS) we are in process of online punching of Family Health Survey data, which will be completed in this year. For the year 2011-12 district will implement online data entry in E-mamta software in block level with the support/instruction of GoI/State.

Orientation and training have to be organized for strengthening of Chikitsa Prabhandan Samiti and VHSC. A Health facility will be upgraded as per IPHS norms. To make the health care mechanism more accountable, health institutions should be upgraded with adequate availability of staff and equipment and drugs. As a part of NRHM it is proposed to provide each health facility with an untied grant, Annual maintenance grant and seed money for local health action during the year 2011-12 like the year 2010-11. It is also proposed to improve outreach activities in un-served and underserved areas, especially in those inhabited by vulnerable populations, through provision of Mobile Medical Units and Medical Mobile Hospital. The MMU and MMH providing services in un- serve and under serve area of district. Certain activities can be implemented to fill up the identified gaps at facility level. In conformity with the innovations expected in NRHM, mainstreaming of AYUSH for strengthening primary health delivery system is also incorporated.

District Dehradun has fully functional 24 State Allpathic Dispensaries (SADs), providing health care services like PHCs & CHCs but not receiving any grant under NRHM like AMG, Un-tied fund & Seed money. We are proposing NRHM Additionalities as per norms of PHCs for the financial year 2011-12.

For improving the performance indicators for child immunization, strengthening of the service delivery infrastructure and vacancy to be filled either on regular/ contract basis. Additionally there is need for in-service training programmes for skill development of field staff. To increase immunization coverage, more outreach camps would be organized for better access by the underserved and un-served populations. VHSCs and PRI are envisioned as playing a role to improve service delivery efficiency and effecting behaviour change.

Under National Disease Control Programmes, to improve the performance of NVBDCP (specifically indicator of malaria) improvement in surveillance activities have been planned for preparedness and response. Sensitization of the community (BCC) and social mobilization can be achieved effectively by involving VHSCs and panchayat members. In addition, there is need for strengthening and upgrading the epidemiological capabilities of laboratories. Moreover, inter- 5 DHAP Dehradun 2011-12 5 5 sectoral collaboration between the health department, water and sanitation department, PRI, education department, ICDS and NGOs has been envisaged for effective intervention.

For achieving the targets for RNTCP in the span of next two years increased BCC activities are suggested for higher acceptance of services and self reporting by patients. Infrastructural strengthening is required with increased manpower and close monitoring. Moreover, the role of private practitioners is envisaged for IEC activities and for the sensitization of the community. The preparation for the implementation of DOT's Plus actvity for MDR patients is complete and the activity will start as the state get approval from GoI.

As evident from the situational analysis, posts are lying vacant for ophthalmologists and PMOAs to provide primary and secondary level eye care services at CHC & PHC level. Thus filling vacant posts would be one of the activities for strengthening service delivery under NBCP. To improve access to rural/ tribal or underserved areas outreach screening camps should be organized. There would be adequate procurement, distribution and maintenance of quality of equipment and drugs. School health camps will be organized to target children 05-15 years of age for refractive errors. Further there is need for promotion of outreach activities by effective communication.

Existing knowledge and awareness about leprosy call for increased BCC activities to eliminate misconceptions and beliefs associated with the disease. This could be achieved by successful intervention of the Panchayat through activation of village health and sanitation committees. Moreover there is need to reinforce the service delivery mechanism by providing quality services for counseling, diagnosis and treatment.

To make the system more accountable, the District Health Action Plan proposes close monitoring and evaluation with continuous integration at each level (village, block and district). This will not only ensure streamlining of strategies but also check for effective collaboration of services related to immunization and institutional delivery, AYUSH infrastructure, supply of drugs, up gradation of CHCs/ PHCs to IPHS, utilization of untied fund, AMG, seed money and outreach services through mobile medical units/Hospital. The VHSCs at village level, CPSs at block level/facility level, Quality Assurance Committees and District Health Missions at District level have to be eventual monitor the outcomes. HMIS will be helpful for collecting and analyzing district data of different indicators. An overview of progress has to be conducted during monthly review meetings.

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Out Come Analysis of PIP during the year 2009-10 and 2010-11(up to Sep. 10) Financial Physical 2009-10 2010-11 2009-10 2010-11 ACTIVITY* Amount Exp Expecte Expecte Amount Achie Achie Approve Expend. (Till d d Approved v em. v em. d Sep, 10) Output Output RCH Flexipool Maternal Health RCH Camps 360000 360000 865000 52000 48 48 66 9 VHND 0 0 843100 203000 8412 6603 8431 2404 1120030 JSY 25501880 23295106 27050570 17414 13840 15500 6230 0 Child Health School Health Day 1202400 755400 1983000 135713 1578 1169 1578 35 PC & PNDT 50000 14400 0 0 2 2 2 0 FBNC 0 0 0 0 0 0 0 0 Family Planning 5685000 5419800 6061500 1223913 5848 4537 5848 1028 ARSH 0 500000 1151000 2312711 2 2 6 6 Urban RCH 0 0 603600 106381 0 0 11 9 Tribal RCH 0 0 0 0 0 0 0 0 Vulnerable Groups 0 0 0 0 0 0 0 0 Innovations / PPP/ NGO - (VMU) MNGO HIHT 0 850307 0 631812 1 1 1 1 NGO Project for Raipur / Chakrata (MIPS) 0 1638878 4000000 419402 1 1 1 1 Infrastructure & HR (SN + ANM) 2704000 2643202 17172000 2397519 18+16 18+9 18+59 18+52 Incentives / Awards Incentives to ASHA (@250 package) 0 1545710 351430 17414 6639 15500 1314 500000 Incentives to Doctors/SN/ANM (Promotion of ID) 0 291500 68200 0 808 1625 194 Institutional Strengthening - (SC Rent & Cont.) Sub Center Rent 201000 161190 189000 69470 67 67 63 63 Sub center contingency 336000 327000 0 0 168 168 168 0 Training 2913770 1707177 0 80000 BCC/IEC 0 331147 0 2 Program Management DPMU 2028000 819136 900000 481743 3 3 3 3 Monthly / Quarterly review meeting 60000 39788 120000 11283 4 3 4 2 Strengthening of Financial Management System 0 0 7280 0 0 4 2 Mission Flexible Pool ASHA Programme Selection & training of ASHA 3983580 4560776 State level 1016680 1418 1166 1418 690 ASHA Resource Center 276000 128606 516000 384770 1 1 1 1 ASHA Ghar 0 0 150000 0 0 0 1 0 Untied Fund 6660000 3190708 9800000 4496143 599 910 910 907 AMG 2750000 2411039 2850000 93500 144 144 139 139 Institutional Strengthening Construction / Up gradation - (CHC & ANMTC) Up gradation of CHC 2825572 2000000 2361109 4 4 4 4 Construction of ANMTC 5590000 4000000 1722000 1 1 1 1 Rogi Kalyan Samiti 2200000 2225278 4100000 472253 14 14 14 30 DHAP 0 0 30000 0 0 0 1 0 Strengthening of Training Centers Swablamban Yojna Health Mela Mobility Support for Medical Officers - (District 240000 239139 240000 91815 Level Mobility & conti.) Logistics Procurement Quality Assurance - (QA & HM hono.) 0 593914 460000 229296 0 1 1 1

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Financial Physical 2009-10 2010-11 2009-10 2010-11 ACTIVITY* Amount Exp Expecte Expecte Amount Achie Achie Approve Expend. (Till d d Approved v em. v em. d Sep, 10) Output Output Difficult Area Allowance Up gradation of Health Centers as per Indian Public 2959000 5000000 1439000 17 11 20 6 Health Standards (IPHS) – SC MMU/EMRI 1757200 1343443 2100000 413757 1 1 1 1 Community Monitoring District Specific Interventions Mainstreaming of AYUSH Management Cost - (BPMU) 1260000 1102368 1842000 746216 6 6 6 6 Deafness Programme. Immunization Mobility support for Supervision and Monitoring at 60000 45567 40000 11011 48 14 districts and state level. Cold chain maintenance 60000 15000 24500 11372 30 3 Alternate Vaccine Delivery to Session sites 267300 400300 609600 129950 5346 6603 8431 2404 Focus on urban slum & underserved areas 151200 151200 201600 107450 9 9 12 9 Social Mobilization by ASHA /Link workers 4017150 3728944 1764000 846950 26781 24860 34167 5647 Computer Assistants support at State/district level 84000 96000 108000 45000 1 1 1 1 Printing and dissemination of immunization cards, tally sheets, charts, registers, receipt book, 0 0 0 0 0 0 0 0 monitoring formats etc. Quarterly review meeting at state/District/Block 115000 107610 337875 56582 24 22 24 12 level District level Orientation for 2 days ANMs,

MPHW,LHV Trainings 0 103824 216000 0 0 31 0 0 To develop micro plan at sub-centre level and block 22800 20400 24700 12400 174 174 174 124 level For consolidation of micro plan at PHC/CHC level POL for vaccine delivery from state to District and 50000 49875 50000 15376 PHC/CHCs Consumables for computer including provision for 4800 4766 4800 2600 1 1 1 1 internet access Red/Black/Zipper bags Bleach/Hypochlorite solution 0 0 14500 14471 0 0 29 24 Twin Bucket 0 0 0 0 0 Civil works Laboratory materials Honorarium IEC/ Publicity Equipment maintenance Training Vehicle maintenance Vehicle hiring NGO/PP support Miscellaneous - (Waste disp. Pit) 54000 Contractual services Printing Medical Colleges Procurement –vehicles Procurement – equipment

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OVERVIEW OF RCH-NRHM PERFORMANCE (2005-11): FACILITY OPERATIONALISATION AND TRAINED SERVICE PROVIDERS - DEHRADUN

Service utilization* (average per month per Number of facilities/HR facility / trained provider) Achievem Percent Based on Area Indicator Planne Plan for Projection ent (2005- age (%) performance d (2005- 2011- Services for 2011- 11, till Achieve during Apr- 11) 2012 12 30.12.10) ment Dec. 2010 C-sections 0.055 (2) 0.88 (32) MTPs 25.55 (460) 27 (648) No. of FRUs Rest 2 Male 4 2 50% 3.27 (59) 4.25 (102) Operationalised FRUs sterilizations Female 20.11 (362) 21.21 (509) sterilizations Normal 7.5 (270) 8.00 (384) deliveries 3 Rest MTPs 1.22 (44) 1.66 (80) and 2 No. of 24x7 PHCs Male Facility 7 4 57.14% more = 5 0.416 (15) 0.90 (43) Operationalised sterilizations Operatio PHC Female nalisation 24X7 1.25 (45) 1.5 (72) sterilizations IUD insertions 15.08 (543) 18.75 (900) Normal No. of sub-centres 3.89 (498) 4.947 (950) deliveries operationalised as 35 16 45.71 35 44.19 delivery points IUD insertions 34.26 (4386) (8486) No. of SNCUs 1 under Newborns 1 1 - - operationalised process treated No. of NBSUs Newborns - - - 7 - - operationalised treated EmOC training C-sections LSAS training 2 2 100% C-sections 1 Deliveries SBA 354 134 37.85% 40 12 40 conducted MTP 25 12 48% 2 MTPs 1 2 RTI/STI 36 30 83% 40 IMNCI 2752 72 2.60% 66 Capacity Children and F-IMNCI Building infants treated Newborns NSSK 107 67 62.60% 40 resuscitated Mini lap Sterilizations 1.6 30 (300) NSV 12 6 50% 4 Sterilizations 5.28 (238) 11.37 (455) Laparoscopic 89.76 4 4 100% Sterilizations 25.22 (1135) sterilization (5386) 71.15 IUD 108 78 72% 40 IUD insertions 43.95 (9889) (21347)

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MONITORABLE INDICATORS (Against each indicator, Chakrata has been taken as a High Focus Block) 2010-11 2011- 12 Baseline Annual (Apr-Dec. Q1 Target Q2 Target Q3 Target Q4 Target Target Sl. 2010) INDICATOR No. Di Dis Dist Dist Dist HF HF stri HF HF tric HF Distr HF rict rict rict Bloc Blo ct Bloc Bloc t Bloc ict Bloc tota tota tota k ck tot k k tota k total k l l l al l A Maternal Health A.1 Service Delivery % Pregnant women 23. 17.37 22.7 20.2 23.7 20.2 23.7 20.2 23.75 80.80 A.1.1 registered for ANC in 20% 75 95% % 5% 0% 5% 0% 5% 0% % % the quarter % % PW registered for 56.43 52.4 66 66 A.1.2 ANC in the first 66% 66% 66% 66% 66% 66% 66% 66% % 3% % % trimester, in the quarter Institutional deliveries 14. 14.44 10.6 19.0 19.0 14.6 19.0 14.6 19.0 14.67 58.6 A.1.3 (%) in the quarter (in 67 76% % 7% 0% 0% 7% 0% 7% 0% % 8% government facilities) % A.2 Quality % unreported deliveries 58.71 49.5 38 38 A.2.1 48% 48% 38% 48% 48% 38% 48% 38% in the quarter % 7% % % % high risk pregnancies 6. 6. 6. 4.95 8.31 3.00 6. 31 6. 31 identified (a) % women 31 3% 31 3% 31 3% 3% % % % % % A.2.2 having hypertension % % % (b) % women having 0.99 6.63 0.77 4.6 0.77 4.63 0.77 4.63 0.77 4.63 0.77 4.63 low Hb level % % % 3% % % % % % % % % % of Home Delivery by 47. 38.46 57.2 27.0 27.0 47.0 27.0 47.0 27.0 47.00 27.00 47.0 A.2.3 SBA (i.e. assisted by 00 % 8% 0% 0% 0% 0% 0% 0% % % 0% doctor/ nurse/ANM) % C-sections performed 17. 0.00 15.5 5.00 5.00 17.5 5.00 17.5 5.00 17.51 5.00 17.5 (%) (a) in Public 51 % 1% % % 1% % 1% % % % 1% A.2.4 facilities % (b) in private accredited

facilities % of deliveries discharged after at least 74. 42.85 64.0 52.8 52.8 74.0 52.8 74.0 52.8 74.03 52.85 74.0 A.2.5 48 hours of delivery (out 03 % 3% 5% 5% 3% 5% 3% 5% % % 3% of public institution % deliveries) 1.14 0.44 0.50 0.2 0.50 0.24 0.50 0.24 0.50 0.24 0.50 0.24 A.2.6 % of still births % % % 4% % % % % % % % %

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2010-11 2011- 12 Baseline Annual (Apr-Dec. Q1 Target Q2 Target Q3 Target Q4 Target Target Sl. INDICATOR 2010) No. HF Distri HF Distr HF Distr HF Distr HF Distr HF Distr Blo ct Blo ict Blo ict Blo ict Blo ict Blo ict ck total ck total ck total ck total ck total ck total % of FRUs 50.00 A.3.2 operationalised as per - - 100% - 100% - 100% - 100% - 100% % the GoI guidelines 12. 12. 12. 12. % of Level 1 MCH 3.3 20.00 12.0 20.00 20.00 20.00 20.00 A.3.3 8.28% 00 00 00 00 centres operationalised 4% % 0% % % % % % % % % % of Level 2 MCH 100 53.84 100 80.00 100 80.00 100 80.00 100 80.00 100 80.00 A.3.4 centres operationalised % % % % % % % % % % % % % of Level 3 MCH 50.00 80.00 80.00 80.00 80.00 80.00 A.3.5 ------centres operationalised % % % % % % 70. 70. 70. 70. % ANMs/ LHVs/ SNs 41 42.00 82.00 70.0 82.00 82.00 82.00 82.00 A.3.6 00 00 00 00 trained as SBA % % % 0% % % % % % % % % 20. 20. 20. 20. % doctors trained as 10.00 40.00 20.0 40.00 40.00 40.00 40.00 A.3.5 - 00 00 00 00 EmOC % % 0% % % % % % % % % 40. 40. 40. 40. % doctors trained as 20 30.00 40.0 30.00 30.00 30.00 30.00 A.3.6 10% 00 00 00 00 LSAS % % 0% % % % % % % % % A.4 HR productivity % of LSAS trained A.4.1 doctors giving spinal anesthesia Average no. of c-sections A.4.2 assisted by LSAS trained doctors % of EmOC trained A.4.3 doctor conducting c- sections. Average no. of c-sections A.4.4 performed by EmOC trained doctor Average no. of deliveries A.4.5 performed by SBA 20 88.75 60 90 60 90 60 90 60 90 60 90 trained SN/LHV/ANM 42. 62. 62. 62. 62. % of SBA trained ANMs 33.58 53.58 62.8 53.58 53.58 53.58 53.58 A.4.6 85 85 85 85 85 conducting deliveries % % 5% % % % % % % % % %

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2010-11 2011- 12 Baseline Annual (Apr-Dec. Q1 Target Q2 Target Q3 Target Q4 Target Target Sl. No. INDICATOR 2010) Dis HF Dist HF Distr HF HF Distr HF Distr HF Distr trict Blo rict Bloc ict Blo Bloc ict Blo ict Blo ict tota ck total k total ck k total ck total ck total l A.5 Facility utilization % of FRUs conducting 25.0 100.0 100. 100.0 100.0 100.0 A.5.1 ------C-section % % 0% % % % Average no. of c- A.5.2 - 1 - 8 - 8 - 8 - 8 - 32 sections per FRU Average no. of MTPs A.5.3 - 230 6 162 6 162 6 162 6 162 24 648 performed in FRUs Average no. of 12.6 A.5.4 deliveries per 24x7 67.5 25 110 25 110 25 110 25 110 100 440 6 PHCs Average no. of MTPs A.5.5 performed per 24x7 - 4.5 6 48 6 48 6 48 6 48 24 192 PHC % of SC conducting at 12.50 5.00 22.85 5.0 22.8 5.00 22.85 5.0 22.85 5.0 22.85 A.5.6 least 5 deliveries per - % % % 0% 5% % % 0% % 0% % month B Child Health B.1 Service Delivery Children 9-11 months 78. 78. 78. 68.1 72.34 78.00 85.00 85.0 78.0 85.00 85.00 85.00 B.1.1 age fully immunised 00 00 00 1% % % % 0% 0% % % % (%) % % % 99. 99. 99. % children breastfed 98.4 82.81 99.47 92.81 92.8 99.4 92.81 92.81 92.81 B.1.2 47 47 47 within 1 hour of birth 7% % % % 1% 7% % % % % % % 70. 70. 70. % of low birth weight 60.7 30.65 70.78 50.65 50.6 70.7 50.65 50.65 50.65 B.1.3 78 78 78 babies 8% % % % 5% 8% % % % % % % B.2 Quality % age of women 56. 56. 56. 36.8 41.01 56.87 61.01 61.0 56.8 61.01 61.01 61.01 B.2.1 receiving PP check up 87 87 87 7% % % % 1% 7% % % % to 48 hrs to 14 days % % % B.2.2 % drop out from BCG 12.5 16.39 5.25 8.25 5.2 8.25 5.25 8.25 5.2 8.25 5.2 8.25 to measles 0% % % % 5% % % % 5% % 5% %

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2010-11 2011- 12

Baseline Annual Sl. (Apr -Dec. Q1 Target Q2 Target Q3 Target Q4 Target INDICATOR Target No. 2010) HF Distr HF Dist HF Distr HF Distr HF Distr HF Distr Bloc ict Blo rict Blo ict Blo ict Blo ict Blo ict k total ck total ck total ck total ck total ck total B.3 Outputs B.3.1 % of SNCUs - - - 100 - 100% - 100% - 100% - 100% operationalised % B.3.2 % of stabilisation units - - - - 100 100% 100 100% 100 100% 100 100% operationalised % % % % B.3.3 % of new born baby - - - - 100 100% 100 100% 100 100% 100 100% care corners % % % % operationalised B.3.4 % of personnel trained in IMNCI B.3.5 % of personnel trained in F-IMNCI B.3.6 % of personnel trained 30% 62.20 50 72.2 50 72.20 50 72.20 50 72.20 50 72.20 in NSSK % % 0% % % % % % % % % B.4 Facility utilization B.4.1 Average no. of children - - treated in SNCUs

B.4.2 Average no. of children - - treated in NBSUs

C Family Planning C.1 Service Delivery C.1.1 % of total sterilization 40.2 42.2 80. 82.2 80. 82.25 80. 82.25 80. 82.25 80. 82.2 against ELA % % 2% 5% 2% % 2% % 2% % 2% % C.1.2 % post partum - 11.6 - 20.0 - 20.0 - 20.0 - 20.0 - 20.0 sterilization % % % % % % C.1.3 % male sterilizations 100% 54.96 100 84.9 100 84.96 100 84.96 100 84.96 100 84.96 % % 6% % % % % % % % % C.1.4 % of IUD insertions 27.5 43.94 71. 71.1 71. 71.15 71. 71.15 71. 71.15 71. 71.15 against planned % % 1% 5% 1% % 1% % 1% % 1% % C.1.5 % IUD retained for 6 - - months C.1.6 % Sterilization - - acceptors with 2 children C.1.7 % Sterilization - - acceptors with 3 or more children

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2010-11 2011- 12 Baseline (Apr Q2 Annual Q1 Target Q3 Target Q4 Target - Dec. 2010) Target Target Sl. INDICATOR No. Dis HF HF Distr HF tric HF Distr HF Distr HF Distr Distri Bloc Blo ict Blo t Blo ict Blo ict Bloc ict ct total k ck total ck tota ck total ck total k total l C.2 Quality C.2.1 % of complications - 4.64% - 2% - 2% - 2% - 2% - 2% following sterilization C.3 Outputs C.3.1 % doctors trained as minilap C.3.2 % doctors trained as 33.30% 43.30 53.3 63.30 73.30 73.30 NSV % 0% % % % C.3.3 % doctors trained as laparoscopic sterilization C.3.4 % ANM/LHV/SN / MO trained in IUD insertion C.4 HR productivity C.4.1 Average no. of NSVs - 5.28 - 11.37 - 11.3 - 11.37 - 11.37 - 45.5 conducted by trained 7 doctors C.4.2 Average no. of - 2.5 - 7.5 - 7.5 - 7.5 - 7.5 - 30 minilap sterilizations conducted by minilap trained doctors C.4.3 Average no. of - 269.28 - 269.2 - 269. - 269.2 - 269.2 - 1077. laparoscopic 8 28 8 8 2 sterilizations conducted by lapro sterilization trained doctors C.4.4 Average no. of IUDs - - inserted by MO trained in IUD insertion C.4.5 Average no. of IUDs inserted by MO trained in IUD insertion

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Background

The importance of health in economic and social development for improving the quality of life has long been recognized. In order to energize the various components of health system, Government of has launched the National Rural Health Mission (NRHM). 1 This was launched in April 2005, to provide effective health care to the rural population throughout the country with special focus on 18 states which have weak public health indicators and/or weak infrastructure.

The Mission aims to expedite the achievement of policy goals by facilitating enhanced access and utilization of quality health services, with emphasis on the equity and gender dimensions. Especially focus on vulnerable group

Specific objectives of the Mission are:

Reduction in child and maternal mortality Universal access to services for food and nutrition, sanitation and hygiene, safe drinking water Emphasis on services addressing women and child health; and universal immunization Prevention and control of communicable and non-communicable diseases, including locally endemic diseases Access to integrated comprehensive primary health care Revitalization local health traditions and mainstreaming of AYUSH

NRHM will facilitate transfer of funds, functions and functionaries to PRIs and also the greater engagement of CPS/RKS, hospital development committees or user groups. Improved management through capacity development is also planned. Innovations in human resource management constitute a major challenge in making health services available to the rural/tribal population. Thus, NRHM aims at the availability of locally resident health workers, multi-skill training of health workers/doctors and integration with the private sector for optimal use of human resources. The Mission aims to make untied funds available at different levels of the health care delivery system.

Core strategies of the Mission include decentralized public health management. This will be realized by implementation of District Health Action Plans (DHAP), which is formulated in each year and act as a principal instrument for planning, implementation and monitoring. Action plan formulated through a participatory and bottom-up planning process. DHAP enable village, block and district levels to identify the gaps and constraints in order to improve services with regard to access, demand and quality of health care. NRHM-DHAP is anticipated to form the cornerstone of all strategies and activities in the district.

1 NRHM covers the entire country, with special focus on 18 states where the challenge of strengthening poor public health systems and thereby improve key health indicators is the greatest. These are Uttar Pradesh, Uttaranchal, Madhya Pradesh, Chhattisgarh, Bihar, Jharkhand, Orissa, Rajasthan, Himachal Pradesh, Jammu and Kashmir, Assam, Arunachal Pradesh, Manipur, Meghalaya, Nagaland, Mizoram, Sikkim and Tripura. The mission envisions targeting especially rural/ tribal people, poor women and children for providing equitable, affordable, accountable and effective primary health care. 15 DHAP Dehradun 2011-12 1515 15

1.1 Socio-Economic and Demographic Profile of the District

16 DHAP Dehradun 2011-12 1616 16

Dehradun district is the capital of the newly formed state of Uttarakhand, formerly known as Uttaranchal (2000). For administrative convenience, the state has been divided into two regions i. e. Kumaon Region (Eastern part) and Garhwal Region (Western part). The district of Dehradun comes under the Garhwal division of Uttarakhand. It is bounded on the north and northwest by Uttarkashi district, in the east by Tehri Garhwal and Pauri Garhwal, in the south by Saharanpur (Uttar Pradesh) and Hardwar district. Its western boundary adjoins the Sirmour district of Himachal Pradesh with rivers Tons and separating the two. The total area of the district is 3,088 sq km.

Table-1.1 Profile of District Dehradun S. No Background Characteristics Number Percent 1 Geographic Area (in sq. kms) 3088 5.7 2 Number of blocks 6 -- 3 Size of Villages (2001 Census)

1-500 509 65.8 501-2000 199 25.7 2001-5000 45 5.8 5000+ 20 2.5 4 Number of towns 15 17 5 Total Population (2001) 1,282,143 15.1 -Urban 678,742 53 -Rural 603,401 47 6 Sex Ratio (F/M*1000) Population Sex Ratio 887 -- Child Sex Ratio 894 -- 7 Decadal growth rate 24.71 8 Density- per sq. km. 414 9 Literacy Rate (6+ Pop) 79 - Among Males 85.9 - Among Females 71.2 10 Percent of SC/ST population 21.2 11 BPL Families 55199 -- 12 Length of road per 100 sq. km. 40 13 Percentage of villages having access to 79.6 safe drinking water facility 14 Percentage HH having access to safe 76.9 drinking water* 15 Percentage of households having 74.7 sanitation facility (latrine)*

The administrative set up comprises of six Tehsils, namely Dehradun, Chakrata, Tuni, Kalsi, and and six Community Development blocks, viz, Chakrata, Kalsi, Vikasnagar, Sahaspur, Raipur and Doiwala. It has 403 Gram Panchayats, 735 revenue villages (21 without habitation) and 15 towns. Nearly 66 percent of villages have populations of less than 500. The district has 5.7 percent of the state’s geographical area and 15 percent of its population (12.8 lakhs, as per 2001 census). The estimated population will be 15.98 lakhs in 2010-11 which is calculated with decade growth of 24.71 percent means 2.47 per year. As per SRS ’08 birth rate is 20.1 per 1000. Dehradun has a significantly higher proportion of urban settlement (53 percent) than the 17 DHAP Dehradun 2011-12 1717 17 state as a whole (26 percent). The district has 21.2 percent of scheduled caste and scheduled tribe population. Little more than half (51 percent) of the total population of the state are living below poverty line. Almost 90 percent households have electricity facility, 76.9 percent households have access to safe sources of drinking water and 71.2 percent households have toilet facilities.

The decadal growth rate of population is 24.71 percent. Census 2001 indicates a sex ratio of 887 (2001) which is much lower than the state, Uttarakhand (964). The lower sex ratio in the district could probably be due to sex-selective (male) immigration for enhanced employment and educational opportunities. With respect to the literacy rate, the district scenario is better compared to the state as a whole. The overall literacy rate in Dehradun is 79 percent with higher male literates (85.9 percent) than females (71.2 percent). The State’s total literacy rate is 72 percent with 83.3 percent male and 60 percent female literacy.

18 DHAP Dehradun 2011-12 1818 18

Introduction

Infrastructure : As a preparatory exercise for the formulation of DHAP the first step towards the process of planning entailed identification of performance gaps with respect to key programme indicators by doing a situational analysis, of the existing health scenario from sub center to block level. In order to bridge the identified gaps certain strategies and plans of action were laid down.

2.1 Public Health Infrastructure and Human Resources

Availability of health facilities and human resources are essential prerequisites to ensure delivery of health services. The available statistics (Table below) indicate that the district has one male (level-III) and one female district hospital (level-III). Four sub divisional level hospitals (level-III) and one mental Hospital.

Table 2.1. Public Health Infrastructure Health Facility Required as Number Number having per population available government norm building District Male Hospital (Level-III) 1 1 1 District female hospital (Level-III) 1 1 1 Sub Divisional/Joint Hospital (Level-III) -- 4 4 Mental Health Institution -- 1 1 Female hospital (Level-II) -- 2 2 FRUs (Level-III) 4 4 4 CHC (Level-II) 12 7 7 PHC + Additional PHC (Level-II & I) 45 22 17 Sub Centre (Level-I) 180 168 118 UFWC/PPC/Health post 11 2 Leprosy Hospital -- 1 1 District TB clinic 1 1 1 State Allopathic Dispensary -- 24 18 Ayurvedic Dispensary -- 37 3 Homeopathic Dispensary -- 8 1 Medical College (Private) -- 2 2 Source: District CMO Office, December 2010

Dehradun has four FRU (Level-III); Three CHC and Seven PHC (Level- II) 15 PHC and 168 Sub center (Level-I). Out of these most of the health facilities occupy government building except five PHCs (level-I). As far as sub centre is concern total 70% of sub-centre (level-I) in government premises. In addition to this, the district has 12 UFWC/ PPC/ health posts, one leprosy hospital, one TB clinics in government building, 24 State Allopathic Dispensaries, 37 Ayurvedic dispensaries and 8 Homeopathic dispensaries. Only a few of these facilities are located in government buildings.

Human Resource: The human resource situation in the district shows that 83 percent of the sanctioned positions are filled. However, major gaps are found in case of positions such as Dy CMO (63 percent vacant) and medical officers including specialists (17 percent). Positions are also vacant for Medical Superintendent (44 percent) and staff nurses at CHCs (18.2 percent). 3 FRUs and 3 CHCs are functioning as Basic Obst. Care facilities. 1 DH and 1 SDH functioning as Complicated

19 DHAP Dehradun 2011-12 1919 19

Emergency Obs. care level facilities. Six Blood banks in District one out of them in district hospital, two in private medical college, one in ONGC hospital, one in Indian Medical Association and one at Military Hospital. Two FRUs Doiwala and Vikas Nagar have blood storage facility. One block PHCs and seven other PHC proposed to be functioning as 24*7 delivery institution. It is also proposed that 35 sub center (21% of total SC) will provide delivery services in 2011-12. (Some ANMs at Sub Center are providing delivery services were promoted to HV and transferred in Health Post during the year 2009-10)

Table 2.2. Staff Positions of District Sanction In- Percentage of Staff Vacant ed Position Vacant Post Chief Medical Officer 1 1 - 0.0 Deputy CMOs 6 2 4 66.7 Medical Superintendent in SDH/CHC 9 5 4 44.4 Medical Officers including specialists 125 104 21 16.8 Medical Officer on Contract (included in above) 17 17 - 0.0 Lady Medical Officers 10 9 1 0.0 DHEIO 1 1 - 0.0 Pharmacist 74 74 - 0.0 Pharmacist at Sub Centre 43 43 - 0.0 Health Supervisor Male 34 32 2 19.1 Health Supervisor Female/LHV 68 55 13 19.1 Lab technicians 17 14 3 17.6 X-ray technicians 9 5 4 44.4 Staff Nurse at CHC 22 18 4 18.2 Staff Nurse at SDH 46 43 3 6.5 Staff Nurse at DH 80 74 6 7.5 ANM at Sub center 168 157 11 6.5 ANM at Female Hospital (other than DH) 2 2 - 0.0 ANM at PHC 2 2 - 0.0 ANM at CHC 10 9 1 10.0 ANM at other facilities (SD/DH) 23 23 - 0.0 Male MPW 34 32 2 5.9 Dais 14 5 9 64.3 Drivers 33 24 9 27.3 Source: Establishment Section (District CMO office, December 2010)

Out of Seven CHCs only two (Doiwala & Vikas Nagar) are fully functional in terms of availability of specialists, Three have two or three specialists available whereas one has no specialist. At present 17 Medical Officers are working on contact basis, all critical staff positions are vacant in CHC Sahiya. Out of 22 PHCs, medical officers are in-position only in 18 and ANMs are also posted in 157 sub- centers out of 168.

20 DHAP Dehradun 2011-12 2020 20

Table 2.3: Current position of Critical Staff in FRUs, CHCs, PHCs, and Sub-Centre Critical Staff Availability Vacant Position FRU Doiwala (L-III) Gynecologist - 1, Anesthetist -1, ----- Pediatrician -1, Surgeon-1 FRU Vikasnagar (L-III) Gynecologist - 1, Anesthetist -1, ----- Pediatrician -1, Surgeon-1 FRU Sahiya (L-III) MOs-2 Gynecologist-1, Pediatrician-1 Anesthetist -1, Surgeon-1 FRU Raipur (L-III) Pediatrician-1, LMO-1, MO-3 Gynecologist - 1, Anesthetist - 1, Surgeon-1 CHC Chakrata (L-II) Pediatrician-1, LMO-1 Anesthetist -1, Surgeon-1 CHC (Level-II) Pediatrician-1, LMO-1 Anesthetist -1, Surgeon-1 CHC Sahaspur (Level-II) Pediatrician-1, LMO-1, Anesthetist -1 Surgeon-1 PHC - 21 MOs -18 & LMO-3 MO-5 Female Hospital (2) LMO-1 LMO-1 SAD-24 MO-9 MO-15 Sub centre – 168 (Level-I) ANMs– 157 ANM-11 Source: CMO Office, December 2010 *Note-Anesthetic post has to be sanction at FRU Doiwala.

