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CHAPTER ­3 REPRODUCTIVE AND CHILD HEALTH PROGRAMME -II 3.1. Maternal Health including JSY (Costing for each activity at village level, Sub Center level, PHC level, FRU level is detailed in 3.1.6 ­ budget for maternal health) 3.1.1. Background Karnataka is better placed as far as the maternal health indicators are concerned in comparison to the national maternal health indicators. Maternal mortality is considered one of the best indicators of women's health as also of the quality and accessibility of the health services. The maternal mortality rate for Karnataka is 2.28 deaths per 1000 live births (SRS 2001-03) as compared to the national level of 3.01maternal deaths per 1000 live births. In Karnataka 65.1% are institutional deliveries (DLHS 3: 2007-08). Deliveries at home usually lack the services of trained personnel. Institutional delivery rate has increased from 72.8% in 2007-08 to 77.06% as per the department data. Further the institutional deliveries in North Karnataka (Gulbarga and Belgaum division is much lower than the south Karnataka (Bangalore and Mysore division). The brief details are given in annexure-1: Maternal Health Indicators: Karnataka (source DLHS) DLHS-2 DLHS-3 Sl. Indicator No. 2002-04 2007-08 1 3 Antenatal check ups 78.6% 81.6% 2 Consumption of IFA for 90 33.0% 40.7% days 3 Safe deliveries 66.5% 71.5% 4 Institutional delivery 57.95 65.1% 5 Home delivery 41.9% 34.1% 6 Post natal care within NA 69.2 2weeks of delivery 8 un met need for family 15.8 15.1 planning There is an improvement in the institutional delivery rate from 57.9% as reported by DLHS 2(2002-04) to 65.1% as per the DLHS-3(2007-08)

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Causes of maternal deaths in Karnataka 2007-2008 as per the data received in form -9 The major cause of maternal death remains PPH and late referrals resulting in death during transit and arriving at hospitals at last stages. Hence efforts are made to provide quick and early transport and setting up blood storage units. Anemia accounts for 8% of the deaths hence more stress on the prevention and treatment of anaemia Causes of maternal deaths:

Source: Deaths reported to the HFW Dept. in Form -9

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3.1.2. Goals for maternal health for Karnataka Indicators Reduction in MMR Institutional deliveries Safe deliveries Reduction in IMR Total fertility rate Current status 228 SRS (2001-03) 65.1%(DLHS-3) 71.5%(DLHS-3) 47 SRS (2007) 2.1(NHFS-3) 2009-2010 150 85% 90% 30 2.0 2010-2011 125 90% 93% 28 1.9 2011-12 100 99% 100% 25 1.8

3.1.3. OBJECTIVES: a) To increase Safe deliveries to 100 % b)To increase Institutional deliveries to 99% 3.1.4. STRATEGIES: a) Improving coverage and quality of antenatal care, high risk identification, referrals improving nutrition and treatment of anemia. b) Quality intra natal care by trained staff c) Strengthen facilities at the PHCs, to enable them to function 24x7. d) Operationalize the FRUs to enable the staff to offer quality services. e) Strengthen the referral services f) Increase the demand of institutional delivery through Janani Suraksha Yojana. g) Improve postnatal care h) Involvement of the private sector i) Encourage staff to stay at head quarters j) Record and audit all maternal deaths k) Encourage staff through awards 3.1.5. ACTIVITIES: 3.1.5.1. Staff Nurses recruitment: a) 24 x 7 PHC's: Karnataka has 2195 PHC (including 516 upgraded PHC's). Of the old 1679 PHC's,it was proposed to make 1000 PHC's as 24 x 7 during Fy: 2008-09 out of which 974 PHC's have been identified as 24x7. The DH&FW Officers were permitted to hire services of three Staff Nurses at all such PHC's (including the regular Govt. Staff Nurses) so as to ensure continuity of services. 2250 Staff Nurses are working and institutional delivery has shown on upward trend. During Fy: 2009-10 it is proposed to identify additional 200 PHC's in 6 `C' category districts and in those districts where MMR & IMR is above the State average, as 24x7 and provide inputs on similar lines. There are 150 regular govt. staff nurses working in these PHC's, whose salary will be booked under State Budget. Hence the budget required under this component for Fy: 2009-10 will be approximately Rs. 2898.0 lakhs. (@ Rs. 7000 pm x 1200 PHC's x 3 Staff Nurse (-150govt Staff nurses) / PHC x 12 months) KARNATAKA NRHM PIP 2009-10 3

However the NPCC has suggested a budget provision of Rs.2318.40 lakhs b) First Referral Units: Out of the identified 192 FRU's in Karnataka, 107 are conducting LSCS. To strengthen maternal health services at these 192 FRU's, it was proposed to provide services of two Staff Nurses/FRU during Fy: 2008-09. 280 staff nurses are in position. It is proposed to continue the services of these staff nurses during Fy: 2009-10. The Budget required under this component for Fy: 2009-10 will be approximately Rs. 0323.0 lakhs. (@ Rs. 7000 pm x 192 FRU's x 2 Staff Nurse / FRU x 12 months) c. Staff Nurses/ANM for vacant sub centers: During the Fy: 2008-09, out of 8143 sub centers, 1744 sub centers did not have the services of ANM/staff Nurse. To improve MCH services in rural areas, it was proposed to provide service of one Junior Health Asst. Female (ANM) or Staff Nurse to such vacant sub centers. Hence 1058 staff have been contracted and are in position. Further during Fy: 2008-09, 584 Junior Health Asst. (female) have completed training from Govt. ANM Training Centers, will be posted to vacant sub centers and the expenditure for these 584 Junior Health Asst. (female) will be booked under State Sector. Hence during Fy: 2009-10, it is proposed to continue the services of Junior Health Asst. (female)/Staff Nurses for 1160 vacant sub centers. (1744-584 = 1160). The Budget requirement under this component during Fy: 2009-10 will be approximately Rs. 0975.00 lakhs (@ Rs. 7000 pm x 1160 sub centers x 1 staff nurse/sub center x 12 months) d) Strengthening of services in 6 `C' category districts: The MMR and IMR is high in 6 `C' category districts namely Bidar, Gulbarga, Raichur, Koppal, Bijapur and Bagalkote. The area covered by the ANM is large and field work suffers as a consequence. One sub center in the Northern Districts caters to a population of 6521 ­ 8266 while as in Southern Districts one sub center caters to a population of 4098 approximately. The details are attached as Annexure ­ 2. To strengthen and improve services in these 6 `C' category districts, services of 2 nd Junior Health Asst. (Female)/ Staff Nurse was proposed in nearly 1500 sub centers. However due to large scale recruitment of Staff Nurse/ Junior Health Asst. (female) for 24 x 7 PHC's and FRU's, recruitment under this component has not made much progress, which will show an improvement during Fy:2009-10. The Budget requirement under this component during Fy: 2009-10 will be approximately Rs.1260.00 lakhs. However due to above cited reasons, it is proposed to provide 50% of the required budget during Fy: 2009-10 of Rs. 0630.00 lakhs. (@ Rs. 7000 pm x 1500 sub centers x 1 staff x 12 months = 1260.00 lakhs(50%) = 0630.00 lakhs) a) Strengthening of Community Health Center (CHC) Services (new initiative): Under NRHM the services at PHC's and FRU's, have been strengthened in terms of manpower, equipments, logistics, transport facilities etc. There are about 150 CHC's which are 30 bedded hospitals, already providing Maternal and Child Health services. Some of these CHC's do not have either sufficient staff nurse sanctioned posts, or are below IPH standard or workload is very high. Hence it is proposed to provide services of two contractual staff nurses for 150 CHC's to strengthen NRHM activities with special emphasize on MCH services. KARNATAKA NRHM PIP 2009-10 4

The Budget requirement under this component during Fy: 2009-10 will be approximately Rs.252.00 lakhs.(@ Rs. 7000 pm x 150 CHC x 2 staff nurses / CHC x 12 months) 3.1.5.2 Night Dai as helper: a) 24 x 7 PHC's: Services of Dais have been provided at 24 x 7 PHC's. The Dais stay at the PHC during the night and also assist in the delivery room .This has facilitated conducting night deliveries at PHCs. It is proposed to continue this service at 1200 PHC's, which includes additional 200 PHC's, which will be operationalized during this year. The Budget requirement under this component during Fy: 2009-10 will be approximately Rs. 0144.00 lakhs. (@ Rs. 1000 x 1200 PHC's x 1 Dai 1 PHC x 12 months) a) 24 x 7 CHC's (New initiative): Similar to 24x7 PHC's, it is proposed that services of one Dai per CHC for 150 CHC's, which will function as 24x 7 CHCs The Budget requirement under this component during Fy: 2009-10 will be approximately Rs. 0018.00 lakhs. (@ Rs. 1000 pm x 150 CHC's x 1 Dai per CHC x 12 months) 3.1.5.3 Laboratory Technicians: Services of one Laboratory Technician per FRU have been provided during Fy: 2008-09. This service was provided at 108 FRU's so as to strengthen the investigation facilities in these institutions. As of date 98 Lab technicians are working. The services of these 98 are to be continued though no fresh recruitment is proposed. The Budget requirement under this component during Fy: 2009-10 will be approximately Rs. 76.44 lakhs. (@ Rs.6500 pm x 1 Lab Tech / FRU x 98x 12 months) 3.1.5.4.Medical Officers under RCH: Services of 100 contractual MBBS Doctors was provided in 6 `C' category districts as an additional MBBS Doctor to improve the MCH service delivery system at PHCs from 200708. Hence it is proposed to continue their services during Fy: 2009-10. It is noticed that Minimum Needs Program PHC's are having services of one MBBS Medical Officer with which it has become difficult to provide 24x7 services in rural areas. Hence it is proposed to provide services of one more contractual MBBS Doctor at Minimum Needs Program PHC's which are made 24 x 7 PHC's and are functioning with one MBBS Doctor as well as performing well with more than 25 deliveries per month. Accordingly it is proposed to recruit 200 MBBS doctors on contract basis to such PHC's. Moreover there are FRUs where specialists are busy with regular duties apart from their specialist duties. The priority for the specialists is to work for the maternal and child health activities hence for regular duties these MBBS doctors to be posted to FRUs on a need base. The Budget requirement under this component during Fy: 2009-10 will be approximately Rs. 0612.0 lakhs. (@ Rs. 17000 pm x 300 MBBS Doctors x 12 months) However the NPCC has suggested a budget provision of Rs.459.00 lakhs. KARNATAKA NRHM PIP 2009-10

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3.1.5.5. Mobility Support: a. PHC Medical Officers: In the State of Karnataka there are 2195 Primary Health Centers 1679 PHCs and 516 upgraded PHUs). One Primary Health Center caters approximately to a population of 30,000. Hence a medical officer who is posted at these PHCs has to manage 5-6 sub centers. The medical officer apart from managing the clinic at the PHC has to manage all the national health programs. One of the important job responsibilities of the medical officer at the PHC is supervision of all the national health programs as also the monitoring of the work turned out by the ANMs, Male health workers, ASHAs and also conducts out reach services in the inaccessible areas. For the above activities at present there is no vehicle facility for the doctors, this hampers the program. In order to improve the maternal and child health parameters it is essential to provide the doctors with mobility support. It is proposed to provide a sum of Rs 500/pm as mobility support to doctor at the PHC The Budget requirement under this component during Fy: 2009-10 will be approximately Rs. 131.00 lakhs. (@ Rs. 500 pm x 2195 PHC Medical Officers x 12 months) b. Junior Health Asst. (female) / ANM: ANM's apart from conducting the activities in the sub center also have to conduct field visits, hence Junior Health Asst. (female)/ ANM is provided with mobility support. The Budget requirement under this component during Fy: 2009-10 will be approximately Rs. 0195.00 lakhs.(@ Rs. 200 pm x 8143 sub centers x 12 months) c. Senior Health Asst. (Female) / Lady Health Visitor (LHV): The Senior Health Asst. (female) /LHV has to supervise the entire PHC will have 4-6 sub centers. It is proposed to extend mobility to one Senior Health Asst. (female)(LHV)/PHC The Budget requirement under this component during Fy: 2009-10 will be approximately Rs.60.00 Lakhs (@Rs.300 pm x 1LHV /PHC x 1679 PHC's x 12 months) 3.1.5.6. Remote Area Allowance: a. Most remote PHC: Generally doctors and staff nurses are not keen in serving in the remote rural areas. They have to be motivated for taking up jobs in remote PHCs. 219 PHC's in Karnataka are identified as most remote PHC's. It is proposed to continue assistance as in the previous year to encourage three Medical Officers and three Staff Nurses to work in these hard to reach areas. The Budget requirement under this component during Fy: 2009-10 will be approximately Rs. 394.20 lakhs. (@ Rs. 5000 pm x 219 PHC's x 3 MOH / PHC x 12 months) Similarly it is proposed to continue assistance to three Staff Nurses working in most remote areas. The Budget requirement under this component during Fy: 2009-10 will be approximately Rs.0236.52 lakhs.(@Rs. 3000 pm x 219 PHC's 3 staff nurse / PHC x 12 months) b. More remote PHC's

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Similar to most remote PHC's, 219 PHC's have been identified as more remote PHC. It is proposed to continue assistance as last year for three Medical Officers to work in these hard to reach areas. The Budget requirement under this component during Fy: 2009-10 will be approximately Rs. 0236.52 lakhs. (@ Rs. 3000 pm x 219 PHC's x 3 MOH x 12 months) for doctors. Similarly it is proposed to continue assistance to three Staff Nurses working in more remote areas. The Budget requirement under this component during Fy: 2009-10 will be approximately Rs. 0118.26 Lakhs (@ Rs. 1500 pm x 219 PHC's 3 staff nurse / PHC x 12 months) for staff nurses. Hence the total budget requirements allowance is approximately Rs.985.50 lakhs. However the NPCC has suggested Rs.492.50 lakhs (reduced by 50%) 3.1.5.7. Incentive for managing High Risk Pregnancies: Karnataka had registered approximately 6.20 lakhs deliveries from April 08 to Nov 08. This means during Fy: 2008-09 approximately 9.0 lakhs deliveries may be registered. Out of this 67% will be institutional deliveries. It is estimated that 10% of the institutional deliveries are of high risk (HRP) in nature. It is noticed that 35-40% of maternal death are occurring due to late referrals and during transit. Hence it is proposed to continue assistance to Junior Health Asst. (female)/ASHA for early registration of HRP ANC and to ensure safe delivery. The Budget requirement under this component during Fy: 2009-10 will be approximately Rs. 0150.00 lakhs. (@ Rs. 250 x 1 HRP x 60000 HRP during Fy : 2009-10). Maternal care for HIV +mothers : Yeshasvini Scheme : This is the first time in the country that integration of HIV has been done with NRHM. Under this scheme HIV pregnant women are registered, reassured, treated and followed up for 18 months. For the delivery purpose the woman has the choice to deliver in a private hospital accredited under the Yashwasni scheme or in a Govt. hospital. For every delivery in a private setup the private hospital is reimbursed Rs.6,000/-. In a Govt. setup the Rs.6,000/- is divided between the Arogya Saksha Samithi and the hospital. Further in addition it is proposed to provide assistance for consumables, protective gear, pregnant mother deliveries, Yeshaswini charges. The Budget requirement under this component during Fy: 2009-10 will be approximately Rs. 0288.0 lakhs. (@ Rs. 6000 x 4800 HIV +ve pregnant mother deliveries) ANM who accompanies the HIV positive women for delivery and does the follow up of the woman and the baby till 18 months is given an incentive of Rs.1,500/- per case in 2 installments The Budget requirement under this component during Fy: 2009-10 will be approximately Rs.0072.0 lakhs. (@ 0.8% of 6 lakhs deliveries = 4800 HIV +ve pregnant mothers deliveries @ Rs.1500) 3.1.5.8. Maternal Death Audit: To encourage public, Anganwadi worker or ASHA to inform maternal deaths so as not miss such deaths occurring in their areas, it is proposed to extend a cash assistance. It is proposed to give an incentive of Rs 500 to the first informant for reporting a death.

