Analysis of National Flagship Programme National Rural Health Mission (For the Years: 2009-10, 2010-2011 and 2011-12) District: Chhatarpur State: Madhya Pradesh Supported by UNICEF Under GoI – UN Joint Programme on Convergence 1 Disclaimer With Technical support from Randstad India Limited for designing of tools, data analysis and drafting of the report. Data collection was carried out from the districts by the UNICEF supported District Facilitators under GoI-UN joint programme on convergence 2 Acronyms ANM Auxiliary Nurse Midwife ANC Ante Natal Care ARSH Adolescent Reproductive and Sexual Health ASHA Accredited Social Health Activist AYUSH Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy BPM Block Programme Manager BEmONC Basic Emergency Obstetric and Newborn Care CEmONC Comprehensive Emergency Obstetric and Newborn Care CHC Community Health Centre DH District Hospital DHAP District Health Action Plan DHS District Health Society DOT Directly Observed Therapy DPM District Programme Manager DPMU District Programme Management Unit FGD Focused Group Discussion GP Gram Panchayat HIV Human Immunodeficiency Virus HMIS Health Management Information System ICDS Integrated Child Development Services IPHS Indian Public Health Standards JSY Janani Suraksha Yojana LHV Lady Health Visitor NBCC New Born Care Corner PCPNDT Pre-Conception Pre Natal Diagnostic Act PRI Panchayat Raj Institute PHC Primary Health Centre PNC Post Natal Care RKS Rogi Kalyan Samiti RTI Reproductive Tract Infection STI Sexually Transmitted Infection SHC Sub-Health Centre TT Tetanus Toxoid VHND Village Health and Nutrition Day VHSC Village Health and Sanitation Committee VHSNC Village Health, Sanitation and Nutrition Committee 3 Contents A. Background……………………………………………………………………………………………………..…………………………..5 B. Objectives…………………………………………………………………………………………………..…………………………....….5 C. Material and Methodology……………………………………………………………………..………………………………......5 D. Results & Discussion…………………………………………………………………………….……………..……………………….7 1. Health Facilities…………………………………………………………………………………...……………..……………………….7 2. Infrastructure preparedness………………………………………………………………….….……..………………………....8 3. Service Delivery……………………………………………………………………………..…..……..……………………………….12 3.1 Maternal Care………………………………………………………………………………….……..………………………………..14 3.2 Child Care…………………………………………………………….……………………..………..………………………………….18 4. Communitisation of Maternal, Child and Comprehensive Care 4.1 ASHA programme……………………………………………………………………………..……..………………………………19 5 Platforms for Convergence 5.1 Village Health and Nutrition Day…………………………………………….……………….……..………………………..21 5.2 Village Health, Sanitation and Nutrition Committees………..…………………………… ……..………………..22 6. Training…………………………………………………………………………………………..……..…………………………………..24 7. Processes 7.1 Planning……………………………………………………………………………………………..…………………………………....25 7.2 Monitoring Structures………………………………………………………………………………..…………………………….27 8. Finance…………………………………………………………………………………………..……..…………………………………..28 E. Key Findings…………………………………………………………………………………….……..………………………………….29 F. Suggestions………………………………………………………………………………………..……..……………………………….33 Annexure Fund utilization statement for the year 2009-10, 2010-11 and 2011-12..…………………………………37 4 A. BACKGROUND The GOI- UNJPC programme is being implemented for promoting convergence at the district level to meet MDGs, improve participatory planning and implementation of plans and schemes, and strengthen monitoring at all levels; Government, Panchayats and Community. It also includes strengthening data collection and reporting mechanism for fund flows and social audit. The present study was carried out with support from UNICEF in 35 districts across 7 states of the country where GOI- UNJPC (UN Joint Programme on Convergence) is being implemented with the Planning Commission. In Madhya Pradesh state, Chhatarpur is one of the districts covered under the aforesaid programme. Analysis of the National Rural Health Mission (NRHM) was undertaken in this district to understand and assess the status of health services in the district and role of various stakeholders in planning and implementation, for achieving the targets set as per the District Programme Implementation Plan (PIP). As regards the relevant data/information on health services in the district and sub-district levels, the study examines the data available for the last three years; 2009-2010, 2010-2011 and 2011-12. The analysis was undertaken to identify areas which require strengthening and gaps that need to be addressed, which would be of help to the District Level Implementers and Planners to improve the implementation of the programme. It would also be of use to the State Governments to issue directives wherever required for making the programme effective and increasing its