2.4 Block wise Coverage of Public Health Institution The population coverage and number of institutions by block-level facilities have been analyzed and presented in below Table.

Table 2.4: Block wise Coverage of Public Health Institution Estimated Population No. of Number Sl. No. Block / urban area Coverage (2011-12) PHC/APHC of SCs 1 Chakrata 74160 3 28 2 Kalsi 68749 2 29 3 Vikas Nagars 154947 5 28 4 Sahaspur 149712 3 28 5 Raipur 110528 3 32 6 Doiwala 188606 6 23 7 Urban area 852258 - - Total 15,98,961 22 168 Source: Population estimated on the basis of Census 2001 for year 2010-11 If the population coverage and number of facilities are examined, then the distribution seems to be more or less even. For instance, there are only two PHC/APHCs in blocks Kalsi, three in Chakrata, five APHC in Vikas Nagar, three in Sahaspur block, three in Raipur block and Six APHC in block Doiwala. In terms of GOI norms for hills, there is a shortfall of about 23 APHCs and 106 sub centers in the district. If establishment of new APHCs and the sub centers are planned, then its location has to be carefully planned through geographic mapping so that areas within the block that are under served can benefit. This will also require additional human resources to fill in the current vacancies and for the new facilities. 21 DHAP Dehradun 2011-12 2121 21

Criteria of Classification of Health facilities are as follows:

Height Distance Distance Distance of Availability of from sea Residential of Govt. Category from NH link road water & level (in facility Secondary (Km.) (Km.) electricty feet) school No distance Availability of Availability No distance No distance Accessable upto 2000’ from link both water & / from NH from school road electricty Residencial 1 to 4 Km. Availability of Availability Around 1 2000’ to 1 to 4 Km. Difficult from link either water or / improper Km. from 5000’ from NH road electricty residencial school 5 Km. & 5 Km. & Non-availability Non 2 Km. & More 5000’ & above from above from of both water & Availability above from difficult above NH link road electricty of residence school Indicator of distribution of Health Facility: If a facility comes accessible in 4 out of 6 categories it is accessible, if it comes difficult in 4 out of 6 it is difficult, if it comes most difficult in 4 out of 6 it is most difficult. If a facility comes 3 out of 6 accessible and the remaining 3 in difficult then it is accessible. If a facility comes 3 out of 6 difficult and the remaining 3 in most difficult then it is difficult.

Table 2.4.1: Classification of MCH care Centers MCH Care Accessible Difficult Most Difficult Centers MCH Doon Male Hospital and Doon Female Hospital, St. Marry level-3 Coronation Hospital, SPS Rishikesh, Combine Mussoorie, CHC Hospital Prem Nagar, CHC Doiwala, CHC Raipur, Sahiya CHC Vikas Nagar, Total 8 2 0

MCH Care Accessible Difficult Most Difficult Centers MCH CHC Sahaspur, PHC Rudrapur, PHC Rajawala, CHC Mussoorie, level-2 PHC Dudhli, PHC Nayagaon Pelio, PHC Thano, CHC Chakrata, PHC Chhiddarwala, PHC Mehuwala, PHC Kalsi PHC Tuni Total 9 3 0

22 DHAP Dehradun 2011-12 2222 22

Table 2.4.1: Classification of MCH care Centers MCH Accessible Difficult Most Difficult Levels PHC Bhaniawala, PHC Balawala, PHC Raiwala, PHC Kwansi, PHC Gumaniwala, PHC Nehrugram, PHC PHC Manthat, Bhagwantpur, PHC Harbertpur, PHC Kunjagrant, PHC Panjitlani PHC Sabhawala, PHC Rudrapur, PHC Pachimwala

Kesavpuri, Dudhli, Bullawala, Kheri, Jogiyana, Sarona, Kyara, Buraskhanda, Fatehpur, Saregarh, Jolly, Badonwala, Kandarwala, Itharna, Sumeth, Gadol, Nakronda, Nathuwala, Harrawala, Samsharegarh, Chamasari, Gangaro, Chiddarwala, Shyampur, Gari, Gumaniwala, Dwara Samoli, Kaitri, Khunna, Bapugram, VirpurKurd, Raiwala, Pratit Nagar, Dharkot, Astad, Koftimarlav, Haripurkala, Ranipokhri, Maldevta, Nanurkhera, Basaya, Matiyawala, Ambedkarbasti, Kirsali, Badasi, Sodasaroli, Chandeu, Delau, Dasu, Vayla, Ghammowala, Bhogpur, Sangaon, Ram Demau, Hayya, Kandoibharam Nagardanda, Raipur, Badripur, Majri, Nehrugram, Juddo, Kamla, , Koti Kanasar, MCH Ajabpur, Kargi, Mathurawala, Nawada, Kanwali, Khatar, Korba, Sawra, Jadi, level-1 Sewala Kala, Sewala Khurd, Mohbewala, Koti, Lakhwar, Mohna, Sujau, Mehuwala, Majra, Dhaki, Charba, Kainchiwala, Lelta, Magti, Buraswa, Rampur, Saelaqui, Telpur, Bhagwantpur, Malsi, Naraya, Panjiya, Mairavana, Gajiyawala, Chandroti, Bhatta, Bhitarli, Kaulagarh, Pipaya, Rikhard, Maipavta, Hariyawala, Rajawala, Bhauwala, Dunga, Tilwadi, Sainj, Samalta, Qwansi, Jhajra, Kotra Santur, Pondha, Siddhowala, Sureu, Thaina, Manthat, Umedpur, Prem Nagar, Shyampur, Bhuntowala, Kwanu, Hanol, Lakhamandal, Baniyawala, Pelio, Bhuddi, Harbertpur, Jassowala, Raigi, Arnu, Kunna, Jamnipur, Fatehpur, Atanbag, Dhakrani, Tuni, Baronth, Kunjagrant, Dharmawala, Dhalipur, Badripur, Chilhard, Majri, Sabhawala, Sharepur, Rudrapur, Jeetgarh, Kerad, Fanar, Langha, Badwa, Horrawala, Pachimwala, Bagi, Birnard, Doctorganj, Dakpathar, Mehuwala, Jeevangarh, Bhataad, Bardwala, Katapather, Koti Dhalani, Johari Mundhol Total 114 36 31

Category and Status of MCH Care Centers Operationalisation

Facilities Total No Total Targets S. should be at operationalised till Facilities Identi for Remarks No. the level of December 2010 fied 2011-12 MCH Center (cumulative) Dist. Male Hosp., St. Marry MCH Centre 1 2+4+4=10 7 5 2 Hosp. & Corronation Level -3 Hosp. dropped MCH Centre 2 3+9=12 12 7 5 Level- 2 MCH Centre 3 168+13=181 35 16 19 Level-1

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Identification of level 1 MCH Care Center with gap (35 units)

Infrastructure Human Training Gaps Gaps Identified /Equipment Resource Name of level-1 Sl. L E MCH Care 1st 2nd M IM Infr No. b. NB Del. SB IUC NS H Trg q Centre AN AN P NC a R CC Equ. A D SK R . ui M M W I stru o. p. 1 Nanurkhera Y N Y Y N N Y Y Y N Y Y N N 2 Kirsali Y N Y Y N N Y Y Y Y Y N N N 3 Majri N N Y Y N N Y Y Y N Y Y Y N 4 Nehrugram Y N Y Y N N Y Y Y N Y Y N N 5 Kargi N N Y Y N N Y Y Y N Y Y Y N 6 Selaquai Y N Y Y N N Y Y Y N Y Y N N 7 Sahaspur Y N Y Y Y Y Y Y Y Y N N N N 8 Bhuddi Y N Y Y N N Y Y Y N Y Y N N 9 Charba Y N Y Y N N Y Y Y N Y Y N N 10 Sabhawala Y N Y Y N N Y Y Y Y Y N N N 11 Jeetgarh Y N Y Y N N Y Y Y N Y Y N N 12 Sharepur Y N Y Y N N Y Y Y N Y Y N N 13 Lakhwar Y N Y Y N N Y Y Y N Y Y N N 14 Hayya Y N Y Y N N Y Y Y N Y Y N N 15 Buraswa N N Y Y Y N Y Y Y N Y Y Y N 16 Raiwala Y N Y Y N N Y Y Y N Y Y N N 17 Sharegarh Y N Y Y N N Y Y Y N Y Y N N 18 Sewala Khurd N N Y Y N N Y N Y N Y Y Y N 19 Itharna Y N Y Y Y Y N N Y N N Y N N 20 Bhuntowala Y N Y Y N N Y N N N Y Y N N 21 Chandroti Y N Y Y N N Y N N N Y Y N N 22 Kainchiwala Y N Y Y N N Y N N N Y Y N N 23 Sumeth Y N Y Y Y Y N N N N Y Y N N 24 Jassowala Y N Y Y N N Y N N N Y Y N N 25 Juddo Y N Y Y Y N N N N N Y Y N N 26 Naraya Y N Y Y Y Y Y Y N Y N Y N N 27 Matiyawa Y N Y Y Y N Y Y N Y Y Y N N 28 Pipaya Y N Y Y N N Y Y N N Y Y N N 29 Gadol Y N Y Y Y Y Y N N N N Y N N 30 Thaina Y N Y Y N N Y Y N N Y Y N N 31 Johari N N Y Y N N Y N N N Y Y Y N 32 Kandoibharam Y N Y Y N Y Y N N N Y Y N N 33 Kotikanasar N N Y Y N N Y Y N Y Y Y Y N 34 Jadi N N Y Y Y Y N Y N N N Y Y N 35 Kherad N N N Y N Y Y N N N Y Y Y Y N N- N N- N- N- N- N- N- N- N- Total N-1 N-0 - N-3 3 -8 35 26 27 4 12 16 29 27 5 4

Y=Yes, N=No (MPW = Pharmacist at SC)

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Identification of level- 2 MCH Care Center with gap (12 Units)

Infrastructure / Human Gaps Training Gaps Equipment Resource Identified(Y/N) Name of level-2 Sl. NB MT I MCH Care N De SN / Be NSV/ N Infr No L Stabl M S P / IU M H Centre BC l. AN LT MO Mini SS Trg a Eq. R . O BA MV CD NC R C Eq. M C Lap K stru Unit A I 1 Chiddarwala Y N N Y N Y N N Y N N Y Y Y Y Y Y Y 2 Thano Y N N Y Y Y N Y Y N Y N Y Y Y Y Y Y 3 Nayagaon Pelio Y N N Y N Y N N Y N N Y Y Y Y Y Y Y 4 Rajawala Y N N Y N Y N N Y N N N Y Y Y Y Y Y 5 Tuni Y N N Y Y Y Y Y Y N N N N Y N Y Y Y 6 Kalsi Y N N Y Y Y Y Y Y Y N Y Y Y N Y Y Y 7 Rudrapur Y N N Y Y Y N N Y N N N Y Y Y Y Y Y 8 Dudhli Y N N Y N Y N N Y N N N N Y Y Y Y Y 9 Mehuwala Y N N Y N N N N N N N Y N Y Y Y Y Y 10 Sahaspur Y N N Y Y Y Y Y Y N Y Y Y Y N Y Y Y 11 Mussoorie Y N N Y Y Y Y Y Y Y N Y Y Y N Y Y Y 12 Chakrata Y N N Y Y Y Y Y Y N N Y Y Y N Y Y Y N N- - N- N- N N N- N N- N- N N N N- N- Total N-1 N-10 N-0 0 1 12 0 -5 -7 6 -1 10 5 -3 -0 -5 0 0 2 Y=Yes, N=No

Identification of level- 3 MCH Center with gap (7 Units)

Infrastructure Human Training Gaps Gaps Identified /Equipment Resource Sl. Name of level-3 N NB SN L E MT NSV Bl. S La N IM Infr No. MCH Care Centre O L B Sta. Spec / S M P/ / IU H. T Eq Sto LT B pr SS NC a T R C Un. / ialist AN A O MV Mini CD R. rg . . A o. K I stru. C SNCU M S C A Lap Doon Female 1 Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N N N Hosp. 2 SPS Rishikesh Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y N N Y Y C.Hosp. Prem 3 Y Y N N Y N Y Y Y N Y Y Y N Y Y Y Y Y Y Y Naga. 4 FRU Doiwala Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y N N Y Y 5 FRU Vikas Nagar Y Y Y N Y Y Y Y Y N Y Y Y Y Y Y Y N Y Y Y 6 FRU Raipur Y Y Y N N N Y Y N N Y Y Y N Y Y Y Y Y Y Y 7 FRU Sahiya Y Y N N N N Y Y N N Y N N N Y Y Y Y Y Y Y N N N N N N N N N N N N N- N N N N Total - - - N-6 N-3 - - - N-1 - - - N-1 -2 -0 -4 1 -1 -0 -4 -1 0 0 2 0 2 0 3 0 3 Y=Yes, N=No

25 DHAP Dehradun 2011-12 2525 25

PHC Kerad Tyuni Mapping of MCH Care Center N District Dehradun

Kotikanasar Kandoibharam

Jadi Matiyawa

Uttarkashi CHC Chakrata Buraswa Gadol Naraya Himachal Pipaya Pradesh Haiya Lakhwar FRU Thaina Sahiya

Johadi PHC Kalsi Juddo CHC Mussoorie PHC Sumeth Rudhrapur Charba la FRU wa hi nc Vikasnagar ai CHC K Jassowala PHC Sahaspur Selaqui Rajawala Combine Chandroti Sherpur Hospital PHC Sahaspur Premnagar Krishali Nayagaon Tehri Palio Saharanpur Sabhawala Buddhi Doon Garhwal PHC Bhuntowala Female Mehuwala Hosp. Nanurkhera Sewlakhurd FRU Kargi Raipur

Nehrugram PHC Itharna Thano

Majri Legends FRU : Level 1 (existing units/SC) Doiwala : Level 1 (proposed units/SC) SPS : Level 2 (existing units/PHC/CHC) PHC Rishikesh : Level 2 (proposed units/PHC/CHC) Dudhli : Level 3 (existing units/FRU/SDH/DH) Shergarh : District boundary : Roads PHC Chidderwala

Raiwala Haridwar

26 DHAP Dehradun 2011-12 2626 26

2.5 Logistics Presently there is one dedicated warehouse in the district for stocking medical supplies with a functional system for assessing the quality of vaccines. The existing quality testing system includes checking of temperature chart, expiry dates and physical conditions. No stock outs of any vital supplies are reported during the last one year. Indents from the peripheral facilities are received on a monthly basis. Drug storage facilities are also available at 10 Level–III MCH Centers, 10 Level-II and 8 levels–I MCH Center.

Table 2.5: Logistics Logistics Elements Description Availability of a dedicated District warehouse for 1 health department

Stock out of any vital supplies in last year Nil Indenting Systems (from peripheral facilities to Receive monthly indents districts) Existing system for assessing Quality of Vaccine Checking temperature chart, expiry date, physical condition Source: CMO Office, December 2010

2.6 Training Infrastructure Continuous capacity building of health personnel is one of the most important strategies envisaged in NRHM. Dehradun has one ANM training centre functional with adequate facilities like water, electricity, hostel, teaching aids and common audio-visual aids. Out of 5 sanctioned faculty positions 4 are filled.

Table 2.6: Training Infrastructure ANM Training Centre (Acquired) Key issues Availability of lecture halls Yes 1. 1 Hostels

2. 1 Dining Hall with furniture, safe drinking water and electricity

3. Provide details of Faculty 4 in position

4. Availability of Teaching Aids Common audio visual aids at the facility Adequate

Availability of annual training plans for the last year and achievements of the Yes plan Source: CMO Office, December 2010

2.7 Private Health Facilities The district health office does not maintain records on private health infrastructure. However, the available service statistics (December’10) show that there are 58 Hospital/nursing homes and 247 (App.) Private Allopathic and AYUSH practitioners in the district.

2.8 ICDS Programme The Integrated Child Development Scheme is one of the most critical programmes from the convergence point of view. The complementary nature of job functions of the ICDS worker at the village level and those of the ASHA/ANM strongly advocate convergence of services for better 27 DHAP Dehradun 2011-12 2727 27 accessibility to health care services. Approximately 98 percent of sanctioned Anganwadi centre are operational in the district with all CDPOs /ACDPOs and supervisors in position.

Table 2.8: ICDS Programme No. of Sl No. of No. Of No. Of No. of ACDPO No. Of No. Of . Name of Mini Supervis Mini AWCs s AWWs AWHs N Block AWCs ors AWWs /CDPO o. S O S O S IP S IP S IP S IP S IP 1 Vikas Nagar-R 106 106 2 2 1 1 4 4 106 104 2 2 106 104 2 Doiwala-R 199 194 12 9 1 1 6 6 199 185 12 9 199 174 3 Sahaspur-R 162 161 7 3 1 1 6 7 162 160 7 3 162 161 4 Raipur-R 139 134 4 2 1 1 6 5 139 133 4 2 139 126 5 Kalsi-T 96 95 9 7 1 1 5 4 96 88 9 7 96 83 6 Chakrata-T 98 96 10 7 1 1 5 4 98 92 10 7 98 89 Dehradun- 7 108 107 0 0 1 1 4 4 108 104 0 0 108 101 Urb. Total 908 893 44 30 7 7 36 34 908 866 44 30 908 838 **S=Sanctioned, O=Operational, I-p=In-position Source: Monthly Project Report for the month of December 2010

Activities undertaken by ICDS also include, provision of supplementary nutrition through AWCs to pregnant and lactating women, as well as children below 6 years. With regard to convergence activities with the health sector, children are weighed monthly and classified on the basis of nutritional status. As per the NFHS-3, 32% children’s are stunted, 16.2 % are wasted and 38% are under weight below three years.

2.9 Panchayati Raj Institutions (PRIs)

NRHM has placed strong emphasis on addressing local issues and solutions and making this community-centric through involvement of PRIs. Available information regarding PRIs shows that the district has 403 Panchayat Pradhans out of which 50 percent are males and 50 percent are females. Among the 33 Zila Parishad members 50 percent are females and out of 240 BDC members 50 percent are females.

Table 2.9. Panchayati Raj Institutions (PRIs) Revenue Kshetra S. Nayay Gram Zila Gram Village Panchayat N Name Block Panchayat Panchayat Panchayat Panchayat with Member o. (NP) (GP) Member Member habitation (BDC) 1 Chakrata 9 97 154 40 5 617 2 Kalsi 9 97 204 40 5 593 3 Vikasnagar 5 52 66 40 5 512 4 Sahaspur 6 55 103 40 6 499 5 Raipur 6 55 133 40 5 451 6 Doiwala 5 47 54 40 7 515 Total 40 403 714 (735) 240 33 3187 *Data on the basis of DPRO office December 2010

28 DHAP Dehradun 2011-12 2828 28

2.10 NGOs and CBOs An important role of mother /field NGOs and CBOs is providing support for service delivery activities in the district. NRHM strongly advocates their involvement in community mobilization as a prerequisite for achieving better results. In Dehradun district, the Himalayan Institute of Hospital Trust, Sparsh Janjati Samajik and Sanskritic Organization, Society for Motivational Training and Action (Samta), Organisation for Prosperity Education and Nature (OPEN), DRISTE, MERD, Mamta Samajik Sanstha, Mahila Samajik Sansthan, and Society for Voluntary Approach in Rural Development (VARDAN) are the NGOs working on health, education, women empowerment and sanitation.

2.11 Safe Water Supply As per the planning of Jal Nigam, Jal Sansathan and Swajal Pariyojan many scheme of water supply have to be design and rejuvenate in the district. All three departments are working in swap mode. These schemes are designed for different rural village of district Dehradun to provide safe drinking water supply. There are different types of schemes to feed the village and towns. Portable water plays important aspect of life which affect the health status of human beings because vast majority of communicable disease are water born. These include: Diarrhea including cholera Bacillary and Amebic Dysentery Intestinal worm (Helminthiasis) Typhoid Poliomyelitis Vector born diseases are common where there are stagnant pools of water which leads to breeding of mosquitoes and then spread of vector borne disease. Important amongst disease would be: a) Malaria, b) Japanese Encephalitis, c) Dengue. The component water and sanitation would impact significantly on health.

2.12 Total Sanitation Campaign

Of the total target set till the year 2009 for the construction of individual House Hold latrines 41.61 percent was achieved up to November 09 in below poverty line (BPL) houses and 63.85 percent was achieved in above poverty line (APL) houses. Only 1 Rural Sanitary Mart had been constructed in the district out of five till November 09. Out of total target of 497 school latrines, 268 were constructed which is 54 % of current target and out of 19 anganwadi latrines, 19 (100%) has been built.

Table 2.12: Sanitation Programme Target (till 2010) Achievement (in %) Individual Latrines Constructed APL 24463 15621 (63.85) BPL 37212 15486 (41.61) Rural Sanitary Mart 5 01 (20) School Latrines 497 268 (53.92) Anganwadi Latrines 19 19 (100) Source: Swajal Pariyojana, November 2010

2.13 Situation of Inter-Sectoral Convergence The implementation of an omnibus programme like NRHM is a complex task which requires coordinated and sustained efforts by various related functionaries. Convergence is one major tool for meeting the challenges of Mission. Currently, initiatives of convergence between health and

29 DHAP Dehradun 2011-12 2929 29 other sectors already exist at different levels of the hierarchy. Deliberations at village and block levels have clearly indicated that various departments other than health such as ICDS, PRI, Education, Water and Sanitation have began to think beyond their own workspace and understand the larger responsibility. However, there is an existing lacuna which impedes the synchronization of activities. Though the ICDS department is largely working in close coordination with the health department, involvement of the PRI in health related matters is limited but after formation of Village Health and Sanitation Committees at different revenue village coordination with the department and stakeholder has been improved. ASHAs, trained community health workers, are also working in association with ANMs and AWWs. Interventions by ASHA have provided crucial inputs in improving access to information and services at the grassroots level.

To some extent schools, through the organization of school health programmes, also share a responsibility and provide an effective platform for higher utilization of services and health education. The convergence status of village water and sanitation groups is unsatisfactory. Drinking water supply and sanitation facilities, which are directly linked to conditions of health, are not satisfactory. In order to make convergence a success, roles and responsibilities of each of the functionaries needs to be closely understood. Continuous monitoring and obtaining feedback from each will be an important element in forging the convergence.

To increase participation of Village Health and Sanitation Committee and PRI member at village and block level a training /Orientation is requied, which should be implemented through block level health stakeholder so that coordination will be developed at all level. Convergence brought into activities at community level can greatly benefit the end users.

2.14 Quality of Services

Utilization of health services in Dehradun is low. The major factors that prevent the community from availing of institutional health care services are: low accessibility, inadequate transportation facilities, expenditure involved for transportation, non-availability of doctors, perception regarding quality of services and prevalence of traditional myths and beliefs. In addition low educational levels and socio-economic deprivation create unwillingness among the community to avail of services. During discussions at the village and block levels, community members spoke of an inadequate health care delivery mechanism with a difference in the quality of service between government and private institutions. Due to longer waiting time at government health facilities due to unavailability of staff members and lack of trust, so that the private facilities preferred more. However, because of the predominance of social compulsions and traditional practices, the greatest preferences are for home or the traditional modes of treatment.

30 DHAP Dehradun 2011-12 3030 30

SECTION - B

RCH Flexi Pool

31 DHAP Dehradun 2011-12 3131 31

PART - A REPRODUCTIVE AND CHILD HEALTH -II

3.1 Vision Statement To provide equitable RCH services in particular and health services in general on a mission mode with the objective of bridging the spatial variations and achieving the goals set out in the state policy specifically and national policies at large by improving accessibility to quality services by improved and strengthened infrastructure facilities. The service provision would be attempted through a comprehensive approach through partnerships with private and civil society organizations, increasing public health investments, reducing gender discrimination and involving elected representatives and community at large.

3.2 Technical Objectives, Strategies (or interventions) and activities • Reduce MMR from the present level 315 (SRS 2008) to below 100 by 2012 • Reduce IMR from the present level of 44 per 1000 live births to 30 by 2012 • To reduce the TFR from the current level of 2.55 to 2.1 by 2012 • Increase modern CPR from the present level of 55% to 70% by 2012

3.3. MATERNAL HEALTH

3.3.1 Goal: To provide quality health care services to all women and improve the health status of reproductive age group. 3.3.2 Current Situation:

Utilization of three ANC services is low in rural area that is 28.3% (DLHS-3) in compare to over all totals that is 32.3% (DLHS-3). In rural area majority of women depend on public health facilities due to absence of private facilities and shortage of staff in hill area. As a whole, awareness among women about the various services and social customs and traditional practices of the community govern/direct utilization of either availing ANC or postnatal/post-delivery services. It is planned to cover ANC coverage up to 65% in rural and 80% in urban area during year 2011-12 with the help of ANC tracking software/records at block level.

ANC Registered Data of last three year as per District HMIS 3479

Year 2007-08 2008-09 2009-10 20010-11 (Up to Dece. 10) ANC as per HMIS 29197 35107 40120 25652 Year wise increase in Numbers - 5910 5013 -

Though State has better average then the National but Maternal Mortality Rate is still a great challenge. Our present status of MMR is 315 per lakh (SRS 2008). District plans to bring it down to 100 per lakh by the end of mission period. Institutional delivery and a minimum stay of 48 hours in the hospital after delivery is one of the key interventions that can make difference not only from the point of view of reducing MMR but from the point of view of bringing down the IMR as well.

Deliveries in district Dehradun take place both at home, public and private institution. The home deliveries are attended by untrained and trained persons. Emergency obstetric facility is limited in rural area maximum numbers of these facilities are available in urban hospital, while basic obstetric care in 14 government facilities. At present district have seven level-3, ten level-2 and sixteen levels - 1 MCH Care Center are being providing delivery services as are under:-

32 DHAP Dehradun 2011-12 3232 32

Level I Level-II Level-III Nanurkera, Krisali, Majri, Nehrugram, Chiddarwala, Thano, Doon Female Hospital, SPS Kargi Selaqui, Sahaspur, Buddhi, Nayagaopelio, Rishikesh, Combine Charba, Sabhawala Jeetgarh, Sharpur, Rajawala, Tuni, Kalsi, Hospital Prem Nagar Johari, Lakhwar, Haiya and Buraswa Rudrapur, _ CHC Sahaspur, CHC FRU Doiwala, FRU Mussoorie & CHC Vikasnager, FRU Raipur & Chakrata FRU Sahiya 16 7+3 =10 3+4 = 7

Year wise Institution delivery Achievements

Sl. No Name of Delivery Institution 2008-09 2009-10 2010-11 (Upto Dec. 10) 1 District Female Hosp. 8239 8582 6480 2 SPS Rishikesh 2504 2580 1872 3 Com. H.Hosp. Premnagar 0 73 137 4 CHC Doiwala 851 798 557 5 CHC Raipur 39 82 211 6 CHC Sahaspur 102 68 108 7 CHC Mussoorie 135 114 78 8 CHC Vikas Nagar 977 1041 838 9 CHC Sahiya 178 199 168 10 CHC Chakrata 206 205 96 11 PHC Chiddarwala 0 101 67 12 PHC Dudhali 0 21 0 13 PHC Thano 0 10 5 14 PHC Nayagaon Pelio 7 33 26 15 PHC Rajawala 0 2 0 16 PHC Rudrapur 0 10+4 11+2 17 PHC Kalsi 244 85 67 18 PHC Tuni 117 144 114 19 SC Nanurkera 1 3 5 20 SC Krisali 5 6 4 21 SC Nahrugram 8 11 4 22 SC Majri 0 0 3 23 SC Kargi 6 2 1 24 SC Sahaspur 75 97 165 25 SC Charba 0 16 25 26 SC Selaqui 128 242 196 27 SC Buddi 17 28 30 28 SC Jeetgarh 0 16 28 29 SC Sherpur 0 13 34 30 SC Sabhawala 0 3 11 31 SC Johari 56 39 9 32 SC Lakhawar 16 12 10 33 SC Hayya 60 69 32 34 SC Buraswa 0 13 4

33 DHAP Dehradun 2011-12 3333 33

Year wise Comparison of Institutional Deliveries

2010-11 Years 2007-08 2008-09 2009-10 (Upto Dec. 10)

Institutional delivery in govt. facility 11307 13850 14916 10706 (15500 –estimated)

Year wise increase in Numbers 8322 2543 1066 584

Delivery status (Yearwise)

16000 14932 13850 14000 11307 12000 10706 10000 8000 7150 6000 4756

No. of delivery of No. 4000

2000 2381 2408 0 2007-08 2008-09 2009-10 2010-11 (upto Dec., 10) Years

Institutional Delivery (Public) Home Delivery

Delivery and JSY Beneficiaries Estimation

During the year 2011-12, the institutional delivery will be increase up to 13% of this year (2010-11) estimation achievement of 15500, which will be 17500 in government institution. To Progress of Institutional Delivery achieve this target we have planned to 18000 strengthen and upgrade our seven level-3 (1 14918 15500 15000 13983 DH, 2 SDH, 4 FRUs), twelve level-2 (3 CHCs, 11833 9 PHCs) and 35 Level-1 (SCs) for providing 12000 delivery services. Link workers ASHA also 9000 facilitating and mobilizing expectant mother to avail institutional services for delivery. 6000

Graphical representation of ID progress deliveries No. of 3000 during three years 0 April 0 8 to Ap ril 09 to Ap ril 10 to Proposed March 09 March 10 Decemb er, 10 delivery Year's

34 DHAP Dehradun 2011-12 3434 34

Proposed level-1 and level-2 MCH Care Centers will be upgraded during 2011-12 are as follows:-

S. No. Block Level-I (Sub Center) No. 1 Doiwala Raiwala, Sharegarh 2 2 Raipur Sewalakhurd, Itharana 2 3 Sahaspur Bhuntowala, Chandroti, Kainchiwala 3 4 Vikas Nagar Sumeth, Jassowala 2 5 Kalsi Juddo, Naraya, Matiyawa, Pipaya, Gadol, Thaina 6 6 Chakrata Kandoibharam, Kotikanasar, Jadi, Kerad 4 Sub-Total 19 S. No. Block Level-2 (24X7 PHC) No. 1 Doiwala Dudhali 1 2 Raipur Mehuwala 1 Sub-Total 2 Total 21

The DLHS–III survey put the District’s institutional delivery at 54.8 % (2007-08). District is hopeful that by the end of mission period it will be around 80% (including Public and Private). This upsurge has been more due to the benefits that are being extended to the communities under Janani Suraksha Yojana (J SY) and mobilization through ASHAs.

Married women between the group of 15 to 49 years of age the anemic percentage is 47.6 (NFHS-III) and the percentage of pregnant women who are anemic in above age group is 45.2 (NFHS-III), which shows that nutrition status among women is not good in the district/state, which required special intervention to reduce this percentage level.

Similarly, awareness of RTI is very low among women i.e. 45.5% (DLHS-3). The ANMs will be oriented in syndrome management and awareness programme for ASHA and Anganwadi as well. Menstrual Hygiene training is also proposed to ANMs and ASHAs during the year 2011-12.

In regard to MTP/MVA facility, there are few doctors offering services. Most of the doctors are trained to provide services in public institution but women shy to avail this service especially in tribal block (Chakrata & Kalsi) at public facilities. It is also due to the fact that there is often an inherent need of confidentiality attached with such cases and general insensitivity of public health functionaries tends to force the service seekers to approach private practitioners, even though they may be unqualified. To sum up it concrete that the maternal health indicators in the district and utilization of various services was not good. The reproductive health indicators among urban women were better than their rural counterparts and also among women from other caste group in comparison to SC/ST women.

3.3.3 Problems/Constrain: • Deliveries are conducted at home due to social customs and traditional practices of the community govern/impede utilization of availing institutional delivery, ANC or postnatal/post-delivery services. • Literacy and poor living standard of rural population. • Perception of ANC services being non essential and lack of awareness regarding these services were primary reasons for not seeking ANC services • Involvement of ASHA with women/community is low.

35 DHAP Dehradun 2011-12 3535 35

• Pregnant women availed complete antenatal check up in rural area because of unavailability of private services provider. • Awareness regarding pregnancy complications is high but proportion of women seeking services remain low because of unavailability of services • Treatment seeking by women in rural areas for delivery and/or post delivery complications is very low in compare to urban area.

3.3.4. Objectives:

The basic objectives for different indicators of maternal health are as below:-

• Reduce maternal mortality rate (MMR) from 315/lakh to 100/lakh up to mission period. • Reduce the anemic level of pregnant women from 47.6 (NFHS III) to 30 percent. • Increase the percentage of pregnant women receiving three ANC and PNC services. • To increase awareness about Menstrual Hygiene among women especially adolescents girls. • Availability of IFA tablets in all sub center and ASHA as well. • Availability of counseling and treatment of RTI/STI services in Level 2 & 3 MCH care centers with the help of ICTC. • Availability of MVA/MTP services in Level 2 & 3 MCH care centers for safe abortion services. • To increase Institutional delivery up to 13% of last year estimated achievement (15500) during the year 2011-12.

3.3.5 Out comes: • Reduction in maternal mortality rate (MMR). • Reduction in percentage of anemic pregnant women. • Increase in percentage of pregnant women who receiving ANC (1-2). • Increase in percentage of pregnant women receiving ANC services (3+). • Increase in percentage of pregnant women receiving IFA tablets. • Increase in percentage of awareness about Menstrual Hygiene in women. • Increase in percentage of pregnant women receiving TT. • Timely Identification and referral of complicated pregnancy. • Increase in counseling and HIV testing of expectant mother in ICTC. • Increase in Institutional delivery especially in government institution.

3.3.6. Strategies: In order to achieve the above objectives, the following strategies are planned: • Increase coverage in ANC and ensure all complications receive timely attention. • To develop awareness among pregnant women about nutrition with the help of ASHA. • To increase access to early & safe abortion services at Level 2 & 3 MCH care centers. • To reduce anemia in pregnancy through distribution of IFA during 1st ANC Checkup. • To increase awareness about Menstrual Hygiene in women through training and safe practices. • To increase counseling and HIV testing of expectant mother in ICTC. • To strengthen 9 PHC into 24 x 7 (Level –2) institutional delivery centers namely as Tuni, Kalsi, Rudrapur, Nayagaon Pelio, Rajawala, Mehuwala, Thano, Chiddarwal & Dudhali. • Availability of doli in hard to access area to transport expectant mothers at road head to convert home delivery in institutional delivery. • Services of 108 dial ambulance will be taken for referral transport and communication systems. • To make 35 sub centers (Level -1) of 168 provide MCH care service. 36 DHAP Dehradun 2011-12 3636 36

• Availability of BP instrument, hemoglobin meter, weighing machine, TT vaccine etc at SC level for identification of complicated delivery. • To upgrade existing level-3 (4 FRUs) and sub divisional district hospital from Basic Obstratic Care Services to Emergency Obstetric Care level services. • Increase mandatory PNC in both home and institutional delivery situations. • To improve access to RTI/ STI services in all PHCs and CHCs. • BCC activity especially in rural area to promote of ANC services and Institutional delivery especially for VHSC members, female pradhan and panchayat member.