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The Budget requirement under this component during Fy: 2009-10 will be. Rs..500x1200=Rs 6.0 lakhs Further necessary Govt. order has been issued stating that all maternal deaths and infant deaths shall be audited by Deputy Commissioners in their districts. It is proposed to provide expenses towards conducting such meetings. The Budget requirement under this component during Fy: 2009-10 will be Rs. 0001.0 lakhs To gather complete picture that has led to maternal/ infant death, it is necessary to enquire details with spouses/relatives. To facilitate their presence, it is proposed to extend cash assistance for their transport & refreshment. The Budget requirement under this component during Fy: 2009-10 will be Rs. 0003.6 lakhs (@ Rs. 300 per maternal deaths x 1200 deaths) 3.1.5.9 Awards: To encourage the field staff working at PHC, General Hospitals, CHC's and at District Hospitals it is proposed to institute awards to various categories of staff. Brief details and budget requirement are as follows: Awards 1 Best Junior Health Asst. (Female)/ANM a. (@ Rs. 5000 for / 1 best ANM/ 1 Taluk x 175 taluk ANM) b. (@ Rs. 7500 for / 1 best ANM/ 1 District x 29) c. (@ Rs. 10000 for / 1 best ANM for State x 1) 2 Best Staff Nurse: PHC a. (@ Rs. 7500 for / 1 best Staff Nurse working at PHC x 175 Taluk Staff Nurse) b. (@ Rs. 7500 for / 1 best Staff Nurse/ working at PHC x 29 District Staff Nurse) c. (@ Rs. 15000 for / 1 best district Staff Nurse working at PHC for State x 1 3 Best Staff Nurse: CHC/FRU/GH a. (@ Rs. 7500 for / 1 best district Staff Nurse/ working at CHC/FRU/GH x 29 Districts) b. (@ Rs. 15000 for / 1 best Staff Nurse/ working at CHC/FRU/GH for State x 1) 4 Best Staff Nurse: District Hospital a. (@ Rs. 7500 for / 1 best Staff Nurse/ working at District Hospital x 25 b. (@ Rs. 15000 for / 1 best district Staff Nurse working at District Hospital for State x 1 5 Best Doctor (working at PHC/CHC/GH) (@ Rs. 10000 x 1 Best Doctor of PHC/CHC/GH x 175 Taluk) (@ Rs. 20000 x 1 Best Doctor /District of PHC/CHC/GH x 29 District) (@ Rs. 30000 x 1 Best Doctor of PHC/CHC/GH x 1 State) 6 Best Specialists (OBG,Pediatricts & Anesthetist : one each) (@ Rs. 10000 x 3 Best Specialists working at FRU' x 29 s Districts) (@ Rs. 25000 x 3 Best Specialists working at FRU' x 1 State) s KARNATAKA NRHM PIP 2009-10 Rs. In lakhs 0011.0

0020.0

0075.8

0009.45

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Best Specialist (OBG,Pediatricts & Anesthetist) from District 7 Hospital (@ Rs. 10000 x one Best Specialist working at District Hospital x 1 29 Districts) (@ Rs. 25000 x one Best Specialists working at District Hospital x 1 State) 2 Awards distribution on function at District level (@ Rs. 10000 / District x 29 events in respective district) 3 Awards distribution on function at State level (@ Rs. 50000 x 1 event)

0003.15

0002.9 0000.50

3.1.5.10. ANM Training Centers: a. New ANM Training centers Nine Govt. new ANMTC have been sanctioned during Fy: 2008-09 which have commenced from 01-08-08. It is proposed to continue to provide budget towards salary, logistics, stipend, contingency, rent, contractual staff etc. The Budget requirement under this component during Fy: 2009-10 will be Rs. 0341.6 lakhs. Salary & allowances @ Rs. 25 lakhs x9 but only 75% expexpenditure is projected Furniture + pol+ phone / ANMTC @ Rs. 5L x 9ANMTC) Stipend (@ Rs. 500x270 trainees x 12 months) Contingency (@ Rs. 2 lakhs x 9 ANMTC) Rent (@ Rs. 0.5 x 9 ANMTC x 12 months) Contractual staff (only 75% expenditure is projected because of vacancies) (1 driver, 2 cooks, 3 group ' , 1 Data Entry Operator x 9 D' ANMTC x Rs.7000 x 12 months but only 75% expenditure is projected) b. Old, Auxilliary Nurse Midwife Training Center (ANMTC) : Karnataka has 19 old ANMTC. It is proposed to provide untied funds assistance for smooth functioning of these old Govt. ANMTC. The Budget requirement under this component during Fy: 2009-10 will be Rs. 0019.0 lakhs (@ Rs. 0001.0 lakhs / ANMTC x 9 ANMTC) 3.1.5.11. Contracting in Specialists for FRU's/Taluk Hospitals: To overcome the shortage of specialists at FRU and to make the functional it is proposed to contract in specialists either on a case to case basis or monthly retainer ship as suited to both parties. In continuation of approved PIP for Fy: 2008-09 it is proposed to continue contracting in services of Obstetrician, Anesthetist and Pediatrician to Taluk Hospital FRU's. It is proposed to make such services available at 100 FRU's The Budget requirement under this component during Fy: 2009-10 will be approximately Rs. 600.00 lakhs. (@Rs. 0.5 lakhs / FRU/Month x 100 FRU's x 12 months) However the NPPC has suggested a budget provision of Rs.480.00 lakhs KARNATAKA NRHM PIP 2009-10

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3.1.5.12. Stationery Printing: a. ANC Registration Booklet (Thayi Card) : Karnataka has printed a comprehensive Antenatal registration on booklet (Thayi card). It encompasses all the mother components from early ANC registration to post natal follow up, Immunization of child, weight gain record etc. It is proposed to continue to provide ANC registration booklet. The Budget requirement under this component during Fy: 2009-10 will be approximately Rs. 0080.0 lakhs. (@ Rs. 10/booklet x 8.0 lakh booklets) Included in JSY budget b. Registers and formats: It is necessary to document Registration on of JSY Beneficiaries & Prasuthi Aaraike beneficiaries with photos and signature. Further it is necessary to provide Medical case Sheets, Referral slips, parturition register for proper registering of deliveries etc. The Budget requirement under this component during Fy: 2009-10 will be approximately Rs. 0040.0 lakhs) (Included in JSY budget) 3.1.5.13. Rent for sub centers: a) In continuation of approved PIP for Fy: 2008-09, in Karnataka out of 8143 sub centers 2800 sub centers do not have building of its own. It is found that the amount prescribed of Rs. 500/- per sub centre/month is inadequate. Hence it is proposed to continue rent for such sub centers @ 1000 pm per sub center x 2800 sub centers x 12 months. This will facilitate stay of Junior Health Asst. (female) at her place of posting and to provide MCH services at the need of the hour. The Budget requirement under this component during Fy: 2009-10 will be Rs. 0336.0 lakhs. (@ Rs. 1000 pm per sub center x 2800 sub centers x 12 months) b) Rent allowance for contractual Staff Nurse working at 24x7 PHC's: Karnataka has 2195 PHC (including 516 upgraded PHC's). Out of the old 1679 PHC's, it was proposed to make 1000 PHC's as 24 x 7 during Fy: 2008-09. 974 PHC's have been identified as 24x7. The DH&FW Officers were permitted to contract services of three Staff Nurses at all such PHC's (including the regular Govt. Staff Nurse) to ensure continuity of services. 2250 Staff Nurses are hired and institutional deliveries have shown on upward trend. It is noticed that the contractual staff nurses are finding it difficult to stay in rural areas due to availability of inadequate accommodation facilities. In order to encourage staff nurses to stay at rural areas, it is proposed to provide rent allowance of Rs.750.00 per month per contractual Staff Nurse working at 24x7 PHC's This will facilitate stay of staff nurses at the place of posting and to offer MCH services at the need of the hour. The Budget requirement under this component during Fy: 2009-10 will be approximately Rs. 0310.5 lakhs. (@ Rs. 750 pm per staff nurses x 3450 staff nurses x 12 months)

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3.1.5.14. Janani Suraksha Yojana: The flagship program of Govt of India to extend financial assistance to BPL mothers during 1st and 2 nd live births has received wide popularity. Nearly 2.3 Lakhs and 2.8 Lakhs mothers have received benefit during the previous year. During Fy:2009-10 the beneficiaries under this scheme could be approximately 4 lakhs. Further it is proposed to provide incentive to ASHA for ensuring early ANC registeration & institutional delivery of Rs.200/- per case for approximately 2.2 lakh beneficiaries . (Rural institutional deliveries + LSCS cases). The brief details are as follows Projected total No. of deliveries during Fy: 2009-10: Approx. No. BPL deliveries (2/3rd): Approx. No. Deliveries with 1st & 2nd Child (71.5%): Approx. No. LSCS (10% of 4 lakh @Rs.1500) : Approx. No Urban Deliveries (1/3 of 3.6 lakhs): (@ Rs. 600 x 1.2 lakhs deliveries) Approx Rural Deliveries : (2/3rd of 3.6 lakhs @ Rs. 600 x 1.2 lakhs deliveries) Approx No. of Rural Institutional Deliveries (75% of 2.4 Lakh deliveries = 1.8 lakhs @ Rs. 700) Approx. No . Rural & Home Deliveries : (25% of 2.4 Lakh Rural Deliveries) (@ Rs. 500x 0.6 Lakh Deliveries) Printing of ANC registration booklet(Thayi card) and registers Escorting JSY beneficiaries as an incentive to ASHA workers (@ Rs. 200 x 2.2 L Deliveries) 8.5lakhs 5.6 lakhs 4.0.lakhs 0.4 lakhs 1.2 lakhs

2.4 lakhs

0.6 Lakhs

440.00 lakhs

The Budget requirement under this component during Fy: 2009-10 will be approximately. Rs. 3440.00 lakhs. 3.1.5.15. Prasuthi Aaraike program : To encourage rest, nutritious food and medical care during 1st & 2 nd live births for BPL mothers Karnataka has extended financial assistance in 6 C category district during the previous year. The program provides an assistance of Rs.2000/- (1 st & 2 nd installment during 2 nd & 3 rd trimester @ Rs.1000/- respectively). Now the program has been extended to entire Karnataka. The funding is from Govt. of Karnataka. The brief details are as follows. Projected total No. of deliveries during Fy:09-10: Approx. No. BPL deliveries (2/3rd): Approx. No. Deliveries with 1st & 2nd Child (71.5%): Add 2% of approx. no. deliveries with 1st &2nd child (71.5%): (JSY) (Shift to ' ) : X' (@ Rs. 2000 x 4.08 Lakh) 8.5 lakhs 5.6 lakhs 4.0 lakhs 4.8 lakhs 0.08 lakhs

The Budget requirement under this component during Fy: 2009-10 will be. Rs. 8160.0 lakhs. 3.1.5.16. Thayi Bhagya: KARNATAKA NRHM PIP 2009-10 11

Karnataka is experiencing shortage of specialists particularly in the field of obstetrics, anaesthesia and paediatrics. At the same time the private medical sector has a strong presence in Karnataka offering above services. To tap this resource, as a public private partnership, it is proposed to recognize some of the private hospitals in 6 `C' category and Chamarajanagar districts, which has poor MMR and IMR parameters. It is based on the model of Chiranjeevi scheme in Gujarat. Objectives: To increase the skilled birth attendance To increase the institutional delivery rate To buffer against the high cost of emergency obstetric care. Strategy: Scheme for BPL women who get authorization from the authorities to enable them to avail the scheme. Private providers are empanelled in the identified districts to provide the delivery care package as depicted in the table below. The private providers to be screened by District Health Society so as to be sure of the facilities being provided for emergency obstetric care in their private facilities. Facility survey to be conducted. Private providers are reimbursed for every 100 deliveries on a capitation basis. Empanelled private providers are given Rs. 30,000 as advance and subsequently reimbursed Rs. 2,70,000 for every 100 deliveries conducted in their own private facility. Sensitization workshops to be conducted in all the districts. Extensive IEC by the government for the families as well as for the providers. Dignity of the specialists to be respected through mutual interaction and trust. Simple reporting formats to be used for the reporting at the Taluka level. Strong government ownership and support for implementing.

Approx. No. of Deliveries : in 6 ' & Chamarajanagar district C' Approx. No. BPL deliveries (66% of 2.65 lakhs ) Approx. No. of Deliveries with 1st & 2nd child Approx. No. BPL deliveries Approx. No Institutional Deliveries (60% of 1.18 lakhs deliveries with 1st & 2nd child) (includes SC, PHC,CHC etc. Deliveries) Approx. No. of Deliveries under Thayi Bhagya Scheme : Recognised Hospitals including FRU' s (66 % of 0.7 lakhs Institutional Deliveries) KARNATAKA NRHM PIP 2009-10

2.65 lakhs 1.77 lakhs 1.18 lakhs 0.7 lakhs

0.46 lakhs

12

Approx. No. of Deliveries at Pvt. Thayi Bhagya Hospitals : 0.12 lakhs : 0360.0 L (25% of 0.46 lakhs Deliveries at Thayi Bhagya Scheme Pvt. Hospitals (@ Rs. 3000 x 12000 deliveries) Approx. No Deliveries at FRU' under Thayi Bhagya Scheme : s 0510.0 l (75% of 0.46 lakhs Deliveries at Thayi Bhagya Scheme) ( at Rs. 1500 x 0.34 lakhs) The Budget requirement under this component during Fy: 2009-10 will be approximately. Rs. 0870.0 lakhs. 3.1.5.17. Maintenance grant to Women & Children Hospitals : Some of the hospitals in Govt sector are offering exclusive Maternity and Child Health Services. They are as follows: 1. Chituguppi corporation Maternity Hospital, Hubli, 2. Women & Children Hospitals , Madikeri, 3 Lady Goshan Women & Children Hospital, Mangalore 4. HSIS Ghosha Hospital, Shivajinagar Bangalore 5. SMT Maternity Hospital, Mysore, 6. Women & Children Hospital Udupi, 7. Women & Children Hospital Davangere, 8. Women & Children Hospital Ranibennur, 9. Women & Children Hospital Gadag, 10. Women & Children Hospital Chikkamagalur 11 Maternity hospital Sedum, Gulbarga District 12. General Hospital Jayanagar,(maternity wing). Bangalore 13.Maternity Hospital Jayanagar Mysore 14 Chamundipuram maternity Hospital Mysore (@ Rs. 5 lakhs / W&CH x 14 hospitals) It is necessary to support such hospitals in terms of equipments, logistics. It is proposed to provide funds as untied grants of Rs.5 lakhs per year. The Budget requirement under this component during Fy: 2009-10 will be approximately. Rs. 70.0 lakhs. (@ Rs. 0005.0 lakhs / W&CH x 14 Hospitals) 3.1.5.18. Procurement a. Sub centers : Karnataka has 8143 sub centers offering a range of services with special emphasis on Maternal and Child Health Services. Attempt has been made to fill up the vacant sub centers with contractual Junior Health Asst.(Female)/Staff Nurses. 1030 have been hired and are in position. It is required to supply basic investigation consumables and drugs as per the specifications prescribed by the MoHFW, Govt of India. The brief details are as follows. Sub centers (8143) Haemoglobin estimation books (@ 100 B/SC) = 8143 Urine testing strips 1000 / sub centers Pregnancy Detection Card - 3 Lakhs SSD kits - 3 Lakhs KARNATAKA NRHM PIP 2009-10 13

