Gap analysis and budget for RMNCH+A strategy Overview:In order to further accelerate the decline in maternal and child mortality and galvanize unified efforts a lifecycle approach “RMNCH+A” has been adopted under NRHM. It focuses on key high impact interventions, with special emphasis on weakly/poorly performing geographies. Such focused approach would lead to substantial gains in reduction of maternal, neonatal, infant and under 5 morbidity and mortality resulting from the most common causes. RMNCH+A approach to improving maternal and child health describes the most essential health preventive, promotive and curative interventions and packages of services across various life stages which when delivered to scale will provide maximum gains in terms of saving lives and improving overall health status of the community. Annual Health Survey 2010-11 shows that progress has been uneven between districts and within districts, hence the need to focus on poor performing geographies and the populations with highest burden of mortality. Relative ranking of districts has been done in Bihar (based on a composite index) and bottom 25% of the districts have been selected as High Focus Districts for that State. There are 10 High priority Districts in Bihar (out of total 184 High Priority Districts across India) In order to enhance technical assistance to these districts and make provision for coordinated planning and monitoring at state level, it was decided to leverage the existing strength and local presence of the Development Partner (DPs) agencies. In this District UNICEF is the development partner for RMNCH+A. Methodology of Gap analysis: Orientation of all development partners working in the respective Districts and District officials for undertaking the gap analysis was conducted in September 2013 using the prescribed tool by GOI, a gap analysis exercise was conducted across all 10 HPDs. The team conducting the gap analysis comprised of local health officials and representatives of respective development partners. The gap analysis was conducted for District Hospitals, all FRUs, all Block PHCs, one functional APHC and HSC of each Block PHC. In case none of the APHCs/HSCs were functional; then the ones with potential chosen for gap analysis. Data analysis was done to develop District specific action plans during the District RMNCH+A orientation workshop. In addition to that an extensive exercise was undertaken to identify and conduct gap analysis for all the functional delivery points of the respective Districts. Subsequently a detailed budget for infrastructure, equipment and drugs& consumables was prepared. Findings of Gap Analysis: Following are the salient findings Gaya District. Infrastructrure a. Insufficient geographical Access to quality health services due to difficult terrains and Naxal affected areas. b. Inadequate beds and infrastructure at BPHC for the 48 hrs stay of the mother after delivery. c. Inadequate number of FRU/CHC/PHC/APHC/HSC and L1/L2/L3 facilities in the district to cater the need of the population. d. Inadequate infrastructure in the functional PHC/APHC/HSCs. e. Poor infrastructure for LR and OT in the BPHCs. f. Poor staff quarters in the facilities to provide 24X7 services g. Non availability of transportation (public & pvt.) in remote areas and inadequate ambulatory services h. SNCU has not been established even at the district health facility. NBCC available in only 18 facilities out of 39 functional delivery points. HR a. Insufficient number of skilled Human resource in the district. b. Case load is very high among existing staffs. c. No of vacant posts of Specialists/MO/SN/ANM/ LT/Pharmacists/MPW/LHV/ Group D and other support staff is high. d. Lack of performance monitoring systems of staffs. e. Skills of ANM, LHV, ASHA, Medical and Paramedical staff in imparting quality RMNCHA services are poor. f. Inadequately trained staff in terms of numbers and quality. g. Poor training status of HR on CEmOC/BEmOC/LSAS/SBA/NSSK/IUCD/PPIUCD/MTP/NSV/Mini lap h. Poor supportive supervision structure for the facility and community level staffs Equipment a. Inadequate beds, labor table, delivery set, tray ( Delivery, Episiotomy,IUD, PPIUCD,etc ) NBCC equipments etc in the Facilities. b. Equipments for MTP ( MVA, EVA) not available in most of the PHC. c. Poor availability of Examination table, BP apparatus, Stethoscope, Haemoglobinometre, Weighing scale, Timer in the VHSND sites . Drugs & consumables a. Irregular supply of,medicines, emergency drugs and consumables. Inadequate quality of care a. Lack of accountability b. Nonpayment or delayed payment of incentives c. Lack of Motivation at every level d. Multiple reporting , poor data management e. Poor Mobility support / No hardship allowance List of functional Delivery points. Sl No Block Name of the Facility Category 1 Gaya JPN Hospital DH 2 Gaya Prabhawati Hospita DH 3 Amas PHC Amas PHC 4 Amas HSC Chandisthan HSC 5 Atri PHC Atri PHC 6 Bankey bazar PHC Bankey bazar PHC 7 Barachatti PHC Barachatti PHC 8 Barachatti APHC Shivganj APHC 9 Belaganj PHC Belaganj PHC 10 Belaganj APHC Bhagwanpur APHC 11 Bodhgaya PHC Bodhgaya PHC 12 Bodhgaya APHC Cherki APHC 13 Dobhi PHC Dobhi PHC 14 Dobhi APHC Karmauni APHC 15 Dumariya PHC Dumariya PHC 16 Fatehpur PHC Fatehpur PHC 17 Guraru PHC Guraru PHC 18 Guraru APHC Ismailpur APHC 19 Gurua PHC Gurua PHC 20 Gurua APHC Simaru APHC 21 Imamganj PHC Imamganj PHC 22 Imamganj APHC Raniganj APHC 23 Khizarsaray PHC Khizarsaray PHC 24 Khizarsaray APHC Mahkar APHC 25 Konch PHC Konch PHC 26 Konch APHC Anti APHC 27 Manpur PHC Manpur PHC 28 Mohanpur PHC Mohanpur PHC 29 Mohra APHC Jethian APHC 30 Nimchak PHC Nimchak Bathani PHC Bathani 31 Paraiya PHC Paraiya PHC 32 Sherghati SDH Sherghati SDH 33 Tankuppa PHC Tankuppa PHC 34 Tekari SDH Tekari SDH 35 Town Block APHC Chakand APHC 36 Wazirganj PHC Wazirganj PHC 37 Wazirganj APHC Tarma APHC Budget: 1) Below mention is the budget for as per the findings of Gap analysis under the major headings Budget S. No. Budget Head (Rs. Lakhs) PART I NRHM + RMNCH plus A Flexipool A Reproductive and child health JSY 1386.26 JSSK mothers 1789.00 JSSK infants 108.00 Maternal Death Review 0.45 Safe Abortion Services 7.50 Line listing and follow-up of severely anemic women 3.60 NBCC 43.20 NBSU 16.00 Management of Diarrhoea 48.00 Management of children with SAM (NRCs,CDNCs, 192.00 Community based management) Child Death Audit 3.75 Terminal limiting methods 36.10 PPIUCD 1.00 Door step delivery of contraceptive by ASHA 0.50 Family planning indemnity scheme 2.00 Adolescent friendly health clinics (AFHC) 1.20 RBSK 66.77 Human Resources 2506.02 Training 91.55 Programme management 377.36 Others 33.48 B NRHM initiatives ASHA drug kit 34.35 HBNC kit 8.78 ASHA incentive (including MH, CH, FP and AH) 203.08 Untied Funds 535.65 Annual Maintenance Grants (only for Government 69.50 institutions) Hospital Strengthening (including MCH wings) 9370.00 IEC-BCC NRHM 28.20 National Ambulance Service 229.00 Procurement 452.80 Others 223.98 C Immunisation 418.72 GRAND TOTAL RMNCHA + 17105.62 2) Budget for functional Delivery points of Gaya district. Sl. No. Particulars Budget ( Rs) 1 Infrastructure 99231000 2 Equipments 23312400 3 Drugs & Consumables 70654975.8 Total Budget 193198375.8 Based on the major causes of maternal and child mortality, the priority interventions across RMNCH+A should be put in place. These include the following: Antenatal care package; tracking of high risk pregnancies; line listing of anemic women and their management Strengthening of delivery points in terms of infrastructure, manpower, equipment, supplies Essential newborn care at NBCC established at all delivery points Initiation of home visits to new-born (HBNC scheme) Implementation of JSSK and JSY Prioritization of training of ANMs, SNs for Skilled Birth Attendance, NSSK, IMNCI, IUCD insertion, starting from those deployed at delivery points Roll out of National Iron Plus Initiative covering all women in the reproductive age group, adolescents, pregnant and lactating women, and children (6-60 months; 6-10 years) Intensification of Routine Immunization ORS and Zinc use in diarrhea; antibiotics for ARI Establishment of Nutrition Rehabilitation Centers and community based programme for management of SAM Doorstep delivery of contraceptive by ASHAs and services for IUCD insertion Behavior Change Communication for compliance with health practices at home/community S.no Major Gaps Budget (In Lakh) Person Responsible Timeline 1 Infrastructure: Poor Rs. 9370.00 CS/DPM Q3 to Q4 2014 infrastructure for LR and OT in the BPHCs. 2 Human Resource: Rs. 2597.57 CS/DPM Q3 to Q4 2014 Shortage of frontline workers specifically ANMs 3 Equipment: Rs. 663.52 CS/DPM Q3 to Q4 2014 Inadequate beds, labor table, delivery tray etc. 4 Drug and supplies: Rs. 452.80 CS/DPM Q3 to Q4 2014 Irregular supply of medicines, emergency drugs and consumables .