3.3.7. Activities Proposed to meet out the above strategies:

(a) RCH Camps:

During the year 2011-12 district Dehradun plans to conduct on an average 9 RCH camps in each block. This implies that district will be organized approximately 54 RCH camps in a year covering all the 6 blocks. If require the block target may be shifted to other block.

RCH Camps conducted at CHC and PHC level are found to be highly effective and benefited a large number of clients. These camps provide a wide range of services including Gynecologist, Surgeon, Pediatrician, Anesthetist, Ayush doctor, Antenatal and Post natal checkups, TT, vaccination, IFA distribution, RTI/STI treatment along with services related to child health and family planning. During the camp Antenatal check up will be done with taking through taking BP, hemoglobin test, weighing of pregnant women etc. to identify the complicated delivery timely referral to higher facility.

It was being felt widely that to strengthen and enhance the effectiveness of camp a wide publicity through banners print materials and public announcements is required to reach out and inform the maximum possible number of clients.

The camps will be held at health centers that have the requisite facilities and health infrastructure necessary for providing all RCH services.

RCH Camp Progress and Achievement

Male Female Sterilization Total Nirodh Sl. No. Of Sterilization No. of Year Steriliz No. RCH Mini Abdo. Genera IUD New Old Lepro NSV ation Total lap Tubec. l users Users 1 2 3 4 5 6 7 8 9 10 11 12 13 1 2009-10 48 740 94 0 0 71 900 155 1141 958 2505 2010-11 2 44 565 43 0 1 57 665 104 516 717 2066 (Dec,10) Oral Pills Check IFA to TT to Imm. Checkup Pregnancy Test Sl. Couns RTI/ Year Up of Expectan Preg. of of women No. New Old eling STI Total Positiv Expect t Mother Mother Child. / Expect. users Users by LMO Test e 1 2 14 15 16 17 18 19 20 21 22 23 24

1 2009-10 331 295 593 544 306 535 2066 1084 398 844 71 2010-11 2 341 424 367 1209 308 540 1673 732 235 706 77 (Dec,10)

37 DHAP Dehradun 2011-12 3737 37

Activities: • Wide publicity will be given prior to the RCH camp, covering villages and towns in the catchment areas. • A detailed schedule of camps will be prepared at the district level with dates, venues, list of doctors, staff nurses, lab technicians, pharmacists and other paramedical staff. • All line departments, Panchayat members, NGOs, ASHAs, Dais, ANMs and AWWs will be provided all the details about the RCH camps. • Proper ANC coverage to pregnant mother to identify complicated pregnancy.

Budget for activity:

Sl. No. Camp Detail No. of Camps Rate / Unit cost in (Rs.) Total Amount (Rs.) 1 First two Quarter 18 7500.00 1,35,000.00 2 Second two quarter 36 7500.00 2,70,000.00 Total 54 7500.00 4, 05,000 .00

RCH camp will be organized in different health institution of district with a target that 33% (18) out of total 54 RCH camps will be organized on first two quarter of the year @ Rs. 7500.00 per camp and rest 67 % (36) RCH camp will be organized in last two quarter @ Rs.7500.00 per RCH camp.

(b) Village Health and Nutrition Day (VHND)

The basic objective of organizing Village Health and Nutrition Day in AWCs is to provide momentum to the efforts towards increasing early registration, ANC checkups, counseling on institutional deliveries, counseling on breastfeeding, family planning, immunization, menstrual hygine etc. leading to better maternal and child health. Village Health and Nutrition Days proposed to be organized once in a months at each Anganwadi Centre. ANM, Anganwadi Worker and ASHA will ensure their presence on Saturday (as per Schedule) and will coordinate to make this activity at village level an effective intervention. During the VHN Day, CHC/PHC wise supervisor/ HV/BPMU will be responsible for Supervision/monitoring of VHND in their respective area.

Progress and achievement of Village Health & Nutrition Day

Referral Immunization 0 to 1 years Childrens Regist. TT to IFA to Targe Orga of high Year of ANC Expect Expecta t n. risk DPT Polio Mea Vita mothers ant. nt BCG Pregnancy sles min Dose-1 Dose-2 Dose-3 Dose-1 Dose-2 Dose-3 A 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 1238 2009-10 8412 6593 9986 12208 17914 1534 8918 9018 8847 8405 8243 8168 9119 9095 6 2010-11 1293 8412 7286 10546 12879 18811 2720 9001 9731 9462 9054 8935 8787 9753 9654 (Dec,10) 8 Immunization 1 to 2 Immuni Identifi No of Grading of Mal Nutrition No. of years Children’s zation 3 Nirod Distrib cation person Child Targe Distributi IUD Year to 5 distrib ution and particip t on of ORS insertio Vitami years uted of OCP referral . in Grade- Grad Grad Gra Polio DPT n n- A children of Counse 1 e-2 e-3 de-4 Handic. ling 1 2 17 18 19 20 21 22 23 24 25 26 27 28 29 30

2009-10 8412 8152 9204 14102 13868 40186 221674 23252 1031 497 130335 3081 1268 195 27 2010-11 8412 8152 9204 14102 13868 40186 221674 23252 1031 497 130335 3081 1268 195 27 (Dec,10) 38 DHAP Dehradun 2011-12 3838 38

Activities:

• ANC checkup of expectant mother to identify complication’s weight, hemoglobin test, BP etc. and timely referral of complicated delivery. • Counseling of expectant mothers on ANC, Safe and Institutional Delivery, PNC and Nutrition • Counseling on menstrual hygiene and use of safe sanitary pads. • Counseling expectant mother for HIV testing in health institution if required ANM will refer to ICTC. • Counseling on early and exclusive Breastfeeding to expectant mother • Counseling supplementary feeding to above four month child and Child Immunization • Counseling of Family Planning methods. • Specific IEC materials will be developed to ensure their availability at the level of ANMs and ASHA for counseling and motivating clients at VHND. • Focal Group Discussion, where maternal death taking place. • Awareness on Safe Drinking Water and Clean Environment. • After completion of each Village Health and Nutrition Day, ANM and AWW will also prepare a report of that day activity and submit that report to their respective area wise departmental heads with join signature. • ANM & AWW will be responsible for referral /treatment of malnutrition children of respective Anganwadi centre to area wise PHC/CHC. • BPMUs/Health Supervisor will be responsible for monitoring up to 20% of total VHND in their respective block, advance plan of monitoring and tour report should be also submitted to DPMU in proper format in time. • A new reporting format for VH&N Day will be circulated to Sub Center level, in which name of beneficiary’s will be maintained at the time of providing services in AWCs.

Block wise distribution of Village Health and Nutrition Day: No. of VH & Proposed Proposed No. of VH No. of * ND and Sl. Name of AW Center & ND and AW Outreach Camps Outreach No. Block for VH & N Outreach Center for inaccessible Camps in Day Camps area Year 1 Chakrata 95 93 0 93 1116 2 Kalsi 95 95 0 95 1140 3 Vikas Nagar 106 91 22 113 1156 4 Sahaspur 161 144 0 144 1728 5 Raipur 137 142 25 167 2004 6 Doiwala 197 137 4 141 1692 Total* 791 702 51 753 9036 Note-VH&N Day planning on the basis of 2009-10 AWCs. * Including out reach camp.

Budget for activity:

Sl. No. Activity No. Rate/Unit cost in (Rs.) Total Amount (Rs.) 1 VH & ND 12 x 753 125.00 11,29,500.00

39 DHAP Dehradun 2011-12 3939 39

(c) Staff Nurse Required for 9, Level-II units (27 –Staff Nurse)

As per DLHS–III Institutional Deliveries in the District has shown an improvement and has been reported as 54.8 % in compare to DLHS– II which was 31.6%. It shows that the percentage of people preferring deliveries in the public institutions has increased. This has been due to the wider publicity and the associated benefits of the Janani Suraksha Yojana. The demand has increased and obviously the need of the hour is to provide facilities at all level including PHCs and Sub Centre.

During the year 2011-12 it is planned that two more PHC (level-2) will be upgraded for providing 24 X 7 services name as Dudhli and Mehuwala. Efforts are on to bridge this gap and to achieve the overall target of making all the institution of this level as a level-2 MCH Care Centers.

It will ensure that the availability and placement of three Staff Nurses for a 24 X 7 level-2 facility. In district total, nine level-2 MCH care center will be providing 24X7 services with the help of contractual Staff Nurse. If required Skilled ANM / LHV who can conduct delivery will be deployed to make availability of three persons till the district gets sufficient number of Staff Nurses as per the IPHS norms.

Activities:

• Efforts to upgrade 9 Level-II as per IPHS norms for providing 24-hour delivery services will be made to provide round the clock services. • All 9-health institutions will be equipped to provide 24 x 7 delivery services based on gaps identified with the help of facility survey. • Purchase of equipment, based on gaps identified with the help of facility survey • Residence of staff as per requirement of facility survey. • To provide 24 x 7 delivery services at all 9 Level –2 MCH Care Centers. District will appoint 27 staff nurses on contractual basis for these institutions during F.Y. 2010-11. (including existing staff Nurse) • Replacement/renewal of existing Staff Nurse contract as per his/her performance.

Budget for activity:

Name of No. No. Rate/ Sl. No. S.N. in Req Total of S. N. Position Unit N 24 x 7 delivery uire Amount Block 24X7 Req cost in o. units/Level -II d (Rs.) PHC u. Regu . Con . (Rs.) 1 Chakrata Tuni 1 3 - 3 3 18000 6,48,000 2 Kalsi Kalsi 1 3 - 3 3 10000 3,60,000 3 Vikas Nagar Rudhrapur 1 3 - 3 3 10000 3,60,000 Nayagaon 4 Sahaspur 2 6 - 6 6 10000 7,20,000 Pelio, Rajawala Thano, 5 Raipur 2 6 - 6 6 10000 7,20,000 Mehuwala Chiddarwala, 6 Doiwala 2 6 - 6 6 10000 7,20,000 Dudhali Total 7 27 - 27 27 35,28,000

40 DHAP Dehradun 2011-12 4040 40

(d) Operationalised Sub Center (Level-I) for institution delivery

At present out of 168 level -1 MCH Care Center, 114 Sub centre are functioning in government building and 54 in rented building (up to 31 March 2011, 4 more will be handed over to district). To improve institutional delivery numbers in sub center, it is planned to up grade 19 more sub centers. It has been observed that the percentage of people preferring deliveries in the public institutions has been increased due to the wider publicity and the associated benefits of the Janani Suraksha Yojana. In the year 2011-12, district planning to 19 more Sub Center will provide delivery services, either ANM will be trained in SBA or the skilled ANM who can conduct delivery will be deployed in each sub center. Instrument and equipment will be purchase for respective sub center after gap identification as per IPHS norms. (If require through untied)

Activities:-

• Identified gap level-1 (Sub Centers) will be fulfilled in time. • Rent for Sub Center functioning in rented building will be provided. (@ Rs. 250/- per sub Center) • Monthly Honorarium will be paid to part time dai for helping ANM at sub center @ Rs. 100/- per month • Purchase of equipment, based on gaps identified with the help of facility survey. • SBA training of 28 ANMs for performing delivery at Sub Center

Sub Center in Government Building with labor Room Sl. No. Name of Block No. of S. C. SC with Labour room SC with Labour room 1 Chakrata 28 02 26 2 Kalsi 29 09 20 3 Vikas Nagar 27 07 20 4 Sahaspur 29 11 18 5 Raipur 32 13 19 6 Doiwala 23 07 16 Total* 168 49 119

Budget for activity: Sl. No. Activity Head No. of SC Unit Cost (Rs.) Amount Required 1 Sub Center Rent 50 250X12 1,50,000.00 2 Part time Dai 150 100X12 1,80,000.00 Total 3,30,000.00

Note: The budget of SC will meet-out from RCH Flexipool.

(e) Up gradation of FRUs (Manpower gap)

In district total level-3 (4 FRUs) are functioning and providing 24X7 institutional delivery services with the help of contractual Staff Nurses. A sufficient number of staff nurses are not posted on regular basis. So in each level-3 (FRUs) at least existing 3 Staff Nurses required to provide these services on facilities on contractual basis.

Activities:

41 DHAP Dehradun 2011-12 4141 41

Appointment/Placement of 12 staff Nurse on Contractual basis. 09 Staff Nurses in Plain area and 3 Staff Nurses in Hill area level- 3 MCH care center. SBA Training for Staff Nurse, if required. Training of nurses on new born care and stabilization at least of 3 to 4 days.

Budget for activity: Sl. No. Activity Head No. of SC Unit Cost (Rs.) Amount Required 1 Staff Nurse in Plain 9 10000.00X9X12 10,80,000.00 2 Staff Nurse in Hill 3 18000.00X9X12 6,48,000.00 Total 17,28,000.00 Note: This budget will be meet-out from NRHM Additionalities.

(f) PC & PNDT Awareness Campaign at District level

Sex ratio may have shown an improvement at state level (964 as per 2001 census) from its previous findings (927 as per 1991 census), but the situation in the age group of 0 to 6 years is quite alarming which for the State stands at 906 / 1000. Even in general category it is as low as 893 in the district Dehradun. Out of various reasons, one has been widely tipped as the main reason sloping the scale in unfavorable manner is the misuse of available diagnostic facilities and illegal abortions.

PC&PNDT Act prohibits sex determination tests and its enforcement is not very effective in many places. In the preceding two years efforts have been on to recognize all the diagnostics clinics having ultrasound facilities in the district. Violations were reported in few ultrasound centers against which severe actions were taken by the district authorities. Strict enforcement of the act involving all the enforcement agencies will be ensured.

Apart from the above initiative communication campaign at district level will be conducted to make service providers and general population aware of PC&PNDT Act. Activities: • Action against illegal/unregistered diagnostic facilities and clinics. For this sensitization of officials of enforcing agencies is proposed. • Organized awareness and sensitization two work shop for ultrasound center and law enforcement agencies in the district @ Rs 50,000/-per work shop. • Implementation of PNDT act will be reviewed and all necessary measures will be initiated for its strict enforcement. • BCC/IEC campaign will be conducted addressing both private and public health service providers. • Orientation workshop/Training will be organized for ASHA and AWW to aware community on PC&PNDT acts in each block.

Budget for activity:

42 DHAP Dehradun 2011-12 4242 42

Sl. No. of Unit Cost Amount Activity No. Participants (Rs.) Required PC & PNDT Workshop at district level 1 50 50000 LS 50,000.00 for ultrasound centers. PC & PNDT Workshop at district level 2 50 50000 LS 50,000.00 Law enforcement agency Orientation workshop/ Training for 3 60 25000 LS 1,50,000.00 ASHA and AWW at 6 block level Total 2,50,000.00

(g) SBA – Training

All level-3, level-2 and level-1 are expected to provide delivery services. The district societies will be responsible for coordinating the training programs for participants. During the current year 2010- 11 district had trained 3 SN and 12 ANMs up to December 10. The districts will be going to conduct training in 10 batches (4 participants each) during the year 2011–12. The training will be organised for 12 staff nurses and 28 ANMs in the district .

Budget for activity:

Sl. No. of Unit Cost Activity Amount Required No. Participants (Rs.) Skill Birth attendant Training at 1. 40 5500 LS 2,20,000.00 district level Total 2,20,000.00

(h) MVA /MTP

In year 2011-12 MVA /MTP training has been planned for 2 Medical Officer of PHCs by experienced and qualified trainers. They would also be sensitized towards ensuring the secrecy and confidentiality of the women undergoing MVA/MTP. This would ensure availability and greater acceptability of safe MTP services at the public institution.

The trained MOs would be provided MVA kits for MVA. MVA is the safest method for abortion till 12 th week of pregnancy. The ANMs would be oriented to provide counselling advice regarding the appropriate time and safe methods of getting an MVA/MTP done. They would also inform the women about the location of the nearest available MVA/MTP clinic. This would reduce mortality due to unsafe and poorly administered MVA/MTP.

Activities:

• MTP/MVA training will be provided to 2 Medical officers during year 2011-12. • After completion of training, successful trainees will be certified and authorized to conduct MTPs. • All training programs conducted for MOs will emphasize the need to maintain confidentiality and privacy. • All sites providing the MVA services for abortion will be publicized with proper display boards at each facility.

43 DHAP Dehradun 2011-12 4343 43

• IPC methods through ANMs, ASHAs and AWWs will be adapted to aware women about availability of safe abortion.

(i) Janani Suraksha Yojana (JSY)

The benefit of JSY will be provided to all beneficiaries as per norms. The target of making at least 85 percent deliveries in the district institutional by the end of mission period seems to be an achievable.

An estimated target of the district is to cover at least 75 % (25,184) of total deliveries in public and private institution (70% public & 30% private approx) on the estimated target 33,578 deliveries (100% of district), during year 2011-12. The benefit of JSY will be provided to all beneficiaries as per norms. As per the last three year JSY/institutional data trend reflects that during the year 2011-12 institutional delivery of Dehradun will be approximately 17500 (public ID). Out of total institutional delivery in public health institution 70% (12250) will be rural benefieries and 30% (5250) will be urban benefieries. Estimated JSY home delivery for the year 2011-12 will be 10% (2518 Approx.) 10 % of total proposed institutional deliveries.

Delivery and JSY Beneficiaries Estimation

Population of District in year 2001 12,82,143 Total Estimated Population for 2011-12 15,98,961 2.18 % growth per year in Population Estimated 100 % delivery of district 33,578 On the basis of per year growth rate Estimated 75% delivery of district 25,184 Proposed for the year 2011-12 Estimated 70% delivery in Government 17,500 70% deliveries of total ID (25,184) Facilities (Approx) Estimated 30% delivery in Private Hospitals 7684 30% deliveries of total ID (25,184) (Approx) Rural Beneficiaries will be 70% of total ID in 12,250 70% deliveries of total ID (17500) Government Facilities Urban Beneficiaries will be 30% of total ID in 5,250 30% deliveries of total ID (17500) Government Facilities Assumed JSY home deliveries benefieries 2,518 10% deliveries of total ID (25,184)

At district level efforts are required to keep the momentum and to improve upon the issue of converting the domiciliary deliveries into institutional deliveries. At community level, all men and women will repeatedly inform about availing institutional facilities for deliveries. Need for using health facilities for deliveries will be central point of counseling in all interactions between ASHA/health workers and pregnant women.

District is trying its level best to strengthen Institutional infrastructure, make available qualified and skilled personnel at all institutions. Especial emphasis on women from the Scheduled Castes and Tribes, other poor section and vulnerable group of the society, increased emphasis on institutional deliveries at service provider’s level and improved infrastructure will result in higher proportion of women availing delivery services in public health institutions.

Since accessibility is one of the prime concern efforts is on to bridge this gap to some extent by introducing efficient ambulance services on call toll free number–108, under PPP mechanism and doli (Manual transportation system) at hard to reach un served /under served area.

44 DHAP Dehradun 2011-12 4444 44

Activities:

• Availability of EDD list with ASHA to escort expectant mother in time. • EDD list will be provided to near by 108 ambulances through ASHA /ANM/AWW. • JSY registration of pregnant women at the time of ANC registration as per the norms of GoI under JSY scheme. • Publicity of 108 emergency services for promoting free transport to pregnant women particularly during nights. • Linkage of 108 transport or local transport with doli at un-served /under served area to promote institutional delivery. • Women preferring deliveries in Govt. Institute (General ward) will be getting benefit as per the norms of GoI under JSY scheme.

Budget for activity:

Sl. Activity No. of Unit Cost (Rs.) Amount No. Delivery Required A 1 Institutional Delivery at Govt. Institution 5250 1200.00 63,00,000.00 (Urban) 2 Institutional Delivery at Govt. Institution 12250 2000.00 2,45,00,000.00 (Rural) 3 Home Delivery 2518 500.00 12,59,000.00 Sub Total (A) 3,20,59,000.00 B1 48 Hours stay at institution of Mother and 9625 200.00 19,25,000.00 New Born (9625-55% of ID) B2 Doli/Palki for transportation of Expectant 200 400.00 80,000.00 Mother from Interior Village B3 Institutional delivery Incentive LS @ 300.00/400.00 2,00,000.00 Sub Total (B) 22,05,000.00 Total 3,42,64,000.00 Administrative Cost (5%) of JSY head (A) 16,02,950.00 Grand Total 3,58,66,950.00

(j) Incentive Package for Institutional Delivery Promotion:

To promote institutional delivery in peripheral institutions such as level-2 and 1 MCH Care Centers an innovation was proposed during last year 2009-10 and 2010-11. In which public health institutions those performed more deliveries during this year in comparing last year will be awarded incentive against per increasing of deliveries. Incentives proposed not only for the institution in particular but also the for the manpower involvement in achieving those benchmarks. This incentive will be applicable for CHCs, PHCs and Sub Centres only.

This will have a dual benefit, by generating the interest of the manpower going for more and more institutional deliveries and by leading to a lesser case load at district hospitals. Incentive will be distributed to all following staff involved in institutional deliveries as follows as per achievement.

45 DHAP Dehradun 2011-12 4545 45

Sl.No Detail FRU/CHC/PHC SC 1 Doctors Rs 200.00 - 2 Staff Nurse/ ANM Rs 75.00 Rs 200.00 3 Forth Class Rs 50.00 Rs 50.00 4 Institution Rs 75.00 Rs 50.00 Total Rs 400.00 Rs 300.00

Achievement of delivery incentive :

2009-10 2010-11 (Upto Dec, 10) Health Facilities Physical Financial Physical Financial CHCs 225 90000 171 68400 PHC's 266 106400 73 29200 Subcenter 317 95100 204 61200 Total 291500 158800

A budget proposed on the basis of difference of current year (2010-11) target with proposed target for the year 2011-12 i.e. Rs. 2 lakhs has been earmarked in JSY head.

(k) Prevention and treatment of RTI / STI

One of the major concerns in this regard that the percentage of women aware about RTI/STI is only 45.5% (DLHS-3). One of the major reasons behind it is poor awareness among the grass root population and untrained public health staff at the Sub centre & PHC level. The basic intervention activities will be strengthening all level-2 and level-3 staff for diagnosis and treatment of RTI/STI. This training programme will be dovetail will UKSACs.

Activities:

• Orientation cum treatment training programme 20 Medical Officer and 20 Staff Nurses has been planned during the year 2011-12. • Coordination will be developed with ICTC for compulsory counseling and HIV testing of expectant mother. • Service guidelines will be made available to all institution. • Establishing ICTC at the CHCs Promote awareness regarding causes, prevention and early treatment seeking behavior for RTI/STI • Strengthening lab services at all level-2 and level-3 MCH care centers. • Regular supply and availability of essential drugs, reagents, VDRL kits • Awareness regarding RTI/STI and importance of seeking timely care. • The integrated BCC and IEC strategy will include the following activities as reflected in Pictorial hand book on RTI/STI for the rural population.

Orientation cum treatment training programme 20 Medical Officer and 20 Staff Nurses prgramme will be tie-up with UKSACS.

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3.4. CHILD HEALTH

3.4.1. Goal:

To provide quality health care services and improve the health status of all children.

3.4.2. Current Situation

Similar to maternal health child health also is a cause of concern in the district. The current IMR status being 44 per thousand live births (SRS-2008) which have to bring reduce up to 30 per 1000 by the end of the mission period. Total estimated population for the financial year 2011-12 of district 15,98,961 children below the age of 12 month will be 34,857 (2.18 % of estimated population) and 2,71,823 (17 % of estimated population) will be the under the age of five. Current full immunizations status is 68.7% (DLHS-III) and plans to increase it up to 85% during year 2011-12. Women feeding colostrums to new born child within one hour of birth is 48.9% and exclusively breast feeding less than six months 48.1% (DLHS-III) the status of breast feeding to newly born children will be increase up to 60 % during the year 2011-12. In between the age group of 6 to 35 month the anemic children are 61.5%, which is very high (DLHS-III)

Focus on strengthening routine immunization remains the key intervention apart from activities ranging from promotion of early and exclusive breast feeding practices. New born corner and new born stabilization units will be established upto level-2 and 2 MCH Care Centers level, which improve the IMR in the district. Medical Officers, Staff Nurses and ANMs will be trained in IMNCI, NSSK and SBA etc.

3.4.3. Constrain/Problems

• Vacant post of Doctors/Peditrician at PHCs/CHCs particular in rural area. • Unavailability of service provider especially for immunization in rural area. • Lack of knowledge of child care due to illiteracy and poverty in rural area. • Weak Neo Natal checkup in institution and also in home visits. • Lack of nutrition counseling of family through health volunteers • Low awareness among villagers about nutrition and sanitation in rural area. • Non availability of transportation mechanism to avail health services

3.4.4. Objectives:

The basic objectives for different indicators of child health are as below:-

• Reduction in Infant mortality rate (IMR) from 44/1000 to 30/1000 up to mission period. • Coverage of complete immunization of children in 12-23 months from 68.7% (DLHS-III) to 85 percent by 2012 • To increase awareness of nutrition and sanitation among women and children through ASHA/AWW. • To increase the percentage of three neonatal check up services • To establish new born stabilization and care unit in level- 2 & 3 MCH care unit. • To increase newborn care at the time of delivery at new born stabilization unit. • To increase first week of postnatal care. • To increase clinical care, especially Diarrhea, ARI and childhood illness. 47 DHAP Dehradun 2011-12 4747 47

• To increase children exclusively breastfed for first six months 48.1% (DLHS-III) to 65% during the year 2010-11. • To ensure refrerral of malnutrition children at level-2 and level-3 MCH care centers for proper treatment.

3.4.5. Out comes:

• Reduction in Infant Mortality Rate (IMR) • Increase in coverage of complete immunization of children from 12-23 months. • Awareness of nutrition and sanitation will increase among women and children. • Increase in percentage of PNC and Neonatal checkup. • Increase percentage of colostrums and exclusively breastfed for first six months of children. • Increase percentage of newborn care at the time of delivery at new born stabilization unit. • First week postnatal care will be increase. • Increase in clinical care, Diarrhea, ARI and childhood illness. • Decrease in the percentage of malnutrition children.

3.4.6. Strategies: In order to achieve the above objectives, the following strategies are planned:

• Increase safe and institutional delivery. • Increase coverage in ANC, PNC and immunization. • Strengthen 24X7 delivery institutional • Establishment of new born corner and stabilization unit at level-2 and level-3 MCH care centers. • Postnatal care in First week at each level-2 and level-3 MCH care centers. • To increase awareness and services in clinical care, especially Diarrhea, ARI and childhood illness. • Awareness in children exclusively breastfed for first six months to 65% by 2011-12. • Ensure care of malnutrition children with linkage through mid day meal and posha-ahar at AWC and refrerral to higher center for treatment, if required.

3.4.7. Activities Proposed to meet out the strategies:

(a) Integrated RCH Camps:

As it has been mentioned earlier in the maternal health section, District will be organizing Integrated RCH Camps to extend RCH services in the regions that usually are underserved or un-served because of poor infrastructure and shortage of manpower. This includes Child Health services. Immunization services along with counseling on Breastfeeding, supplementary feeding etc. will be provided to the mothers and other family members during these camps.

(b) Early ANC Registration to Breastfeeding Package (including birth registration) for ASHA:

During the year 2010-11 an incentive package on bunch different activity of Rs 250/- was implemented in state, in which ASHA will get an incentive against in each activity, when she escort expectant /lactating mother in ANC, IFA, TT, breast feeding and child birth registration in each child.

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This package improve the status of Early ANC registration, 3 ANC check up, TT immunization, IFA tablets, early breast feeding and birth registration at various level.

This incentive amount to ASHA package will help to identify the danger sign expectant mother and reduce IMR and MMR with taking precaution in time.

During the year 2011-12 this incentive package of services is also proposed with a revision in existing packages from Rs. 250.00 to Rs. 500.00 as follows: -

Incentive Package Proposed Incentive Package Sl.No Detail of Services during 2010-11 during 2011-12 1 Registration of ANC Rs 20.00 Rs 40.00 2 ANC-1 Rs 20.00 Rs 40.00 3 ANC-2 Rs 20.00 Rs 40.00 4 ANC-3 Rs 20.00 Rs 40.00 5 IFA Rs 40.00 Rs 60.00 6 TT-1 Rs 30.00 Rs 40.00 7 TT-2 Rs 30.00 Rs 40.00 8 Breast Feeding Rs 50.00 Rs 50.00 9 Birth Registration Rs 20.00 Rs 50.00 10 Micro Birth Planning _ Rs 100.00 Total Rs 250.00 Rs 500.00

As an impact/result of this package services the ANC to Birth registration services will be increased.

Achievement of incentive package :

Sl. Incentive 2009-10 2010-11 (upto Dec,10) Detail of Services No (Rs.) Physical Financial Physical Financial 1 Registration of ANC Rs 20.00 5928 1,18,560.00 4766 95320.00 2 ANC-1,2 & 3 Rs 60.00 6639 3,98,340.00 3952 237120.00 3 IFA Rs 40.00 6118 2,44,720.00 4423 176920.00 4 TT-1 & 2 Rs 60.00 6021 3,61,260.00 4712 282720.00 5 Breast Feeding Rs 50.00 6023 3,01,150.00 3873 193650.00 6 Birth Registration Rs 20.00 6084 1,21,680.00 3111 62220.00 Total Rs 250.00 15,45,710.00 1047950.00

Activities:

• Early Micro planning of birth, ANC registration, 3 ANC check up, TT immunization, IFA tablets, early breast feeding and birth registration through ASHA. • Area wise MOIC/BPMU/HV/ANM will coordinate these activities with the help of ASHA. • Cross verification each above activity by ANM/HV/BPMU/MOIC at each level. • Counseling on Early and exclusive breastfeeding practice will be increased with the help of ASHA • Timely payment of incentive package to ASHA if she motivate expectant/lactating mother. • Awareness promotion through IEC material and BCC at various health facility level

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Budget summary: -

Sl. No. of Unit Cost Amount Activity No. units (Rs.) Required Early ANC Registration to Breastfeeding 1. 8000 500.00 40,00,000.00 Package for ASHA Total 40,00,000.00

(c) Complete Immunization of Children:

The universal immunization program was launched to protect all infants (0-12 months) against six major but preventable diseases namely Tuberculosis, Diptheria, Pertussis, Tetanus, Poliomyelitis and Measles. DLHS-III shows that the complete Immunization percentage has increased from 31.3% to 68.7%.

During the year 2011-12 the complete immunization coverage in the district will be improved by reducing the drop-out rates between the doses. Immunisation tracking programme/software will help children information at block level which will strengthened the system of identify children dropping out and proper follow up mechanisms will be established at each level to immunised them. ASHA will help and provide assistance to mobilizing those children who are not covered by immunization program. More training and manpower will be placed. Special campaign in un-served and under served areas will be organised.

Activities:

• Compilation of immunization data children wise /area wise to track drop out children • ANMs prepare and provide immunization cards to mothers and retain one copy with them. However, children not turning up for the second dose are neither monitored nor followed up by ANM and ASHA. Monitoring systems will be strengthened to drastically reduce drop out rates. • Special efforts will be made to identify children not immunized at all. Community support will be sought and link person services will be utilized to mobilize such children. • ANMs spend two to three days in a week to carry vaccines from CHCs/PHCs to villages. This precious time of ANM can be saved so that she gets more time to visit villages to provide services. In each PHC area, a central location nearer to sub-centers will be identified, route map will be prepared and vaccines will be supplied to all ANMs on the morning of immunization day. Unused and partially used vials will be collected on the same day in the evening. • All PHCs will have vaccines depots and PHCs not having ILRs will be supplied with them, through the GoI supply. • Cold chain system will be streamlined from state to PHC level, by provision of fridges, deep- freezers and regular visits by vaccine vans to ensure adequate supply of vaccines.

(d) Integrated Management of Neo-Natal & Childhood Illnesses (IMNCI) Training.

The IMNCI training will be impart as envisaged in IMNCI, and implement a comprehensive newborn and child health package at all facilities (level-1, level-2 and level-3) through health staff. A comprehensive new born and child health package at household level would be initiated through AWWs/ASHA in the districts.

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In bringing down the prevalence of diarrhoea and ARI and other childhood diseases in the district will implement the IMNCI training programme in a holistic way.

All the staff members from the Health and the Women and Child Development (WCD) departments will be trained in IMNCI. Since this training provides a good platform for convergence of services between the two departments, the health department proposes to involve the staff members of ICDS at district and block levels in addition to those at village level. As far as status of IMNCI Training of district is concerned, at present three batches had been completed during last year 2009-10. Batch - 1 of 23 Medical Officers, Batch-2 and 3 of 24 and 25ANMs respectively. During the current year 2010-11, up to 31 March 2011 two more batches will be completed. It is planned to complete 3 batches of IMNCI training during the year 2011-12.

Activities:

• District/block level training programs will be conducted for staff members of PHCs/ CHCs and ICDS. District level master trainers will impart these training programs as resource persons • MOs, Paramedical and ICDS functionaries who attended the district-level training will be the lead trainers for training of Supervisor, ANMs, AWWs and ASHAs. • In each block on an average 2 Medical Office, 1 CDPO/supervisor, 2 staff Nurse, 4 S.C. ANMs and 2 AWW’s will be trained during the year 2011-12.