Drugs (as per MOHW, GOI )for 8143 sub centers The Budget requirement under this component during Fy: 2009-10 will be approximately. Rs. 0450.0 lakhs. However the NPCC has suggested a budget provision of Rs.337.50 lakhs

b. Primary Health Centers : i. Drugs and Consumables It was proposed to make 1000 PHC's as 24 x 7 during F'y 2008-09. 976 PHC's have been identified as 24x7. Further during Fy 2009-10 it is proposed to identify another 200 PHC's as 24x7 in the districts where there is high MMR & IMR. It is required to supply basic investigation consumables. It is also proposed to supply drugs for RTI/STI per PHC as per the specifications prescribed by the MoHFW, Govt of India. The brief details are as follows. Urine testing strips (@ 1000 strips x 24 x 7 1200) Pregnancy Detection Card (@ 500/PHC x 1200) SSD Kits for 24 x 7 PHC (@ 20 Deliveries per month x 1200 PHC x 12 months) 1 Drug pack for PHC as per the GOI guidelines per 24 x 7 PHC x 1200 PHC' s RTI/STI drug pack per 24 x 7 PHC x 1200 PHC' s) Glucometer with strips (@ 1 glucometer &500 strips / 24 x 7 PHC x 1200 PHC) The Budget requirement under this component during Fy: 2009-10 will be approximately. Rs. 0600.0 lakhs. However the NPCC has suggested a budget provision of Rs.447.75 lakhs ii. Tab. Misoprostol SN 1 2 3 4 5 Parameter Projected number of deliveries for 2009-10 Institutional deliveries (70%) Deliveries in the government institutions 60% of the institutional deliveries Cost of 1 tab of misoprostol Total for 4 lakh deliveries @ 3 tab per delivery Total budget for 2009-10 Rs 14 12 lakh tablets Rs 2.0 cr 8.5 lakhs 6.0 lakhs 4.5 lakhs

The medical officers will use it for delivery of patients at the PHC and also will supply the tab misoprostol to the ANMs/ Staff nurses working at the sub centers in his area as and when required. KARNATAKA NRHM PIP 2009-10 14

However the NPCC has suggested a budget provision of Rs.150.00 lakhs Community Health Center i. Drugs and Consumables Karnataka has 325 CHC's out of which 150 are situated below the blocks/ Talukas. Now it is proposed to strengthen these CHC's with manpower & logistics to offer 24x7 services. Most of these CHC's are 30 bed hospitals. It is required to supply basic investigation consumables. It is also proposed to supply drugs as per GOI specifications ,RTI/STI drugs per CHC as per the specifications prescribed by the MOHFW, Govt of India. The brief details are as follows. CHC drug pack as per MOHW, GOI guidelines per CHC x 150CHCs Urine testing strips (@ 1000 strips x 150 CHC Pregnancy Detection Card (@ 600 x 150 CHC SSD Kits (@ 40 Deliveries/ Month x 150 x 12 months Drugs for RTI/STI (as per MOHW, GOI, NACO) Resuscitation Kits The Budget requirement under this component during Fy: 2009-10 will be Rs. 0300.0 lakhs. However the NPCC has suggested a budget provision of Rs.195.00 lakhs

d) First Referral Units: As per the approved PIP, Karnataka has 192 FRU's. All these hospitals are providing Maternal & Child Health Services, treating RTI & STI cases and other services. It is required to supply basic investigation consumables. It is also proposed to supply drugs as per GOI guidelines and RTI/STI drugs per FRU as per the specifications prescribed by the MOHFW, Govt. of India. The brief details are as follows. FRU drugs as per MOHW, GOI 1 per FRU x 192 FRU' s Urine testing strips (@ 3000 Strips x 192 FRU' s) Pregnancy Detection Card (@ 2000 Card x 192 FRU' s) RTI / STI drugs as per MOHW, GOI, NACO) The Budget requirement under this component during Fy: 2009-10 will be Rs. 0500.0

lakhs.

e) Iron Sucrose: In Karnataka iron deficiency anaemia in pregnant women as per NFHS-3 is 59.9% as compared to 48.6% in NFHS -2. Anaemia is a major contributing factor for maternal morbidity and maternal mortality. It is also associated with poor fetal out come Oral iron and intramuscular iron have been used but it is not possible to achieve the target rise in the Hb level in a limited time period when the patient is approaching full term. Hence to improve the anemia it is proposed to provide iron sucrose to the anemic women which is able to KARNATAKA NRHM PIP 2009-10 15

raise the Hb to satisfactory level when used in severely anemic women. Iron sucrose is safe and more effective alternative to oral iron It is proposed to be taken up as a pilot in 3 districts with close monitoring under a closed system. Severe anemia i;e less than 7 gm hemoglobin in pregnant women will be identified and treated. Budget: The cost per beneficiary is Rs 3000. For beneficiaries in 3 districts the cost would be Rs 201.00 lakhs 3.1.5.19 Equipment: a) Boyle's apparatus :33 FRUs are being provided with Boyle's apparatus. Cost per unit- Rs.4-00 lakhs Total budget required =:Rs. 132-00 lakhs b) Manual Vacuum Aspiration syringes for MTP would be procured under NRHM for 192 FRUs @ 2 syringes each. SN MVA Syringe Cost 1 Unit cost per MVA syringe Rs.1600/2 For 192 FRUs @ 2 per FRU (384x1600) Rs 6,14,000/

c) Adult resuscitation kits: Requirement 33 Cost per unit Rs.40,000

Total budget required Rs.13,20,000/d) Blood Storage Centers at FRU' : s During Fy: 2009-10 it is proposed to set up 20-blood storage center at FRU's, which are situated at block level hospitals. Hence it is required to supply some of the equipments. The brief details are as follows: a. Blood Storage Center Regrigerator with Thermograph (@ Rs. 0.65 L x 40) b.Tabletop Centrifuge (@ Rs. 0.06 L x 40) c. Insulated Cold Blood unit transfer boxes (@ Rs. 0.05 L x 40) d. Air Conditioner-1ton (@ Rs. 0.25 L x 40) e. Binocular Microscope (@ Rs. 0.25 L x 40) f. Furniture (@ Rs. 0.25 L x 40) g. Consumables & Reagents disinfectants (@ Rs. 0.25 L x 40) The Budget requirement under this component during Fy: 2009-10 will be approximately. Rs. 0040.0 lakhs. Further there is need to provide budgetary support for the FRU's which were proposed during previous years with consumables. The Budget requirement under this component during Fy: 2009-10 will be approximately. Rs. 0019.0 lakhs (@ 0.20 lakh x 94 FRU' s)

KARNATAKA NRHM PIP 2009-10

16

e) Generator : It is noticed that several 24x7 PHCsand CHCs are conducting deliveries round the clock. It is required to provide uninterrupted power supply Hence it is proposed to supply one generator on a need base per 24X7 PHC(1200) and CHC (150). Budget: For PHC @0.5 Lakh x1200 PHCs= Rs 600 lakhs For CHCs @0.6 Lakh x150 CHCs = Rs 60 lakhs f) Haemoglobinometer for 24x7 PHCs and for 150 CHC: Budget : 3.0 lakhs g) Oxygen concentrator: It is required to provide availabilty of oxygen services for the mother and neonates. It is difficult to refill the oxygen cylinders at the FRUs in the field.The oxygen concentrator supplied earlier has been found useful. Oxygen Concentrator with accessories will be provided to 150 CHCs @ 0.6 lakh = 90 lakhs However the NPCC has suggested a budget provision of Rs.708.26 lakhs in place of Rs.944.34 lakhs. 3.1.5.20. Cancer cervix : Problem Description of cancer cervix in Karnataka: Cancer of the cervix uteri continues to be the most predominant site of cancer and accounted for 26.7% of all cancers in females. Cancer of the breast is the second most common site (16.6%) followed by cancers of oral cavity (11%), Oesophagus (5.7%) and ovary (5%). Over the years, a gradual decrease in the proportion of cervical cancers and marginal but steady increase in the numbers and relative proportion of breast cancers is observed In rural areas, 80% of population is at high risk due to low socio-economic status, poor genital hygiene, early marriage, multi-parity and lack of knowledge about the condition and facilities available for early diagnosis.Leading Sites of Cancer - Female: (KMIO 2004-05) Strategy: It is planned to implement the screening of cervical cancer intensively on a relatively large scale so as to reduce the incidence of cancer cervix. Cervical cancer screening and treatment using the services of specialists at the specialist camps conducted at Taluka and district level in every district. Action Plan at the specialist camps: Mobilization of target group: The PHC medical officer shall sensitize the ANMs/ASHAs and Anganwadi workers as well as Self Help Groups (SHGs) to mobilize the women in the age group of 18-45 years to the specialist camps for cervical cancer screenin .Case detection and referral of cases and follow up by the concerned PHC medical officer. The Administrative Medical Officer of the General Hospitals/Taluka hospitals and the District Surgeon, District Hospital shall provide the required consumables from the budget already provided for conducting specialist camps under NRHM. 3.1.5.21) Training of MBBS doctors in the life saving Anesthesia and obstetrics skill: Maternal Mortality in our country is a major concern and as such the 10th plan targets to reduce maternal mortality rate upto 100 per one lakh live births by the year 2012. To achieve this provision of adequate and timely emergency obstetric care has been recognized globally as the most important interventions for saving lives of pregnant women who may develop complication during pregnancy and child birth. The operationalization of first referral units at sub district / CHC level for providing Em.O.C. to pregnant women is a crucial strategy of RCHII, which needs focused attention. It has not been possible to operationalize these FRUs till now due to shortage of specialist manpower, i.e. gynecologist and Anesthetist; shortage of emergency KARNATAKA NRHM PIP 2009-10

17

drugs; shortage of blood and in some case non-availability of properly functioning operation theaters. To reduce the maternal mortality rate, under RCH programme, steps have now been taken in Karnataka to tackle these issues. Shortage of specialist manpower, i.e. Gynecologist and Anesthetist is one of the major problem. To overcome the shortage of specialists, a scheme for engaging anesthetist and gynecologist form private sector has also been in operation. However due to acute lack of anesthetist and gynecologist in sub district areas it has not been possible to get their services. To overcome this, training of MBBS doctor in life saving anesthetic skills (18 weeks) and obstetrics (16 weeks) for emergency obstetric care has already taken up in Karnataka. Altogether 11 Medical Colleges are identified as master training centers in anesthesia and Bangalore Medical College is identified as master training institute for OBG. Following the training these doctors will be posted to identified FRUs to provide EmOC services. To encourage these doctors incentive of Rs. 1000/- per case for conducting caessarian section is proposed subject to a maximum of Rs. 7000/- per month. Status report showing the no. of doctors trained in OBG and anesthesia during 2007-08 and 2008-09. No. of MBBS doctors trained in LSAS up to March'09 No. of MBBS doctors trained in EmOC up to March'09 Total Incentive per month Total Budget Required (74x 12 x 7000) NO. of MBBS doctors trained in LSAS during 09-10 Budget required for 16 trained doctors of first batch for 8 months (16 x 8 x 7000) Budget required for 16 trained doctors of 2nd batch for 4 months (16 x 4 x 7000) Total No. of MBBS doctors trained in EmOC during 09-10; Budget required for 8 trained doctors in 1st batch (8 x 6 x 7000) Budget required for 8 trained doctors in 2nd batch (8 x 2 x 7000) Total 336000.00 112000.00 4.48Lakhs 896000.00 448000.00 13.44Lakhs 50 24 74 Rs. 7000.00 62.16Lakhs

KARNATAKA NRHM PIP 2009-10

18

Bangalore Medical College is identified as the Nodal Center to train MBBS Doctors in EmOC and master trainers for EmOC training from other States. Under NRHM Rs. 9805400/- was released during 2008-09 for center setting. The recurring cost for manpower required for Bangalore Medical College under EmOC programme is as follows: Unit price in Rs. MAN POWER 1 Master trainer' assistants s 2 Anaesthetists 3 Lab-Technician 4 Nursing staff 5 cleaning staff Total PG in OBG 4 2 3 8 8 25000 25000 6500 7500 4000 1200000 600000 234000 720000 384000 31.38Lakhs Total amount

Sl. No.