outreach. B. OBJECTIVE In District Chhatarpur, the study was undertaken with the following objectives:- • Analyse the processes and results, covering various elements and components of the programme as per the PIP for the years 2009-10, 2010-11 and 2011-12. • Identify bottlenecks at different levels in planning and implementation of the programme. • Assess the extent of outreach of the health services. • Examine the role of functionaries and health workers at district, block and village levels. • Identify the existing and possible areas of convergence. C. MATERIAL AND METHODS The methodology was a mix of quantitative and qualitative analysis including Desk review, data collection from secondary sources, Focus Group Discussions, In-depth interview and field visits. Desk Review A desk review/literature review was undertaken of the NRHM guidelines, DLHS-3 data, Programme Implementation plans (PIPs) at State and District level, HMIS data at the district level, Monthly and Annual Progress Reports, and Financial utilization statements at the District level. The documents were reviewed on the following thematic areas:- 5 • District Planning under NRHM • Financial Plans at district level and utilization • District Health Infrastructure • Human Resource for Health- Planning and Training • Maternal and Child Health, including ASHA programme • Convergence platforms at community level- Village level committees Tool Development for Data Collection Based on the desk review and following a participatory process, a tool was developed for quantitative and qualitative data collection. The tool was divided into the following three sections. Section A - Statistical information from Secondary Sources. Section B - Checklist for observation during the field visit on the Village Health and Nutrition Day (VHND) Section C - Guidelines for discussions with focused groups and structured interview with District Planning Officer. Statistical Information was collected for three years; 2009-10, 2010-11 and 2011-12, on the indicators; infrastructure availability in the district for implementing the programme, Maternal and Child Health including, Janani Suraksha Yojana (JSY) & ASHA programme, VHND, VHSNC and financial utilization in the district. Under NRHM, VHND is recognized as one of the important platforms for inter-sectoral convergence between ICDS and NRHM. Through the checklist at Section B in the tool, information was collected on the planning and preparation undertaken for organizing VHND and services provided on that day. A set of guidelines were prepared for discussions with the stakeholders who play or ought to be playing (as per the NRHM guidelines) a significant role in planning, implementing and monitoring the programme, to get an insight into their perspective and role at district, block and village level. Pointers for focused group discussions were also laid out for end line beneficiaries, for whom the programme is intended to; for obtaining their feedback and identify the areas that need strengthening. The following groups and officials were interacted with to collect qualitative information. • ANMs • ASHAs • PRI representatives • Beneficiaries like pregnant women and lactating mothers, and out-door patients. • Village Health, Sanitation and Nutrition Committee members • District and Block Programme Managers • District Planning Officer 6 The draft tool was shared with District Facilitators (DF) who has been appointed under GOI- UNJPC and UNICEF officials. After incorporating the feedback the tool was pre-tested in the District-Rajgarh of State Madhya Pradesh. Following which the tool was finalized and in a one day orientation programme, the techniques for administering the tool in the districts was shared with the DFs. Data Collection The data collection was done by the District Facilitators during the period, January, 2012 to May, 2012. For section A of the tool, the programmatic and financial data was collected from the following Secondary sources, i.e.; the databases maintained within the system. District Health Data 2009-10, 2010-11 and 2011-12 District Programme Implementation Plan HMIS data at the District Level Fund utilization statement ICDS reports 2009 -10 and 2010-11 District specific data from DLHS-3, 2007-08 on the following indicators: For Section B & C, qualitative information was collected from the three village of district Chhatarpur district. The each of these 3 villages was selected from different blocks. The socio- economic status was the main criteria for selecting these villages like % SC population and low literacy of female. And all these villages are headed by a women sarpanch. The profile of the 3 villages is given hereunder- Block GP Village SC ST Other Total % SC % ST % of Female Literacy as per