Sl. No. Participants Detail No. 1 Medical Officers 12 2 CDPOs /Supervisors 06 3 Staff Nurses 12 4 ANMs 24 5 AWWs 12 Total Trainee No. 66 ♦ Budget summary:-

Sl. No. of Unit Cost Amount Activity No. participants (Rs.) Required 1. IMNCI training in 3 batches 66 7000.0 LS 4,62,000.00 Total 4,62,000.00

(e) Set Up of New Born stabilization Unit in 7 Facilities:

During the year 2011-12 it is planned to setup new born stabilization units in 6 Level-3 (SPS Rishikesh, Combine Hospital Prem Nagar, Doiwala, Vikas Nagar, Raipur & Sahiya and 1 level-2 MCH care Centers i.e. Sahaspur).

These stabilization units provide prompt, safe and effective resuscitation of babies and care of sick newborns.

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A New born stabilization unit includes’, Care at birth, Provision of warmth, resuscitation, Monitoring of vital signs, initial care and stabilization of sick newborns, Care of low birth weight newborns not requiring intensive care, Breast feeding and feeding support and referral services.

Activities:

• Set up of New born stabilization unit at level 2 and 3 MCH care centers. • New born stabilization unit will be located within or proximity of the maternity ward. • Space of approximately 40-50 sq. feet per bed is needed, where four radiant warmers can be kept. • Availability of equipment and renewable required for a New Born Stabilization Unit. • One Dedicated nursing staff needs will be available round the clock for newborn care in the stabilization unit. • One Medical Officer skilled in new born care or pediatrician will be placed for clinical care and oversight. • Doctors and nurses posted in the stabilization unit must undergo skill-based training for 3-4 days. • Availability of referral transport facility in each unit. • Publicity of available facility through IEC

Budget required for setting up a stabilization unit

Sl. No. Budget Detail In Rs. 1 Renovations and civil works Rs.3,00,000.00 2 Equipment and furniture Rs. 2,75,000.00 3 Capacity building Rs. 25,000.00 Sub Total Rs. 6,00,000.00* Recurring or running cost per year (does not include the salaries of staff) 4 Consumables Rs.25,000.00 5 Maintenance cost Rs.1,50,000.00 Sub Total Rs. 1,75,000.00 Total Cost Rs. 7,75,000.00 Total set up cost for 7 units @ Rs. 7,75,000.00 will be Rs. 54,25,000.00 * Civil and electrical work has been taken at an average of Rs. 3 lakh rupees.

(f) New Born Care Corner in level-II (9 - 24X7 PHCs):

In year 2011-12 district planned to setup a proper newborn care corner in nine level-2 MCH Care centers at labor room to have appropriate facility for providing essential care to newborn and for resuscitating those who might require it. Newborn care corner provides an acceptable environment for all infants at birth. The Services provided in the Newborn care corner include; essential Care at birth, resuscitation, Provision of warmth, early initiation of breast feeding and weighing the neonate.

It is also planned to procure new generator set for these 9 level- 2 MCH care centers, so that uninterrupted power supply for new born care and cold chain maintenance will be ensured. These level-2 MCH centers are Chiddarwala, Dudhli, Thano, Mehuwala, Nayagaon pelio, Rajawala, Rudrapur, Kalsi and Tuni.

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Activities:

• The New born corner will be established in nine level-2 MCH Care centers. • New born corner will be located within the labor room having clear floor area. It will be 20- 30sq.ft in size, where a radiant warmer is kept. • Resuscitation kit will be placed and availability of oxygen source. • The area will be draughts of air and having appropriate power connection for plugging in the radiant warmer. • Availability of Equipment, apparatus, instruments and renewable which are required for the corner. • One staff nurse or ANM will be placed in addition to the one conducting the delivery for providing appropriate care at birth. • All staff posted in facilities will be trained in providing essential care at birth and basic resuscitation. • Monitoring and supervision of each unit with quality assurance committee • Procurement and Installation of Generators for nine level-2 MCH Care centers for uninterrupted power supplies.

Budget required for setting up Newborn care corner

Sl. No. Budget Detail In Rs. A -1 One time establishment cost 1 Equipment and furniture Rs. 75,000.00 2 Capacity building Rs. 5,000.00 Sub Total Rs. 80,000.00 A-2 Recurring or running cost per year (does not include the salaries of staff) 3 Consumables Rs. 5,000.00 4 Maintenance cost Rs. 15,000.00 Sub Total Rs. 20,000.00 Grand Total Rs. 1,00,000.00 A Total set up cost for 9 units @ Rs. 1,00,000.00 will be (A+B) Rs. 9,00,000.00 B Generator cost for all 24X 7 PHCs @ Rs. 6,00,000.00X 9 will be Rs. 54,00,000.00 Grand Total Rs. 63,00,000.00

(g) School Health Programme (Chirayu Yojana):

A School Health Program being run in Maharashtra State has been adopted in Uttarkhand during last year 2010-11. This program/screening camp are organized at primary and upper primary school namely as Chirayu Yojana . In this programme team of doctors pharmacist and social worker are recruited on contractual basis. They are screening the students at school level. For the year 2011-12 it is planned that the school health team will organized health check up camp minimum twice in a year. As per the numbers of school (Primary- 953 and Upper primary-301) in district 3 teams are proposed and deployed for completion of this activity two cover whole school twice in a year with coordination of education department. The said team will be recruited and place through district societies. An advance screening plan will be made by each team to cover whole school in district. Activities:

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• Calendar for school to be examined, will be developed by each district for each quarter, in advance. • Intimation of dates of concerned school to Regional Coordinator will be given well in advance • There will be no deviation from the fixed schedule in any circumstances. • Vehicle for each team in each district will be hired in advance so that team may proceed as per proposed schedule. • Arrangements of team stay at different places will be made by Medical Unit in the area. Each member will bear his/her expenses individually. • Two or three schools, depending on the strength of school will be selected. Minimum 150 in hills and 200 students per day in plane district will have to examine by each team. • Each team will reach in the identified schools in time. • MSW in the team will be responsible on mobilization of parents on this day. He will mention the list of diseased/disputed student for four the treatment and re-examination. Tracking of referral cases for higher institution and what happened at the end will also be recorded by him. • Education department will nominate one teacher in each school for this activity with whom this team will interact and educate him for referral if needed he will inform to the parents of diseased or handicapped children for further treatment. He will maintain the records of such children at his level for follow up and re examination. • IEC for this activity will be done by concerned ANM, AWW and ASHA of the area. • Each District team will submit their monthly work done to concerned CMO and District Education officer for necessary action from their side. • One copy will also be given to Regional Coordinator who will compile and verify 5% of work done at this level. • During school holidays the school team will organized health camp for Adolescent groups in district. • If the modified school health examination plan is approved by state. Following will be time line & funds requirement for year 2011-12.

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Sl. No. of Amount No Heads Unit Cost (Rs.) Units Required . 1 MBBS/AYUSH Medical Officer (1 Male/1 4 25,000.00 (+5%)=26250 12,60,000.00 female) in each team 2 25,000.00 6,00,000.00 2 Pharmacist of Allopath 2 15,000 (+5%)=15750 3,78,000.00 1 15,000 1,80,000.00 3 Motivator (MSW) 1 15,000 (+5%)=15750 1,89,000.00 2 15,000 3,60,000.00 4 Vehicle on daily basis @ Rs. 2000.00 per 3 5,76,000.00 for a year 17,28,000.00 day Rs. 576000.00 5 DA for Doctors Rs. 500/- per day for 24 12 72,000.00 8,64,000.00 days= 500X6X24=72,000.00 per month 6 DA for Staff Rs. 300.00 per day for 24 days 12 43,200.00 5,18,400.00 Rs. 300X6X24=43,200.00 per month 7 Medicine Expenditure per month @ 12 60,000.00 720,000.00 20000.00X3=60,000.00 per month 8 Contingencies @ Rs. 1000.00X3= 3000.00 12 3000.00 36,000.00 per month 9 One time examination equipments 1 15000.00 15,000.00 10 Budget for IEC and documentation @ 3 50,000.00 150,000.00 50,000.00 per team. Total in Rs. 68,98,400.00

(h) Navjat Shisu Suraksha Training (NSSK).

It is planned that Navjat Shisu Suraksha Training (NSSK) of Medical Office and staff Nurses will be imparted during the year 2011-12. Trained staff will be taking care of delivery and new born services. The district societies will be responsible for coordinating the training programs for participants. During the current year 2010-11 district had trained 10 MO, 38 SN and 19 ANMs up to December 2010. District will be going to conduct training in 2 batches (20 participants each) during the year 2011–12.

Budget for activity:

Sl. No. Activity No. of Participants Unit Cost (Rs.) Amount Required NSSK Training at district 1. 40 40,000 LS 80,000.00 level Total 80,000.00

Proposed Participant of NSSK training in Annexure (h)

(i) BCC/IEC activities:

Organising IEC/BCC activities i.e. campaigns, BCC material on Institutional delivery promotion, child care and Immunisation, family planning, Menstrual Hygiene, seminars on breast feedings, complementary feedings, mal Nutrition etc. would be carried out time to time at district level. BCC

55 DHAP Dehradun 2011-12 5555 55 specific plan will be developed for each BCC/IEC activity in the district. This plan will also include monitoring and evaluation of activity.

Activity:-

Behaviour S.N. Themes Tools Group to be Addressed Outcomes Mass communication Attention Small Family –Happy Advertisements Eligible Couple/Family Awareness 1 Family Interpersonal members Desire Creation communication Promote Action For Safe and Clean Mass communication Attention Delivery-Avail Advertisements Expecting Pregnant Awareness 2 facility of institutional Interpersonal women/ Family members Desire Creation delivery or JSY communication Promote Action Start breast feeding Attention to New born Expecting women/ Interpersonal Awareness 3 immediately after Lactating mother/ Family communication Desire Creation birth / Importance of members Promote Action colostrums Advertisements NSV-Easy Attention Interpersonal dependable and Eligible Male /Family Awareness 4 communication successful method of members / Desire Creation Hoardings contraception Promote Action Counseling Mass communication Attention Eligible Couple/Family Emergency Advertisements Awareness 5 members / Adolescent contraception Interpersonal Desire Creation girls communication Promote Action Mass communication Attention Eligible Couple/Family Safe Abortion Advertisements Awareness 6 members / Adolescent Services Interpersonal Desire Creation girls communication Promote Action Mass communication Attention Emergency Obstetric Advertisements Eligible Couple/Family Awareness 7 Care Interpersonal members Desire Creation communication Promote Action Attention Interpersonal Family members/ Home based Neo- Awareness 9 communication ASHA/ TBA / Natal Care Desire Creation Lactating Mother Promote Action Attention Interpersonal Eligible Couple /Family Awareness 10 Adolescent Health communication members / Adolescent Desire Creation Print Media girls Promote Action Mass communication Attention Stop sex selection-Let Advertisements Eligible Couple /Family Awareness 11 girls be born Interpersonal members Desire Creation communication Promote Action Attention Mass communication Adolescent girls/ ASHA/ Awareness 12 Menstrual Hygiene Interpersonal PEG / Desire Creation communication Family member Promote Action

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Budget for BCC/IEC activities:

Sl. No. BCC/IEC activities Amount Required in (Rs.) 1. BCC/IEC activities for MH 6,00,000.00 2. BCC/IEC activities for CH 6,00,000.00 3. BCC/IEC activities for FP 4,00,000.00 4. Other activities 1,00,000.00 Total BCC/ IEC 17,00,000.00

Note: The budget of BCC/IEC will be meet-out from RCH Flexipool.

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3.5. FAMILY PLANNING

3.5.1. Goal:

To reduce Total Fertility Rate & population stabilization

3.5.2. Situational Analysis:

Total estimated population of district Dehradun for the year 2011-12 is 15,98,961 children below the age of 12 month will be 34,857 (2.18% of estimated population) and 2,71,823 (17 % of estimated population) will be the under the age of five. Total fertility rate is 2.55 (NFHS III), Crude birth rate 21.8 per thousand, couple protection rate is 61.4 (DLHS-III) and Modern Contraceptive utilization rate was 57.8 (DLHS-III), Married women with two living children wanting no more children is 86.3 %( NFHS III). Eligible couple those who are using any modern method are Female Sterlisation-27.4, Male Sterlisation-0.9, IUD-2.2%, OCP-6.5% & condom-20.7% (DLHS III).

Comparison of NFHS III and DLHS III

Indicators NFHS III DLHS III Total Fertility Rate 2.55 Any method 59.3 61.4 Any morden method (%) 55.5 57.8 Female Sterlisation (%) 32.1 27.4 Male Sterlisation (%) 1.8 0.9 IUD (%) 1.5 2.2 OCP (%) 4.2 6.5 Condom (%) 15.7 20.7 Total unmet need (%) 11.3 23.2 For spacing method (%) 4.6 7.8 For limiting method (%) 6.7 17.0

Problems/Constrain: • • Unavailability of sterilization services in all government health facilities. • Unavailability of temporary contraceptive method. • Unavailability of emergency contraceptive pills at rural area. • Interpersonal communication and counseling is very less through health volunteers • Lack of service provider/trained manpower in laparoscopic, mini lap etc. • Poor literacy and awareness about family planning method in rural area. • Service provider are not so much interested in maintenance of records to identify and motivate eligible couple for avail the services

Increasing the Demand for FP Services:

Even though the awareness of modern methods of contraception is high in the district, it has not translated into actual practice in terms of demand for these services. In Dehradun unmet need for both limiting and spacing is 11.3% (NFHS-III). In fact district with high acceptance for the terminal

58 DHAP Dehradun 2011-12 5858 58 methods. Increased use of spacing methods will have dual advantage of reducing the fertility as well as help in bringing reduction in Infant Mortality and Maternal Morbidity.

Year wise Achievement of Sterilization

Permanent and Temporary Methods of Sterilization Years Male Female Total Copper-T C.C. Users OCP Users 2005-06 199 4297 4496 18559 17500 7324 2006-07 159 4542 4701 19334 18420 3092 2007-08 225 4359 4584 18219 17749 4960 2008-09 481 4676 5157 15235 15900 5961 2009-10 427 4839 5266 15240 11747 4154 20010-11 238 2116 2354 9889 6555 2592 (Upto Dec. 10) Source: Yearly reports of district Dehradun.

3.5.3. Objective:

• Reduce Total fertility Rate 2.55% to 2.1%. • Increase couples protection by any method from 61.4 % to 65%. • Reduce couples unmet needs from 11.3% to 9 %. • Increase use of modern methods for family planning. • To promote permanent methods of family planning. • Increase the male & female sterilization target up to 5% of last year target.

Strategies:

• District will organize half yearly population stabilization week. • The campaign will emphasize on following issues: • Males as ‘responsible partners’ • Promotion of NSV • Universal availability of services • Counseling and IPC skills will be applied through service providers • Display of IEC material at service sites describing the range of available services. • Availability of sterilization services at level-2 & level-3 MCH center to provide contraceptive services through RCH camps as per target. • Organizing Regular camps for NSV, Laparoscopic, tubectomy and minilap with extensive IEC and proper planning on fixed day approach basis. • Skill up gradation of MOs during NSV camps/training. • NSV, Leproscopic and Mini lap training for MOs to provide services at periphery level. • Provision for conducting NSV at District Hospital regularly. • The technical and counseling skills of ANMs in providing IUCD services will be upgraded. • Uninterrupted supply of Contraceptives and emergency contraceptive pills in all health institutions.

3.5.5. Activities:

• Facility wise distribution of target of male & female sterilization target upto 5% increase of last year target (i.e. 6138: Female sterilization–5683, Male Sterilization– 455).

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• Two population stabilization weeks will be organized in a year. • Each block will organized at least 4 camps in block, total 36 RCH camp will be organised excluding family planning camps in a year. • Since no surgeon is available in the periphery, it becomes very tough for a single surgeon to organize various RCH/family planning/NSV camps in peripheral units. It is urgently required to train at least 4 MOs in minilap and 2 in laparoscopic from Level-2 /level-3 MCH Care centers to sort out the challenges. • ANMs and Staff Nurses will be trained to provide IUCD services at periphery level. • Uninterrupted supply of contraceptives through CMSD and make one person responsible at level-2 & level-3 to fulfill the purpose. • Use of transport services for beneficiaries to drop them to their native place after undergoing tubectomy. • VHND will be utilized to put across the views and counsel the targeted couples through interpersonal communication. • To further substantiate awareness regarding the family planning options being provided to the community by way of IEC, interpersonal communication campaign through ASHA. • IEC & BCC campaign covering all the rural and urban areas.

(a) IUCD Insertion Training.

Intrauterine contraceptive devise is one of the very effective safe, long terms, reversible method of contraception in married women. IUCD insertion data in HMIS Year 2008-09 2009-10 20010-11 (Upto Dec. 10) IUCD insertion in govt. facility 7366 14003 6420

District HMIS data shows less numbers of women of Reproductive age group are users of IUCD. Despite the fact that the government offers IUCD services free of cost, it still remains under utilized. Some where provider’s knowledge and skills hamper the service provider. To increase the users of IUCD more and more provider has to be trained at district level. Strategy:

During the year 2011-12 it planned to trained more health provider at periphery level. In district 5 Medical Officers and 35 ANM/Staff Nurse will be trained. Which includes IUCD insertion practice on ZOE pelvic model and then supervised insertion is done on clients. Trained SN/ANMs are given IUCD kits and other supplies. The training is participatory and user-friendly and is based on adult learning principles.

Activities:

• A team consisting of two lady medical officer will provide training to 12 ANMs/SNs in one batch for three days. • Training will be conducted in three batches to cover 40 ANMs/SNs/LMOs within a year. • Training programme of IUCD insertion will be practice on ZOE pelvic model and then supervised insertion is done on clients. • All ANMs will be trained with manuals, poster instructions for IUCD insertion and IUCD insertion kit.

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• PHC MOs will monitor the performance of ANMs/SNs with the help of checklist provided to them for the purpose.

(b) RCH Camps

NHFS –II revealed that the TFR of the State is 2.6% which came down to only 2.55% as per NFHS – III findings. A mere drop of .5 % is definitely not an encouraging sign from the point of view of district objective of bringing it down to 2.1 by 2012. Efforts that are being made at the institutional level are being strengthened but remains short of the desired level. One strategy that is being planned is to increase the number of RCH camps and NSV training cum camps. District has planned to organize 54 RCH camps during 2011-12. Dehradun is partially hilly terrain, it is difficult for needy person to come to district headquarter or Sub District Hospital for availing such services. Shortage of service providers is also a problem. In order to counter these constraints, frequency of RCH/quarterly Sterilization week (four in years) camps will be organized in the district. These camps will provide a wide range of FP services including counseling, IUCD insertions, oral pills, condoms and sterilization services including NSV at CHC, FRUs, SDH and DH.

Activities:

• There will be nine RCH camps in each block in a year. A detailed schedule of camps will be prepared with dates, venues, list of doctors, staff nurses, lab technicians, pharmacists and other paramedical staff. • The laparoscopes provided by the state would be maintained in good condition. • Wide publicity will be given prior to the RCH camp, covering villages and towns in the catchments area. • Panchayat members, NGOs, ASHAs, dais, ANMs and AWWs will be provided all the details about the RCH camps. • In time distribution of compensation/incentive to beneficiaries and motivator. • Sterilization acceptors will be provided with free transport services to the nearest facility.

(c) NSV

Among the various contraceptive methods available under the National Family Welfare Program terminal method of Family Planning has been the most popular strategy adopted by the people for regulating their family size, though the Government has been promoting both spacing and terminal methods, as per the need of the family. Acceptance of male sterilization in the district is satisfactory. In order to extend this facility up to CHC and PHC, it is necessary to train more MOs in NSV and will be trained by the certified trainers in 2011-12 in the district.

Activities:

• NSV will be promoted in order to popularize male participation in the programme. • One district level camp will be organized and as per the GOI guidelines these camps will also be utilized for providing trainings to 4 Medical Officers. • NSV training will be linked with sterilization week. • IEC/IPC/BCC will be used to promote NSV at community level. • Transport services to the accepter will be provided duing Sterilization week

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Budget for family Planning activity:

Sl. No. of Unit Cost Amount Activity No. client /Camp/Training (Rs.) Required 1. Male sterilization in No. 455 1500.00 6,82,500.00 2. Female sterilization in No. 5683 1100.00 62,51,300.00 3. Population week 02 5,00,000.00 10,00,000.00 4. NSV training for 4 01 53000.00 53,000.00 participants at district. 5. IUCD Training (40 ANMs/ 40 2500.00 1,00,000.00 SNs /LMOs) Total 80,89,800.00

3.6.1. Adolescent Health (ARSH)/ (UDAAN-Understanding and Addressing Adolescent Needs):

3.6.2. Current Situation:

Adolescents in Dehradun constitute about 23% of the District population. This is a second decade of life, an age of 10-19 years. As found elsewhere in the region or the district, discussing reproduction and sex with elderly persons or parents is considered a social taboo irrespective of whether it is an urban or a rural area.

An adolescent who discusses reproduction and sex in the open is looked down to be a person of bad character. In this vulnerable age, the adolescent is going through various physiological, sexual, emotional and psychological changes. This can be attributed to increased body’s needs for growth, physiological changes of puberty and psychological stresses of marriage, career, and peer pressures.

A very few in the society have ever received any formal education on the subject of adolescence. Comprehensive adolescence counseling programmes, therefore, will have an important bearing on the future health status of the community. Hence there is a need to change the environment, by educating the adolescents, community and service providers, and make available adolescent specific counseling and other services at health facilities. It is also essential to train a school teacher as an adolescent counselor for school-going children.

3.6.3. Objectives:

• To increase access to information/services at health institution. • Provision of life skills education for adolescents. • To reduce burden of anemia in rural adolescent girls. • To improve hygienic practices amongst rural adolescent girls

3.6.4. Out comes:

• Adolescent friendly health information/services available at health institutions. • Adolescent desk at health institution to provide life skills education through formal education system • Reduction of Anemic adolescent girls. • Improvement in hygienic practices in amongst adolescent girls. • Reduction in hesitation and shyness of adolescent in sharing problem related to lifestyle.

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3.6.5. Strategies:

The ARSH (UDAAN-Understanding and Addressing Adolescent Needs) programme is implemented through FNGOs working in 6 blocks of district. These NGOs are block level implementing agencies. Their activities will include: Identification and formation of adolescent group at village level, training of PEGs, mentoring of adolescent, organizing activity AFCs, Coordinating and facilitating adolescent services in schools, Establishing advocacy with the VHSCs, parents of adolescents at the village level with the support of local PRIs, Facilitating the district PAG meetings and Establishing adolescent health management information systems (HMIS) at all levels etc.

These activities will be continuation in year 2011-12 under UDAAN project in 6 blocks of district Dehradun. After assessment of FNGOs contract will be revised through DHFWS. Other strategies on ARSH programme will be as following: • Orientation workshop will be organized block health officer/ service providers • Collaboration with Women and Child Development Department (ICDS) for activity intervention. • Providing Adolescent Friendly Health Service information in CHCs/PHCs at Adolescent desk. • Increasing awareness through FNGOs Adolescent Friendly Help Desk among the adolescents about the life skills. • Anemia control in adolescent girls (even boys if possible). • Adolescent sexuality and reproductive health will have nutrition messages on importance of proper nutrition for proper growth and future reproductive health-IEC/BCC.

3.6.6. Activities:

• Sensitization workshop for the teachers will be conducted to create interactive and adolescent -friendly environment within the school premises • Provision of adolescent friendly health services at CHCs/PHCs. • A core services package for improving adolescent health through FNGOs. • Capacity building of PEGs at block and village level through for correct and timely information and counseling on physical development & changes, personal care and ways of seeking help. • Scholarship for Peer group Educators. • Convergence with school health team during lean period. • Advocacy of menstrual hygiene and demand generation of sanitary napkins. • Carries counseling and enhancement • MIS will be implemented for ARSH programme.

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Budgets for FNGOs in 6 Blocks

A Budget for UDAAN - FNGO; 12 months Line Items Units Rate (Rs.) Period/ Budgeted S.No Months/Day amount (Rs.) 1 Personnel cost i Block Coordinator 1 6500.00 12 Months 78000.00 ii Female Field trainers (2 for each 2 5000.00 12 Months 120000.00 block) iii Male Field trainers ( 2 for each block) 2 5000.00 12 Months 120000.00 iv Part-Time MIS cum Accountant 1 2500.00 12 Months 30000.00 v Scholarships for 100 PGEs for 11 100 200.00 10 Months 200000.00 months Sub Total 548000.00 2 Travel Charges i TA for Block Coordinator 1 1000.00 12 Months 12000.00 ii TA for Female Field Trainers 2 1500.00 12 Months 36000.00 iii TA for Male Field Trainers 2 1500.00 12 Months 36000.00 Sub Total 84000.00 3 Training i 5-day training for Female PGEs (50 50 150.00 5 Days 37500.00 from each block) ii 5-day training for Male PGEs (50 50 150.00 5 Days 37500.00 from each block) iii School Workshops on Adolescent. 10 1000.00 1 Days 10000.00 Issues iv Advocacy on Menstrual Hyg. On VHND among VHSC, ASHA, AWW 100 200.00 1 Days 20000.00 and Adolescent. Girls Sub Total 105000.00 4 Cluster Meetings i TA to Female Sakhis (PGE) for attending cluster level meetings. (50 50 25.00 9 Months 11250.00 from each block) ii TA to Male PGEs for attending cluster 50 25.00 9 Months 11250.00 level meetings. (50 from each block) iii Cluster meetings cost 10 200.00 9 Months 18000.00 Sub Total 40500.00 5 BCC Activities i Health Camps 10 2000.00 1 20000.00 ii Inter Club (AFC) Competitions 5 1000.00 1 5000.00 iii Wall Writings (50 Villages) 50 450.00 1 22500.00 Sub Total 47500.00 6 Adolescent Friendly Services i Establishing AFC (15 per block) 15 5000.00 1 75000.00 ii School Based Activities 20 1000.00 1 20000.00 Poster/Drawing competition iii Enrolment and sponsorship of Adolescents in Skill based training 1 1000.00 20 Adol. 20000.00 program

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Sub total 115000.00 7 Exposure visit for adolescents 4 2000.00 1 8000.00 8 Administrative expenses 1 1000.00 12 Months 12000.00 9 Office Rent (at the block level) 1 2500.00 12 Months 30000.00 10 Contingency 1 10000.00 1 Time 10000.00 Grand Total 1000000.00 Total Budget for 6 Old Blocks 6000000.00 B District Society Activity for ARSH 1 Establishment of Adolescent Help 6 1,00,000.00 6,00,000.00 Desk 2 Menstrual hygiene Training of 205 205 250.00 51,250.00 ANMs 3 Menstrual hygiene Training of 1418 1418 150.00 2,12,700.00 ASHAs Grand Total 68,63,950.00

3.7.1. URBAN HEALTH 2011-12

Background:

Urbanization trends over the past decade show that while the overall urban population is growing at about 3% annually, slum population is growing almost twice as rapidly at 5 to 6%. It has also been noted that health indicators for the urban poor are far lower than urban average data denotes. With increasing urbanization and growth of slums, providing quality primary health services to the urban poor has become a priority for the state government. The state government has already emphasized urban health issues in the annual action plan of NRHM under RCH since 2009-10. Urban Health has been identified as a major thrust area under NRHM since last 2 years. The state government has identified the cities of Haridwar & Haldwani in 2009-10 and Dehradun & Roorkee in 2010-11 for improving the public health service delivery systems along with community mobilization activities within the RCH Programme under NRHM.

Objective and Strategies:

• To provide integrated and sustainable system for primary health care delivery with focus on urban poor living in slums and other health vulnerable groups in cities. • To enhance capacities among city stakeholders to plan and implement urban health programs. • To strengthen linkages between communities and primary level health facilities and referral system from primary to secondary facilities. • To improve health status of the urban poor through increased coverage of key reproductive child health services and adoption of healthy behaviours 3.7.3. Key Strategies:

• Involve the NGOs/Private Sector in the provision of primary health care services and also part of the referral system. • Provide affordable and integrated health services to vulnerable poor. • Promote and strengthen capacities in communities to demand services. • Promote convergence of efforts among public sector and private sector stakeholders to improve health of the urban poor.

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3.7.4. Service Delivery Model:

• Urban Health programme is being implemented in Public-Private Partnership (PPP) mode. This partnership is providing a model for urban health programm under the NRHM and will focus on: • Improving health service coverage through establishment of Urban Health Centres in the proximity of slums and through regularized outreach camps; • Strengthening community-provider linkages through community mobilization and demand generation for primary reproductive and child health services; • Identify and build capacities of ASHA (women residing in slums) who would mobilize people in their communities, contact them on one-to-one level and through group meetings, build the information base there and help in being a link between the facilities and the people. In the current financial year the urban health centers are being running in the district.

Key Result Area No. 1:

Strengthened service delivery mechanism for improving service coverage and promoting behaviour adoption among the urban poor community

Activity 1 : To ensure UHCs functional and providing following services: Immunization, Vitamin A supplement ANC/PNC Medical treatment of common illnesses Provide services of a LMO Promotion of institutional and safe deliveries with a follow up in the field for neonatal care Meeting contraception needs Established linkages with the TI partner of UKSACS for providing treatment of STIs/STDs. Referral services for hospital care, specialized care and investigations Any other activity mentioned in the agreement

Activity 2 : Identify target beneficiaries i.e. pregnant women, 0-1 year and 1-3 years old children and eligible couple by conducting House Hold survey and generate slum maps in the slums of targeted area.

Activity 3: Update list of target beneficiaries (Pregnant women and children in the age group of 0-1 years and 1-3 years and eligible couples) regularly with support from MAS and ASHA in targeted slums.

Activity 4 : Conduct outreach clinics and follow up for immunization to improve service coverage and behaviour adoption in underserved slums in the catchments area slums.

Activity 5: Coordinate with district Health UKHFWS and develop outreach plan and conduct outreach clinics in underserved slums.

Activity 6: Establish and promote linkages of ASHA and women's health group members (Mahila Arogya Samiti) with service providers of private/public and District hospital for improved service coverage.

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Activity 7: Disseminate information on OPD timings in all the slums through various awareness activities and household visits for further increasing the client flow in UHC

Activity 8: Conduct IEC/Behavior change communication activities to sensitize communities for adoption of appropriate health behaviors. Such focused behavior promotion activities will enable sensitization of slum community and enable them to dispel myths, facilitate uptake of services, and adopt appropriate behaviors. Conduct community health rallies on various health themes-etc. Breast-feeding, hygiene promotion, and Routine immunization family planning. Conduct slum level events such as Healthy Mother/Baby Competitions and felicitate the mothers for adopting healthy practices. Conduct thematic group counseling sessions in slums through ASHAs/ASHA Continued family based thematic counseling sessions in slums. Conduct persuasive counseling visits to 'special attention households' identified by ASHAs. (e.g. Pregnant women with danger signs, malnourished child, weak newborn, resistant to immunization etc.)

Activity 9: Participate in Health Department, UKHFWS’s meeting at District level, UHC coordination committee meeting at UHC level and seek suggestions for program improvement .

Key Result Area No. 2:

Increased Community capacity among the urban poor to coordinate and negotiate with service providers for availing RCH services

Activity 1: Conduct community meetings to:

Identify community resources - such as community halls, schools and other common spaces, for organizing outreach sessions and conducting program activities in identified slums. Continue to seek support from community for place, furniture and other support required for IEC program & outreach sessions in the remaining needy Slums.

Sensitize the male members of slum community on reproductive and child health issues and increase their involvement in fostering maternal and child health in the community Identify community (ASHAs) through meetings & interaction with local leaders for hitherto uncovered clusters within new assigned slums. The ASHA will be local resident of the slum and will also be trained by the organization to address RCH issues and establish linkages with primary health service providers.

Activity 2 b: Promote coordinated and collective efforts at community level to address maternal and child health issues:

Initiate MAS formation - Identifying group members Contact women who seem active and interested during transect walk and initial informal discussions, take interest in the basti activities and are well informed time and have family’s support for being involved in activities outside the house, and conduct meeting with these identified capable women.

Garner information on the slum community, their immediate and long term needs and assess their interest and willingness to address issues within the slum as individuals (ASHA will meet these

67 DHAP Dehradun 2011-12 6767 67 identified women during this period for encouragement, reducing apprehensions and motivating them). Encourage women to do a slum mapping exercise for complete understanding of the slum/lanes, resources etc. by all women, and do a complete house listing (lane wise) and identify left out pockets. Women will mark their respective households on the map. Draw attention of women towards lanes from where no women has been identified so far and discuss advantages of proper representation and identify women who could be involved from these lanes and conduct meetings with these identified women.. Sensitize women on maternal and health issues and prioritize issues starting with maternal and child health and moving on to water, sanitation and other issues; facilitate discussion around working as a ‘Samiti’ with identified roles and responsibilities.

Strengthen institutional capacity of women's health group ( Mahila Arogya Samiti ) in targeted slum

• Initiate formation of health group for collective efforts. • Facilitate selection of office bearers and division of roles among them. • Ensure rules related to regular meeting, maintenance of records and meeting minutes are being discussed and approved upon by the members of health group. • Facilitate that the group members meet regularly, prepare meeting minutes and review the action plan of the previous month.

Initiate strengthening of program capacity of women's health group (Mahila Arogya Samiti ) for various activities in all intervention slums.

Ensuring that roles and responsibilities are clearly defined among each member (assigned lanes and Number of households) Develop understanding about support to be provided to ASHA in listing of target population and depicting target families of their assigned lanes on the slum map. Making efforts towards encouraging group members to give prior information to community about organization of outreach camps and ensuring the presence of beneficiaries during these camps. Develop their understanding on RCH issues, tracking left out, drop outs and counselling skills for quality home visits and tracking of beneficiaries. Support group members to discuss about health issues during their meetings Encourage involvement of group members in participatory community health planning exercise and deciding upon responsibilities for implementation of the plan. Facilitate linkages with other government hospital, accredited private hospitals, charitable hospitals, for referral services. Develop coordination between UHC service providers and ASHA/ women's health group for receiving regular health supplies – ORS, IFA, Contraception’s.

Activity 2 c: Initiate and strengthen community based monitoring on selected themes (such as IFA consumption, DPT, Measles coverage, TT Coverage, ANC checkups, consumption of oral pills) in slums.

Explore possibilities of individual and group mechanisms to track the status of healthy behaviour adoption and implement CBM (community based monitoring) options. Facilitate regular updating of slum maps – Depicting target beneficiaries, immunization status and special attention households.