Particulars

Specifications Qty

KARNATAKA NRHM PIP 2009-10

19

Total budget required: Incentive for LSAS & EmOC during 2008-09 Incentive for LSAS & EmOC during 2009-10 Total Monitoring and contingency charges and TA & DA for Master trainers of EmOC and LSAS Rs.40,000/- per month x 12 Recurring cost for manpower required for BMC under EmOC programme TOTAL BUDGET REQUIRED FOR LSAS AND EMOC TRAINING PROGRAM IS 62.16Lakhs 17.92Lakhs 80.08Lakhs 4.80Lakhs

31.38Lakhs 116.26Lakhs

3.1.5.22) Janani Suraksha Vahini: A new scheme called Janani Suraksha Vahini was proposed during 2007-08, where in ambulances are provided in 192 identified FRUs with two drivers to attend emergency cases (Pregnant Woman & Children). These ambulances have one regular driver at present. Two drivers are appointed by outsourcing. So that 24 x 7 services of Ambulance will be available in all 192 FRUs of Karnataka state. One mobile Phone will be provided for each FRU. The proposed salary component for each driver is Rs. 7200/- per month. The total salary component for drivers in 192 FRUs will be Rs. 7200/- x 2 x 192 x 12 = 332 lakhs per annum The recurring cost of each mobile phone is Rs.112.36/- per month. The total recurring cost of 192 mobiles is Rs. 2.58 lakhs per annum. Budget Required1. Salary component (Drivers) 2. Recurring cost of Mobile phones Cost: Rs. 332.00 lakhs Rs. 2.58 lakhs Rs.334.58 lakhs

KARNATAKA NRHM PIP 2009-10

20

3.1.5.22) SN 1 A. Goal 2 Reduction in MMR

Linkage between the Goals, strategies and activity keeping the outcome in mind Targeted outcome 3 150 Per lakh live births by 2009-10 Situation analysis Strategies 5 Scheme/activity 6

1 Improving antenatal care

4 SRS (2003) states that MMR is 228 per lakh live births.During 200809 (April ­Dec 08) in absolute figures the number of maternal deaths recorded is 792 The MMR as per department data is 120 . It is to be noted that there is under reporting. Ante natal care Constraints are: for 100% pregnant women a) ANC registration is 81 % as per the DLHS -3 data b) Quality antenatal care lacking c) Vacancies of ANMs more in north Karnataka d) Full antenatal care 37.7%DLHS )

Quality antenatal a)all vacant sub care and early centers to have ANMs . registration

b)9 new ANM training centers and 29 Private ANMTC in pipeline c) 6 "C" category districts where MMR is high to have second ANM d) ASHA recruitment

e) Community health day f) Seemantha Active detection of anemia and treatment

High rate of anemia Improving the (59.9% as per nutrition NFHS-3)

KARNATAKA NRHM PIP 2009-10

21

Prasusithi Araike wherein financial support is provided in the antenatal period for nutrition Correcting the anemia High risk identification Out- reach sessions for antenatal check ups Iron Sucrose IV for severe anemia cases(pilot ) Incentive for AWW/ASHA/ANM for early registration of HRP

Sub center clinics Incentive for ANM to by doctors accompany HIV pregnant woman Mobility support for the MO Mobility support for the ANM and LHV 2 Increase in 85% institutional institutional deliveries delivery by 2009-10 90% safe delivery by 2009-10. The institutional delivery rate as per the DLHS -3 is 65.1% Safe delivery rate as per the DLHS -3 is 71.5 % Constraints are: Functionalization PHCs identified as of 24x7 PHCs 24x7 to have staff nurses round the clock.

a)lack of adequate & trained staff at PHCs

Quality intra natal care by trained staff

In the backward districts (6 C category districts) 300 contractual MBBS doctors to be appointed. SBA training for all the ANMs/staff nurse and the Medical officers

KARNATAKA NRHM PIP 2009-10

22

Lack of adequate staff nurses at FRUs

Improve Labour Room functioning

Appointment of staff nurses at FRU and CHC FRU can in source specialists on a case to case basis or monthly retainer ship EmOC and LSAS training of MBBS doctors Incentive to all the trained doctors on per case basis

b) lack of specialists Functional FRUs at FRUs

PPP

To reach vulnerable women c)lack of transport facilities Strengthen the referral system

Thai Bhagya scheme wherein cashless delivery for beneficiaries by private hospitals/nursing homes( in districts where IMR and MMR is poor) JSY scheme in all districts Arogya Kavacha (108) wherein vehicle is provided for pregnant womenThe EDD list is made available to 108. Janani Suraksha Vahini(JSV) wherein 2 drivers are recruited at Taluka level and are provided with mobile phones.

Staff not staying at head quarters

Encourage staff to stay

Rent for Sub centers without building Rent allowance for contractual staff at 24X7 PHCs

KARNATAKA NRHM PIP 2009-10

23

Most and more remote area allowance for doctor/staff nurse 3 Post natal care Mobility support for ANM and LHV Madilu scheme for post natal woman and child IMNCI training. Recruitment of ASHAs Till December 2008 Record and audit Rs 500 for first the maternal deaths all maternal informant of maternal reported are 792 deaths death deaths for 658210 DC to audit all deaths live births. This Supply tab indicates an MMR Misoprostol of 120 which shows Under reporting of maternal deaths As of now Encouraging Awards for there is meager good work in all specialists/doctors/staff encouragement districts nurse, ANMs.at all for staff doing levels good work mandatory post natal visits

4 Maternal death audit

E

Awards

KARNATAKA NRHM PIP 2009-10

24

3.1.6. Budget for Maternal health Sl No 1 2 3 4 5 6 7 8 9 10 11 Total budget in Rs.in lakhs 195.00 131.00 60.00 150.00 72.00 288.00 394.20 236.52 236.52 118.26

Component Maternal health Mobility support at sub center to the ANM. Mobility support for PHC,MOH Mobility support for LHV Incentive for pregnancies ANM's high

Unit cost

Rs 200 pm for 8143 sub centers @ Rs 500 pm for 2195PHCs @ Rs 300 pm for1679 PHCs risk @ Rs 250 per delivery For 60,000cases @ Rs 1500 For 4800 cases @ Rs6,000 For 4800 cases For 3 doctors at @ Rs 5000 pm 3 staff nurses @ Rs 3000 pm

Incentive for ANM to assist HIV positive pregnant women Yashaswini coverage (HIV+ve pregnant women) Remote area allowance for doctors for 219 PHCs (Most backward) Remote area allowance for staff nurses for 219(most backward) PHCs

Remote area allowance for doctors for For 3 doctors at 219 PHCs (More backward) @ Rs 3000 pm Remote area allowance for staff nurses for 219(more backward) PHCs Maternal death audit: a) For reporting of deaths b) For conducting meetings. c) For transport & refreshment for relatives Best ANM award @ Taluka @ district @ State Best doctor award @ PHC, CHC.GH @ Taluka @ district @ State Best Staff nurses award (PHC) @ Taluka @ district @ State Best Staff nurses award (CHC) KARNATAKA NRHM PIP 2009-10 @ Rs 1500 for 3 staff nurses a) Reporting Rs 500 per case for 1200 cases b)meeting. c) @ Rs. 300 for 1200 deaths. @ Rs. 5000 for 175 talukas @ Rs. 7500 for 29 districts. @ Rs. 10,000 @ Rs 10,000 per doctor For 175 talukas @Rs. 200.00 per district @ Rs. 30,000 for state @ Rs. 7500 for 175 talukas @ Rs. 7500 for 29 districts. @ Rs. 15,000

6.0 1.00 3.6 11.00

12

75.8

13

20.00

14

25

15 16 17

@ Taluka @ district @ State Best Specialist award (FRU) per district & @ State.

@ Rs. 7500 for 175 talukas @ Rs. 7500 for 29 districts. @ Rs. 15,000 for 3 doctors. @ Rs 10,000 per specialists. Rs. 25,000 at State. Best Specialist award from district Rs 10,000 per district hospital and at state Rs 25,000 for State Awards distribution at District @ Rs 10,000 per district Awards distribution at State ANM training center(new) @ Rs 50,000 For 9 centers

9.45 3.15 2.9 0.50 341.00 19.00 336.00 310.00 3440.00 70.00

19 20 21 22

old ANM training center For 19 centers Rent for sub center For 2800 SC@ Rs 1,000 pm Rent allowance for staff nurse for 24x7 For 3450 @Rs 750 pm PHCs JSY Maintenance grant to Women and @ Rs 5 lakhs for 14 hospitals children hospitals

Drugs and Consumables: 1 2 3 4 5 6 Sub centers (8143) Drugs and consumables Primary Health Centers(2195) Drugs and consumables Community Health Centers (150) Drugs and consumables FRU(192) Anemia treatment of pregnant women with parentral iron Tab Misoprostol Total 450.00 597.00 260.00 519.00 201.00 200.00 2227 Total budget Rs. in lakhs 600.00 060.00 132.00 6.14 3.00 13.20 40.00 90.00 944.30 Total budget Rs. in lakhs 26

Sl Equipment and logistics No 1 Generator for PHCs @0.5 lakhs x 1200 PHCs 2 Generator for CHCs @0.6lakhs x 150 CHCs 5 6 7 8 9 10 Boyles apparatus for 33 FRUs MVA syringe for 192 FRUs Haemoglobinometer Adult resuscitation kit Blood storage center at FRU Oxygen concentrator Total Component Human resources KARNATAKA NRHM PIP 2009-10 @ Rs.4 lakhs 2 syringes per doctor @ Rs.1600/1000 PHC and CHC @ 40,000 / kit X 33 FRU @ Rs 2 lakhx 20 FRUs @0.6lakhs x 150 CHCs

Sl. No.

Unit cost

1 2 3 4 5 6 7 8 9 10 ·

Contracting specialists Incentive for EmOC & LSAS trained doctors ANM /Staff nurse for1160 vacant sub centers. 2nd ANM for sub centers in 6 C category districts Contractual MBBS doctor for the PHCs/FRUs in the 300 posts Contractual staff nurses at 24x7 PHCs Staff nurses@ 2 per CHC for 150 CHCs Staff nurses at FRU 2 staff nurses for 192FRU's 98Lab tech at FRU's 98x 12 months Dai at 24x7

@ Rs 50,000 per FRU for 100 FRUs @ Rs 7000 pm for 12 months @ Rs 7000 pm 750 ANMs @ Rs 17,000 pm @ Rs.7000/- p m 1200PHCs @ Rs.7,000 pm @ Rs.7,000 pm @ 6500 pm 1200 PHCs 150 CHCs for

600.00 116.26 975.00 630.00 612.00 2898.00 252.00 323.00 76.44 144.00 18.00

The modifications to the budget line items as suggested during NPCC meeting has been mentioned in blue colour under the concerned line items.

ANNEXURE ­ I Brief details of deliveries, Maternal and Infant Deaths during 2008-09 (April to December 08) Home Deliveries Total deliveries Institutio nal deliveries Maternal Deaths Name of the District Infant Deaths Live Births 10 30760 33387 7699 19439 27 MMR Sl No. IMR 9 6.5 2 12 19

1 1 2 3 4

2 Bmp Bangalore (U) Bangalore ( R) Chitradurga

3 4 24549 24549 33405 32226 9841 8643 19618 14930

5 0 1179 1198 4688

6 45 5 8 29

7 146 15 104 149

8 200 66 93 379

KARNATAKA NRHM PIP 2009-10

5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Davangere Kolar Shimoga Tumkur Chikkaballapur Ramanagara Bangalore Division Belgaum Bijapur Bagalkote Dharwad Gadag Haveri U.Kannada Belgaum Division Bellary Bidar Gulbarga Raichur Koppal Gulbarga Division Chikkamagalur D.Kannada Udupi Hassan Kodagu Mandya Mysore Chamarajnagar Mysore Division Grand Total

23104 18533 18990 31930 18001 11623 209594 68028 35036 27249 18851 14943 19085 14795 197987 38078 24829 52388 28948 21066 165309 10836 15128 9453 16559 5180 13565 28282 7992 106995 679885

18620 14827 17091 28435 15615 10898 185834 57046 19620 14986 12321 10075 12608 13906 140562 18277 17941 20955 15594 8793 81560 10219 14732 9309 15097 4886 12929 26303 6580 100055 508011

4484 3706 1899 3495 2386 725 23760 10982 15416 12263 6530 4868 6477 889 57425 19801 6888 31433 13354 12273 83749 617 396 144 1462 294 636 1979 1412 6940 171874

35 153 22 149 17 102 34 108 26 165 4 35.2

424 124 212 529 201 134

19 8.4 13 17 13 12 12 30 28 17 33 25 17 18 25 30 17 18 23 28 22 15 9.5 11 15 15 20 18 18 15 18

22888 14765 16699 31573 15767 11370 204347 52468 31579 28046 17318 16242 16764 15530 177947 29055 24665 59762 28527 19139 161148 10811 16814 10745 16466 5157 13479 31364 9932 114768 658210

110 225 2362 91 173 1579 41 130 884 33 118 475 44 254 571 18 111 411 25 149 292 12 77.3 285 264 52 41 70 41 24 148 179 166 117 144 125 4497 862 413 1060 653 541

141 228 3529 12 111 160 10 59.5 160 4 37.2 117 7 42.5 244 6 116 78 14 104 270 13 41.4 565 9 90.6 175 75 65.3 1769 792 120 12157

KARNATAKA NRHM PIP 2009-10

28

Details of population covered by sub centers Annexure ­ 2 District No. of sub wise No. of population SubArea wise centers Sl. No. District Population / (2001 Centr sq in kms area(in Sub centers census es sq. kms) data) 1 2 3 4 5 6 7 1 BANGALORE (U) 2850009 185 15405.5 2190 11.84 2 BANGALORE (R) 842191 192 4386.41 5815 30.29 3 CHIKBALLAPUR 1153398 184 6268.47 8388 45.59 4 CHITRADURGA 1510227 273 5531.97 6018 22.04 5 DAVANAGERE 1789693 291 6150.15 8223 28.26 6 KOLAR 1470008 201 7313.47 8465 42.11 7 RAMANAGARA 1035225 240 4313.44 10598 44.16 8 SHIMOGA 1639595 307 5340.7 4254 13.86 9 TUMKUR 2579516 477 5407.79 3555 7.453 10 BAGALKOTE 1652232 224 7376.04 13145 58.68 11 BELGAUM 4207264 539 7805.68 10475 19.43 12 BIJAPUR 1808863 285 6346.89 6575 23.07 13 DHARWAD 1603794 179 8959.74 4230 23.63 14 GADAG 971955 174 5585.95 4657 26.76 15 HAVERI 1437860 290 4958.14 4851 16.73 16 U. KANNADA 1353299 120 11277.5 10291 85.76 17 BELLARY 2025242 272 7445.74 8450 31.07 18 BIDAR 1501374 234 6416.13 5448 23.28 19 GULBARGA 3124858 378 8266.82 16224 42.92 20 KOPPAL 1193496 183 6521.84 5559 30.38 21 RAICHUR 1648212 196 8409.24 8458 43.15 22 CH' NAGAR 964275 246 3919.82 7201 29.27 23 CHIKMAGALUR 1139104 334 3410.49 4843 14.5 24 D. KANNADA 1896403 431 4400.01 3598 8.348 25 HASSAN 1721319 420 4098.38 6814 16.22 26 KODAGU 545322 188 2900.65 4102 21.82 27 MANDYA 1761718 375 4697.91 4961 13.23 28 MYSORE 2624911 432 6076.18 6269 14.51 29 UDUPI 1109494 293 3786.67 5685 19.4 Total 49160857 8143 182778 199342 24.48

KARNATAKA NRHM PIP 2009-10

29

KARNATAKA NRHM PIP 2009-10

30

3.2 CHILD HEALTH: 3.2.1. GOALS: for child health Mortality rates are good indicators of health and health care in different countries. They also help in assessing the over all socio economic development of a State. Infant Mortality Rate (IMR) is universally regarded as an important indicator of health and also the level of living of people in the community and effectiveness of MCH services in particular. As per the UNICEF 2007 report the main causes of Infant Mortality and under five mortality is depicted below:

CAUSES OF NEONATAL DEATHS

U ER IV M R A IT ND -F E O T L Y

IN AN D TH F T EA S BET WEEN0- 7 D S AY

OTHERS PRETERM ASPHYX IA INFECTION

IN AN D TH F T EA S BET WEEN7- 2 8 D S AY IN AN D TH F T EA S BET WEEN2 AYS8D 1 AR YE C ILDD T S H EA H BET WEEN1YE & AR W HIN5 YEA SO IT R F BIR H T

To reduce IMR from present 47 /1000(SRS 2007) live births to 30 by the year 2010 To reduce Neonatal Mortality from 40/ 1000 live births to 25 by the year 2012 To increase exclusive Breast feeding to 90% by 2012 Present Status & Goals Curre nt Status DLHS 2008-09 35/1000L B 80% 80% 60% 90% 50% 2010 30/100 0LB 90% 90% 70% 100% 70% 2012 25 99% 100 % 80 % 100 % 90 % Goals

Health Indicators

Current Status NFHS-III

IMR

43/1000LB 47 (SRS2007) Fully immunized 55% 78% Diarrhea taken for treatment 64.8% Diarrhea treated with ORS ARI taken for treatment Know about danger signs 31% 78.9% 40% 75.8% 20%

KARNATAKA NRHM PIP 2009-10

31

It is reported that the common causes of Neonatal deaths in Karnataka are as follows: Conditions % causing Neonatal deaths Preterm 35% Infection 24% Asphyxia 23% Congenital 6% Others 6% Diarrhea 2%

KARNATAKA NRHM PIP 2009-10

32

3.2.2 OBJECTIVES: a. Ensure early Breast feeding & exclusive Breast feeding for 6 months b. Complete primary Immunization by age one year to 100% c. To reduce child malnutrition levels d. Create awareness for care-seeking in early stages of Pneumonia e. Promote use of ORS in diarrhoea 3.2.4 SITUATION ANALYSIS Component NFHS NFHS NFHS III I II IMR per 1000 live births 65 52 43 (SRS 47) IMR URBAN per 1000 live 60 40 37 births IMR RURAL per 1000 live 68 57 47 births Fully immunized % 52% 60% 55% Diarrhea taken for treatment 64.8% % Diarrhea treated with ORS 31% % ARI taken for treatment % 78.9%

IMR

70 60 50 40 30 20 10 0

58

DLHS

85% 40% 75.8%

66

64

55

52

60

58

49

50

58

57

48

57

43

Nos.

Kar. India

3.2.3. STRATEGIES: · Immediate care of new-born & identification & referral of High risk new-borns through SBA(Skilled Birth Attendance )Training. · 99% immunization including the booster dose · Community level care for all sick children and neonates · Regular House visits and counseling by community level care gives for preventive and promotive health, of children and the reduction of child malnutrition. · Strengthening and supervising the subentries for its routine services esp. immunization. · Adequate referral arrangement and secondary care facilities for sending a sick child or neonate when it requires hospitalization. Reducing cost of care especially on inessential and hazardous drugs and therapies so as to favorably impact on poverty levels KARNATAKA NRHM PIP 2009-10

20 01 20 02 20 03 20 04 20 05 20 06 20 07

Year

33

·

It is abserved that the decrease in IMR has been progressive over the past years. It is observed that the decrease in IMR is slightly higher in the urban areas (38.33%) compared to rural areas (30.88%). This is expected because of better access to health facilities & better awareness in the urban population. The cases of ARI taken for treatment & Diarrhea taken for treatment are quite high, however the knowledge about danger signs of Pneumonia & treating diarrhea with ORS is low. These are the contributing factors for high mortality as the child reaches the hospital during late stages. The scenario under Nutrition, there is need to strengthen nutrition status for the children in Anganwadi's. The weight for height is proportional in 80% of children. However, the height & weight for age should also be proportionately improved & this can be achieved through regular monitoring of Growth against Growth Charts. In Karnataka there are about 54260 Anganwadi centers, the dept. of women and child the Department of Women & Child has been requesting the Dept. of Health & FW to provide weighing machines. Anemia among children below 3 years is high which indicates de-worming and iron & folic acid tablets is required. It is proposed to supply Kit A & Kit B (one each) to all the 8143 sub centers in Karnataka from which anemia among children, deworming, diarrhoeal diseases, vitamin A deficiency, Tab. Zinc for treating diarrhoeal diseases will be taken care of.

·

·

·

Hence the focus will be on Preventive & promotive aspects. BCC will be targeted towards community members and the health personnel with focus on preventive aspects such as early breast-feeding, use of ORS, information on danger signs and early referral. Apart from this, the emphasis on improved Reporting from Districts needs to be addressed. The HMIS under KHSDRP is one solution.

KARNATAKA NRHM PIP 2009-10

34

3.2.5. ACTIVITIES: A. Integrated Management of Neonatal and Childhood Illnesses (IMNCI) approach will include: Co-ordination Committee Meeting, Facility-based outpatient & In-patient care component, Home / community-based care component (ANMs and AWWs), training component. During fy: 2006-07 & 2007-08 it was proposed to implement IMNCI components in the districts i.e., Bidar, Gulbarga, Bellary, Gadag, Bijapur, Koppal, Chamarajanagar & Kodagu, including the pilot district of Raichur, Further during fy: 2008-09 it was proposed to undertake IMNCI training in the districts of Belgaum, Uttara Kannada, Dharwad, Haveri, & Bagalkot. However training is under progress for the former 9 districts only. Hence it is proposed to undertake focused intervention in the initially proposed 9 districts only. Analysis of CNAA reports (April-December 2008) show ­ number of the child deaths in the 1-5 years age group: Belgaum division ­ 37.78% & Gulbarga division ­ 28.74% Together they account for 66.53%. Perhaps the comparatively better figures of Gulbarga are because most of the districts have IMNCI activities. A. Co-ordination Committee Meetings To formulate these approaches, the State level committee, which has been constituted in 2006, will meet twice in a year and review the program and formulate the plan of action periodically. (@ Rs. 25000/ sessions x 2 sessions at state level). Further, District level committees will meet quarterly at each district and, a budget of Rs.5000 /- session for 9 districts is proposed. (@ Rs. 5000/ session x 4 sessions / District x 9 Districts).) The Budget requirement under this component during Fy: 2009-10 will be approximately. Rs.0002.3 lakhs. B. Facility based Child Care The Hospitals will be provided with a New Born Care Corner in the labour wards of all Health facilities. It is ensured that every PHC, CHC/TH/DH should be provided with an enclosure in the existing labour wards with a provision for multiple electrical points & a socket to fix a 200-Watt bulb so as to receive the newborn baby in a warm environment. B.1. At Sub center level: Equipment for conduct of safe deliveries in the form of SSD kits will be supplied to all ANMs. Details have been provided under Maternal Health. The ANMs are trained in SBA, where they are trained about Essential New born care. They are especially taught resuscitation, safe transport & kangaroo Mother care. Drugs in the form of Kit A and Kit B for treatment of early sepsis will be given to the ANM. B.2 At PHC level: All the existing 24x7 PHCs will be equipped to conduct safe deliveries in a phased manner giving preference to the PHCs located in most backword area as per Nanjundappa committee report. 400 PHCs will be provided with Neonatal Resuscitation Equipment consisting of Suction apparatus, Ambu bag, Weighing Machine, etc during Fy 2009 ­10. The Staff Nurses & ANMs KARNATAKA NRHM PIP 2009-10 35

will be taught the use of Bag & mask in the Skilled Birth Attendance training. They are taught to treat infections with injectable antibiotics in case of severe illness & the necessary drugs will be supplied. . The Budget requirement under this component during Fy: 2009-10 will be approximately. Rs.0076.0 Lakhs. B.3. At CHCs & FRUs It is proposed to provide 150 CHCs with Neonatal equipment. A kit consisting of a Radiant Warmer, Phototherapy Unit, Glucometer, weighing Machine, Resuscitation Equipment (Ambu Bag, Suction Apparatus). The Budget requirement under this component during Fy: 2009-10 will be approximately. Rs.160.0 Lakhs. C. 1. Home Based Care Component: As 30% of deliveries continue to occur at home, the community has to be trained in New Born care & the concept of TBA & ANM conducting Home deliveries cannot be denied. The SSD kits provided to the ANMs can be used to conduct deliveries in the home setting wherever it is inevitable. It is proposed to hold Community Awareness programmes once in a quarter in the CHCs/schools in CHC area, etc with the Pediatrician if available. The Administrative Medical Officer of the CHC who will be responsible to conduct these programs. This will result in the involvement of the Specialists in Community Health & ensure active participation of the Hospitals in National Programmes & preventive & promotive health. Participants will include local women leaders, Shree Shakti Groups, NGOs Women & Child Department & Anganwadis of the PHCs coming under the CHC apart from the main participants who are the Community people. The event could be organized on ANC / Immunization Days before the start of the session. It should be more of a demonstration exercise & an interactive session rather than a lecture. Topics could vary as per the season as mentioned in Facility based care. Community awareness camps at CHCs, ORS in the first quarter, Breast feeding second quarter (August-Breast feeding week), Newborn care third quarter, Nutrition fourth quarter or any topic of relevance to that area at that particular time. The Budget requirement under this component during Fy: 2009-10 will be approximately. Rs.0018.0 Lakhs. (@ Rs. 0003 Lakh / 4 sessions/ CHC/ 150 CHC) The Anganwadi workers and ASHAs will be informed about the early identification of common childhood illness and treatment of simple illnesses. The Community also will be apprised of identification of danger signs & early referral through Village Health & Nutrition days. Also through activities at the CHCs, which will be outlined under Home based care for all districts mentioned in the subsequent chapters. C.2 Care at birth KARNATAKA NRHM PIP 2009-10

36

It is linked intimately to maternal care. The principle is that as soon as the baby is born, is provided warmth, resuscitation, clean care and exclusive breastfeeding. Baby is weighed, examined, and if her clinical conditions not manageable, baby is referred and transported to higher facility. Newborn care is relatively easy to implement in facilities because of the presence of skilled birth attendants (doctor / nurse / ANM/LHV). Skilled Birth Attendant Training enables the health staff to deliver services in a more effective manner. In order to provide newborn, two approaches of Facility based newborn care & Home Based Newborn Care, it is necessary to provide the following items in a kit: 1. 2. 3. 4. 5. Digital Thermometer, Weighing Scale with sling Ambu bag silicon( Infant) Disposable Plastic Mucus extractor Torch with cell

Medicines like Tab. Paracetamol 500mg and Co-trimoxazole (Trimethoprim 40 mg, Sulphamethoxazole 200 mg) suspension may be supplied from respective PHCs. The Budget requirement under this component during Fy: 2009-10 will be approximately. Rs.112.00 lakhs. Adequate referral arrangement and secondary & Tertiary care facilities for sending a sick neonate when it requires hospitalization As many as 10% of all neonatal illnesses need secondary and Tertiary neonatal care for their better management and survival. The major problems managed at NICU (Neonatal Intensive Care Unit) are: 1. Preterm babies for general preterm care 2. Preterm babies with complications like · Respiratory distress syndrome · Infections and sepsis · Hyper Bilurubenemia · Feeding Problems · Convulsions · Meconium aspiration syndrome · Major & minor congenital anomalies 3. Term babies with · Birth asphyxia · Hyper Bilurubenaemia · Infections and Sepsis · Convulsions · Bleeding diathesis · Congenital anomalies 1. To facilitate the availability of such treatment to many neonates all over the State and to cater to the demand of such sick neonates a corpus amount of rupees 500.00 lakhs has been reserved for the tertiary neonatal care either in the private or the Government institutions which are going to be identified subsequently on the basis of a) Strategical KARNATAKA NRHM PIP 2009-10 37

location and accesability, b) Number of districts that can utilize the services of the Institution, on the model of successfully implemented Yashashwini scheme. Rs. 500.00 lakhs has been reserved for this. 2. Indira Gandhi Institute of Child health, Bangalore will be the Nodal institute to guide the State on selection of Institutions, technical specifications, Analysis of present scenario in those institutions, and continued support to these institutions. 3. Selection of Institutions for the service provision shall be done by preeparing a check list on the basis of standards set by the Nodal Institution i.e Indira Gandhi institute of Child health. Indra Gandhi Institute of Child health, Bangalore which is a premier research and an autonomus apex institute headed by Honorable Minister for Medical Education , Government of Karnataka. The institute has submitted a proposal, and rendering advanced child health care by providing Medicare services such as Paediatric medicine , Paediatric Intensive care Unit ( PICU), Neonatal services with Intensive care Unit ( NICU) and other superspeciality services like Paediatric surgery. Many high risk cases are referred to this institute for advanced treatment from different levels of health centres from urban and rural areas of the State and from neighbouring states. It is proposed to extend a grant of Rs.100.00 lakhs towards strenghnening tertiary neonatal care, to IGICH, which will contribute to a large extent in reducing IMR.

E. Infant & Young Child Feeding Breast feeding-Early & Exclusive will be advocated. Breast feeding week will be observed in all Hospitals. Right composition of complementary feeds with locally available food & time of introduction will be told at VHSC meetings & Village Health & Nutrition days. Care of children below 3 years is being given in collaboration with Women and Child Department through Anganwadis. The problem of underweight and stunted children below 3 years will be addressed by early identification through regular weighing of children and monitoring with Growth charts. The Nutrition wing of DH & FWS, will be involved in this activity. G. Control of Acute Respiratory Infections Acute Respiratory Infections are one of the major causes of under 5 mortality in India. Management of Respiratory Infections is as per the guidelines under RCH where the Health workers are taught to classify Respiratory Infections as Upper & lower respiratory Tract infections & as mild, moderate & sever illness as per findings of Respiratory rate, Chest in drawing, wheeze, drowsiness etc.,

KARNATAKA NRHM PIP 2009-10

38

Sub center level-as outlined above: the ANM will examine the child & after ensuring that the child is properly classified: will start the child on medicines as per the dosage prescribed in the guidelines. PHC level-doctors are trained to give antibiotics & other drugs for Respiratory Infections. CHC level Apart from drugs, Oxygen Concentrator, which will help in the management of Asthma & related conditions. H. Management of Diarrhoea Diarrhea is a major cause of death in under 5 children. Recognition of symptoms & signs & Classification of diarrhoea into No Dehydration. Some Dehydration & Severe Dehydration will be taught to all the Doctors & Para medical personnel through formal & on-job training. Use of ORS, Tab.Zinc & Intravenous fluids will be taught & the same will be supplied through GOI drugs. The same will be ensured under Home-based care also. As mentioned earlier, the activities of CME & community awareness at CHC, PHC & Village Health & Nutrition days will create more awareness of the importance of seeking treatment in the early stages. I. Promotion of Child Health Village Health & Nutrition Days will be used as platforms to educate the community about Home based care of newborns, diarrhea, Respiratory Infections & danger signs along with informing the public of nearest services available (presence of doctors, diseases which can be treated at various levels & emphasizing about which patients have to be taken to Higher Facilities without wasting time. J. School Health & Nutrition Programme School health check-ups for Government school children is being regularly under-taken. Nutrition of school children is being looked after by the WCD and Education Departments under mid-day meal programme. De-worming tablets & IFA being given to children. GOAL To reduce IMR to 30/1000 Live Births SRTATEGY IMNCI program ACTIVITY MONITORABLE INDEX HBNC- Supply of equipment Total no. of trained personnel ( SDI ) - 120 lakhs provided with necessary equipment FBNC ­ Supply of Total no. of facilities that are equipment to PHC/CHCs ( able to provide FBNC SDI ) 236 lakhs Community awareness (CLI Number of Awareness )18 lakhs campaigns conducted Coordination meetings Number of meetings /CMEs 2.3 lakhs conducted Number of FRUs with oxygen Oxygen concentrator (SDI) 90 lakhs concentrator

KARNATAKA NRHM PIP 2009-10

39

1 2 3 A B C D E 4 5

6 7

CHILD HEALTH PROGRAMME Integrated Management of Neonatal Child Illnesses (IMNCI) Co-ordination meetings Facility based out patient & in patient component Procurement of Kits for the newly proposed 150 CHC' s Neo Natal equipment Baby warmer Phototherapy unit Glucometer Weighing Machine Suction apparatus Home based child care (community awareness program) (@ Rs. 0003.0 lakhs /4 sessions/ CHC / 150) Care at birth (weighing scale with bal, ambubag, mucous sucker) (@ Rs. 1000x 11200 ASHA' a) Assistance to IGICH Provision of tertiary neo natal care Total