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Activity 2 d: Develop coordination and linkage with other government hospital, TI Partner charitable hospital and other accredited private hospitals in surrounding Area for referral services and institutional deliveries.

Activity 2 e: Conduct capacity building sessions for women's health group (Mahila Arogya Samiti) representatives from all slums:

• Conduct needs assessment for identifying training needs of MAS representatives. • Conduct capacity building sessions to provide technical knowledge on RCH issues, regular updating and effective use of slum maps, community based monitoring, counselling skills etc. • Conduct exposure visits for MAS representatives to other NGOs program slum. • Conduct intense and regular CB sessions on group strengthening aspects for MASs from identified demonstration slums. • Develop a plan for MAS federation at cluster/program level and initiate functioning of such a federation (identify active women from each MAS and facilitate meetings at cluster/program level to discuss on health issues & try to sort out the issues collectively. One member or members in rotation may coordinate all samities of the slums.)

Key Result Area No. 3:

Strengthened and effective linkage with UKHFWS of Health and Family Welfare and establishment of Inter Sector Coordination Committee

Activity 3 a: Coordinate with UKHFWS and other related for indent submission for vaccine, contraceptive and medicines.

Activity 3 b: Coordinate with CMO/Dy CMO for monthly review meeting at district level with subject on regular supply of vaccine, contraceptive, medicine. Participate in UKHFWS's meeting at city level and seek suggestions for program improvements.

Activity 3 c: Submit timely programmatic & utilization reports to CMO Office.

Activity 3 d: Facilitate the development of a system of regular program review with key public and private stakeholders at UHC level such as constitution of a Ward level Coordination Committee / UHC level coordination committee to better address health and other development needs of urban poor community in target area. The above activities are being conducted by the partner NGO in the Dehradun. It is proposed that in the financial year 2011-12 these activities will be strengthened and the budgetary, reporting and monitoring mechanism would be same for all partner NGOs.

3.7.5. Proposed Activities in Year – 2011-12

Continuation of existing 9 Urban Health Centre in Dehradun. In respect to cover the entire urban population for primary health care and RCH services. These UHC,s will be continued in Public Private Partnerships (PPP) mode with the already engaged partner NGO’s. In Dehradun 2 partner NGO’s are running 9 UHC’s (6 UHC’s are being run by one partner NGO and 3 UHC’s by the second one). It is proposed that these hired NGO’s will continue in the year 2011-12. also render following services-

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• The UHC will provide their supporting in Pulse Polio programme, IDSP, DOTS & other national health programme. • The UHC will have to conduct minimum 15 outreach camps, 3 Health camps and 3 Slum level meeting per month in the coverage area. • It is proposed that the UHCs will also provide lab facilities (Haemoglobin) for the ANCs. For this purpose 1 Lab Technician will be appointed for per 3 UHCs. In each UHC 1 LMO (MBBS), 1 Pharmacist, 3 ANM & 1 Community Mobilizer will be appointed by the partner NGO on full time basis. Apart from these ward aya, watchman cum sweeper can be appointed on part time basis. The ANMs, and Pharmacist must be qualified and registered in the concern state faculty. The qualification for the community mobilize must be graduate and minimum 5 year experience in social sector. The project co-ordinator and accountant will not be provided to per UHC. However, it is provide to partner NGO. So this cost will be calculated as per engaged number of NGO. The ANM of each UCH will be trained on IUD insertion so the UHCs can perform the IUD insertion in the respective UHCs. Besides this the UHCs will also involve in all FP activities such as condom & OCP distribution and motivating clients for adopting permanent method. The new proposed unit cost of the existing 1 UHCs is as follows :-

EXISTING UHC BUDGET Total S.No. Particular Unit Unit Cost Total Cost Months 1 UHC Running Cost Per UHC: 1.1 Medical Officer 1 35,000.00 12 4,20,000.00 1.2 Lab Technician 1 4,000.00 12 48,000.00 1.3 Pharmacist 1 10,000.00 12 1,20,000.00 1.4 ANM,s 3 9,000.00 12 3,24,000.00 1.5 Watchman Cum Sweeper 1 3,000.00 12 36,000.00 1.6 Ward Aya 1 3,000.00 12 36,000.00 1.7 Community Moblizer 1 10,000.00 12 1,20,000.00 1.8 Rent of Premises for UHC 1 12,000.00 12 1,44,000.00 including Electricity 1.9 Up-Gradation of Infrastructure L.S 50,000.00 50,000.00 including LAB 1.10 Slum Level Meeting 3 2,000.00 12 72,000.00 1.11 Training/Capacity Building of L.S 25,000.00 12 25,000.00 ASHA 1.12 Medical Supplies 1 20,000.00 12 2,40,000.00 1.13 Travelling for ANMs 3 1,000.00 12 36,000.00 1.14 Intuitional Charges @ 5% of per 83,550.00 UHC (Documentation, Stationery, Communication etc.) Total 17,54,550.00 2 Office Management Cost 2.1 Project Co-ordinator 1 15,000.00 12 1,80,000.00 2.2 Accountant 1 10,000.00 12 1,20,000.00 2.3 Travelling For Project Co- 1 1,500.00 12 18,000.00 Ordinator Total 3,18,000.00

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* The office management cost will not be provided to per UHC. However, it is provide to partner NGO. So this cost will be calculated as per engaged number of NGO.

Establishment of New UHC in Rishikesh. The State Urban Health Unit has visited the city and finalizes the proposed number of UHCs with the consultation of city municipal authorities and concerned health authorities. It is proposed that in Rishikesh, two UHCs will be establish to cater the entire urban area of the respective city. These UHCs will function in the similar way as the existing UHCs are functioning. These proposed UHCs will cover population of 10000 to 20000. The slum mapping and house hold survey of concern UHCs will be carried out by the partner NGO who will run the UHC. The proposed budget for establishing new UHCs is as follows

New UHC BUDGET S. Particular Unit Unit Cost Total Total Cost No. Months 1 UHC Running Cost Per UHC: 1.1 Medical Officer 1 35,000.00 12 4,20,000.00 1.2 Lab Technician 1 4,000.00 12 48,000.00 1.3 Pharmacist 1 10,000.00 12 1,20,000.00 1.4 ANM,s 3 9,000.00 12 3,24,000.00 1.5 Watchman Cum Sweeper 1 3,000.00 12 36,000.00 1.6 Ward Aya 1 3,000.00 12 36,000.00 1.7 Community Moblizer 1 10,000.00 12 1,20,000.00 1.8 Rent of Premises for UHC 1 12,000.00 12 1,44,000.00 including Electricity 1.9 Establishment Cost including L.S 1,00,000.00 1,00,000.00 LAB 1.10 Mapping & House Hold Survey L.S 25,000.00 25,000.00 1.11 Slum Level Meeting 3 2,000.00 12 72,000.00 1.12 Training/Capacity Building of L.S 25,000.00 12 25,000.00 ASHA 1.13 Medical Supplies 1 20,000.00 12 2,40,000.00 1.14 Traveling for ANMs 3 1,000.00 12 36,000.00 1.15 Institutional Charges @ 5% of 83,550.00 per UHC (Documentation, Stationery, Communication etc.) Sub Total (1 UHC) 18,29,550.00 Total (11 UHC) 11 18,29,550 2,01,25,050.00 2 Office Management Cost: 2 NGOs 2.1 Project Co-ordinator 2 15,000.00 12 3,36,000.00 2.2 Accountant 2 10,000.00 12 2,40,000.00 2.3 Travelling For Project 2 1,500.00 12 36,000.00 Coordinator Total 6,12,000.00 Grand Total of NGOs 2,62,45,050.00 * The office management cost will not be provided to per UHC. However, it is provide to partner NGO. So this cost will be calculated as per engaged number of NGO.

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The UHCs of Rishikesh will be looked after by City PMU Dehradun. All city PMU will be strengthened. It is proposed that compute/laptop, furniture etc. Will be procured by concern city PMUs. The training of UHCs staff will be imparted by SPMU in association with UHRC, New Delhi. The periodic monitoring of UHC,s will be carried out by city PMU, CMO & SPMU. Further it is proposed that SPM Department of State Gov. Medical College will monitor and evaluate the progress of UHCs. It is proposed that some innovative IEC and BCC strategies will be adopted to improve the health and hygiene of slum dwellers.

3.7.6. Programme Management Cost of Urban Health

S. No. Particular Unit Cost Unit Total City PMU Management-Salary of 1 30250 12 363000.00 Urban Health Officer 2 Salary of Finance & Admin Officer 20650 12 247800.00 3 Office Running & Maintenance Cost 6000 12 72000.00 4 Travel Cost 6000 12 72000.00 Total 7,54,800.00

3.7.1 Quality Assurance:

Quality is a concept of continuous improvement, striving for better service delivery without being pushed by external factors but through internal motivation. Quality assurance alludes to a planned and systematic approach to monitoring and improving the quality of health services on a continuous basis.

The DQAC coordinate the activities to ensure availability of quality services at all the health facilities. These would include the guidelines for treatment (similar to WHO treatment guidelines), guidelines for performance management, with minimum standards of healthcare delivery, and client satisfaction monitoring. Regular field visits and inputs/feed backs to CHC/PHC/SCs will be ensured by the DQAC.

As for the interventions in district the Quality Assurance project in the Dehradun District on pilot basis has completed its tenure. This was implemented in collaboration with Engender Health and USAID. The activities, further to piloting will be continuing in District Dehradun during 2010-11. State quality assurance team will be providing technical inputs for these interventions. Budget provision for Dehradun district is Rs. 1.0 lakhs proposed in the year 2011-12. Two Quality Managers and executive assistant are appointed in District Hospital and Sub District Hospital SPS Rishikesh during the year 2010-11, will continue provide there services in said hospitals.

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Budget for Quality Management Units at District Level

S. Budget Heads Unit Cost Quantity Months Total No. Quality Management Units (District level) 1 Salary of Quality Managers 25000 2 12 600000 2 Salary of Executive Assistant 10000 2 12 240000 3 Capacity Building/Training/Workshops, 40000 1 1 40000 Etc 4 Contingency 10000 2 12 240000 5 TA/DA for Quality Manager 5000 2 12 120000 Sub Total 12,40,000.00 Doon District Hospital- Hospital Administrator 6 Contingency for Hospital Administrator 120000 1 1 120000 7 Salary of Executive Assistant 10000 1 12 120000 8 TA/DA for Hospital Administrator 5000 1 12 60000 9 Capacity Building/Training/ Workshops, 40000 1 1 40000 Etc Sub Total 340000 10 District quality Assurance Expenditure 1,00,000 1 12 1,00,000 TOTAL BUDGET 16,80,000.00

3.8.1. HMIS – monitoring tool for NRHM:

An information system that is especially designed to assist in the management and planning of all health programmes. The role of a HMIS specifically is to support the process of data collection, its conversion into useful population based information that answers basic questions about the health of the people served and which can be used for practical management of community/public health. However, a key observation in the field is that the existing HMIS (paper and/or computer based) do not systematically support the collection, collation and use of data. The HMIS involves following:

3.8.2 Objective:

A system that integrates processes of data collection, processing, reporting and use of the information necessary for improving health service delivery effectiveness and develop efficiencies in the reporting systems.

Routine service reporting- Hospital/health center based indicators on performance of the various services

Epidemiological surveillance -Identification/notification of diseases and risk factors, Investigation, follow up, control measures

Specific program Reporting- Various programs in operation in a particular country, topically include; Reproductive child health, AIDS, MALARIA, Integrated Child health and many other programs

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Administrative systems- Account and financial systems Drugs management (procurement, storage and delivery) Personnel management Asset management (equipment /buildings etc) Maintenance system Vital registration- Birth, deaths, migration etc.,

The data would be collected on the pattern of GOI guide line and entered in reporting net base programme. The district Nodal Officer HMIS will be responsible to support to health facilities to train in punching of data in on line reporting HMIS format.

3.8.3. Budget for family Monitoring and Evaluation/HMIS activity:

Sl. Activity No. of Unit Cost Amount No. Block (Rs.) Required 1. Printing of Register and formats 6 25,000.00 per 1,50,000.00 (Child and pregnant women tracking block by ANM) 2. Training on HMIS and on line 6 15,000.00 90,000.00 punching and other data 3. Mobility support for HMIS reporting 6 20,000.00 1,20,000.00 and Monitoring/evaluation. Total 3,60,000.00

3.9.1. Monitoring and Evaluation:

3.9.2 Monitoring:

RCH II, under NRHM would be generating information that needs to be captured and utilized for monitoring the program. The focus of monitoring needs to be to assess the progress so that mid- course corrections can be effected through solving problems and resolving issues that are hampering the progress. A set of forms under NRHM has been introduced with periodicity ranging from monthly to quarterly to annual reporting. These formats have been made available to the concerned authorities at Block levels to generate/collect information accordingly.

DPMU in the district is already in place and from 2007-08 onwards a Block Level Accountant in all the 6 blocks to maintain all accounts as per the society guideline and block Programme Manager is placed in a block for smooth implementation of activity/plan and support block level health units under NRHM. The PMUs at district and block levels will also facilitate the process of monitoring and evaluation. In addition to this the system of reporting is being computerized to process and analyze the information more accurately and in a timely manner. District level society will be responsible for monitoring of activities and take corrective action if required. Programme Officer of respective programmes and DPMU team will monitor the activities at district level on regular basis for monitoring the quality and quantity of the programmes being implemented under NRHM.

Strategies: • A system will be developed for monitoring and evaluating activity which involves the following: • • Online reporting of activities in a district • Field visits • Audit of reports 74 DHAP Dehradun 2011-12 7474 74

• District and block level review meetings • Concurrent evaluation.

Activities:

• GoI web portal will be used for generating report. • Fixing the date for visits • Program officers review meetings • Submission of reports in time • Strengthening of data compilation system at block and district level. • Introducing computer data entry at PHCs level • Setting up norms for facility visit/ field & development of checklist for monitoring level-1, level-2 and level- 3 MCH Care Center • Stream lining review meetings at district/block level. • Training of concerned facility staff for online HMIS and other format at block level for quality reporting. • Revise reporting format if required which reflect each indicator wise progress.

3.9.2 Evaluation

The NFHS round III, would form one source for evaluation. A mid-term evaluation would be carried out during the end of F.Y. 2010-11 to assess the progress in the health outcomes of the district. This would be carried out using the information available through the HMIS. The HMIS format having limited field data other supplementary information also requird at district level will be collected to review the progress of activity under NRHM.

INDICATORS FOR MONITORING

Key Development Indicators

• Increase in CPR • Reduction in unmet need • Increase in institutional deliveries • Increase in proportion of safe deliveries • Increase in ORS consumption • Increase in fully immunized children • Reduction in vaccine preventable diseases

Key Progress Indicators

• Full ANC coverage of pregnant women • Deliveries at institutions • Delivery by medical or paramedical professionals • Number of institutions, fully operational, providing 24 hour delivery • Number of institutions, fully operational, providing 24 hour emergency obstetric care • services • Percentage of pregnancies with complications that required EmOC and received it • Percentage of fully immunized children in the age group 13-24 months • Reduction in malnutrition among children • Increase in number of acceptors of contraceptives 75 DHAP Dehradun 2011-12 7575 75

• Percentage of couples with 2 or more children accepting sterilization • Number of institutions providing FP services • Number of institutions providing MTP/MVA services. • Number of FRU operationalizedd

Key Financial Indicators

• Quantum of funds received according to schedule • Number of institutions reporting availability of program funds without delay • Percentage of utilization of funds by institutions against allocation • Percentage of fund utilization at the Blocks and district level • Number of institutions submitting accounts according to time schedule

3.10.1 Programme / NRHM Management Cost;

Sl. Rate/ Unit Total Amount HEADS Duration No. cost in (Rs.) (Rs.) 1 District Programme Manager 40,000.00 12 Month 4,80,000.00 2 District Accounts Manager 35,000.00 12 Month 4,20,000.00 3 District Data Assistant 28,000.00 12 Month 3,36,000.00 4 District Progarmme Support Assistant 20,000.00 12 Month 2,40,000.00 5 Mobility Support to DPMSU (Vehicle hiring 48,000.00 12 Month 5,76,000.00 & POL) 6 Stationary and Contingency 10,000.00 12 Month 120,000.00 7 Mobile Phone rent @ 500.00 to DPMU 1,500.00 12 Month 18,000.00 8 TA /DA DPMU Staff (@ 12,000.00 12 Month 1,44,000.00 9 Monthly Review meeting of NRHM 10,000.00 12 Month 1,20,000.00 10 Block Programme Manager (Six) 20,000.00X6 12 Month 14,40,000.00 11 Block Level Accountant (Six) 18,000.00X6 12 Month 12,96,000.00 12 Block Data Assistant (Six) 12,000.00X6 12 Month 8,64,000.00 13 Stationary and Contingency 4,000.00X6 12 Month 2,88,000.00 14 Mobile Phone Rent @ 200.00 to BPMU 600.00X6 12 Month 43,200.00 15 TA /DA BPMU Staff (@ 4000.00X6 12 Month 2,88,000.00 16 Quarterly Review meeting of NRHM at block 5000.00X6 One year 30,000.00 level 17 Strengthening of financial management LS 50,000.00 System Total 67,53,200.00 18 Training of DPMU and BPMU Training on 8,000.00 4 Days 176,000.00 capacity Building Grand Total 69,29,200.00

3.11. Detailed Budget

Attached sheet

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CONSOLIDATED BUDGET SHEET - RCH FLEXIBLE POOL Required Unit Physical Sl. No. Activity fund under Cost Targets NRHM RCH Flexible Pool A.1 MATERNAL HEALTH 3,74,01,450 A.1.1 Operationalise facilities (only dissemination monitoring and quality) A.1.1.1 Operationalise FRUs 4 A.1.1.2 Operationalise 24x7 PHCs 9 A.1.1.3 MTP services at health facilities 8 A.1.1.4 RTI/STI services at health facilities 9 - A.1.1.5 Operationalise Sub-centers 168 - A.1.2 Referral Transport A.1.3 Integrated outreach RCH services 405000 A.1.3.1 RCH Outreach Camps (for first 6 months of F.Y.) 7500 54 405000 A.1.3.2 Monthly Village Health and Nutrition Days (100+25) 9036 1129500 A.1.4 Janani Suraksha Yojana / JSY 17750 33059000 A.1.4.1 Home Deliveries 500 2518 1259000 A.1.4.2 Institutional Deliveries 17500 A.1.4.2.1 Rural Deliveries 2000 12250 24500000 A.1.4.2.2 Urban Deliveries 1200 5250 6300000 A.1.4.2.3 Caesarean Deliveries - 2625 - A.1.4.2.4 Promotion of 48 hours stay at hospital to beneficiaries 200 9625 1925000 incentive A.1.4.2.5 Doli / Palki for transportation of expected mother from 400 200 80000 interior village to road head A.1.4.2.6 JSY Administrative cost (5% of A.1.4) - - 1602950 A.1.4.2.7 Institutional delivery incentive (@400 at PHC & CHC, - - 200000 @300 at SC) A.1.5 24 Hours Deliveries A1.6 Payment to Link Workers/AWW/ AWS (other than ASHA) A.1.7 Maternal Death Audit - - State level A.2 CHILD HEALTH 2,29,73,400 A.2.1 IMNCI A.2.2 Facility Based Newborn Care/FBNC A.2.3 Home Based Newborn Care/HBNC A.2.4 School Health Programme (@ 50000 IEC & documentation 3 teams 6998400 in SHP) A.2.5 Infant and Young Child Feeding/IYCF A.2.6 Care of Sick Children and Severe Malnutrition A.2.7 Management of Diarrohea ARI and Micronutrient Malnutrition A.2.8 Other strategies/activities A.2.8.1 New born stabilization unit (5 CHC & 2 SDH) 775000 7 5425000 A.2.8.2 New born corner (all 24x7 PHCs) 100000 9 PHCs 900000

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A.2.8.3 Generator for all 24x7 PHCs 600000 9 PHCs 5400000 A.2.8.4 PNDT and Sex Ratio (2 District level ) 50000 2 100000 A.2.8.5 Orientation of ASHAs and AWWs in block to generate 25000 6 150000 awareness about PC & PNDT Act A.2.8.6 Early ANC registration to breast feeding (@500 per) 500 8000 4000000 package to ASHA A.2.9 Infant Death Audit - - State level A.3 FAMILY PLANNING 79,33,800 A.3.1 Terminal/Limiting Methods A.3.1.1 Dissemination of manuals on sterilization standards & quality assurance of sterilisation services A.3.1.2 Female Sterilization camps / Population week 500000 2 1000000 A.3.1.3 NSV camps A.3.1.4 Accreditation of private providers for sterilization services A.3.1.5 Compensation for sterilization services A.3.1.5.1 Male sterilization 1500 455 682500 A.3.1.5.2 Female sterilization 1100 5683 6251300 A.3.2 Spacing Methods A.3.2.1 IUD camps A.3.2.2 IUD services at health facilities A.3.2.3 Accreditation of private providers for IUD insertion services A.3.2.4 Social Marketing of contraceptives A.3.2.5 Contraceptive Update seminars A.3.3 POL for Family Planning A.3.4 Repairs of Laparoscopes A.4 ADOLESCENT REPRODUCTIVE AND SEXUAL 66,00,000 HEALTH / ARSH A.4.1 Adolescent services at health facilities 1000000 6 6000000 A.4.2 Adolescent services at health facilities 100000 6 600000 A.4.3 Other strategies/activities A.5 URBAN RCH 2,69,99,850 A.5.1 Operational Cost of 11 Urban Health Posts 1829550 11 20125050 A.5.2 NGO Programme Management Budget 306000 2 6120000 A.5.3 City PM Unit-Salary of Urban Health Officer 30250 12 363000 A.5.4 Salary of Finance & Admin Officer 20650 12 247800 A.5.5 Office Running & Maintenance Cost 6000 12 72000 A.5.6 Travel Cost 6000 12 72000 A.6 TRIBAL RCH A.7 VULNERABLE GROUPS A.8 Other RCH Activities 0 A.9 INFRASTRUCTURE & HUMAN RESOURCES 1,83,96,000 A.9.1 Contractual Staff & Services - A.9.1.1 ANMs Contractual ( 43 2nd ANM and 23 satellite Sub 180000 66 11880000 Center) A.9.1.2 Staff Nurses A.9.1.2.1 Staff Nurses in Hilly Area - (For 24*7) 216000 3 648000 A.9.1.2.2 Staff Nurses in Plain Area - (For 24*7) 120000 24 2880000 A.9.1.2.3 Staff Nurses in Hilly Area - (For FRU) 216000 3 648000 A.9.1.2.4 Staff Nurses in Plain Area - (For FRU) 120000 9 1080000

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A.9.1.3 Laboratory Technicians MPWs A.9.1.4 Specialists (Anesthetists Pediatricians Ob/Gyn Surgeons - - State level Physicians Dental Surgeons Radiologist Sinologist Pathologist Specialist for CHC ) A.9.1.5 Medical Officers at CHCs / PHCs - - State level A.9.1.6 Additional Allowances/ Incentives to M.O.s of PHCs and CHCs A.9.1.7 Others - Computer Assistants/ BCC Coordinator etc A.9.1.8 Incentive/ Awards etc. to SN ANMs etc. A.9.1.9 Human Resources Development (Other than above) A.9.1.10 Other Incentives Schemes (Pl. Specify) A.9.1.10.1 Other contractual staff (Part Time Dai) 1200 150 180000 A.9.1.10.2 Salary of ANMTC Tutors on Contract 216000 5 1080000 A.9.1.11 Staff/ Supervisory Nurses for PHCsCHCs (for AYUSH) A.9.1.12 Medical Officers at CHCs/ PHCs (for AYUSH) Training State level of 708 Medical Officers and 200 pharmacists of Ayurveda and Homoeopathy A.9.2 Minor civil works A.9.2.1 Minor civil works for operationalisation of FRUs A.9.2.2 Minor civil works for operationalisation of 24 hour services at PHCs A.10 TRAINING 13,54,950 A.10.1 Strengthening of Training Institutions A.10.2 Development of training packages A.10.3 Maternal Health Training A.10.3.1 Skilled Birth Attendance / SBA 40 220000 A.10.3.2 EmOC Training 2 State level A.10.3.3 Life saving Anesthesia skills training 1 State level A.10.3.4 MTP training/ MVA training 2 State level A.10.3.5 RTI / STI Training 40 State level A.10.3.6 Dai Training A.10.3.7 Other MH Training (ISD Refresher ) A.10.3.7.1 BEmOC Training 4 State level A.10.4 IMEP Training A.10.5 Child Health Training A.10.5.1 IMNCI 7000 66 462000 A.10.5.2 Facility Based Newborn Care (FBNC) 21 State level A.10.5.3 Home Based Newborn Care (HBNC) A.10.5.4 Care of Sick Children and severe malnutrition A.10.5.5 Other CH Training (pl. specify) A.10.5.5.1 NSSK training (40 participants) 40 80000 A.10.6 Family Planning Training A.10.6.1 Laparoscopic Sterilization Training 2 State level A.10.6.2 Mini-lap Training 4 State level A.10.6.3 NSV Training 53000 1 53000 A.10.6.4 IUD Insertion Training (40-LMO/SN/ANM) 2500 40 100000 A.10.6.5 Contraceptive Update/ISD Training A.10.6.6 Other FP Training (pl. specify) A.10.7 ARSH Training A.10.7.1 Menstrual Hygiene Training for ANMs 250 205 51250 79 DHAP Dehradun 2011-12 7979 79

A.10.7.2 Menstrual Hygiene Training for ASHAs 150 1418 212700 A.10.8 Programme Management Training A.10.8.1 SPMU Training A.10.8.2 DPMU Training A.10.8.3 BPMU Training\Capacity building 8000 22 176000 A.10.8.3 Training of DAMs/BLAs on TALLY / ERP-9 State Level A.10.9 Other training (pl. specify) A.10.10 Training (Nursing) A.10.10.1 Mental Health ( training of medical officers and State Level paramedical health staff) A.10.10.2 Trg of Diploma Nurses for Post Basic Nursing Prog State Level A.10.10.3 Training of B.Sc /Nurses for M.Sc State Level A.10.10.4 Training of MOs at NIHFW State Level A.10.10.5 PG Diploma in Family Medicine State Level A.10.10.6 Capacity Building of VHSCs for Village Health Plans State Level A.10.10.7 Strengthening of Existing Training Institutions/Nursing State Level School A.10.10.8 New Training Institutions/School State Level A.10.11 Training (Other Health Personnel) A.10.11.1 Promotional Trg of health workers females to lady health visitor etc. A.10.11.2 Training of AMNs Staff nurses AWW AWS A.10.11.3 Other training and capacity building programmes A.11 PROGRAMME / NRHM MANAGEMENT COSTS 67,53,200 A.11.1 Strengthening of SHS /SPMU (Including HR Management Cost Mobility Support field visits ) A.11.2 Strengthening of DHS/DPMU (Including HR Management Cost Mobility Support field visits) A.11.2.1 Strengthening of District society/ DPMU 123000 12 1476000 A.11.2.2 Strengthening of Financial Management systems 50000 A.11.2.3 Mobility support to DPMU (Hiring of Vehicle on monthly 48000 12 576000 basis) A.11.2.4 Stationary and Contingencies 10000 12 120000 A.11.2.5 TA /DA to DPMU staff 12000 12 144000 A.11.2.6 Monthly Review meeting of NRHM 10000 12 120000 A.11.2.7 Mobile Phone rent (DPMU) 1500 12 18000 A.11.3 Strengthening of Block PMU (Including HR Management Cost Mobility Support field visits) A.11.3.1 Salary of BPMU staff (BPM BLA BDA) 600000 6 3600000 A.11.3.2 Block PMSU- Contingency /Print & Stationery 48000 6 288000 A.11.3.3 Block PMSU-TA/DA of BPMU Staff 48000 6 288000 A.11.3.4 Block PMSU-Block level quarterly meetings 5000 6 30000 A.11.3.5 Mobile Phone Rent (BPMU) 7200 6 43200 A.11.4 Strengthening (Others) A.11.5 Audit Fees A.11.6 Concurrent Audit A.11.7 Mobility Support to BMO/MO/Others Total 12,84,12,650

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SECTION – B

NRHM Additionalties

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PART - B NRHM ADDITIONALITIES

Focus of NRHM is to strengthen primary health care through grass root level public health interventions based on community ownership. The duration of NRHM is seven years (2005-2012). It seeks to provide effective health care to the entire rural population in the country with special focus on 18 states that have weak public health indicators.

Objective:

• Reduce IMR 44 (Infant Mortality rate) to 30 per 1000 by 2012 • Reduce MMR 315 (Maternal mortality rate) to 100 per lakh by 2012 • Reduce TFR (Total fertility rate) from present 2.55 (DLHS III) to 2.1 by 2012 • Increase awareness about HIV/AIDS. • Availability of Integrated Universal Primary Health Care • Integration of AYUSH • Increase utilization of FRUs • Placement of ASHA volunteer at village level

The initiatives that are proposed to be taken up in the District under NRHM Additionalities for the year 2010-11 are as follows.

(a) ASHA Programme

ASHA programme is a core programme of NRHM. It was launched in April 2005 to achieve the defined goals of NRHM. ASHA Programme is related to the improvement in the access to health care at the household level through the mobilization efforts of a village health worker called ASHA. ASHA is responsible for mobilizing and providing information to the community on the need for timely utilization of health and family welfare services, especially to the pregnant women. Empowered with knowledge and a drug-kit to deliver first-contact healthcare, every ASHA is expected be the catalyst for community participation in public health programmes in her village.

Progress till Dec., 2010

Sl. No. Issues in Planning in ASHA 2010-11 status 1 Selection of ASHA 1418 ASHAs in place 2 Trainings of ASHA Trained in 6 th A* module -1072 out of 1418 3 Drug Kits to ASHA Procurement Process is going on by State 4 Establishment of DARC Established 5 Trainings of ASHAs on ARSH, RSBY, 1260 (out of 1418) Homeopathy

* The earlier state specific Training of ASHAs on Module 6 in state has been declared as ASHA Training Module 6th A.

A.1 Selection and Training ASHA According to directions of the state, district initiated the selection of ASHAs in 2005 and by the end of second financial year; the selection of the required number of ASHAs was completed. Currently, there are nearly 1418 ASHAs in the district. 82 DHAP Dehradun 2011-12 8282 82

Sl No. Name of Block No. of ASHAs 1 Doiwala 185 2 Raipur 237 3 Sahaspur 187 4 Vikas Nagar 185 5 Kalsi 90 6 Chakrata 110 7 Urban Area 424 Total 1418 Trainings, as suggested by state, till the sixth module (A), have been completed across the district, covering all the selected ASHAs.

A.2 Regarding ASHA Training Module 6 (B) and 7

ASHAs have now completed five and 6 (A) modules of training. The first four rounds have served as an introduction to health issues and built up awareness on a number of health services. The fifth and six (A) rounds focussed on the theme of empowering ASHAs to understand her own role and the role of social mobilisation and health rights. Now as the programme moves into the fourth year, there are increasing requests from community and from ASHAs themselves, to develop specific skills that could enable her to be more effective to respond to immediate health priorities, and which would also allow for development of selected measurable outcomes from the programme.

Objective: As per our orientation given by the state on ASHA modules 6 (B) and 7 focuses on the development of a set of competencies the majority of which relate to improving maternal and newborn health, child health and nutrition, and selected disease control programmes.

Eligibility of ASHA for modules 6 and 7: ASHA who are already trained in Modules 1-4 will be selected for training in Module 6 and7.

Level of ASHA Training: (In Top to Bottom Mode)

The training for Modules 6 and 7 is envisaged as taking place at four levels:

Levels Category to be trained Site of training

Level 1 Training of National and State ASHA State activity Trainers

Level 2 Training of District ASHA trainers State activity

Level 3 Training of ASHA facilitators At specific training sites of the district

Level 4 Training of ASHA At specific training sites of the district

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Basic Needs for Conduction of ASHA Training Programme:

Strong Support Structure -

As per this need state has a strong support structure.

• State ASHA Mentoring Group (At the state level, it has been established) • State ASHA Resource Centre (At the state level, it has been established.) • District Community Mobilisers: There are 1 Community Mobiliser placed in District ASHA Resource Centre (DARC) • Block Coordinator : There are 3 Block Coordinators placed in District ASHA Resource Centre (DARC) (As per 1 BC for 2 blocks ) • ASHA facilitators: There are 56 ASHA Facilitators (1 ASHA facilitators per 20 ASHAs in the district as per the direction of state.)

Committed Cadre of Trainers at State and District/Block levels:

• State Level Trainers- State has 6 standard State ASHA trainer certified by NHSRC and SEARCH Gadchiroli, Maharashtra. • District Level Trainers- Till March, 11 we will have 17 District ASHA Trainers in first round training of ASHA 6th B & 7th Module. • ASHA facilitators - Till March, 11 we will have 56 ASHA Facilitators in first round training of ASHA 6th B & 7th Module.

Details of Training sites:

S.No. Level of Training No.of Sites Facilities of Site Site

1. Block Level- (For 3-5 There is adequate training facilities, Training of ASHA boarding and lodging arrangements, close Facilitators ) 1 Training Site can access to a community. And close linkages be for 2 blocks to a health facility with an adequate caseload of newborns and children with illnesses.

2 Block Level- (For Same 3- 5 sites of As above Training of ASHAs ASHA Facilitators ) Training will be used.

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Details of Selected Trainer’s Team:

Sl. Name Selected No. Batch Specification/Qualification No /Levels of Size . Trainers

She/he is an individual selected from within the district, preferably at the block level. Every block has a team of two ASHA trainers. The team of two trainers from every block will constitute the District Training Team. One of the two trainers should have a health and clinical training and District 12 experience, such as a staff nurse, ANM or LHV or Level a doctor who is also motivated, interested, (2 trainers ASHA qualified and experienced. If such an individual from every 23-25 1. Trainers is selected from within the public sector, she /he block = /Actual should be deputed to the training programme and 2x6=12) relieved from other work as a priority. The other ASHA trainer should be an individual with experience of community based health interventions, drawn from an NGO, with the experience of working with communities on health issues. This trainer should be employed as a full time worker. This individual could also be the Block Community Mobilizer.

3-5 District Resource An ASHA district resource person is an Persons Note: individual, (man or woman), who is experienced District There will be in training and has an understanding of Resource 12 Distt. 23-25 2. health/clinical issues. Such an individual could be Persons ASHA /Actual deputed from the government or from an NGO, (DRP) Trainers +5 but is required to be full time and available for 18 DRP.(17 Distt. months during the entire process of training. ASHA Trainers)

20 (3 ASHA ASHA facilitator is a woman who has an batches Facilitator academic qualification of Class XII and above, has 3. 56 of 20 s (Block demonstrated success, and is dynamic has been candidat Level) promoted as ASHA facilitator. es)

Activities and Timeline for Rolling out ASHA Modules 6 B and 7

Categories to be trained over successive Rounds of training to complete Modules 6 B and 7 training.

85 DHAP Dehradun 2011-12 8585 85

Category Number of days in Number of days in Number of days Number of days of Trainer Round 1 Round 2 in Round 3 in Round 4 District Fourteen Days Eight days (four Five days (four NA Trainer (evaluation on 14 th months after months after day) Round 1) Round 2) will Complete till Proposed in June- Proposed in Jan.- March,2011 Aug, 2011 March,2012 ASHA Seven Days Five days (three Five days (four Five days (four Facilitator months after months after months after Round 1 ) Round 2 ) Round 3 ) will Complete till Proposed in July, Proposed in Proposed in March,2011 2011 Dec.,2011 March,2012 ASHA Five Days Five days (three Five days (four Five days (three months after months after months after Round 1 ) Round 2 ) Round 3 ) will Complete till Proposed in Sep., Proposed in May , 2011 2011 Feb., 2012

ASHA HBNC Kit :

Under 6 th B and 7 th Module of ASHA Training state is providing one ASHA HBNC Kit to every ASHA as per the guideline of GOI .In this kit there are 6 items - Thermometer, Weighing Scale, Blanket, Warm Bag, Digital Watch , Bag. In the current financial year state is providing 1418 kits to 1418 ASHAs of District.

Forms for ASHA under ASHA Trag.6 th & 7 th Module:

As per guideline of GOI regarding ASHA Training 6 th B and 7 th Module, ASHA has to fill some forms also regarding mother and newborn care after receiving this training .These forms are Pregnancy Form, Birth Planning Form, Delivery Form, First Exam of New Born Form, Home Visit Form-Fix Days, Home Visit Form-Other Days).

On the basis of a calculation of 20 Birth Rate @ 1000 population in a village. State will provide us 160 Forms (40 Pregnancy Form, 40 Birth Planning Form, 20 Delivery Form,20 First Exam of New Born Form, 20 Home Visit Form-Fix Days, 20 Home Visit Form-Other Days) for each ASHA in a year.

Registers for ASHA Facilitators & ASHA under ASHA Trag.6 th & 7 th Module

As per guideline of GOI regarding ASHA Training 6 th B and 7 th Module, ASHA Facilitators and ASHAs have to maintain some records regarding their day to day activities after receiving this training .These registers are Village Health register/Common Register, ASHA diary, Drug kit stock Register.

In Village Health Register ASHA will record details of pregnant women, children, 0-5 years, eligible couples and others in need of services. In ASHA diary ASHA Facilitators and ASHAs will record of their work and it is also useful for tracking performance based payments due to them. Drug kit stock Register: As per GOI guideline, state is providing a drug kit to every ASHA so as to be able to treat minor ailments/problems. To keep a record of consumption of the drugs and for effective re-

86 DHAP Dehradun 2011-12 8686 86 filling and ensuring adequate/timely availability, a drug kit stock register has to be maintained by every ASHA or this can be completed by the person who refills the kit .For this purpose state will provide these registers to all 1410 ASHAs and Village Health Register/Common Register, ASHA Facilitator diary all 56 ASHA Facilitators of the district.

Current Status:

As per the GOI norms training on 6 th (B) and 7 th Module is going on in the district. Till March, 11 we will have completed its first round training of all District ASHA Trainers , 56 ASHA Facilitators of the District . For next financial year we are proposing rest all 2 rounds (2 nd & 3 rd Round) training of District ASHA Trainers, rest all 3 rounds (2 nd , 3 rd & 4th ) training of ASHA Facilitators only 3 rounds (1 st , 2 nd & 3 rd ) training of ASHAs.

Break-up of one batch Participants : ASHA facilitators Resource person :District ASHA trainers Target to be trained all ASHA Facilitators of district-56 Participants/batch-20/batch Duration-5 days Total number of batches to be conducted- 3 (56/20) Heads for Expenditure Unit Days Rate Amount Honorarium for Master Trainer 2 5 350 3500 TA for Master Trainer 2 - 500 1000 Fooding, Accommodation, Venue 20 6 200 24000 for ASHA facilitator DA for ASHA facilitator 20 5 100 10000 TA for ASHA facilitator 20 200 4000 Training Material 20 5 100 10000 Sub Total 52500 Institutional overheads at 10% 5250

Total of one batch 57750 Total number of batches to be conducted - 3X3 Rounds 519750

20 Days Training of ASHAs-(Total 4 Rounds:5+5+5+5) Training of ASHAs-(Total 3 Rounds:2nd, 3rd & 4th 5+5+5) Participants-ASHA Resource person - District ASHA Training Team (Distt. ASHA Trainer + DRP) Target to be trained in district 1410 ASHAs 30 Participants per batch( 1410 /30 = 47 batches) Duration-15 days 87 DHAP Dehradun 2011-12 8787 87

Item of Expenditure Unit Rate in QTY Days Budget RS. Training for 20 days ASHA Compensation 100 1410 15 2115000 ASHA Food, accomodation, Venue 150 1560 15 3510000 ( 1410 ASHAs + 56 AF + 94 BT = 1560) Training Material 50 1410 70500 ASHA Travel( 4 DaysTrips) 60 1410 4 338400 Trainer Fees ( 2 trainers per batch x 47 batches= 94) 350 94 15 493500 Trainers & Facilitators Travels (94Trainers+56AF= 60 150 4 36000 150) Sub-total 6563400 Institutional Overheads (10 %) 656340 Total 7219740 Supervision & Support Costs Supervision costs ( By AF) 150 56 15 126000 Review Meeting of ASHA/ASHA day (Two in a 200 1410 24 6768000 month) Review Meeting of supervisors at district level 100 59 12 70800 (3BC+56 AF) Sub-total 6964800 Grand TOTAL 14184540

Total Budget of ASHA Training 6th & 7th Module Sl. No. Type of Training Budget Amount 1 Training of ASHA facilitators 5,19,750.00 2 Training of ASHAs 1,41,84,540.00 Grand Total 147,79,242.00

A.3 ASHA Drug Kit:

District has need of ASHA drug kits. So, on the basis of our demand for the year 2010-11, two types of ASHA drug kits will be provided by the State for 1418 ASHAs of the district. • Allopathic Drug Kits • Homoeopathic Drug Kits • For the year 2011-12 District has again need of two types of ASHA Drug kits for all 1418 ASHAs. • Allopathic Drug Kits • Homoeopathic Drug Kits

Budget for ASHA Drug Kit

S. No. Particular Unit Cost Unit Total 1 Allopathic Drug Kits 1000 1418 2836000.00 2 Homoeopathic Drug Kits 1000 1418 2836000.00 Total 56,72,000.00 88 DHAP Dehradun 2011-12 8888 88

A.4 ASHA Resource Centres

Implementation of the ASHA component is a challenging task, especially from the point of view of sustainability. The success of the ASHA scheme depends not only on how well the scheme is implemented and monitored, but also on the motivational level of the ASHAs, their mentoring, supportive supervision and the quality of all the processes involved in implementing the scheme.

It is, therefore, necessary that well-defined and yet flexible and participatory institutional structures are put into place at all levels from state to village. In this context, it is very important to provide technical inputs and strong supportive mechanism to the programme, so that expected results can be achieved. Constant mentoring and creation of a good enabling environment are the key ingredients, especially when it is a recognized fact that ASHAs cannot function without adequate institutional support.

The GOI has suggested institutionalization of such structures at the state, district and block levels in the form of ASHA mentoring groups and resource centers.

Establishment of DARC In 2008-09, ASHA Resource Centres were established at state and district levels. Though, as per the GOI norms, these were to be established within the State Health Resource Centre (SHRC), the state decided to involve non-governmental organizations (NGOs) and civil society organizations (CSOs) actively in this role. As a result, Rural Development Institute (RDI), a rural outreach division of HIHT was identified as the agency to manage the State ASHA Resource Centre.

Similarly for the District ASHA Resource Centres (DARC) within the DPMU, Mother NGOs (MNGOs) in each district of the state were identified as the agencies which would coordinate as the DARCs. In Dehradun OPEN was identified as the agency to manage the District ASHA Resource Centre.

Strengthening of DARC

District ASHA Support system staff

The ASHA Support System at district level is the second level after SARC and is to be headed by a designated District Nodal Officer (Chief Medical Officer). The District Nodal Officer along with the District Programme Manager is supported by the DARC officials. As per the GoI guideline, the DARCs were to be managed by one community mobilizer and a data assistant. Community Mobilizer is paid a lum-sum of Rs. 12000 per month which includes Rs. 2000 per month for the field visits. Block level structure

The district level staff is supported by block level facilitators. In view of the mismatch between the expected outputs and the staff strength at the district level, it was proposed to have Block Coordinators at DARC level. Now we have 3 Block Coordinators (1 Block Coordinators for 2 blocks).

Qualification and selection criteria of Block Coordinator

Block Coordinators: Graduate in social sciences with experience in health sector, preferably in ASHA program. One block coordinator over two blocks was selected by respective DARCs in that district on contractual basis. The consolidated salary for the block coordinator is Rs. 8,000 per 89 DHAP Dehradun 2011-12 8989 89 month. But there is no allowance for field visit of block coordinators .So we are proposing 1,000/- @ per month for additional field visit allowance for block coordinators.

The role and responsibilities of Block Coordinators: • Manage and supervise the activities of ASHA facilitators, • Coordinate with Block Nodal Officer and Community Mobilizer for smooth • Implementation of activities at block level • Supervise trainings to be organized at the block level for the ASHAs • Periodic reporting to the Block Nodal officer

Each Block Coordinator is responsible for the activities in blocks as per the following arrangements:

Block District Blocks Average Load Coordinator Dehradun 6 3 2 Total 6 3 2

ASHA Facilitators: As per the GOI norms we have created a support structure between District and Village level i.e. one ASHA facilitator over approximately 20 ASHAs. There are a total number of 37 ASHA facilitators positioned in the District.

S. No. Name of District ASHA Facilitator 1 Dehradun 56 Grand Total 56

Qualification and selection criteria of ASHA Facilitators:

Eligibility criteria for ASHA Facilitator are High school pass with past experience as ASHA in that block of that district. Extra weightage was given to applicants having higher qualification and to ASHAs ever received the best ASHA award. ASHA facilitator is paid @ 250 per visit for 20 visits in a month. Her visits are monitored not only by the Block Coordinators but also by the Village Health and Sanitation Committee of the respective village.

Budget of District ASHA Resource Centres Personnel Community Mobilizer (@ Rs.12000*12 months= Rs 144000) 1 144000 144000 {includes 2000 per month as cost of field visits} Block Coordinator Honorarium (@ Rs.9000*12 months= Rs 3 108000 324000 108000) {includes 1000 per month as cost of field visits} Data Assistant (@ Rs. 7000 * 12 months = Rs. 84000) 1 84000 84000

Activities (to be pooled from NRHM funds) Training (ASHA Training Fund) Separately given. Meeting ASHA Sammelan (ASHA Training fund) Monitoring/Supervisory Visits (NRHM Funds)

90 DHAP Dehradun 2011-12 9090 90

Contingency Sub Total – District 552000

Personnel ASHA facilitator (@ Rs. 5000 / month * 12 month = Rs. 60000) 56 60000 3360000

Honorarium to AF for assisting BNO @ 200 / month = Rs. 2400 56 2400 134400

Activities Contingency allowance to BNO (Block Nodal Officer) (@ Rs. 6 12000 72000 1000 / month * 12 month = Rs. 12000) ASHA Sammelan (ASHA Training fund) Meeting Expenses (NRHM Addl. Fund) 12 Stationary for DARC (@ Rs. 1000 / month * 12 month = Rs. 1 12000 12000 12000)

Sub Total – Block 3578400 Grand Total 4130400

Total Budget of ASHA Programme for Financial Year 2011-12 Sl. Name of Activity Budget Amount 1 ASHA Training 6 th (B) & 7 th Module 147,79,242.00 2 ASHA Resource Centres (SARC & DARC) 41,30,400.00 Grand Total 1,89,09,642.00

A5 Establishment of ASHA Ghar

ASHA Ghar will be established at SPS Rishikesh and FRU Vikas Nagar been proposed during this year 2011-12, @ Rs 1,50,000.00 per facilities

ASHA Ghar Sl. Name of Activity Unit cost Budget Amount 1 ASHA Ghar for 2 facility 1,50,000.00 3,00,000.00 Grand Total 3,00,000.00

(b) Village Health and Sanitation Committee:

Current Situation: The NRHM implementation has been planed with in the framework of Panchayati Raj Institution at various levels. The Village Health and Sanitation Committee envisage under NRHM is also within the overall umbrella of PRI. The Village Health and Sanitation Committee are constituted at Revenue Village level at least 50% members in the committee should be women with the involvement of member from every hamlet as well as representation of SC, ST and other backward classes. Government employees and honorarium paid staff e.g. school teachers, ANMs, AWWs are member

91 DHAP Dehradun 2011-12 9191 91 of committee but should not be more than one third of its strength or special invitee in the committee.

The Panchayati Raj institutions can play a major role in effective and efficient implementation of health and sanitation committee. Several of the elected representatives do not have a clear understanding of their roles and responsibilities. Their knowledge of health and sanitation committee is very limited. It is therefore necessary to conduct training programmes for elected Panchayat members who can play a major role in community mobilization for health programmes, organization of RCH camps, establishment of coordination linkages, monitoring of programme performance, collection of information from households, resource mobilization and above all in creating awareness about health services available and in influencing health care seeking behavior. Presence of 50% of women representatives at all levels in the system is an added advantage to maternal and child health services. Involvement of elected representatives in village health planning and implementation of all health programmes at grass root level is crucial and central to the success of health programmes.

In all there are 928 villages in Dehradun, with 403 Gram Panchayats in place. Under Panchayati Raj Act – Village Health and Sanitation Committees (VHSC) has been constituted in all 714 (with habitation) out of total 735 revenue village in the district; though not fully functional, these Committees have been identified as one of the important agency that will be ensuring proper implementation and monitoring of the activities at village level. The committee under NRHM for village levels i.e. the Village Health and Sanitation Committee (VHSC) that comprise of Pradhan, Village Development Officer, ANM, ASHA, AWW, a representative from the Sanitation division, education local group etc. As innovation part Sudarwarti Swasthy Sahayak (SSS) has been placed in 119 village of district to provide primary health services. It is also planned that honorarium of Rs. 500.00 per month will be given from untied fund of VHSC to them.

2.2. Objective:

• Orientation of VHSC’s members regarding Village Health & Sanitation Committee and its role of members under NRHM (as per guideline/GO) • Training of Village Health & Sanitation Committee (VHSC’s) for preparation of village health action plan and its monitoring.

2.3. Strategies:

• Orientation of VHSC’s members at Nayay panchayat/block level about their role and responsibility (Dehradun 714 Revenue Village with habitat). • Orientation of VHSC members about the utilizing fund at revenue village level as per the guide line. • Ensure participation of all member of VHSC’s in preparation of village health action plan health and sanitation (Gram pradhan, VDO, ASHA, ANM, AWW, member from GP, Local NGO member and member from education dept.). • Honorarium will be given to Sudarwarti Swasthy Sahayak (SSS) from untied fund on monthly basis @ Rs. 500.

2.4. Activity:

• For strengthening of Village Health & Sanitation Committee • Orientation about NRHM. 92 DHAP Dehradun 2011-12 9292 92

• Roles & responsibilities of VHSC’s member in NRHM. • Monthly coordination meeting at village level with all stakeholders. • Orientation about utilization of untied fund at revenue village level and proper documentation of activities • Health workers and link workers will be encouraged to involve in Village Health and Sanitation committee to implement all RCH interventions at village level. • One day District Level orientation programme for Jila Panchayat Sadasya and Pramukh on NRHM as well as DHAP Planning. • Timely payment of honorarium to Sudarwarti Swasthy Sahayak (SSS) from untied fund on monthly basis through VHSC.

2.5. Budget:

Total habitat Revenue Rate/Unit Cost Sl. Health Institutions Total (Rs.) villages in No. (Rs.) 1 Revenue Village (735) 714 10,000.00 71,40,000.00 TOTAL 71,40,000.00

(c) Chikitsa Prabhandan Samity /Rogi Kalyan Smaitis : To ensure a degree of permanency and sustainability, a management structure called Hospital Management Committees were constituted in Hospitals. These have been envisaged as an institutional mechanism leading to commoditization of health services and making services accountable to the users.

District and Sub District Hospitals: As per the norms each District Health Institutions having a registered Hospital Management Committee is eligible for a revolving grant based of Rs. 5, 00,000. A sub district level hospital is entitled for a grant of Rs. 1, 00,000 as revolving fund. This amount is being deposited in the committee’s account and being used for providing better services to the patients and upgrading the services in the health facilities. Since this a recurring amount therefore seed money for the year 2010- 11 is proposed for 2 district and 4 sub district hospitals.

Funds Required: for 2 District Hospitals X 5, 00,000 = Rs. 10, 00,000.00 For 3 Sub District Hospital X 1, 00,000 = Rs. 3, 00,000.00

CHC: A part from this, the seed money to Chikitsa Prabandhan Samiti’s (the Hospital Management Committee) of all the 7 CHCs is to be made available @ Rs. 1, 00,000 per CHC. As on date there are 7 CHCs in the District Dehradun hence funds for 7 CHCs.

Funds required: 7 CHCs X Rs. 1, 00,000 per CHC = 7, 00,000.00

PHC: A part from this, the seed money to Chikitsa Prabandhan Samiti’s (the Hospital Management Committee) of all the 17 PHCs is to be made available @ Rs. 1, 00,000 per PHC. As on date there are 17 CHCs in the District Dehradun hence funds for 7 CHCs.

Funds required: 17 PHCs X Rs. 1, 00,000 per CHC = 17, 00,000.00

93 DHAP Dehradun 2011-12 9393 93

(d) Annual Maintenance Grants and Untied Funds

The Infrastructural Strengthen (Health Facilities) of the district and its amount required for AMG and UF for the institutions during the year 2010-11 is as follows: Annual Maintenance Grant:

Rate/Unit Cost Sl. No. Health Institutions In Govt. Building Total (Rs.) 1 Community Health Centers 7 1,00,000 7,00,000 2 Primary Health Centers 17 50,000 8,50,000 3 Sub Centre 118 10,000 11,80,000 4 State Allopathic Dispensary 18 50,000 9,00,000 Total 36,30,000

Untied Fund:

Total Rate/Unit Cost Sl. Health Institutions Total (Rs.) Institutions (Rs.) 1 Community Health Centers 7 50,000 3,50,000 2 Primary Health Centers 17 25,000 4,25,000 3 Sub Centers 168 10,000 16,80,000 4 State Allopathic Dispensary 24 25,000 6,00,000 Total 30,55,000

(e) Untied Fund for ANMTC Dehradun

ANMTC Dehradun is functioning in acquired premises. Untied fund for ANMTCs have been proposed @ Rs. 1, 00,000.00 for the year 2010-11.

(f) Mobile Medical Units:

Mobile Medical Van has been placed in district Dehradun through NRHM last year 2009-10 in hard to reach areas, especially un-serve and under served of Kalsi and Chakrata. A proper monitoring system will be developed at each level in terms of performance and achievement.

Performance parameters will be developed as below checklist: • Advance tour Programme of MMU • Advance Intimation of Schedule • Duration of Stay and Timing of MMU • Doctors and other paramedical accompanying • No of Patient investigated • Availability of Medicine • Cured of illness in last visit • People satisfaction about skill and behaviour • Location of MMU • Average distance traveled to MMU • Average time taken per patient • Availability of diagnostics • Follow up of Patients, need to be reflected in the MMU plan 94 DHAP Dehradun 2011-12 9494 94

Funds Required for MMU = Rs. 23, 00,000.00 (Fund includes Rs. 50,000.00 @ Rs. per session to ASHA and Rs. 1, 50,000.00 repairing of vehicle as per government Norms.

(g) Salary of ANMTC Tutor

One of the major constraints in making ANMTC functional is un-availability of Tutors. The basic requirement of a Tutor for ANMTC is B.Sc Nursing or a qualified PHN. Thus there is an immediate requirement of Tutors to make these ANMTCs functional. For ANMTCs Dehradun the requirement will be 5 ANM Tutors.

S. No. Issue Rate Unit/Rate Amount 1 Salary of ANMTC Tutor Rs. 18,000 per month 05 x 18000 x 12 10,80,000.00

(h) Salary of ANM on contact

District having 43 sub centers in un-served / under served specially in hill area, where pharmacist are place. An additional ANM were places during the year 2010-11 to provide health services in out reach area. So during the year 2011-12 ANMs will continues provide there services to rural community. Same way district also have 23 satellite sub center in far flung area and hard to reach ANM will be also placed to serve vulnerable group. In these sub centers ANM on contact basis will be placed through NRHM budget.

S.No. Issue Rate Unit/Rate Amount 1 2nd ANM at 43 Sub Rs. 15,000 per month 43 x 15000 x 12 77,40,000.00 Center 2 ANM for Satellite Rs. 15,000 per month 23 x 15000 x 12 41,40,000.00 Center Total 1,18,80,000.00

(i) Up gradation of FRUs (Manpower gap)

In district total 4 FRUs are functioning and providing 24X7 institutional delivery services with the help of contractual Staff Nurses. A sufficient number of staff nurses are not posted on regular basis. So in each FRUs at least existing 3 Staff Nurses required to provide these services on facilities on contractual basis.

Activities:

• To provide 24 x 7 delivery services at all 7 institutions, District will have to appoint 21 staff nurses on contractual basis for these institutions during F.Y. 2010-11. (including existing staff Nurse) • Replacement/renewal of existing Staff Nurse contract as per his/her performance. • SBA Training for new Staff Nurse • Residence of staff as per requirement of facility survey.

95 DHAP Dehradun 2011-12 9595 95

Budget for activity:

Name of No. S.N. in Rate/ No. No. Re Unit Total Sl. Position of S. N. qui cost Amount No. Block FRUs FRUs Req. Regu Co red in (Rs.) . n. (Rs.) 1 Kalsi (Hill) CHC Sahiya 1 3 - 3 3 18000 6,48,000.00 Vikas Nagar CHC Vikas 2 1 3 2 3 3 10000 3,60,000.00 (Plain) Nagar 3 Raipur (Plain) CHC Raipur 1 3 3 3 3 10000 3,60,000.00 CHC 4 Doiwala (Plain) 1 3 4 3 3 10000 3,60,000.00 Doiwala Total 4 27 9 12 1 2 _ 17,28,000.00 ♦

(j) District Action Plan:

The formulation of the DHAP envisages a participatory approach at various levels. To make the plan more practicable and to ensure that grass root issues are voiced and heard. A preparation of Action plan required collection and compilation of data mostly at three stages; at village level, Block level and District level. This stages of process of plan development included data collection and Focal group discussion at village for set priorities of their needs of health services. These priorities reflect in block health action plan. After compilation of each block level data these data are compiled at district level to address the actual problems of the district. This Action plan formulation process required community participation and need-based service delivery with improved outreach to disadvantaged communities, village and block level and vital information to guide the district health action plan. This process will be applied for the next year 2011-12. For this process adequate budget is required to work on, so budget is proposed on this head to share findings of the village and block level process with a larger stakeholder group, and to finalize a strategic action plan.

Budget for Activity

S. No. Issue Unit/Rate Amount 1 Preparation of Action Plan 50,000.00 LS 50,000.00

(k) Up gradation of Sub District hospital as per IPHS standards:

As per the IPHS survey of conducted in Sub District Hospital (SPS Rishikesh, Corronation Hosp. & Combine Hosp. Premnagar) it is found that these facilities having gape of equipment as per standard. So during the year 2011-12 budget of rupees 5 lakh per SDH is proposed to fulfill the gape of facilities. Budget for Activity

S. No. Issue Unit Rate Amount 1 IPHS Gape completion at SDH 3 5,00,000.00 15,00,000.00

96 DHAP Dehradun 2011-12 9696 96

Detailed Budget

CONSOLIDATED BUDGET SHEET FOR NRHM ADDITIONALITIES Required Unit Physical fund Sl.No. Activity Cost Targets under NRHM Mission Flexible Pool B1 ASHA 2,20,45,642 B1.1 Selection & Training of ASHA 1418 14779242 B1.2 Procurement of ASHA Drug Kit 1418 2000 2836000 B1.3 Incentive to ASHAs under JSY B1.4 Incentive under Family Planning Services B1.5 Incentive under Child Health B1.6 Other Incentives to ASHAs B1.7 Awards to ASHA's/Link workers B1.8 Other ASHA’s activity B1.8.1 Management Structure of DARC-Community 1 4130400 Mobiliser and Block Coordinator B1.8.2 ASHA Ghar at SPS Rishikesh (Sub District Hospital) 150000 2 300000 and CHC Vikas Nagar (FRU) B2 Untied Funds 1,02,95,000 B2.1 Untied Fund for CHCs 50000 7 350000 B2.2 Untied Fund for PHCs 25000 17 425000 B2.3 Untied Fund for Sub Centers 10000 168 1680000 B2.4 Untied fund for VHSC 10000 714 7140000 B2.5 Untied fund for ANMTC 100000 1 100000 B2.6 Untied fund for SADs 25000 24 600000 B.3 Annual Maintenance Grants 36,30,000 B.3.1 CHCs 100000 7 700000 B.3.2 PHCs 50000 17 850000 B.3.3 SCs 10000 118 1180000 B.3.4 SADs 50000 18 900000 B.4 Hospital Strengthening 16,50,000 B.4.1 Upgradation of CHCs, PHCs, Dist. Hospitals to IPHS) B4.1.1 District Hospitals B4.1.2 CHCs B4.1.3 PHCs B4.1.4 Sub Centers B4.1.5 Others B 4.2 Strengthening of District, Su-divisional 500000 3 1500000 Hospitals, CHCs, PHCs B.4.3 Sub Centre Rent 3000 50 150000 B.4.4 Logistics management/ improvement

97 DHAP Dehradun 2011-12 9797 97

B5 New Constructions/ Renovation and Setting up 0 B5.1 CHCs B5.2 PHCs B5.3 SHCs/Sub Centers B5.4 Setting up Infrastructure wing for Civil works B5.5 Govt. Dispensaries/ others renovations B5.6 Construction of BHO, Facility improvement, civil work, BemOC and CemOC centers B.5.7 Major civil works for operationalisation of FRUS B.5.8 Major civil works for operationalisation of 24 hour services at PHCs B.5.9 Civil Works for Operationalise Infection Management & Environment Plan at health facilities B.6 Corpus Grants to HMS/RKS 37,00,000 B.6.1 District Hospitals 500000 2 1000000 B.6.2 CHCs 100000 7 700000 B6.3 PHCs 100000 17 1700000 B6.4 Other or if not bifurcated as above (Sub District 100000 3 300000 Hospitals) B7 District Action Plans (Including Block, Village) B8 Panchayati Raj Initiative 0 B8.1 Constitution and Orientation of Community leader & of VHSC,SHC,PHC,CHC etc B8.2 Orientation Workshops, Trainings and capacity building of PRI at State/Dist. Health Societies, CHC,PHC B8.3 Others B9 Mainstreaming of AYUSH 0 B9.1 Activities other than HR B10 IEC-BCC NRHM 17,00,000 B.10 Strengthening of BCC/IEC Bureaus (state and district levels) B.10.1 Development of State BCC/IEC strategy B.10.2 Implementation of BCC/IEC strategy B.10.2.1 BCC/IEC activities for MH - - 600000 B.10.2.2 BCC/IEC activities for CH - - 600000 B.10.2.3 BCC/IEC activities for FP - - 400000 B.10.2.4 BCC/IEC activities for ARSH B.10.2.5 Other activities (please specify) - - 100000 B.10.3 Health Mela B.10.4 Other activities B11 Mobile Medical Units (Including recurring 23,00,000 expenditures) B12 Referral Transport 0 B12.1 Ambulance/ EMRI

98 DHAP Dehradun 2011-12 9898 98

B12.2 Operating Cost (POL) B13 School Health Programme 0 B14 PPP/ NGOs 0 B14.1 Non governmental providers of healt h care RMPs/TBAs B14.2 PNDT and Sex Ratio B14.3 Public Private Partnerships B14.4 NGO Programme/ Grant in Aid to NGO B14.5 Other innovations( if any) B15 Planning, Implementation and Monitoring 20,90,000 B15.1 Community Monitoring (Visioning workshops at state, Dist, Block level) B15.1.1 State level B15.1.2 District level B15.1.3 Block level B15.1.4 Other B15.2 Quality Assurance (SDH-QA team + DH QA team+ 2 1680000 DQA team) B15.3 Monitoring and Evaluation B15.3.1 Monitoring & Evaluation / HMIS 60000 6 360000 B15.3.2 Computerization HMIS and e-governance, e-health B15.3.3 Other M & E B15.3.3.1 District Health Action Plan 50000 1 50000 B.16 PROCUREMENT 0 B16.1 Procurement of Equipment B16.1.1 Procurement of equipment: MH B16.1.2 Procurement of equipment: CH B16.1.3 Procurement of equipment: FP B16.1.4 Procurement of equipment: IMEP B16.1.5 Procurement of Others B.16.2 Procurement of Drugs and supplies B.16.2.1 Drugs & supplies for MH B.16.2.2 Drugs & supplies for CH B.16.2.3 Drugs & supplies for FP B.16.2.4 Supplies for IMEP B.16.2.5 General drugs & supplies for health facilities B.17 PNDT Activities 0 B.18 Regional drugs warehouses 0 B.19 New Initiatives/ Strategic Interventions (As per 0 State health policy) / Innovation/ Projects (Telemedicine, Hepatitis, Mental Health, Nutition Programme for Pregnant Women, Neonatal) NRHM Helpline) as per need (Block/ District Action Plans) B .19.1 NABH accredition of doon hospital , and PHC in State Level

99 DHAP Dehradun 2011-12 9999 99

backward district B .19.2 PROMIS State Level B .19.3 Community Monitoring State Level B.20 Health Insurance Scheme 0 B .20.1 RSBY Cell State Level B.21 Research, Studies, Analysis 0 B.22 State level health resources center (SHSRC) 0 B23 Support Services 0 B23.1 Support Strengthening NPCB B23.2 Support Strengthening Midwifery Services under medical services B23.3 Support Strengthening NVBDCP B23.4 Support Strengthening RNTCP B23.5 Contingency support to Govt. dispensaries B23.6 Other NDCP Support Programmes Total 4, 74,10,642

100 DHAP Dehradun 2011-12 100100 100

SECTION - C

ROUTINE IMMUNIZATION

101 DHAP Dehradun 2011-12 101101 101

PART - C ROUTINE IMMUNIZATION

Situational Analysis: Immunization is an essential component of child health and it has led to a considerable decrease of immune preventable diseases in past. If immunization rates falls there is always the danger that some of these diseases could reappear.

Total estimated population of district Dehradun for the year 2011-12 is 15,98,961 children below the age of 12 month will be 34,857 (2.18 % of estimated population) and 2,71,823 (17% of estimated population) will be the under the age of five. Total fertility rate is 2.55 and Crude birth rate 21.8 per thousand. (NFHS-III) Percent of fully immunized children is 68.7% in Dehradun (DLHS-III) Hence, it is important to improve full immunization coverage up to 85% during year 2011-12.

District Profile:

Indicators Current Situation Source of Data Total Population 15,98,961 Estimated for year 2011-12 Rural (%) 47% do Urban (%) 53% do Infant Mortality Rate (IMR) 44 SRS 2008 Below Poverty Line (BPL) (%) 27% Planning Comm. Crude Birth Rate (CBR) 21.8 NFHS-III Infants / year 34,857 CBR x Population Blocks 6 DPRO 2010 Gram Panchayat 403 DPRO 2010 Revenue villages 714 (735) DPRO 2010 Villages 1165 E-mamta Data Entry Towns / Urban Areas 3 DPRO 2010 No. of CHCs 7 CMO Office, 2010 No. of PHCs 17 (22) CMO Office, 2010 No. of Sub Centre 168 CMO Office 2010 Full immunization coverage (12 to 68.7 DLHS III 23 months children) Dropout BCG to Measles 10.3 DLHS III

Strategy: The universal immunization programme was launched to protect all infants (0-12 months) against six major but preventable diseases namely Tuberculosis, Diphtheria, Pertussis, Tetanus, Poliomyelitis and measles. In Dehradun 68.7% (DLHS-III) of the children aged 12-23 months have

102 DHAP Dehradun 2011-12 102102 102 received all the doses of the prescribed vaccines or, in other words, are fully immunized. The drop out rates from BCG to Measles users is 10.3% (DLHS-III). Complete immunization coverage in the district will be improved by reducing the drop-out rates between doses; by reaching the children not-at-all immunized particularly those from low-income families. Immunization tracking software will be helpful to identify children dropping out and proper follow up mechanisms will be established at each level to immunize them. ASHA will help to mobilizing those children who are not covered by immunization program. Information systems will be strengthened to identify children dropping out .

Level -1 (Sub centers): In hill block of District Dehradun, nearly 25 level-1 MCH Care Centers (Sub Centers) cater to more than 5000 population in their respective area and in foot-hills/plain Block 47 Sub Centers cater to more than 7000 population. In terms of number of villages covered, 72 level-1 MCH Care Centers (Sub Centers) cover more than 6 villages. Naturally, given the difficult terrain and lack of road connectivity and transport facilities, it is impossible for female workers to visit such large number of villages and to cover the large population. A large proportion of population in these Sub Centers areas goes un-served. To make service more accessible it is therefore proposed to recruit ANMs for vacant sub center on contractual basis. It is planned to place 2 nd ANMs in hard to reach level-1 MCH Care Centers. This will help increase access to health services.