Total Rs.in lakhs 2.30 76.0 160.0

18.0 112.0

100.00 500.00 968.30

KARNATAKA NRHM PIP 2009-10

40

3.3. Family Welfare Programme 3.3.1. Situational Analysis: The statistics of total sterilization operations for Karnataka show that, there is moderate progress in vasectomy (NSV) achievement, during 2008-09. While the total number of all sterilization operations stands at 2.80 lakhs upto December 2008 for a target of 4.00 lakhs upto March 2009. Total number of NSV done is 1679 for the same period for a target of 8143 (one case per Sub centre). The percentage of male participation in the family Welfare programme as regards to total sterilization operations (Tubectomy, Laparoscopic Operations and Vasectomy), is only 0.2%.(NHFS-3 & DLHS -3) 3.3.2.Programme objectives:

(a) Improve management performance by statewide implementation of policy change referred to as the "participatory planning approach,"'and institutional strengthening for timely, coordinated utilization of project resources; (b) Improve quality, coverage by Fixed Day Static approach and effectiveness of existing FW services; (c) Progressively expand the scope and content of existing FW services to include more elements of a defined package of essential reproductive and child health (RCH) services; (d) In selected disadvantaged districts and cities, increase access by strengthening FW infrastructure while improving its quality. 3.3.3.Goals: Total fertility rate 2008-09 2.1 2.10 NFHS-3 SRS-07 2009-10 2.00 2010-11 1.8

3.3.4 Strategies: Strategy-1 Action at District level At the District level an implementation team consisting of District Surgeon, District H&FWO, District IEC Officer, District NSV Trainer is to be formed. District level workshops of one day duration would be held by the District team with the elected representatives, opinion leaders, media and other departmental representatives to sensitize them on male participation and in particular NSV and orient them with the implementation strategy. The committee shall fix up responsibility for pre-camp, camp and post-camp. Strategy-2 Action at Block Level. Each district would hold ½ day orientation workshops at block level to workout action plan at block level. A working group of 4 members consisting of ANM, Anganawadi Worker, MPW (male), malaria worker / male worker from other departments would be formed for one sub-centre in the rural area and for one ward in an urban area. The block IEC official / Health KARNATAKA NRHM PIP 2009-10 41

Supervisory / Anganwadi Supervisor / Malaria Inspector would be the supervisor of the group. · Prepare a schedule for visits to the homes of the target couple, inform, counsel and motivate the couples for male sterilization and inform them of the camp dates. Each worker would make at least 2 visits to counsel and motivate. · Make a list of motivated men and inform the block supervisor who would in turn inform the District FW officer. · The District FW officer would make arrangements of the camp regarding logistics, number of surgeons required for the number of cases motivated etc. · The camp would be held on a pre determined date at the district hospitals, strictly following the guidelines laid down in the standards on sterilization manual of GOI. Strategy-3 IEC Activities : 1. Meetings at District level, Block level, PHC level. 2. House-to-House hand bill distribution. 3. Posters and stickers pasting on public and Govt. vehicles 4. Publication of daily cam activities like place and date in local news paper. 5. Movement of NSV Rath as done in Madhya Pradesh. 6. Publicity in city cable and electronic media 7. Utilizing Mahila Swasthya Sanghs where it exists. 8. Interpersonal Communication through house to house contact of the target couple to provide information and motivate. Strategy-4 Complaint Redressal mechanism: All complaints arising out of the services provided in a camp should be addressed to the district collector who shall set up a complaint Redressal unit as follows: a. One nodal officer may be nominated by the district magistrate to lot into the complaints received from the clients / family members of the client b. He shall inquire into the complaint and give suitable reply to the complaint. c. The district collector shall take appropriate action as deemed necessary, if the complaints are found to be true. Strategy-5 At the State Level: The quality Assurance Guideline of GOI has laid down that the district quality Assurance Committee would be responsible for monitoring quality care in all matters related to sterilization. Hence this committee would monitor the quality of care strictly during the camp as per the guidelines. The dates of the camp and performance report of the camp after its completion should be sent to the centre regularly. 3.3.5. Activities: The following strategies as per the guidelines of Government of India, are incorporated in the PIP for 2009-2010. · It is proposed to hold NSV camps in 50 centres (29 district hospitals & other 21 major hospitals-1 camp per month) @ Rs.35000/- for each camp. Total amount would be 50 x 12 x 35000 =Rs.210.00 lakhs · Female sterilization is expected to be around 3.9 lakh cases during 08-09 & it is expected conduct 4.2 lakh cases during 09-10. 4224 Female sterilization camps are planned to be KARNATAKA NRHM PIP 2009-10

42

·

held in 176 taluks (2 camps per month) @ Rs. 15000/- per camp. Total amount would be Rs.633.60 lakhs A detailed break up compensation package given to BPL,APL &SC,ST beneficiaries is mentioned below as per GOI new revised compensation scheme A break-up of cash incentive per case is given below:Tubectomy Vasectomy(ALL) (BPL+SC/ST only) Rs Rs 1,100 200 50 100 0 15 15 10 10 1500 600 150 100 75 25 15 15 10 10 1000 Unit cost 0.001 0.15 0.35 0.01 Tubectomy (NonBPL+Non SC/ST only)i.e.APL Rs 250 150 100 75 25 15 15 10 10 650 No. of units 2000 4224 600 230000

Break up of the compensation package Acceptor Motivator Drugs and dressings Surgeon charges Anaesthetists Staff nurse OT Technician/helper Refreshment Camp management Total

3.3.6. Budget required for Family Planning: Sl.No Unit of Activity measure 1 Printing & dissemination of manuals on sterilisation standards Manual & quality assurance of sterilisation services 2 Female Sterilisation camps Camp 3 NSV camps Camp 4 Compensation for female BPL Person sterilisation (including ASHA 5 APL person incentive) 6 Compensation for male sterilisation Person (including ASHA incentive) Other Activities 7 State level workshop on QA for Workshop state nodal officers 8 Zonal level workshop on QA for district nodal officers , 176 THOs, Workshop NGOs & AMOs 9 Monitor progress , quality and audits by QA committee (quarterly meetings meetings in all 29 districts and Biannual State level meetings) TOTAL for FP FP Drugs: DH =Rs.75.00 lakhs. KARNATAKA NRHM PIP 2009-10

Total amount 2.00 633.60 210.00 2300.00 1235.00 120.00

0.0065 190000 0.015 8000

1.00 1.75 5000 10000

1 4 116 2

1.00 7.00 5.80 0.20 4514.60

43

Equipments: NSV kits=Rs.37.50 lakhs, Minilap kit=Rs.50.00 lakhs, Laproscopes =Rs.262.50 lakhs. Total: Rs.350.00 lakhs.

Grand total for FP=Rs.4939.60 (including drugs & equipments)

KARNATAKA NRHM PIP 2009-10

44

3.4. Adolescent Reproductive and Sexual Health 3.4.1.Introduction: Adolescent Reproductive and Sexual Health is an important component of NRHM. Adolescents form nearly 22% of the total population. Adolescents in the age group of 10-14 years form more than 50% of the adolescent population. According to reports females form 47% of them are males 53%. As per 2001 census the sex ratio among adolescents is 880 for 1000 males. The present adverse sex ratio among 0-6 years will affect the future adolescent population. 43% of ever married females are below 18 years even though the legal age at marriage for girls is 18 in our country. Nearly 20% of the 1.5 million girls under 15 are already mothers (Census 2001). Female mortality is higher than males in the age group of 15-24 years and in the age group of 0-9 years. The pervasiveness of discrimination, lower nutritional status, early marriage, complications during pregnancy, and child birth among adolescents are some of the factors responsible for higher female mortality (SRS 99). Maternal mortality of teenage mothers is a matter of grave concern. Economic compulsions force many adolescents to work. Nearly one of the three in the age group of 15-19 years is working this result in high drop outs in education. Adolescents from rural areas and girls are the disadvantaged sections. 25% of the 15-19 years age group in rural areas and 10% in urban areas are illiterate. Girls account for less than 50% of enrolment figures in schools and dropout rates from class 1-10 is around 70%. Malnutrition and anaemia is rampant among adolescents. More than 70% of the girls in the age group of 10-19 years suffer from severe or moderate anaemia (DLHS RCH 2004). Adolescent mothers are at a higher risk of miscarriages, maternal mortality and giving birth to still born or underweight babies. Iodine deficiency disorders can lead to growth retardation. Use of iodized salt is only among 50% of the households in India. Hence tackling the problems related to malnutrition and anaemia needs to be addressed in the state in order to improve the health of adolescents. Adolescents are prone to drug abuse, trafficking and sex work, premarital sexual relations thus leading to increased incidence of HIV and other sexually transmitted diseases. While knowledge for contraception is being promoted, the availability and use of contraceptives is not published. Even among married women in the age group of -15-19 years there is unmet KARNATAKA NRHM PIP 2009-10

45

need for contraception. 19% of the TFR is contributed by this age group of mothers. Nearly 27% of them have reported unmet need for contraception. (NHFS 2) Reasons for investing in adolescent health and development: · To develop their capacity to cope up with the situation and deal with it positively. · To increase relationship building capacity for happy and health married life. · To reduce morbidity and mortality among adolescents. A healthy adolescent grows into a healthy adult. · To inculcate healthy habits · As human right adolescents have a right to achieve highest level of health. Benefits of investing in adolescent health · Health benefits for individual adolescent in terms of his/her future and in terms of intergenerational effects. · Improved productivity, return on investment averts future health cost. · As human right adolescents have right to attainable highest level of health. 3.4.2. Goal: Reduce IMR MMR TFR and HIV infections among this age group. Build a healthier nation in the years to come

3.4.3. Objectives of ARSH: Improved reproductive health status of adolescent girls and boys. Increase health seeking behaviour among the adolescents. Provide adolescent friendly ARSH services at SCs, PHCs and CHCs. Friendly means the services should be accessible, acceptable, appropriate, comprehensive, and effective and equity services for adolescents. Strong focus on improving the use of RCH services by poorest and under served population. 3.4.4.Strategies: Tackling key issues which keep away adolescents from availing benefits of health services Involving services of NGOs (including MNGOs and FNGOs) to increase health seeking behaviors among the adolescents. To make provision for demand generation activities and provision for health services at all facilities. Increase health awareness among the girls married and unmarried through consorted efforts from departments like women and child, education, PRIs, youth services, water KARNATAKA NRHM PIP 2009-10 46

supply and sanitation (to increase number of toilet users). Registration of all under 19 pregnancies during the first trimester. Involve private health providers in organizing `Teen Clinics' on fixed days to provide health care and counseling services to adolescents. Poor knowledge and awareness is the root cause of reproductive and sexual problems among adolescents hence increase the knowledge on RCH and bring about behavioral changes among adolescents. Use of exiting VCTCs for counseling adolescents on matters related to RCH. At the level of health facilities providing adequate privacy, confidentiality while giving services to adolescents. Training of staff to provide adolescent friendly services, esp. MOs, ANMs in counseling services. Promotion of EC pills to prevent Linkages with WCD, Education and Panchayat Raj institutions. 3.4.5. Coverage: During the year 08-09 ARSH programme with service delivery services shall be continued to be implemented in 4 districts viz. Tumkur, Chamarajnagar, Bagalkot , Koppal and introduced in 8 new selected districts with the following criteria: o Where more than 60% of the girls are married below 18 years o Incidences of teenage pregnancies are more. o Where literacy level of girls is less o Indicators show high rate of IMR, MMR and TFR. 3.4.6. Priorities, Constraints and Actions to overcome constraints in implementing the ARSH programme in the State: Sl.No Priorities . 1 Functional facilities ­ Establishing fully functional SCs, PHCs, CHCs and district hospitals to provide ASRH services Constraints Action to overcome constraints

2

Reducing IMR/MMR and TFR

Absence or dilapidated Infrastructure development physical infrastructure Procurement of drugs and Non availability of equipments doctors/paramedics. Appointment of Drugs / vaccine shortages contractual staff and capacity Dysfunctional equipments building of the staff Untimely procurements Streamlined fund flows Chocked fund flows Improved MIS Lack of accountability Local level flexibility framework Community /PRIs/ARS for No road map to achieve the accountability and M&E desirable results Develop road maps to reach No mandatory services and desirable goals in 5 years. lack of supervision Non availability of trained personnel for counseling services Lack of 24x7 facilities for Make health institutions safe deliveries and emoc 24x7 functional. services Hiring services of Non availability of specialists wherever there is 47

KARNATAKA NRHM PIP 2009-10

3

Action on preventive and promotive health

4

Convergence programmes

of

specialists to handle high risk cases Lack of equity in family welfare services Lack of referral transport system Lack of coordination at the grass root level, each department work parallel. Poor emphasis on locally appropriate communication efforts No action on healthy life style strategies Weak school health programmes Compartmentalised IEC of every scheme Absence of counseling / early detection at facilities in rural areas. Lack of intersectoral coordination between health water supply and sanitation

vacancy. Thrust on Skilled birth attendants Active village and sanitation committees. Synergy of grass root level functionaries of allied departments. IEC as per local needs Improved school health programme IEC training and capacity building Integrated IEC programmes for all schemes Trained personnel to work as counselors.

5

Priority to handle RCH needs of adolescents at every health facilities

6

Burden of disease among the poor

Lack of privacy and confidentiality at health institutions to handle ARSH. Less focus on health seeking behaviours among adolescents. No statistical data on performance of private health providers in the area of adolescent health. No special interventions to reach vulnerable communities like SC/ST, street children, out of school children, in this age group. Large out of pocket expenditure even while attending free public health facilities ­ food transport, escort, livelihood loss etc. No felt need of health care among adolescents.

Convergence of programmes Involvement of PRIs Effective functioning of VH&SCs Effective functioning of ARS Make provision for privacy and confidentiality to handle ARSH care Special programmes to cover vulnerable population under ARSH Involve private health providers in ARSH and seek reports on teenage pregnancies, MTP cases. Special IEC for special groups More efficient demand side financing to reduce disease burden of the poor. Increase awareness to strengthen health seeking behaviour among adolescents

KARNATAKA NRHM PIP 2009-10

48

3.4.7. Activities: The activities can be broadly classified into: a. Service delivery package: b. Organising effective services c. Conducive environment at health facilities d. Capacity building of providers e. Environment building f. Communication with adolescents g. Monitoring and supervision h. Reporting 3.4.8. Training: (Cost for training is covered under TRAINING chapter under RCH-II) a. State Institute for Health & Family Welfare Services and District training centers will be engaged in training of personnel to handle adolescent problems. b. District specific training for ANMs,/LHVs/ contractual Counselors and MOs. c. Develop training modules for different levels of training. d. Organise master trainers and conduct TOTs for master trainers. e. Orient district DHEOs , RCH officers and DPMs in ARSH programme implementation and to be trained in monitoring, supervision and consolidation of report. f. Develop competency building plan g. Translation of training modules developed by GOI. h. Hiring of services of experts to train the staff. 3.4.9. BCC: (Cost in detailed under chapter 3.8) i. Develop district specific strategies. j. Production of materials required disseminating information related to themes specific to adolescents. Level of care Service provider ANM Flow of service delivery activities Unmarried (Males During and Females) routine sub Married (Males center clinics and Females) Target group Services

Sub-center

1. 2. 3. 4. 5.

Enrolment of newly married couples Provision of spacing methods Routine ANC care and institutional deliveries Referral for early and safe abortion RTI/STI and 49

KARNATAKA NRHM PIP 2009-10

6.