Public Health Infrastructure:

Sanctio No. of With Functional Cold Proposed Expansion Building ned Functioning Chain Equipment (No. Of Facilities) Sub-centre 168 161 Nil - SAD 24 24 Nil - APHC 22 17 15 5 CHC/FRUs 7 7 7 - DH /SDH 6 6 6 -

Service delivery improvements: • Integration with ICDS department in village health and Nutrition days • Regular out reach camps in un-served area. • Out of selected 1418 ASHAs, 1166 are trained up to v module.

Accessibility: • Sparsely populated villages with majority of villages with population less than 500. • Level-1 MCH Care Centers has to cater 8-12 villages a population of 3000. • Shortage of trained manpower at field level. • Improper distribution of SCs, as some SCs caters more than 5000 population. • Hilly terrain makes it difficult for the field workers to cover all villages once in a month.

Utilization / Adequate Coverage: • Immunization held at central village point so other village community face problem to reach immunization site. • Timings of immunization are not suitable to villagers as they are busy with their household works. • PRI do not take interest in routine immunization activities.

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Objective:

The overall goal is to increase immunization coverage rates. Based on review of past performance, assessment of critical bottlenecks and planned activities indicate below:

Immunization Coverage Targets:

Current status 2006- 2007- 2008- 2009- Planned Indicator 2000-11 (HMIS 07 08 09 10 2011-12 October 10) BCG coverage (%) 100.9 100% 100% 80% 51% 85% DPT-1 coverage (%) 99.8 100% 100% 79% 49% 85% DPT-3 coverage (%) 97.7 100% 100% 75% 48% 85% Districts with over 80% DPT-3 100%) 100% 100% - - 85% coverage –No. (%) Measles coverage (%) 92.8 100% 100% 73% 48% 85% Vit A coverage (% 2+ doses) 41.5 - - 30% 18% Districts with over 70% Vit A _ - - - - coverage – No. (%) Drop-out rate BCG – Measles 8.1 - - 5% 3% 2% (%) Districts with under 15% BCG ------Measles Drop Out – No. (%) Children fully vaccinated by 92.8 - - 73% 48% 12 months of age (%) Source: District Reporting, CMO Office, Dehradun To improve Vaccine /Supply Logistics:

Current 2006- Indicator 2007-08 2008-09 2009-10 Status 07 2010-11 Districts with any antigen stock-out more Nil Nil Nil Nil Nil than 1 month in the last 12 months – No. (%) Districts with AD syringe stock-out more Nil Nil Nil Nil Nil than 1 month in the last 12 months – No. (%)

To expand Cold Chain Reach and Improve Performance: It is also planned to procure new generator set for these 9 level- 2 MCH care centers, so that uninterrupted power supply for cold chain maintenance will be ensured. These level-2 MCH care centers are Chiddarwala, Dudhli, Thano, Mehuwala, Nayagaon pelio, Rajawala, Rudrapur, Kalsi and Tuni. The generator sets procurement budget already placed in RCH-Flexipool in New Born Corner Activity.

Status 2010- Indicator 2006-07 2007-08 2008-09 2009-10 11 (Dec, 10) Cold chain assessment done within last - - - - - 3 years (exact year done or planned) Proportion of ILR registered (not 20% 10% 10% 3% 5.08% condemned) non-functional (%)

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Improve injection safety by introducing AD-syringes:

Indicator 2006-07 2007-08 2008-09 Planned 2009-10 PHCs using ADS for all immunizations (%) 100% 100% 100% 100% PHCs with appropriate waste disposal in 30% 50% 50% 100% (functional) place (%)

Ensure accurate record-keeping/monitoring with improved supervision:

Indicator 2006-07 2007-08 2008-09 2009- Current year 10 2010-11 Gap between reported and evaluated 40% 30% 20% 10% 8% full immunization coverage (%)

Child health strategies proposed under RCH-II: Objective:

Intermediate Indicators Current Objectives in % Status 05-06 06-07 07-08 08-09 09-10 10-11 60 % of children 12-23 months full immunized Overall 53.0 45.0 60.0 67.0 76.0 80.0 85.0

Cold Storage Equipments Available with the District:

VACC. District ILR-L/S DFZ-L/S COLD BOX ICE PACKS Generator CARR. Total 59 56 77 1654 13650 13 In working 55 44 68 1638 13050 13 Under Repair 3 4 0 0 0 0 Beyond 1 8 9 16 600 0 Repair

Activities: • Immunization tacking software will be implemented made to identify children not immunized at all. ASHA support services will be utilized to mobilize such children. • ANMs prepare and provide immunization cards to mothers and retain one copy with them. However, children not turning up for the second dose are neither monitored nor followed up. Monitoring systems will be strengthened to drastically reduce drop out rates. • In each PHC area, a central location nearer to Sub Centers will be identified, route map will be prepared and vaccines will be supplied to all ANMs on the morning of immunization day. Unused and partially used vials will be collected on the same day in the evening. • All PHCs will have vaccines depots and PHCs not having ILRs will be supplied with them, through the GoI supply. • Cold chain system will be streamlined from District to CHC/ PHC level, by provision of fridges, deep-freezers and regular visits by vaccine vans to ensure adequate supply of vaccines at all levels.

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Immunization Detailed Budget

Consolidated Budget of Routine Immunization (2011-12) Required Sl. Unit Physical fund Activity No. Cost Targets under NRHM Routine Immunization C IMMUNISATION C.1 RI strengthening project (Review meeting, Mobility support, Outreach services etc) C.1.1 Mobility Support for Supervision & Monitoring(st &Distt) 40000 C.1.2 Alternate Vaccine Delivery C.1.2.1 For hilly 100 2256 225600 C.1.2.2 For Plain 50 6780 339000 C.1.3 Social Mobilisation by ASHA / link workers 150 26665 3999750 C.1.4 Quarterly review meeting at District level (6 bl's 5 person 3000 4 12000 meet per Qtr @100) C.1.5 Quarterly review meeting at block level (@ Rs.50 per PP as 325875 honorarium for ASHAs (travel) & Rs. 25 per person at the disposal of MO-I/C for meeting expenses per year) C.1.6 To develop micro plan at sub centre level 100 168 16800 C.1.7 For consolidation of micro plan at block level 1000 6 6000 C.1.8 For consolidation of micro plan at district level 2000 1 2000 C.1.9 POL for vaccine delivery 50000 1 50000 C.1.10 Consumables for computer including internet 400 12 4800 C.1.11 Bleach/Hypochlorite solution 500 24 12000 C.1.12 Salary of Contractual Staffs 9000 1 108000 C.2 Cold Chain Maintenance (@ Rs 500 per PHC/CHC per 25 22000 year District Rs 10,000 per year) C.3 Pulse Polio operating costs Total (RI budget) 51,63,825

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SECTION - D

NATIONAL DISEASE CONTROL PROGRAMS

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Integrated Disease Surveillance Project (IDSP) Annual Action Plan & Budget for the year 2011-12

Goal:

To detect early warning signals of impending outbreak and help initiate an effective response in a timely manner

Situational Analysis:

• Out of total Government health facilities 85% of institution reporting weekly of IDSP. • Few private institutions of district also providing information of weekly basis. • Mobile phone distributed through NRHM to ANM will also help for prompt reporting of outbreak. • Rapid Response Team is formed at district headquarter which comprises Nodal Officer, Pathologist, Physician and Pediatrician. • Targeted three CHC and Doon Hospital labs were upgraded for surveillance activities. • EDUSAT was also established at DHQ and functioning properly for information transformation. • H1N1 screening centre functioning at the district hospital with trained manpower. Laboratory confirmation is being done at the NICD Delhi. • The epidemiologist is posted at the district IDSP unit for better surveillance.

Objective:

• The project development objective is to improve the information available to the government health services and private health care providers on a set of high-priority diseases and risk factors, with a view to improving the on-the-ground responses to such diseases and risk factors. • To establish a decentralized District based Surveillance system for communicable and non communicable diseases in the District, so that timely and effective public health action can be initiated in response to health challenges for communicable and non communicable diseases. • To improve the efficiency of the existing Surveillance activities of the disease control programme and facilitate sharing of relevant information with health administrations, community and other stakeholders so as to detect disease trends overtime & evaluate control strategies. • Accreditation of a private laboratory in the district for H1N1 testing.

Strategies:

• Regular monitoring from district to block level and block to Sub Centre level. • Organization of workshops for sensitization of ASHAs regarding prompt reporting of cases. • To develop the system of online report receiving from peripheral units to headquarter.

Activities:

• Supply of reagent to District Hospital and CHC labs. • Information Technology and communication • Use of EDUSAT for networking system with state and national level. 108 DHAP Dehradun 2011-12 108108 108

• Computer Hardware & Office Equipments • Software for Surveillance • Strengthening reporting system through different health facilities. • Electronic transformation of data /information to save time and paperwork. • Consultant/Contract Staff honorarium • Use of IDSP manpower for information collection, compilation analysis of disease pattern of district. • Organizing orientation workshop for sensitization health worker regarding prompt reporting of cases. • Sensitization to educational institutions regarding H1N1. • IEC: Printing of SPL formats. Designing and distribution of IEC material for general mass awareness. • Organizing quarterly review meeting at district level for sharing of progress with all stakeholders. • Decentralization of Surveillance activities • Peripheral Surveillance Units –level -2 and Level 3 MCH Care Centers • District Surveillance Units

Monitoring & Evaluation:

District Surveillance Officer/epidemiologist shall monitor overall surveillance activities in the district. Block Nodal Officers shall monitor surveillance activities at sub centre level and report about the same to DSU. RRT shall visit the area in case any epidemic is reported.

Budget:

The overall budget requirement under IDSP for the year 2011-12 will be Rs. 9,90,000.00. Head wise details of budget required are given below in the table.

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No Proposed Activi Sub- Activity Unit cost of Budget for ty activity units 2011-12 Training One day training of Hospital Doctors/One for Pyt MOs 25000 Training 2 50000.0 One day training of Hospital Pharmacist / Nurses 30000 Training 1 30000.0 One day training of Medical College Doctors 25000 Training 1 25000.0 One day training Data entry and analysis training for Block Health Team 20000 Training 1 20000.0 One day training of DM & DEO State level - - - Sub total 125000.0 Staff remuneration* State/district Epidemiologists (1 at 40000 Salary 1 480000.0 State HQs-SSUs and 1 each at district HQs - DSUs) State/ district Microbiologists ( 1 at State HQs- SSUs - and 1 each at identified district priority labs ) Entomologist (1 at State HQs – SSUs) - Consultants Finance (1 at State HQs - SSUs) - Consultants Training (1 at State HQs - SSUs) - Data Managers (1 at State HQs - SSUs and 1 each at district HQs - DSUs) 13500 Salary 1 162000.0 Data Entry Operators (1 at State HQs - SSUs, 1 each at district HQs - 8500 Salary 1 102000.0 DSUs and 1 identified Medical Colleges/Other institutions viz. ID Hospitals) identified under IDSP * The State Health Societies may fix the remuneration as per IDSP guidelines or less as per State policy Sub Total 744000.0 Operational Cost Transport 60000.0 Office Expenses, Broadband 15000.0 Expenses, collection and transportation of samples and other miscellaneous expenses (to be specified) Sub total 75000.0 Total (Surv. Preparedness =Training +Remuneration + Operational cost) 944000.0 Surveillance Preparedness

Mobility/POL for outbreak 24 48000.0 d Total (OB Investing & Resp)

invest igate ion an 48000.0 Grand Total 992000.0

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National Vector Borne Disease Control Programme District Action Plan (2011-12)

Executive Summary Vector borne disease control programme is one of the important national programs being implemented in District Dehradun. In district Dehradun, the major vector borne diseases are Malaria, Dengue and AES/JE. Filaria, Kala-azar and Chikungunya are not prevalent in the District. The comparative situation of vector borne diseases in the District is as follows-

Malaria Prevalence

Total Pf. Deaths due Year Population BSC/BSE ABER Malaria API SPR SFR Cases to Malaria Cases 2007 1440453 73376 4.40 56 02 0.04 0.09 0.003 Nil 2008 1440453 37416 2.60 99 13 0.07 0.26 0.020 Nil 2009 1440453 21039 1.46 203 09 0.14 0.96 0.043 Nil 2010 1440453 30026 2.10 528 55 0.36 1.76 0.183 Nil

Other Vector Borne Diseases

Goals for 2011-12 To reduce the morbidity and mortality due to vector borne diseases Strategies to achieve above said goal – Vector Borne Years Sl .No. Total Disease 2006 2007 2008 2009 2010 1 Dengue 12 21 140 25 2889 3087 2 J.E./A.E.S Nil 01 02 Nil 07 10 3 Filaria Nil Nil Nil Nil Nil Nil 4 Kala-azar Nil Nil Nil 02 Nil 02 5 Chickungunia Nil Nil Nil Nil Nil Nil

Ensuring quality laboratory services in all the PHCs, CHCs and Hospitals either through microscopic centers or rapid diagnostic kits. This will require filling up of the vacant posts of LTs and impartig training to them.

Integrated vector management – Area specific Entomological surveillance has to be planned specially in the transmission period.

Management of Malaria foci – line listing will be prepared on a weekly basis and the activities for control of local foci such a focal spray follow up of the malaria cases and antilarval measures to be undertaken regularly .

Objectives –

• Increase access to diagnosis and treatment in high risk areas with particular focus and remote and inaccessible areas in rural areas as well as urban areas.

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• Ensure high quality integrated vector control in high risk areas • Maintain vigilance in low risk areas by fever surveillance/ vector surveillance • Enhance public awareness with NGOs and Private sector participation about vector borne disease control. • Dengue/ DHF control in high risk areas • Strengthen programme management at critical operational level giving priority to vector surveillance and quality of treatment and diagnostic services. • To provide integrated and sustainable system for control of vector borne disease in the urban areas by strengthening the Primary health care services with focus on socio economically poor community like slums and other vulnerable areas. • Enhance participation of Private Health care institutions in VBD – cases reporting to Govt. system.

The activities proposed in the DAP in view of the above strategies can be summarized as under:

Strengthening of laboratory/ Diagnostic facilities • Complete treatment • Monitoring drug resistance, insecticide resistance • Integrated IEC/BCC activities • Public private partnership • Sentinel surveillance for Dengue and AES/JE • Integrated Vector management • Capacity building of clinicians and other staff

Financial inputs proposed under District Action Plan for above mentioned activities during 2011 – 12 can be summarized as under –

Proposed Amt. Particulars Proposed Amt. (In Rs) (Rs in Lakhs) MALARIA Early case detection and prompt treatment 4164100 41.641 (EDPT) Monitoring & Supervision 712000 7.12 IEC/ BCC 2752000 27.52 VBD consultant (Entomologist) - - Capacity Building 293000 2.93 Miscellaneous 525500 5.255 Anti-Malaria Month-June 2011 148000 1.48 Antilarval /Adulticidal Measures in urban and 1582500 15.825 peri urban areas Larvivorous Fish (Hatcheries) Biological 1750000 17.5 Control Total Malaria 11926600 119.266 DENGUE Diagnostic facilities and Management 550000 5.5 Monitoring and Evaluation 500000 5.0 Epidemic Preparedness 1878000 18.78 112 DHAP Dehradun 2011-12 112112 112

IEC/BCC 2875000 28.75 Capacity Building 150000 1.5 Dengue Month-July 2011 143000 1.43 Total Dengue 6096000 60.96 AES/ JE Monitoring and Supervision 100000 1.0 Epidemic Preparedness - - Diagnostic Management and Lab Article - - Capacity Building - - IEC/BCC 15000 0.15 Total AES/JE 1.15 District Total 18137800 181.378

Malaria Control

Project Component 1: Improving Access to and Use of Services for Control of Malaria [Rs 119.266 Lacks] This component includes activities to be implemented by the Office of DMO, Dehradun. It comprises Following Sub Components -

Proposed Amt. Proposed Amt. Particulars (In Rs) (Rs in Lakhs) MALARIA Early case detection and prompt treatment 4164100 41.641 (EDPT) Monitoring & Supervision 712000 7.12 IEC/ BCC 2752000 27.52 Capacity Building 293000 2.93 Miscellaneous 525500 5.255 Anti-Malaria Month-June 2011 148000 1.48 Antilarval/Adulticidal Measures in urban 1582500 15.825 and peri urban areas Larvivorous Fish (Hatcheries) Biological 1750000 17.5 Control Total Malaria 11926600 119.266

Early diagnosis and Prompt treatment (Rs 41.641 Lacks)

• To reduce morbidity and mortality due to malaria the best means is todetect early and provide complete treatment • Presumptive treatment will be discontinued but all fever cases in thehigh endemic areas will be attended by health worker and will beimmediately tested for P falciparum by RDT Kit. A Blood slide shall alsobe made for microscopy. • All positive Pf patients will receive ACT (other than pregnant women). AllP vivax will be given Chloroquine and Primaquine ( for 14 days ) according to national treatment policy. • Provision of RDT and ACT will be prioritized in areas which do not have access to microscopy in 24 hours and in tribal areas. 113 DHAP Dehradun 2011-12 113113 113

• Private sector partners would be identified for Malaria diagnosis and treatment and efforts will be made to provide the diagnosis and treatment according to national standards.

Monitoring & Supervision (Rs 7.12 lacs) It is an important Programme activity for effective implementation at all levels – Sub Centers to District.

IEC/ BCC Activités (Malaria – Rs 27.52 lacs)

• Enhance awareness regarding source and transmission risk reduction, treatment, availability of services at different levels • Promote attitudinal and value changes among target audiences leading to informed decisions, modified behaviour, desirable practices at individual and societal level • Stimulate increased and sustained demand for quality prevention and care services and optimal utilization of available health care services • Build support for the programme across inter-sectoral partner organizations, influential sectors of society and health care service providers and elicit commitment for action

Anti Malaria Month campaign -June 2011(Rs 1.48 Lakhs)

Integrated accelerated action through communication for behavioural impact and delivery of services for informed decision-making, initiation of individual and social change towards reducing mortality/morbidity on account of malaria, dengue, Japanese Encephalitis, Kala-azar and Lymphatic Filariasis as defined under the National Health Policy (2002).The AMM campaign also an attempt to augment and ensure appropriate public health focus; peoples’ orientation and ownership of public health programmes; community-based approaches; public-private partnership; involvement of local bodies and Panchayati Raj Institutions; gender equity, en route to improved access to primary health care, prevention and control of communicable diseases including vector borne diseases, reduction of infant mortality rate and maternal mortality ratio by 50% by year 2012 and promotion of healthy life styles as per the goals of the National Rural Health Mission (2005 – 2012) launched by the GoI in April 2005.

Capacity Building (Rs.2.93 Lacs) Enhance the skills of clinicians and other staff.

Miscellaneous (Rs. 5.255) For Various components listed below –

S. Requirements Total Total Unit cost No Activity Description Expendit expenditure Name of Numb in Rs. . units er ure (Rs.in Lacks) 1 Miscella Computer system with District 1 75000*1 75000 0.75 neous printer, cartridge HQ Photostat machine, 1 1,00,000*1 100000 1 Laptop and Projector 1 1,00,000*1 100,000 1 with LCD Connectivity/ 1 36000*1 36000 0.36 Networking Computer Operator 1 102000*1 102000 1.02 Bags with logo HW 150 750 112500 1.125 Sub Total 5.25 114 DHAP Dehradun 2011-12 114114 114

Antilarval /Adulticidal Measures in urban and peri urban areas ( Rs. 26.5)

Requirements Total Total Sl. Unit cost expenditu Activity Description Name of Numb Expendi No. in Rs. re (Rs.in units er ture Lacks) 1 Antilarval ABATE in lit 100 lit 1700*100 170000 1.7 /Adulticidal Pyrethrum in lit 1000 lit 1000*450 450000 4.5 Measures in ext. 2% urban and Spray Pump - 25 2500*25 62500 0.625 peri urban POL 1 1 150000 150000 1.5 areas 500 working wages of days @ Rs 500*150 750000 7.5 spray workers 150 Sub Total 15.825

Larvivorous Fish (Hatcheries) Biological Control ( Rs. 87.5)

Suitable water bodies will be seeded with larvivorous fish, which is an environmental friendly and cost effective Bio-Environmental measures. Hatcheries of Larvivorous fish will be established in all 07 CHCs of the district. Viz CHC Chakrata, Sahiya, Vikas Nagar, Sahaspur, Raipur, Mussoorie and Doiwala

Dengue Control

Project Component 1: Improving Access to and Use of Services for Control of Dengue [Rs 60.96 Lacks] This component includes activities to be implemented by the Office of DMO, Dehradun. It comprises Following Sub Components –

DENGUE Diagnostic facilities and Management 550000 5.5 Monitoring and Evaluation 500000 5.0 Epidemic Preparedness 1878000 18.78 IEC/BCC 2875000 28.75 Capacity Building 150000 1.5 Dengue Month-July 2011 143000 1.43 Total Dengue 6096000 60.96

Diagnostic facilities and Management (Rs. 5.5 Lacs)

For sentinal surveillance hospital /referral lab – 1. Doon Hospital Dehradun and RD kits for screening of suspected Dengue fever.

Monitoring and Evaluation (Rs. 5 Lacs) It is an important Programme activity for effective implementation at all levels – Sub Centers to District.

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Epidemic Preparedness (Rs. 18.78 Lacs) to forecasting and control of the outbreaks due to Dengue .

IEC/ BCC (Dengue – Rs 28.75 lacs) Developing creative and implementing IEC/BCC activities as per action plan

Capacity Building (Rs. 1.5 lacs) Enhance the skills of clinicians and other staff.

AES/ JE Control

Project Component 1: Improving Access to and Use of

Services for Control of AES/JE [Rs 1.1.5 Lacks]

It comprises Following Sub Components –

AES/ JE Monitoring and Supervision 100000 1.0 IEC/BCC 15000 0.15 Total AES/JE 1.15

Monitoring and Supervision (Rs. 1 lacs) It is an important Programme activity for effective implementation at all levels – Sub Centers to District.

IEC/BCC (Rs. 0.15 Lacs) Developing creative and implementing IEC/BCC activities as per action plan.

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ANNUAL PLAN FOR PROGRAMME PERFORMANCE & BUDGET FOR THE YEAR 1ST APRIL 2011 TO 31 ST MARCH 2012

District Dehradun State Uttarakhand

This action plan and budget have been approved by the DTCS. Signature of the DTO______Name Dr. V.S. Tolia_ Designation DTO, Dehradun

Section-A – General Information about the District

1 Population (in lakh) 1478262 2 Urban population 814358 3 Tribal population 144557 4 Hilly population 144557 5 Any other known groups of special population for specific interventions No (e.g. nomadic, migrant, industrial workers, urban slums) 1 Population (in lakh) 1478262

Does the district have a DTC - Yes

ORGANIZATION OF SERVICES IN THE DISTRICT:

S. Name of the TU Population Please indicate if the TU is- No. of MCs No. (in Lakhs) Govt NGO Govt NGO Private 1 Dehradun 765636 Govt. Nil 04 04 Nil 2 Rishikesh 460704 Govt. Nil 03 01 Nil 3 Chakarata 251922 Govt. Nil 05 01 Nil DISTRICT 1478262 03 Nil 12 06 Nil

RNTCP performance indicators: Important: Please give the performance for the last 4 quarters i.e. July 2009 to June 2010

Annualiz Total No of new Annualized Cure rate for Plan for the next ed total Proportion number smear New smear cases year case of TB of positive positive case detected in TB Unit detection patients patients cases put detection the last 4 Annualize Cure rate (per tested for put on on rate (per correspondin d NSP rate lakh HIV treatment treatment lakh p op) g quarters CDR (85%) pop) TU 1 Maintain 100/2181= 2181 284.86 621 81.10 317/449=71% > 85% Dehradun % 4.58% TU 2 211/287=73. 106/655= 655 142.17 272 59.04 >70% > 85% Rishikesh 5% 16.18% TU 3 4/174= 174 69.06 53 21.03 54/62=87% >70% > 85% Chakrata 2.29% District 582/798=73 210/3010= 3010 203.61 946 63.99 >70% > 85% (total) % 6.97%

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Section B – List Priority areas for achieving the objectives planned:

Sl. No. Priority areas Activity planned under each priority area

1 Maintaining Good 1 a) Intensified supervision and monitoring Cure and conversion b) Involve more ASHA’s to decentralise DOTS, make DOTS rates more patient friendly c) Involvement of Private Practioner and ensuring more referral of chest symptomatic. 2 Increase Case 2 a) Involvement of Private Practioner, CBO and NGO, ensuring detection Rates more referral of chest symptomatic. 2 b) Involve the ASHA’s to increase DOTS awareness and referrals 3 TB HIV Coordination 3 a) VCTC – MC collaboration 3 b) Ensuring referrals between the programmes 4 Strengthen EQA 4 a) Re-sensitisation of all the staff involved in EQA implementation implementation. 4 b) Reporting 4 c) Monitoring

Section C – Plan for Performance and Expenditure under each head:

Civil Works

Activity No. No. No. Pl provide Estimated Quarter in which required as actually planned justification if an Expenditure the planned per the present for this increase is on the activity expected norms in in the year planned (use activity to be completed the district district separate sheet if required) (a) (b) (c) (d) (e) (f) DTC 1 1 0 - - - TUs 3 3 0 - - - DMC 16 18 0 - - - Total - -

Laboratory Materials

Activity Amount Amount Procurement Estimated Justification/ permissible actually planned during Expenditure for the Remarks for as per the spent in the current next financial year (d) norms in the last 4 financial year (in for which plan is the district quarters Rupees) being submitted (Rs.) (a) (b) (c) (d) (e) Purchase of 2.25 Lakh 1.96 2.25 Lakh 2.50 Lakh as per norms Lab Materials

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Honorarium

Estimated Amount Expenditure Expenditure for Amount actually (in Rs) the next permissible Justification/ spent in planned for financial year as per the Remarks for Activity the last current for which plan norms in (d) 4 financial is being the district quarters year submitted (Rs.) (a) (b) (c) (d) (e) Honorarium for 0.42 Lakh 2.79 L 1.0 Lakh 3.0 L Due to DOT providers backlog (both tribal and non tribal districts) Honorarium for - - - - DOTS DOT providers Plus(CAT of Cat IV IV) not patients started

Annual Action Plan Format Advocacy, Communication and Social Mobilization (ACSM) for RNTCP Information on previous year’s Annual Action Plan Budget proposed in last Annual Action Plan: 32.93 Lakh Amount released by the state: 33.68 Lakh Amount Spent by the district- 30.76 Lakh Permissible budget as per norm : 36 Lakh Budget for next financial year for the district as per action plan detailed below: (34.738L)

Program WHY For WHAT When Challeng WHO By Monitoring Budget es to be ACSM M ACSM Time Frame WHO and tackled Objective Activities M Evaluation by ACSM Target during Audie the Year nce 2010-11 Based on Desired Patien Activit Medi Q1 Q2 Q3 Q4 DTO/I On On existing behavior ts and ies a/ EC Site Site TB or action Gener Outdo Mate Officer verif verif indicators (make al ors: rial / icati icati and SMART: public - wall Requ on on analysis specific, / for paintin ired - - - - Comm by by - of measurab aware gs unicati the the communi le, ness (1 each Wall - - - - on team team cation achievabl gener for all Paint facilitat challenge e, realistic ation Village ing/ or/ s & time and s) Hoar ANM

119 DHAP Dehradun 2011-12 119119 119

(Maximu bound social - ding & m 3 objectives mobili Hoardi / ASHA Challenge ) zation ngs ( Sloga s ) for all n Urban Writi areas) ng - Tin In plates ( All for all PHI/ strategi Sub c Cent locatio er ns & 20 in small no shops) - Banner s - others Challenge 1. Advocacy Activities Sensitizati Com 1 1 1 1 State & - - 10,000. on muni District 00 meetings ty Media Medi - - - 1 2500.00 Informatio a n Booklets Healt - - - - - World TB h Day Wor ker Com 1 - - - 50,000. muni 00 ty Communication Activities TV & Com Talk Talk 1 1 1 1 DTO/ - 0.00 Radio talk muni MO/ ty STS/ STLS Social Mobilization Activities Patient Com Meetin Meet 2 2 2 2 DTO/ - 8000.00 Provider muni g ing MO/ Meeting ty STS/ STLS TOTAL BUDGET 70500.0 0 Comments, if any: - Nil Equipment Maintenance:

120 DHAP Dehradun 2011-12 120120 120

Amount Amount Estimated No. actually Proposed for Expenditure for the actually Justification/ spent in Maintenance next financial year present Remarks for Item the last during for which plan is in the (d) 4 current being submitted district quarters financial yr. (Rs.) (a) (b) (c) (d) (e) Office Equipment 01 3200 25000 15000.00 - (Maintenance includes computer software and hardware upgrades, repairs of photocopier, fax, OHP etc) Binocular Microscopes 14 - 25000 21000.00 - (RNTCP) Total 36000.00

121 DHAP Dehradun 2011-12 121121 121

Training: No. Planned Estimated to be trained Expenditure Expenditure for No. Justi in RNTCP (in Rs) the next No. in already ficati during each planned for financial year the trained on/ Activity quarter of current for which plan district in rema next FY financial is being RNTCP rks (c) year submitted Q 1 to Q4 (Rs.) (a) (b) 1 2 3 4 (d) (e) (f) Training of MOs 161 150 ------Training of LTs of DMCs- 16 16 ------Govt + Non Govt Training of MPWs 208 208 ------Training of MPHS, pharmacists, 180 85 - - - - 20000 - Nursing staff, BEO etc Training of Comm Volunteers 2000 1000 - - - - 20000 - Training of Pvt Practitioners 100 100 - - - - 20000 - Other trainings ------Re- training of MOs ------Re- Training of LTs of DMCs ------Re- Training of MPWs ------Re- Training of MPHS ------Re- Training of Pharmacists ------Re- Training of nursing staff, BEO ------Re- Training of CVs ------Re-training of Pvt Practitioners ------TB/HIV Training of MOs 120 ------TB/HIV Training of STLS, LTs, 2000 ------MPWs, MPHS, Nursing Staff, Community Volunteers etc TB/HIV Training of STS 03 ------Training of MOs and Para medicals ------in DOTS Plus for management of MDR TB Provision for Update Training at ------Various Levels (key staff & MO- PHIs) Any Other Training Activity (Key - staff & MO-PHIs)

122 DHAP Dehradun 2011-12 122122 122

Vehicle Maintenance:

Estimated Amount Expenditure Expenditure Number spent on (in Rs) for the next permissible Number POL and planned for financial year Justification/ Type of as per the actually Maintenance current for which plan remarks Vehicle norms in present in the financial is being the district previous 4 year submitted quarters (Rs.) (a) (b) (c) (d) (e) (f) Four 01 01 28724 1.0 L 1.25L - Wheelers Two 03 03 55442 75000 75000 - Wheelers Total 2.0L

Vehicle Hiring:

Number Number Amount Expenditure Estimated Justification/ Hiring of permissible actually spent in (in Rs) Expenditure for remarks Four as per the present the planned for the next financial Wheeler norms in previous current year for which the district 4 financial plan is being quarters year submitted (Rs.) (a) (b) (c) (d) (e) (f) For DTO Nil Nil Nil Nil Nil Nil For MO-TC Nil Nil Nil Nil Nil Nil

NGO/ PP Support: (New schemes w.e.f. 01-10-2008)

123 DHAP Dehradun 2011-12 123123 123

No. of Estimated currentl Additiona Amount Expenditur Expenditure y l spent in e (in Rs) for the next Justificati involved enrolment the planned for financial year on/ Activity in planned previou current for which plan remarks RNTCP for this s 4 financial is being in the year quarters year submitted district (Rs.) (a) (b) (c) (d) (e) (f) ACSM Scheme: TB Low advocacy, participati 80 10 Nil 25000 10000 communication, and on social mobilization expected SC Scheme: Sputum Nil Nil Nil Nil Nil Collection Centre/s Transport Scheme: Sputum Pick-Up and Nil - Nil Nil Nil Transport Service DMC Scheme: Designated Microscopy 04 Nil 31051 Nil 2.0 L Cum Treatment Centre (A & B) LT Scheme: Strengthening RNTCP Nil Nil Nil Nil Nil diagnostic services Culture and DST Scheme: Providing Quality Assured Culture Nil Nil Nil Nil Nil and Drug Susceptibility Testing Services Adherence scheme: Promoting treatment Nil Nil Nil Nil Nil adherence Slum Scheme: Improving TB control in Nil Nil Nil Nil Nil Urban Slums Tuberculosis Unit Model Nil Nil Nil Nil Nil TB-HIV Scheme: Delivering TB-HIV Nil Nil Nil Nil Nil interventions to high HIV Risk groups (HRGs) Total 2.10 L

124 DHAP Dehradun 2011-12 124124 124

Miscellaneous:

Amou Expendit Amount nt ure (in Estimated permissi spent Rs) Expenditure for the ble as in the planned next financial year for Justification/ per the Activity* previ for which plan is being remarks norms in ous 4 current submitted the quart financial (Rs.) district ers year (a) (b) (c) (d) (e) Telephone Bill, Internet, 2.25 L 76100 2.0 L 2.25L as per norms TA/DA etc. Total 2.25L

Contractual Services: Expendit Estimated No. ure (in Expenditure No. No. planned Amount Justifi Rs) for the next required as actually to be spent in cation planned financial year per the present additional the / Activity for for which plan norms in in the ly hired previous 4 remar current is being the district district during quarters ks financial submitted this year year (Rs.) (a) (b) (c) (d) (e) (f) Medical Officer- Not to be - - - - DTC filled STS 03 03 - 297000.00 310500.00 337500.00 STLS 03 03 - 310500.00 324000.00 351000.00 06 (4+2- TBHV Medical 05 - 216000.00 226800.00 237600.00 College) DEO 01 01 - 82800.00 86400.00 90000.00 Accountant – ------part time Contractual LT 10 - 688800.00 720000.00 751200.00 1767300.00

Printing: Amount Expenditure Estimated Amount spent in (in Rs) Expenditure for the permissible the planned for next financial year Justification/ as per the Activity previous current for which plan is remarks norms in 4 financial being submitted the district quarters year (Rs.) (a) (b) (c) (d) (e) Done at State Printing 2.25 L - - - Level

Research and Studies:

125 DHAP Dehradun 2011-12 125125 125

Any Operational Research project planned (Yes) No (Post Graduate grant for one research paper from Medical College) (If yes, enclose annexure providing details of the Topic of the Study, Investigators and Other details) Whether submitted for approval/ already approved? (Yes/No) No Estimated Budget (to be approved by STCS). No

Medical Colleges

Activity Amount Estimated Expenditure Justification/ permissible for the next financial remarks as per norms year (Rs.) (a) (b) (c) Contractual Staff: MO (In place: No) 156000.00 163800.00 Salary STLS (In place: No) 144000.00 151200.00 Salary LT (In place: Yes) – 02 TBHV (In place: Yes) – 02 Research and Studies: - - State funded Thesis of PG Student Operations Research* Travel Expenses for - - State funded attending STF/ZTF meetings IEC: Meetings and CME - - IMA/GfATM planned Program 315000.00

Procurement of Vehicles:

Equipment No. No. Estimated Expenditure for Justification/ actually planned the next financial year for remarks present in for this which plan is being the district year submitted (Rs.) (a) (b) (c) (d) 4-wheeler 01 - - - 2-wheeler 03 - - -

126 DHAP Dehradun 2011-12 126126 126

Procurement of Equipment:

No. Estimated Expenditure No. actually planned for the next financial Justification/ present in Equipment for this year for which plan is remarks the district year being submitted (Rs.) (a) (b) (c) (d) Office Equipment (computer, modem, 01 - - - scanner, printer, UPS etc) Any Other Binocular BM are non 14 5 1.0 L Microscope functional -

Section D: Summary of proposed budget for the district –

Budget estimate for the coming FY 2011- 12 S.No. Category of Expenditure (To be based on the planned activities and expenditure in Section C) 1 Civil works 0.00 2 Laboratory materials 250000.00 3 Honorarium 300000.00 4 IEC/ Publicity 70500.00 5 Equipment maintenance 36000.00 6 Training 0.00 7 Vehicle maintenance 200000.00 8 Vehicle hiring 0.00 9 NGO/PP support 210000.00 10 Miscellaneous 225000.00 11 Contractual services 1767300.00 12 Printing 0.00 13 Research and studies 0.00 14 Medical Colleges 315000.00 15 Procurement –vehicles 0.00 16 Procurement – equipment 100000.00 TOTAL 3473800.00

Additionality Funds from NRHM-Details of the activities for which Additional funds are proposed to be sought - Nil

127 DHAP Dehradun 2011-12 127127 127

National Blindness Control Programme Annual Plan for Programme Performance & Budget for the year 2011-12

Introduction: National Programme for Control of Blindness started in the year 1976 with a goal of reducing the prevalence of blindness in India. A large no of blind people in a country denote poor socio-economic development and an inefficient eye care service in the country. This is because about 80-90% of the blindness is either curable or preventable. Cataract is the leading cause of blindness in India. The Programme is 100% centrally sponsored. The main cause of Blindness is Cataract which is approximately 62% in the country. In Uttaranchal the prevalence rate of Blindness is below 1%, which is among 1st 10 States of the country. Blindness programme emphasis; to provide high quality eye care to public, Strengthen Eye care service in outreach area.

Goals:

• To reduce the prevalence of blindness from 0.56% to 0.3% • To provide high quality of eye care to the affected population. • Objectives: • To bring down the prevalence rate of cataract blindness from 0.56% to 0.3% by the year 2011. • To provide high quality of eye care to the affected population. • To expand coverage of eye care services to the under-served areas. • Strengthen service by providing training to medical/paramedical staff. • To develop institutional capacity for eye care services by providing support for equipment and material. • To cover School for eye screening • To conduct 100% cataract IOL surgery

Strategies:

• Reduction in backlog of blind persons by active screening of population above 50 years of age. Organizing screening eye camps and transporting operable cases to eye care facilities. • Involvement of voluntary Organization in various eye care activities. • Participation of community and panchayat Raj institutions in organizing services in rural areas. • Development of eye care services and improvement in quality of eye care by training of personnel, supply of high-tech equipments, strengthening follow up and monitoring services. • Screening of school going children for identification and treatment of refractive errors with special attention in underserved areas. • Public awareness about prevention and timely treatment of eye ailments. • Specific focus on illiterate women in rural areas. For this purpose there should be convergence with various ongoing schemes for development of women and children. • Awareness generation through the help of ASHA at grass root level.

Activities:

• Free surgery for cataract cases in rural areas. • Free transportation for patients of un reached areas. • Free medicine for all types of eye ailments. • Free spectacles for post operative care and poor school students.

128 DHAP Dehradun 2011-12 128128 128

• All backlog cataract cases would be treated. • Nearly 500 schools would be covered for School Eye Screening. • Timely purches of Istrument for OTs of Government Hospitals such as phachoc machine, microscope ets. • All children would be given vitamin-A supplementation and immunization coverage. • Modern and advanced treatment would be available in all Medical College Hospitals and District Hospitals /Sub District Hospitals. • Training of nurses in ophthalmic techniques & Paramedical Ophthalmic (PMOA)

Budget requirements for District Blindness Control Society for the Year 20011-12: Sl. No. Component Detail /Unit Cost Total (in Rs.) 1 Monthly Renmuniration of @ 2000/- PM 24,000.00 DPO of DBCS, for one year 2 Medicines IOL & Consumble Medicine IOL & Consumble are used @ 13,50,000.00 ets Rs 450.00 for 3000 case 3 Re-imbursement to NGOs @ 750.00 per case to NGOs for 1000 Cases 7,50,000.00 o/C Grant-in-Aid 4 POL and Cost of Vehicle Rs. 8,00,000.00 O/c of Ambulance 10,00,000.00 Rs. 60,000.00 O/c of Driver on Contract Basis Rs. 40,000.00 O/c of POL charges and minor repairing Rs. 1,00,000.00 O/c of minor repairing 5 IEC Activities Hording & Poster to be displayed at the 5,00,000.00 various prominent places in district 6 Training of School Screening Training of 500 School Teachers on eye 2,00,000.00 Programme to Teachers Screening Rs 400.00 per School 7 Purches of Istrument for OTs Phacho Machine and Microscope etc. 70,00,000.00 of Government Hospitals 8 Celibration of Naitional Eye An amount of Rs 24,000.00 24,000.00 Fornight 9 Miscelliouneous Rs 50,000.00 50,000.00 10 Establishment of Vision Rs 50,000.00 X 3 Centers = Rs 1,50,000.00 1,50,000.00 Centres 11 Distribution of Spectacle to Rs 600.00 X 125.00 = Rs 75,000.00 needy person through Eye 75,000.00 refreshanist 12 To make payment of Rs @ Rs 1,000 per patient for 1,000 patients. 1,000.00 per patient of 10,00,000 Diabetic, Glacuma, Squint, Kerato plasty. Grand Total 1,21,23,000.00

129 DHAP Dehradun 2011-12 129129 129

National Leprosy Elimination Programme Annual Plan for Programme Performance & Budget for the year 2011-12

Object to Achieve our Goal • Reduce stigma. • Increase Awareness. • Early detection and improved management. • Improve referral system. • Improve MDT management. • Improve DPMR. • Improve Supervision and Monitoring.

Physical status of District

• Hill Area- 65% Appr. • Plain Area- 35% Appr. • Estimated Population- 14, 45,235 • Total No. of Blocks- 06 • Total No. of Sub centers- 168

Availability of MDT Drugs - 14 Urban Health Facilities

1. ONGC Hospital, Dehradun 2. Military Hospital, Dehradun 3. Survey of India, Hospital, Dehradun 4. Survey of India, Hathibadkala, Dehradun 5. F.R.I Hospital, Dehradun 6. Post Office Dispensary, Dehradun 7. ITBP Hospital, Dehradun 8. Coronation Hospital, Dehradun 9. Police Dispensary, Dehradun 10. Nagar Nigam Dispensary, Dehradun 11. Female Hospital, Dehradun 12. Indiresh Hospital, Dehradun 13. ESI Dispensary Rest Camp, Dehradun 14. Doon Hospital, Dehradun

Number of Primary Health Center- 01 - Kalsi Number of Community Health Center- 07- Chakrata, Vikasnagar, Sahaspur, Mussorrie, Sahiya, Raipur, Doiwala No. of Additional Primary Health Center-18

Staff Position District Dehradun

S.No. Designation Sanction In Position Remark 1 D.L.O. 01 01 2 H.E. 01 01 3 N.M.S. 06 06 4 N.M.A. 38 02 5 P.T.T. 03 02

130 DHAP Dehradun 2011-12 130130 130

N.L.E.P. Progress

Physically progress report 2010-2011 (from April 2010 to October 2010 till) Total New Cases - 49 (PB 24, MB 25) No. of RFT Cases - 37 (PB 21, MB 16) No. of Cases Under Treatment - 67 (PB 22, MB 45) + 80 cases other recorded Prevalence Rate - 0.4/10000 N.C.D.R. - 3.2/lac New Child Cases - 01 Child Rate - 02 Female Cases - 17 Propotion of Female - 34.6 Propotion of MB New Cases - 25 M.B. Rate - 51 No. of Deformed Cases - 02 Rate of Deformity - 4%

High Endemic Area – 02 (Doiwala, Kalsi) Low Endemic Area – 04 (Chakrata, Raipur, Sahaspur, Vikasnagar)

Performance under NLEP-

Ind icators 2006-07 2007-08 2008-09 2009-10 (till date) No. o f new cases 9.9 per 7.1 per 8.5 per 5.7 per detected 100000 100000 100000 100000 (ANCDR) No. of cases on record at yea r 0.7 per 0.5 per 0.6 per 0.4 per end (PR) 10000 10000 10000 10000 No. of Grade II disability among 0.7 % Nil Nil 5.8 % new cases (%) Treatment Completion Rate 70.4 83.7 90.8 73.1 Re-constructive Surgery Nil Nil Nil 12 conducted

Work Plan Analysis Some superior facilities will be provided at all health centers and for we will try to identify of every health facility diagnosis, treatment and counseling for the patient.

Improve Referral System – Proportion of Identify HCF Managing referral cases 50% by 2010, 75% by 2010 and 100% by 2011. Private practitioners and dermatologists of districts a technical leprosy training. Programme of two days is proposed along with 5 days training for 4 LT of Doon Hospital and SPS Rishikesh.

Case Detection and Case Management System- Proportion of cases detected without grade 1 and grade 2 disability reduced.

131 DHAP Dehradun 2011-12 131131 131

Improved Supervision System- DN team using supervision regularly. Proper supervision is essential for the successive improvement of the NLEP programme.

Adequate Drugs (MDT) at all level- Availability of MDT will be provided according to norms of . Medicine will be provided as guidelines. Regular patient will be identified and arrangement of regular treatment will be done.

Improved DPMR Services- Newly appointed MOs/Pharmacists/ANMs will be four days technical training and SMOs+MOs will be given reorientation training at the block level. Grade 2 patient will be identified and given them proper counselling for SCG. MCR sleepers will be provided also. For leprosy affected poor and needy persons also distributed blankets.

Improved Accessibility through public private partnership- Improved accessibility through public private partnership will be improved through mutual discussion and also publicity will be done. In this particular activity NGOs and NSS participatory are acceptable.

Increased Awareness and decreased Discrimination- Special attention will be given for IEC activities. Those blocks have prevalence rate more will be focused. The employees who are working in rural areas especially ANMs & ASHAs doing their field visit by group meeting and IPC will do publicity about leprosy Programme also. Folk shows, school quiz, rallies, wall paintings, IPC meeting will be organized. On the ocasson of Fare, Haats & RCH Campus leprosy exhibitions will be held to make 02 hording proposed 2011712 to post at SPS Rishikesh and Vikasnagar.

Urban Leprosy Programme- In the year 2011-2012 Urban area of Dehradun NLEP Programme will be organised under the urban areas. The Government units which are covered under this programme face the main problem of irregularpatients. Special campaign will be organized and inspired them to take complete treatment. Team of vertical staff will be formed to survey of slum area with group meeting/stall/school rally activities.

BUDGET BREAUP AND SUMMARY-ACTIVITY PLAN-BUDGET, DISTRICT DEHRADUN YEAR 2011-2012 Budget No. of S. Resp. Duration (Details Fiscal Activities Participants Items Required No. Staff and Date in Sources (Approx.) Annex) (i) Training of DLO 15 Medical 2 days DA per diem Rs. 3750 private Officer April 125 (125x2x15) 6000 practitioners 2011 TA per diem Rs. and 200 4500 dermatologists (200x15x2) 1200 Lunch (150x15x2) NRHM TA/DA of Trainers State Level (300x2x2) (ii) Training of DLO 04 5 Days DA per diem Rs. 3000 Lab May 2011 150 (150x4x5) 1600 technicians TA per diem Rs. 3000 200 (200x4x2) 6000s Lunch (150x4x5) 132 DHAP Dehradun 2011-12 132132 132

TA/DA of Trainers (600x2x5) 2-Case Detection and Case Management Improved (i) Technical DLO 20 4 Days DA per diem Rs. 20000 Training of June 2011 250 (250x4x20) 8000 Newly TA per diem Rs. 4800 Appoint MOs 200 (200x4x2) 800 Trainer DA @ Rs. 14400 600x2x4 1000 NRHM Trainer TA @ Rs. 400x2 Lunch @ Rs. 150x24x4 Stationery @ Rs. 1000/- batch (ii) Training of DLO 15 2 Days DA @ Rs. 4500 Newly 150x15x2 6000 Appoint TA @ Rs. 200x2x15 ANMs (iii) Reorientation DLO 100 01 Day DA @ Rs. 200x100 20000 SMO+MO (Block TA @ Rs. 100x100 10000 Level) Trainer DA @ Rs. 800 200x4

S. Activities Resp. No. of Duratio Items Required Budget Fisc No Staff Participan n and (Details in al . ts Date Annex) Sou (Approx.) rces (iv) Reorientation DLO 300 01 Day DA @ Rs. 30000 Pharmacist+ June 100x300x1 30000 ANMs+Other 2011 TA @ Rs. 4000 Paramedical Staff Block 100x300x1 15000 NR Level Trainer DA @ HM Rs. 200x10x2 Lunch @ Rs. 50 x 300 (vi) Honorium to ASHA DLO - During MB-500 PB-300 20000 for case detection the year (25x30) 3-Improved Supervision System (i) Contractual Services DLO 01 April to 12 month x 1 x 54000 (Drivers) Salary + / March @ Rs. 4500 10000 TA/DA CMO (ii) POL+Mobility DLO - April to Field visit and 80000 NR March supervision HM (iii Vehicle DLO - April to - 30000 ) Maintenance March (iv) TA (Leprosy Staff) DLO - - - 50000 4-Adequate Drugs (MDT) available at all level

133 DHAP Dehradun 2011-12 133133 133

(i) Supportive DLO - During - 70000 NR Medicine Year HM 5-Improved DPMR Services (i) MCR DLO - Once in Rs. 250 x 300 7500 year NR (ii) Crutches & DLO - Once in - 20000 HM Splint/Gogels Year

6-Improved Accessibility through Public Private Partnership (i) Meeting with NGOs DLO - One Day Rs. 3000x1 3000 & Leaders (ii) Meeting with Health DLO - One Day Rs. 3000x1 3000 NRH facilities M (iii) Meeting with Nehru DLO - One Day Rs. 3000x1 3000 Yuva Kendra + NSS 7-Increased Awareness and Decreased Discrimination (I.E.C.) (i) Folk Show DLO - Sept. & Rs. 3000x22 66000 Oct. 2011 (ii) Hoarding DLO - Sept. & - 25000 Oct. 2011 (iii) School Quiz DLO - Sept. & Rs. 3000x3 9000 Oct. NRH 2011 M (iv) School Rally (2) DLO - Oct. & Rs. 3000x2 6000 Jan. 2012 (v) IPC Meeting DLO - Sept. & Rs. 500x80 40000 Dec. 2011 (vi) Advocacy Block DLO - May- Rs. 1000x6 6000 Level June 2011 (Vi Meeting of Mahila DLO - Jan to Rs. 1500x6 9000 i) Mangal Dal (Block March Level) 2012

S. Activities Resp. No. of Duratio Items Required Budget Fiscal No Staff Participants n and (Detail Sourc . (Approx.) Date s in es Annex) 8-Programme Management Ensured (i) Office Operation DLO - April - 20000 11 to March 12 (ii) Contingency DLO - April - 20000 NRH 11 to M

134 DHAP Dehradun 2011-12 134134 134

March 12 (iii) Digital Camera DLO - - - 10000 (iv) Computer Desktop DLO - - - 50000 (v) Additional DLO - - - 10000 requirement of funds for all purpose of activities at disposal of DLS 9-Urban Leprosy Programe for 2011-2012 (i) To prepare action DLO - Dec. 12 - 12000 plan, group and circle meeting & printing (ii) Procurement/Deli DLO - April - 5000 NRH very/ Maintenance 11 to M of MDT Medicine March 12 (iii) Supportive DLO - April - 15000 Medicine 11 to March 12 (iv) Supervisory & DLO - April - 6000 Monitoring 11 to March 12 (v) POL and Mobility DLO - April - 15000 11 to NRH March M 12 (vi) Contingency DLO - April - 6000 11 to March 12 Total 9,25,75 0

(Rs. Nine Lakh Twenty Five Thousand Seven Hundred Fifty Only)

GANTT CHART OF ACTIVITY IN 2011-12

Objectives April May June July Aug Sep Oct Nov Dec Jan Feb March Improve referral System One day reorientation of Y Y Y Y Y Pharmacist (allopathic+Ayurvedic) One day reorientation of Y Y Y Y Health Supervisors One Day reorientation of Y Y Y Y 135 DHAP Dehradun 2011-12 135135 135

AWW/ANM Printing of referral slip for Y Y Y Y Y Y Y Y Y Y Y Y MO, ANM & Asha Improve early case detection & case management One day reorientation of Y Y Y trained medical officer Honarium for Asha for case Y Y Y Y Y Y Y Y Y Y Y Y detection & complete treatment Two day technical training of Y Y Y Y Y Y newly appointed pharmacist Four days training of new Y Y Y medical officer (Allopathic, Homeopathy, Ayurvedic) Improve Supervision & Monitoring Vehicle operation Y Y Y Y Y Y Y Y Y Y Y Y

TA/DA to NLEP Staff Y Y Y Y Y Y Y Y Y Y Y Y

Staff printing & Y Y Y supervision/feedback & checklist format Workshop for supervisory Y Y staff Objectives April May June July Aug Sep Oct Nov Dec Jan Feb March Improve drug (MDT) Management Training programme for store Y Y Y keeper and pharmacist on MDT Logistics Printing of SLS Format Y Y Y

Improve DPMR Services Procurement of MCR Y Y Y Y Y Y Footwear Procurement of Supportive Y Y Y Y Y Y medicines Procurement of self care kits, hope kits, Ulcer care kits Regular Monitoring and LAPs Y Y Y Y Y Y Y Y Y Y Y Y specially disabled cases Reduce stigma & increase awareness IPC meeting (80) Y

Folk Show (22) Y Y Y Y Y

IPC Workshop (1) Y

School Quiz Programme (02) Y

Rally (02) Y Y

Printing of handbills (1000) Y 136 DHAP Dehradun 2011-12 136136 136

Printing of Multicoloured Y Y Y poster (2000) Objectives April May June July Aug Sep Oct Nov Dec Jan Feb March Advertisement in Press Y Y Y

Media-04 Hoarding – 02 Y Y

Improve accessibility through public private partnership Sensitization meeting with Y Y Y

Hospital Staff Sensitization meeting with Y Y Y VHSC members & Hospital Staff Strengthening of programme management unit Purhcase of one computer Y system with printer & internet connection for office Office Stationary & other Y Y consumable for 12 months Computerization of all Y accounting work

137 DHAP Dehradun 2011-12 137137 137

Iodine Deficiency Disorder Control Programme Annual Plan & Budget for the Year 2011-12

Introduction

Iodine deficiency is a public health problem. Though the full flashed blown cases of IDD disorders are not seen, but problem this disorder still exists in the district. There is Act for mandatory supplying of the iodize salt in the district; it is being supplied also through ICDS. Since there is provision of industrial salt and animal salt which are not iodized so there is fewer guarantees for 100% availability of iodized salt for human consumption.

Goal: To achieve the goal of consumption of adequate iodized salt use in household up to 90% by the end of 2011

Objective:

• To increase availability of iodized salt at household and retailer outlets. • Promote the use of iodized salt through awareness generation with the help of ASHA and IEC material in the community. • Educating population about the importance of Iodized salt. • Upscale supply of iodized salt in place of common salt and bend on the shops/outlet those selling salt without iodine. • To improve the use of iodized salt with awareness generation in Village health and Nutrition Day and School Health Programme at grass root level. • Salt will be tested by ANM and Doctors at Village health & Nutrition Day and School Health Programme • Regular sampling /Laboratory testing /monitoring of iodized salt with the help of CFI and Health Inspectors. • Orientation and training programme for ASHA, AWW and ANM at block level testing of salt, regarding benefit and use of iodized salt.

Out comes:

• Reduction in use of iodized free salt and use of iodized salt will be increase. • Awareness among the community will be increase about the benefit of use of iodized salt. • Availability of Iodized salt in retailer shop and cases of goiter will reduce.

Strategies:

• In order to achieve the above objectives, the following strategies are planned: • Availability of iodized salt at household and retailer outlets. • Awareness generation among community and population about the importance of Iodized salt. • Iodized salt available at shops/outlet. • Salt testing in Village Health & Nutrition Day and School Health Programme by ANM and Doctors. • Sampling/Laboratory testing/monitoring of iodized salt with the help of CFI and Health Inspectors. Accuse of selling of iodized free will be punished.

138 DHAP Dehradun 2011-12 138138 138

• ASHA, AWW and ANM are trained at block level regarding benefit and use of iodized salt.

Activities: • Regular inspection/testing of salt at the shops of Wholesaler and retailer outlets. • BCC activity through ASHA, AWW and ANM to awareness the community about importance of Iodized salt. • Salt testing kit distribution from CMO office to ANM and Doctor. • Orientation programme for ASHA, AWW and ANM regarding are trained at block level regarding benefit and use of iodized salt. • Awareness and continued dialog with salt producer and traders to obtained their commitment and support for production of adequate iodized salt. • Continued political support to continue with the ban on sale of non-iodized salt for human consumption. • Activity plan will be developed for each activity.

Budget for the year 2011-12 following activities are proposed

Sl. No. Activity Budget 1 Orientation programme Health worker at each block. 2,00,000.00 2 IID testing kit for ASHA (1418 kit) @ Rs 5.00 per Kit 7,090.00 3 Health Education and Publicity 1,00,000.00 4 IDD Workshop for NRHM Stake Holder NGOs and ICDS 60,000.00 5 Miscellaneous 10000.00 6 POL for monitoring/sampling 30,000.00 Total 4,07,090.00

139 DHAP Dehradun 2011-12 139139 139

National Tobacco Control Programme (NTCP) Annual Plan & Budget

The objectives of the NTCP is to build up capacity of the Districts to effectively implement the Anti Tobacco Initiatives; train the health and social workers; take up appropriate IEC and mass awareness campaign including School Health Programme; set up a regulatory mechanism to monitor/ implement the Anti Tobacco Laws including establishment of product testing laboratories; Global Adult tobacco survey for surveillance etc

The main components of the Tobacco Control Programme will be as under: 1. Monitoring and implementation of Anti Tobacco Laws. 2. IEC/ Mass media Campaign 3. School Health Programme 4. Training and Capacity building for Tobacco Control. 5. Tobacco Cessation Centre.

The District Tobacco Control Cell already established in district on contractual basis to support above programme. • one Psychologist • one Social Worker

All the activities of the District Tobacco Control Programme shall be carried under the supervision and guidance of the District Programme Manager, NRHM. The state should submit the budget for district as well as state in the following format

Proposed Budget for state & district Tobacco Control Programme (2011-12)

SI. No Components Calculation Total I. Salaries 1. Psychologist : Rs. 10,000/- 10000 x 12 120,000.00 2. Social Worker : Rs. 8000/- 8000 x 12 96,000.00 3. Data entry Operator 6500 x 12 78,000.00 Total date 294,000.00 II. Training 200,000.00 200,000.00 III. IEC activity 200,000.00 200,000.00 IV. School Activity 400,000.00 400,000.00 V. Monitoring of Tobacco Control Laws & 100,000.00 100,000.00 Re porting VI. Contingency 100,000.00 100,000.00 TOTAL 12,94,000.00

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NATIONAL PROGRAMME FOR PREVENTION AND CONTROL OF DEAFNESS (NPPCD) Programme Annual Plan & Budget for the Year 2011-12

Budget for the year 2011-12 following activities are proposed

Sl. Activity Unit Cost/Details Budget in No. (Rs) 1 Manpower at district level Honorarium @Rs. 12000 2,88,000.00 (Audiometric Assistant & Instructor for x 2 = 24000 Hearing Imparied Rs. 12000.00 per person for 2 contractual person) 2 Screening Camps Camps 1,20,000.00 (Rs. 10000.00 per camps per month) @Rs.10000x 12 = 1,20,000 3 Hearing Aids Aid 4,86,600.00 (@ Rs. 2433 per Aid) @Rs.2433 x200= 4,86,600 4 Misc. & Contingency for District Nodal Misc. & Contingency @ 54,000.00 Agency Rs. 4500 x12 = 54,000 (Rs. 4500.00 per month) Total 9,48,600.00

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SECTION – E

CONVERGENCE

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CONVERGENCE/COORDINATION

Convergence can be defined as the complementary working of departments or agencies that can result in the achievement of a common objective because the beneficiaries with whom they work are common and their activities can enhance the possibility of achievement of the goals and objectives. Multiple sectors with different strategies, programs and projects increasingly develop immediate focus on the needs of the beneficiaries. This offers vast scope for results accruing through such synergies.

• The Departments that have close synergy with the NRHM/RCH are: • Department of Women Empowerment and Child Development- VH& N Day • Department of Panchayati Raj Institution-Village Health and Sanitation Committee. • Mainstreaming of AYUSH- Ayush wing at CHC/PHC in existing Health facilities. • Department of Drinking Water / Total Sanitation Campaign- • Department of Education-School Health Programme • Non Government Organization (PPP) -Moblile Health Clinic & Hospital.

PARTICIPATION & CONVERGENCE AMONG DEPARTMENTS

(a) Panchayati Raj Institutions -

Institutional Framework – District Health Mission is formed in the Chairpersonship of Jila Panchayat Adhyaksh to provide overall guidance and develop close coordination among different Programme at District level.

Village / Block / District Action Plan - Under RCH-II the Village Health and Sanitation Committee has been be formed under Panchayati Raj, at all three levels will be strengthened and these committees will plan, support and monitor activities related to health. District Action planning initiated at each level with close coordination of PRI members.

Untied Funds for Sub Center - To strengthen the sub center village health plan a sum of Rs. 10,000/- is provided to the sub center every year.

Untied Funds for VHSCs - A joint account in the name of Pradhan and VDO has been opened and the expenditures are made in consultation with the Village Health and Sanitation Committee.

Slection of ASHAs -Panchayats have been involved in the selection of ASHA at village level; ASHA have been made accountable to Panchayats.

(b) ICDS Department -

Village Health & Nutrition Days - The Anganwadi Centre is identified as the hub for service provision in the RCH-II, NRHM, and also as a platform for inter-sectoral convergence. VHN days are organized on Saturday at each Anganwadi Center. During these ANMs, AWWs is providing health care services especially maternal and child health services to the community. ASHA play a role of mobizer to the community and collecting and bringing the mothers and children to avail the services of VHN days. The objective of organizing this VHND is to provide momentum to the efforts towards increasing early registration, ANC checkups, institutional deliveries, counselling on breastfeeding, family planning, Immunization, Counselling on Nutrition, Safe drinking water, 143 DHAP Dehradun 2011-12 143143 143

Sanitation, Anti TB Drugs etc. Department of Women and Child Development will also provide information to lactating mother, expected mother, adolescent girls and children regarding nutrition and its importance. After Completion of each Village Health and Nutrition Day, ANM and AWW will also prepare a report of that day activity and submit that report to their respective area wise departmental heads with join signature. ANM & AWW will be responsible for referral /treatment of malnutrition children of respective Anganwadi centre to area wise PHC/CHC. Joint meeting will be organized at each block of LHV and ICDS supervisor for review of work and further planning.

Malnutrition Treatment Center - Severely malnourished children are referred by AWWs health facilities for treatment and follow up.

Micro planning - To implement VHN Days a micro planning is done jointly by the Officers of DWCD and DMHS. Training is provided on micro planning for the activity to the officers of both the departments.

ASHA - ASHA is a joint worker of DWCD and DMHS, selected by the community through Gram Sabhas and is responsible to the community. She is coordinate with Anganwadi and a link worker between community and health care institutions.

Community Needs Assessment Analysis - To assess the health needs of the community, survey is being conducted by ANM with the support of Anganwadi Worker at village level. The information collected from CNNA is used for planning of healthcare services.

Adolescent Reproductive Sexual Health – Coordination of ARSH (UDAAN) programme with grass root level. Kishori group formed at Anganwadi center will be educated by ANM with help of AWW about nutrition messages on importance of proper nutrition for proper growth and future reproductive health. Hemoglobin test will be conducted with the help of Department of medical health of adolescent girls at AWCs. AWW are also triained under ARSH Programme to deciminated activity at village level.

Breast feeding –Joint efforts will be taken at each anganwadi center for promotion of exclusive breast practices to new born babies.

(c) Mainstreaming AYUSH -

The services of AYUSH will be made available in District Hospitals, CHCs and PHCs. The option of choosing the treatment by allopathic or Indian System of Medicine is provided to the patients at different forums for better acceptance of the healthcare services. Camps - RCH camps are organized in district to provide services of specialists to the villagers. In these camps services of YUSH are also available.

Drug Kit for ASHA - The drug kit is provided to ASHA to render basic medical care at doorstep. The drug kits consist of AYUSH medicines also, apart from the other medicines.

School Health Team – Services of AYUSH Doctor’s will be taken in school health Programme for health checkups, diagnose and treatment of student at school level.

VHN Days - Services of AYUSH will be taken to services during VHN days during school vaccation.

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Chikitsa Prabhandan Samities - At present Chikitsa Prabhandan Samities are functional in all DH/ SDH/CHC level health institution in which AYUSH Doctor’s are also involved in society to managing and functioning.

(d) Drinking Water / Total Sanitation Campaign:

Supply of Portable water - Portable and adequate supply of water for drinking and domestic purpose through the water swupply department Jal Nigam/Sansthan which prevent spread of water born disease.

Sanitation Programme- Safe disposal of waste water and adequate drainage also safe disposal of excreta with use of house hold and community latrine are supported by TSC programme which help in prevention of disease and also awareness programme through swajal among village community

Awareness Generation - Through TSC awareness spread over in community about environmental, personal and domestic hygiene to prevent spread of water born disease which indirectly help the helth department. The Swajal and TSC also educating people to use of house hold and community latrine for disposal of excreta

Water testing kit - Distribution of water quality testing kit to community for surveillance IEC and behaviours change communication to ensure the adoption of hygiene, safe health practices through inter sectoral coordination

Swajal/Jal Nigam/ Jal Sansthan - Also a member in National Rural Health Mission and participate in district level meeting.

(e) Department of Education

School Health Programme - School Health Programme is implemented in the district primary school in collaboration with Department of Education. In this Programme medical checkup, treatment and distribution of medicine to students those who will diagnose and services of referrals are provided to the students of primary schools.

Life Skills Education - To empower the adolescent’s girls to deal with the challenges of day to day life and to have healthy living, Life Skills Education is being imparted through teacher, Doctors and Pharmacist during school health proramme.

(f) Non Government Organizations

Institutional Arrangements -The NGOs are the key partners for National Rural Health Mission. The representatives of Non Governmental Organizations are the members of District Rural Health Mission. They are providing support and suggestion to the programme at each level on the basis of their experiences at field level.

Member of ASHA Mentoring Group - ASHA Mentoring Group was constituted to review time to time progress and to provide guidance to strengthen ASHA programme in the field.

ASHA Resource Center - ASHA Resource Center has been established in district. This resource Center is providing technical backstopping to ASHA intervention. All modules, IEC Material, 145 DHAP Dehradun 2011-12 145145 145 reporting formats will be developed by ASHA Resource center. The data base of the intervention is collected, compiled and processed by ASHA Resource Center.

Provision of training -There is a crucial role of ARC in training of ASHA. The training is conducted through NGOs at Distict/block level. These NGOs will mentor, provide support and monitor the activities of ASHA at field level apart from Departmental support mechanism. It will also facilitate to provide enabling atmosphere for work to ASHA.

Blindness Control - NGOs are conducting cataract camps successfully 30 % of the cataract operations are conducted in the camps organized by NGOs.

Behavior Change Communication/IPC -NGOs are functional at grass root level and their workers are directly in contact with the community, hence the NGOs will be involved in favorable environment building at village level. NGOs will also be involved in creating awareness on health issues, promotion of different health schemes and services available at health institutions.

Monitoring Evaluation and Social Audit - External monitoring and of health services is very essential to improve the quality and acceptability of services. NGOs are involved as the monitoring agency which is giving valuable suggestions for overall improvement in service delivery system.

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Budget Summary of NRHM Financial Year 2011-12

Component Budget Proposed for the F.Y. 2010-11

RCH – II 12,84,12,650.00 NRHM Additionalities 4,74,10,642.00 Routine Immunization 51,63,825.00

Sub Total 18,09,87,117.00 National Disease Control Programme IDSP 9,92,000.00

RNTCP 34,73,800.00

NVBDCP 1,81,37,800.00

NBCP 1,21,23,000.00 NLEP 9,25,750.00 NTCP 12,94,000.00 NIDDCP 4,07,090.00 NPPCD 9,48,600.00 Sub Total 3,83,02,040.00 Grand Total 21,92,89,157.00

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