7. PHC/CHC and LHV and Married and Once a week DH Counselor unmarried males teen clinic Medical and females will be officer organized at PHC,CHC and DH for 2 hours 1. 2.

3.

4. 5. 6. 7.

HIV/AIDS preventive education Nutrition counseling including anaemia prevention and personal hygiene. Immunisation for pregnant adolescent mothers Contraceptive, and condom programming Management of menstrual disorders and guidance on menstrual hygiene RTI/STI and HIV/AIDS preventive education and management Counseling and services for MTP Nutritional counseling Counseling on sexual problems Immunisation for pregnant adolescent mothers

3.4.10. Expected Out comes: 1. Increased knowledge, awareness among adolescent population on matters related to personal hygiene, reproductive health, family planning, importance of safe drinking water, nutrition, RTI/STI/HIV and AIDS. 2. Improved health seeking behaviour among adolescents. 3. Better health care practices 4. Better health awareness and health seeking behaviours among vulnerable adolescent population. 5. Better services for the adolescents in the health facilities.

KARNATAKA NRHM PIP 2009-10

50

3.5. Urban Health Urban Health Centre With increasing urbanization, growth of slums and low income population in the cities, the provision of assured and credible primary health services of acceptable quality has emerged as a priority thrust area for both the central and state Governments. The need has arisen to create a well-organized health service delivery structure in urban areas especially for poor people living in slums. The emerging importance of the problem can be gauged from the fact that the total population of Karnataka state is 5,28,50,562 and the urban population is 1,79,61,529. Goal and objective of the program: To improve the health status of the urban poor community by the provision of quality integrated Primary Health Care services.

Objective: The main objective of the program is to provide an integrated and sustainable system for primary health care services delivery in the urban areas of the State, with the focus on the urban poor living in slums and other vulnerable health groups. To attain this, the specific objectives will be: Establishing new facilities in 34 identified urban slums areas, which are not covered by urban health centers. Establish referrals with tertiary care centers, i.e. District hospitals, Medical colleges etc for institutional deliveries, emergency obstetric care and terminal method of family planning. Appoint link workers who will act as link between community and health facility.

Program description: Coverage: The program would be implemented in a phased manner in 34 selected towns of Karnataka states. The proposed urban health program will focus on cities having a population between one to ten lakh/ It is proposed to cover these cities in the phased manner as per the following: Phase Year No. of Centres I 2005-06 4 II 2006-07 6 III 2007-08 8 IV 2008-09 13 V 2009-10 3 Total 34

Strategies: State level steering committee for urban health activities has been constituted. Mapping KARNATAKA NRHM PIP 2009-10 51

of 34 urban slums has already been completed; basic demographic and health indicators have been collected. Each of proposed urban health centers will cover a population of 50,000. Lady medical officers will be appointed on contractual basis for all the selected urban centers. She will be responsible for providing all OP services and also she will conduct at least 4 outreach visits in her geographic area. Identification of tertiary referral centers will be done by Lady medical officer of UHC in coordination with the District health officer and will establish formal linkages for service delivery. Para-Medical Staff i.e, JHAF, SHAF etc and other staff will be appointed on contractual basis. Each JHAF/ANM will cover 15,000 populations for providing outreach services. She has to prepare a micro-plan showcasing the area and days on which outreach services will be provided. To develop and maintain a link between the health facility and the community, the program envisages the engagement of female link workers for every 5000 population who are in the age group of 23-35 and are able to spare three to four hours a day, and are acceptable to the community and preferably to be engaged through local NGOs. Training: The training programs will be conducted for newly appointed staff of urban health canters. Present status: Out of 34 identified cities to start Urban health centers under NRHM, so far 31 centers have been sanctioned during the year 2006-07, 2007-08 and 2008-09. It is proposed to start 3 centers during 2009-10. Budget requirements: Budget requirement for appointing Staff for one Urban Center and their remuneration is as follows: No. of Posts 1 1 3 1 1 1 1 1 Remuneration Cost per year (per Month) in (in Rs.) Rupees 17000 8000 21000 7000 6500 6500 6000 5000 204000 96000 252000 84000 78000 78000 72000 60000

Name of the Post Medical Officer (LMO) LHV / PHN ANM Staff Nurse Lab Technician Pharmacists Clerk Security Guard

KARNATAKA NRHM PIP 2009-10

52

Link workers

10 Total

10000

120000 10,44,000.00

1 Annual Maintenance of equipments, Furniture etc for Health Centre (Recurring) 2 Electrical, Water, Building charges etc. (Recurring) 3 Building maintenance (repair & painting) (Recurring) 4 Drugs (Recurring) 5 IEC Materials (Recurring) 6 Hiring of Vehicles (Recurring) 7 Rent for the Building (Rs. 10,000/- per month) 8 Lab consumables 9 Furniture Total

: : : : : : : : :

10,000.00 50,000.00 50,000.00 50,000.00 10,000.00 12,000.00 1,20,000.00 50,000.00 50,000.00 4,02,000.00

Annual maintenance Salary component Total budget required per center / month Budget for 34 centers per year

(in Rs.) 4,02,000-00 10,44,000-00 14,46,000-00 4,91,64,000-00 i.e. 491.64 lakhs.

As per NPCC meeting recommendations the budget has been revised to Rs368.73 lakhs.

KARNATAKA NRHM PIP 2009-10

53

3.6. TRIBAL AND VULNERABLE POPULATION (Cost of each activity is detailed in 3.6.7) 3.6.1 Introduction Karnataka State has a strong commitment to improve the health status of its population, particularly the poor and vulnerable groups including women, children and those belonging to tribal, nomadic and other vulnerable (T&V) groups. Karnataka has 34,63,986 Scheduled Tribes and 85,63,930 of Scheduled Castes population. This represents 6.55% and 16.20 % of the total population of Karnataka respectively (as per 2001 census). Of this totalof SC/ST population 20% are tribals and the other vulnerable groups. Knowing very well ST & SCs particularly the triblas have a high disease burden particularly in mothers and children, the RCH II program needs to address this group specifically. This is compounded with illiteracy, poverty, malnutrition, poor sanitation and inadequate access to safe drinking water, utilization of health services by Tribal &Vulnerable is low due to the difficult geographical conditions and the social constraints in which they live. Their settlements tend to be small and isolated and difficult to reach with facilities and services. Even when they live in larger villages they may be separated in hamlets and pockets. The health related goals are: a. Reduce Child Mortality b. Improve Maternal Health c. Combat HIV/AIDS, Malaria, TB and other specific diseases to tribal's like sickle cell anemia 3.6.2. Situation Analysis 1. Even though Karnataka remains a high performer in health status when compared to many other states in India with better health indicators, there is scope for improvement. Disaggregated data indicate substantial disparities in various indicators across 29 districts in the state with much worse indicators among the tribal and vulnerable groups. 2. The maternal mortality as well as infant mortality is stated to be specifically high as reported in the State Government (CNA Form 9) and as reported for various morbidity conditions in mothers and children in DLHS- RHS. NFHS 3 data which is the most recent RCH data also confirms the same. Hence the need to address RCH issues in this vulnerable and tribal group in a focused manner.

3.6.3. Objectives: The specific objectives of the program to implement tribal and vulnerable population health are to: To provide RCH services based on the unmet RCH needs in tribal and vulnerable communities. KARNATAKA NRHM PIP 2009-10 54

Making the RCH services integrated, appropriate and quality based. Ensuring equitable access to all the tribals and nomads or other vulnerable groups irrespective of their geographic or social constraints. Educate the population to appreciate the need for improved RCH care and thus create demand for these services. Improve service coverage and acceptability and ensure uniformity in supply of services to all the groups. Promote community participation and inter-sectoral coordination Promote and encourage safe health practices and use alternate systems of medicine if found suitable for these groups. 3.6.4. Strategies to be adopted: Improving the accessibility Infrastructure development Incentives to health functionaries- Human resources Training JSY IEC Equipment , drugs and supplies 3.6.5. Community Participation: Karnataka has been home to many innovations. One of the objectives of the project is to reduce MMR. And this rate is unacceptably high amongst the women belonging to poorer communities. In order to create awareness on safe delivery practices, PHCs are organizing `Samooha Seemantham' or Community Celebration of pregnancy which has proved to be a good strategy for getting the community actively involved in spreading awareness about safe delivery, postnatal care etc. . On this occasion, pregnant women are honored with a Kum-Kum Tika (Vermillion on their forehead) and are given some incentive like blouse pieces and bangles. This is being conducted at the PHC level and has shown tremendous response in all the districts. The budget is met out of the untied funds. 3.6.6. Activities: 3.6.6.1 Tribal area allowance The staff in the tribal areas do not stay in these areas due to lack of accommodation for the staff and poor educational facilities for their children.. To improve the availability of the services and to run 24x7 PHCs it is envisaged to encourage the staff to stay in the tribal areas by providing Tribal area allowance in the districts which have a significant tribal population. As approved in the PIP of NRHM of Karnataka for Fy:2008-09, it is proposed to continue Tribal area allowance for 78 PHC' in the districts of Mysore (25 PHC' Kodagu (26 s s), PHC' & Chamarajanagar (27 PHC' as approved in the PIP of NRHM of Karnataka for s) s) Fy:2009-10. It is proposed to provide an additional allowance of Rs.2000 to doctors, Rs.1000 to staff nurses and Rs.500 ANMs in these tribal areas. It is proposed to continue this allowance to the staff at 78 PHCs Category Doctors Rate of allowance Rs. In Lakhs @ Rs. 2000x 2 Medical Officers /PHC 78x12 0038.0 55

KARNATAKA NRHM PIP 2009-10

months Staff Nurses ANM's @ Rs. 1000x3 staff nurses /PHC 78x12 months @ Rs. 500x4 ANM's /PHC 78x12 months 0028.0 0019.0 Total 0085.0 The Budget requirement under this component during Fy: 2009-10 will be approximately. Rs. 0085.0 lakhs. 3.6.6.2. Tribal Area ANM' Salary working at PHC' s s The salary component of Rs. 0010.0 Lakhs for 25 tribal ANM's working in PHC's which are out sourced under PPP is to be met out of RCH funds. These ANM's are working in tribal areas and are continued from RCH-I The Budget requirement under this component during Fy: 2009-10 will be approximately. Rs. 0010.0 lakhs.

3.6. 7. Budget: SN 1 4 Component Salary component of tribal ANMs 25 ANMs Tribal area allowance Doctor @ Rs 2000 pm x 12 Staff nurse@ Rs 1000 pm x 12 ANM @ Rs 750 pm x 12 Total Rs. in lakhs 10.0 85.0

95.0 lakhs

KARNATAKA NRHM PIP 2009-10

56

3.7. PPP MNGO Scheme: 3.7.1. Introduction Public Private Partnership initiative in health sector in Karnataka is in existence since a long time. Schemes like Yashaswini, Telemedicine, contracting out of mobile health clinics, Management of existing health facility by NGOs, Accreditation of private hospitals, Community Health Insurance, Public Health Competitive Fund, and Training of ASHAs are some of the joint ventures that are already under implementation in the state. The National Population Policy 2000 provides for strategies for addressing RCH needs of the people of which partnership with NGOs is one important strategy. The work of NGOs is supplementary and complementary in nature to that of Government. Keeping the above in mind the Mother NGO scheme is envisaged under RCH program. The partnership between NGO and Government has an important role in providing RCH services to the community especially in the under-served and un-served areas. Objective The broad objective of the intervention is to address the gaps in information or RCH services in the selected area, building institutional capacity at the district/field level, advocacy and awareness generation. Current Status of MNGO programme In Karnataka 14 MNGOs were identified during March 2006, who covered 17 districts. These MNGOs were released with Rs 1.00 lakh each to identify FNGO and to carry out baseline survey in the identified areas where they proposed to work. After the baseline survey, some MNGOs submitted composite proposals during 2007. There was delay in submitting composite proposals for 6 districts The State NGO Coordination Committee assessed the survey findings of some of the MNGOs and felt that the credentials about these MNGOs/FNGOs related to their experience in the field needs to be evaluated afresh. A Joint Appraisal Committee was constituted for the purpose. Meanwhile some MNGOs withdrew from the scheme and some did not qualify in the ReAppraisal. Though Rs 160 lakhs was earmarked for MNGO programme during 2008-09, due to the reappraisal process under progress money could not be released to MNGOs. Situational Analysis The DLHS 3 survey finding of shows that there is sizable number of SC and ST population in these districts. The female literacy rate is low, a major contributing factor for poor Maternal and Child Health status. The Standard of Living index is much below the State's Standard of Living Index. Percentage of girls marrying before the age of 18 is also very high, which is another contributing factor for poor maternal and child health. A sizable percentage of birth order is of 3 and above, indicating that the FP programme needs to be improved. Since there are unserved and underserved pockets where the government health service is inaccessible, there is ample scope for the MNGOs to venture and improve the awareness about health services in such areas. Proposal During the year 2009-10 it is proposed to implement in 9 districts namely, Bidar, Gulbarga, Bijapur, Raichur, Koppal,Haveri, Kolar, Hassan and Mysore. Five of these districts are `C' categorgy districts. Since composite proposals were prepared with reference to the data of year 2005-06 which are outdated, the MNGOs will be asked revise the baseline data, target and indicators keeping the DLHS -3 data as reference. The key service delivery areas under MNGO scheme areas. KARNATAKA NRHM PIP 2009-10 57

Maternal & Child Health Family Planning Adolescent Reproductive Health Prevention & Management of RTI. Measurables The MNGO will clearly identify the output and measurable indicators, demonstrate qualitative and quantitative improvement in meeting the RCH needs of the Community in the identified area. Through the FNGOs it will be responsible for establishing referral services for treatment/ linkages of RTI/STI with other service components, reduction in prevalence of RTI/STI cases, BCC and social mobilization, promotion of condoms, orientation of private practitioners for raising awareness on causation, transmission and prevention of RTI/STI, provide basic package of MCH service, The MNGO should be able to demonstrate a measurable change in maternal and child health status in the community like 1. Reduction in maternal death 2. Decrease in early marriage 3. Increase in birth interval 4. Increase in institutional delivery 5. Promotion of breastfeeding 6. Increase in % of fully immunized children 7. Improved nutritional status of pregnant mothers and children 8. Reduction in unmet need for FP etc. 3.7.2 Budget Requirement: The maximum permissible fund that may be released to a MNGO is Rs 15 lakhs per year. Budget is calculated for 9 MNGOs under whom there are 30 FNGOs. The salary component of the NGO Coordinator is also budgeted. Fund for Existing MNGOs in 9 district for 1 year@ based on the Rs 120 lakhs number of FNGO under the MNGOs (30) + Salary,TA, DA to State NGO coordinator Rs 120 lakhs TOTAL

After NPCC meeting the budget is modified to Rs.90 lakhs.

KARNATAKA NRHM PIP 2009-10

58

Indicators for the Districts as per DLHS 3 Indicator Karnataka Haveri Raichur % SC 16.2 12.2 19.0 Population % ST 6.6 8.8 18.1 Population Sex Ratio 965 944 983 Female 56.9 57.4 35.9 Literacy Standard 42.6 61.6 68.1 Living Index % of girls 22.7 19.7 38.7 marrying before the age of 18 % of Births 32.3 36.6 of order 3 and above Unmet 15.8 14.6 23.4 need for FP % of ANC 71.8 72.7 43.9 registration in 1st trimester % of ANCs 81.6 89.2 55.6 with 3 check ups % of 65.1 64.0 41.7 Institutional Delivery % of PNCs 61.0 53.4 44.9 getting care (NFHS-3) within 48 hours of delivery % of Fully 76.7 81.0 49.9 Immunized Children (12-23 months) % of 37.4 47.6 36.2 women heard of RTI/STI

District Bidar Koppal Bijapur Gulbarga Hassan Mysore Kolar 19.9 15.5 18.5 22.9 18.1 17.7 26.5 12.1 949 48.8 66.9 27.4 11.6 983 39.6 74.5 44.7 1.1 950 43.5 74.5 43.1 4.9 966 37.9 72.8 41.6 1.5 1004 59.0 60.0 3.2 10.3 964 55.8 53.4 14.3 8.1 972 52.2 56.3 18.4

32.7 20.0 82.0

38.4 22.6 52.7

39.7 19.1 64.0

41.6 23.9 57.6

15.6 9.9 92.1

17.3 12.9 84.6

24.8 13.2 87.4

81.6 65.1 56.5

65.7 24.8 44.6

63.9 59.8 57.1

64.2 47.6 55.4

94.0 80.3 68.1

91.7 79.6 70.5

92.3 62.3 57.5

84.5

73.3

50.8

68.3

84.1

91.1

94.7

32.8

18.3

45.2

27.0

53.0

24.9

14.5

KARNATAKA NRHM PIP 2009-10

59

Monitoring & Evaluation Out of the several interventions initiated under NRHM/RCH, evaluation studies can be taken up in the following areas during 2009-10. 1. Effectiveness of Arogya Raksha Samiti in improving service delivery in health institutions and utilization of Untied fund/User fees 2. Impact of Madilu, Prasuti Araike, Tayi Bhagya schemes on Institutional Deliveries. 3. Remote Area allowance and improvement of in service delivery in such institutions. 4. Untied Fund- Utilization and its usefulness Budgetary provision of Rs 15-20 lakhs may be made in the PIP 2009-10 for Evaluation studies.

60

3.8. Behaviour Communication Change 3.8.1 Background: Human behaviour is complex and difficult to achieve change, it needs continued motivation". Over the years, IEC programmes and activities have resulted in improved knowledge about health, family welfare and nutrition, but these results are not to the expected level as this has failed to produce behaviour change". BCC is a process that motivates people to adopt and sustain the healthy behaviour and lifestyles. Sustaining healthy behaviour usually requires a continuing investment in BCC as part of overall health programme. BCC helps in understanding the dynamics of health issues in terms of · Causes of health issues its preventive measures. · Gender, which has major role in all health activities, as adoption of desirable health practices requires support and understanding between both spouses. · Possible health related behaviour (encouraging and discouraging) · Social, economic and political factors · Develop problem statement that summarizes the above points to address the problem. Therefore, in order to reach the target groups and communities, various types of IEC activities at different levels are essential to facilitate them to adopt desirable health practices for improved life style and healthful living. Apart from carrying out awareness activities, the support of village health committees, panchayath raj institutions and other line departments is equality important for the sustainability of the health messages. All BCC/IEC activities focus on all human resources of health & family welfare department at various levels as well the local community based organizations, private sector people, as well as representatives of panachayath raj institutions at all three levels. These human resources need to be capacitated in disseminating NRHM components, its advantages, and services available at various levels so that the community will utilize them for better and improved health. As BCC/IEC activities aim at behavioural changes, it is necessary that these activities are to be carried out regularly for all target groups at various level. This requires meticulous planning, implementation and monitoring. Therefore, it has been planned to procure the consultancy services for Design and Management of IEC activities under NRHM component. Keeping these in view, proposed Action Plan for 2009-10 is prepared which gives the details of man power, equipment, IEC materials (printed & electronic) which are supportive to carry out BCC/IEC activities to the desired level. It is to be noted that all IEC materials are very much essential for all the field functionaries as well as training/capacity building programme activities. The details of action plan for 2009-10 is as follows:

61

3.8.2.Budget

PART ­ A STATE LEVEL Unit cost 2 3

Sl. No Activities I 1 1

2

3 4

II 1 2 3 4 5 6 III 1 IV

BCC / IEC Man power Manager ­ 1 15,000X12 Data Entry Operator -2 7,500X12 IEC Consultant-2 30,000X12 Computer Art Designer / Animation Expert-1 10,000X12 Total Electronic Equipment LCD projector LCD TV with all necessary accessories Exhibition Display boards Periodical display racks 3 Computers, and 1Colour printer Xerox machine Digital Camera-2 Handicam Miscellaneous / Repairs Total Green Ribbon Exhibition bus Procurement of Consultancy Services for Design and Monitoring IEC Total SUB TOTAL BCC Activities at State level Kutumba Monthly Newsletter Kannada - 25,000 X12 5.00 English - 5,000X12 5.00 Outdoor Photo and Video coverage Tableau - 5 1,00,000 Major Exhibition World Event Days Calendar for the year 2010 60,000XRs. 12/SUB TOTAL Studies / Evaluation Studies / Evaluation for mid course corrections SUB TOTAL Workshops / Orientation

Budget Allocated (Rs. in lakhs) 4 1.80 1.80 7.20 1.20 12.00 0.75 2.00 1.00 1.00 2.00 1.75 0.20 0.20 1.20 10.10 50.00 95.00 145.00 167.10 15.00 3.00 0.50 5.00 5.00 5.00 7.20 40.70 3.00 3.00

Rema rks 5

62

1 2 3 4 1 5 6 7 V 1 2 3 4 5 6 7 8 9 10 11 12 VI 1 2

State level IEC/BCC workshop -2 Divisional level IEC/BCC workshops - 4 Divisional Level Folk Artistes workshop ­ 3 Folk media programmes Panel Discussions at Doordarshan ­ 4

1,00,000 50,000 1,00,000 50,000

2.00 2.00 3.00 20.00 2.00 5

2 3 4 Telecasting documentary films/T.V spots 20.00 through Doordarshan and private channels Broadcasting phone-in-programme, Radio 20.00 lessons, Quiz, Radio jingles, dramas Awareness programme through satellite 5.00 SUB TOTAL 74.00 Procurement of IEC materials (Printed and Electronic) Print Media Posters (3 types) 10.00 Folders (5 types) 4.00 Handouts (5 types) 4.00 Booklets / Charts (5 types) 5.00 Brochures on maternal Health 3.00 Brochures on Child Health 3.00 Training / Working Manuals 6.00 Stickers 2.00 Tin plates on K.S.R.T.C/BMTC buses 10.00 NRHM Message on K.S.R.T.C/BMTC bus 5.00 tickets Publication of NRHM articles in weekly / 6.00 monthly magazines of GOK and GOK undertaking institutions Advertisements in Newspapers / Sovereigns / 25.00 Periodicals etc. SUB TOTAL 83.00 Electronic Media Procurement of T.V. documentary films/ spots 10.00 Procurement of Radio Jingles 6.00 Publicity through Electronic Display boards in 30.00 all Health institutions Publicity through CCTV in major bus stands / 20.00 Railway stations / major Health institutions SUB TOTAL 66.00 TOTAL 433.80 PART ­ B

Sl. No

Activities

DISTRICT LEVEL Unit cost

Budget Allocated

Rema rks

63

1 I

2

3

(Rs. in lakhs) 4

5

BCC / IEC Man power 1 Programme Assistant 2 Data Entry Operator 3 Vehicle hiring charge (10 days per month in a year) SUB TOTAL BCC/IEC Activities at District Level 1 PHC Level Awareness programme to Village Health Committee members 2 Sensitisation workshop for Taluk level Panchayath raj institution representatives and members of all co-operative institutions and Gram Panchayath Secretaries (2 programmes in a year) 3 Workshop for Journalists 4 Taluk level Sensitisation workshop for Junior Female Health Assistants 5 Taluk level Sensitisation workshop for ASHAs 6 Taluk level workshop for Private practitioners (MBBS and Specialists) 7 Workshop for ZP representatives 8 Orientation to Mothers through satellite 9 Awareness programme to SHGs and ASHAs 10 Awareness programme to ICDS Supervisors 11 Awareness programme to Adolescents 12 Sensitisation programme for NGOs (taluk level) SUB TOTAL QUIZ / ORATION COMPETITION 1 Quiz competition for High School students 2 Oration competition for P.U.C. students 3 Oration competition for Degree students SUB TOTAL PRESS 1 Press advertisement SUB TOTAL

29XRs. 9000 29XRs. 4,000 29XRs. 750X10X12 2195X1XRs. 2,000

31.32 13.92 26.10 71.34 43.90

352XRs. 5000

17.60

29XRs. 6,000 176XRs. 4,000 176XRs. 4,000 176XRs. 6,000 29XRs. 10,000 176XRs. 4,000 29XRs. 5,000 176X4XRs. 1,000 176X4XRs. 4,000

1.74 7.04 7.04 10.56 2.90 30.00 7.04 1.45 7.04 7.04 143.35

176XRs. 2,000 176X Rs. 2,000 176X Rs. 2,000 29X10XRs. 2,500

3.52 3.52 3.52 10.56 7.25 7.25

64

WORLD EVENTS DAY 1 World Events day SUB TOTAL STUDIES / EVALUATION 1 Studies / Evaluation SUB TOTAL TOTAL PART-A TOTAL PART-B TOTAL GRAND TOTAL

29X2X Rs.10,000 29XRs. 0.25

5.80 5.80 7.25 7.25 245.55 433.80 245.55 679.35

3.9. TRAINING National Rural Health Mission envisages to provide affordable , equitable and quality health care to the population, especially vulnerable group. A major pre-requisite for providing quality health care is upgrading the skills and knowledge of all health personnel as well as key personnel of related sectors. Capacity building taken as one of the associated activity in implementing and functionalizing the NRHM goals. Various functionaries in the department of Health and Family Welfare are sensitized, trained and re-oriented there by upgrading the skills and knowledge in management, communication and clinical services. 3.9.1 Objectives of the in service training: · Up grading the skills and knowledge of all health personnel as well as of key personnel of related sectors so as to provide quality health care. · All the health care personnel in the district acquire skills and knowledge to provide the health care services effectively and efficiently. · All the health care personnel develop the knowledge of the linkages between the various sectors dealing with health determinants for provision of integrated services. · Enabling the Medical and Para Medical staff to develop necessary skill for delivering the maternal health, child health, Family Planning, Disease Control Programmes and other newer initiatives under NRHM at different health institutions and community. · Enabling the Medical Officer of the Primary Health Center and other supervisory staff at block and district level in developing the leadership quality so as to make the staff work as a team and serve the community.

65

Enabling the Medical Officer of the Health Center in effective management of Finances and other logistics at different level of activities. Situational Analysis: Under NRHM for last 3 years of mission period following functionaries were trained under various programmes. Training strategies as per the national guidelines: present strategy looks at the paradigm shift on the following issues: · Paradigm shift from vertical training to integrated training · From knowledge transfer to skill up gradation · Trainingbeing linked to facilities which are functional/ being made functional · Convergence with related departments · Institutionalize training planning from sub center up wards 3.9.2. Mode of Implementing the Training Activities: · State Institute of Health and Family Welfare, Bangalore works as the nodal center for planning, budgeting, monitoring and further facilitating the districts to utilize the trained health personal at appropriate places. District training Centers along with Regional Health and Family Welfare Training centers and Pre service ANM training centers are working with the SIHFW in implementing the trainings at districts and sub district level. · Medical colleges, other non governmental institutions, NGO's having experience in the field of public health are working with SIHFW in mentoring, supporting in providing specialist as resource persons for training. And these institutions also provide the expertise in monitoring and evaluation of trainings at various level. · Trainings are developed as per guidelines Government India, WHO and UNICEF. Standard Operating Procedures are produced based on various standard guidelines. · Various training methodologies are followed keeping in view the Adult Learning Principles. Training manuals developed by GOI are translated in to local colloquial language are used and distributed to each and one of the trainee. · Financial guidelines for the training is followed which is been prescribed by the GOI with few modification required localy. 3.9.3 Proposed trainings and related activities for the year 2009-10: 1. 2. 3. 4. Infrastructure development Teaching Aids and development of training manual Human resource required for the training Institutions Trainings

·

3.9.4 Strategies for Strengthening of training institutes for capacity building : Training institutes for inservice training and pre service trainings will be strengthened with keeping following objectives under KHSDRP 3.9.4.1: Infrastructure development : · Provision of Healthy , Hygienic and aesthetic environment for good quality learning · Provision and usage of modern teaching and learning aids, Library facility and required laboratory facility.

66

Development of manuals and literature required for training will be under taken through conducting workshop of subject specialist. 3.9.4.2: In sourcing of Human Resource for needed specialized field. · In sourcing of Specialists of various fields to provide required knowledge and skills to the designated/specified trainees, for pre-service and inservice course. · In sourcing of teaching faculty for the pre service training schools also will be done.

·

3.9.5: Training Strategies Proposed for the year 2009-10 : health care providers are exposed to following trainings which are under taken through various programmes: - induction training of various health personnel will be under taken for the period of 2 to 4 weeks at the time of entry in to service. This programme is planned under 12th finance commission. - in service training is the major component provided to all the categories of health care workers to up grade the skills and knowledge in technical and management fields. -Refresher training is taken as continuous education for health care providers once in two years.

67

3.9.6: RCH II trainings Matrix of RCH training: enclosed as annexure 1 3.9.6.1: Maternal Health; Specific Objectives: -up grading the skills and knowledge of health care providers in providing essential ANC, assessment of Labour using partographs, Active management of 3 rd stage of labour using tab Mesoprostal, Prevention of Eclamphsia by using Ing MgSO4 in PIH cases, and Essential new born care at birth including resuscitation of the new born. - up grading the skills and knowledge of the health care providers in early detection and complete treatment for the clients with RTI/STD. Out come: Functionalizing all the identified PHC and CHC in providing 24x7 services, thus facilitating the districts to increase the institutional delivery to 85% by end of 2009-10, which further facilitates in reducing the maternal morbidity and mortality. Strategies: Skill birth attendance training; to Medical officers, staff nurses and Head quarters ANM from each of the 24x7 PHC and CHC's including FRU's . Training of above functionaries under taken at 42 identified centers at district and sub district hospitals which are Government, Private including Medical Colleges. EmOc training and LSAS training to identified MBBS doctors followed by posting and placing them at identified FRU where the specialist service of Obstetrician and Anesthesia are not available. Trainings are conducted as per the guidelines of GOI with help of FOGSI, Medical Colleges and district hospitals. Importance is given for exposure to sufficient number of deliveries. Training in MTP by using MVA is taken up for Medical Officers of CHC and FRU where 24x7 services are provided. RTI and STI training to MO, Lab technician, Staff nurses and field ANM will be under taken with the help of KSAPs and as per the NACO guidelines. IMEP training to medical officers and staff nurses will be under taken as per the GOI guidelines through KHSRDP. 3.9.6.2 Child Health: Specific Objectives: Training enables the health functionaries to develop the skill of providing integrated management of new borns with essential care at birth, Nutrition through promotion of exclusive breast feeding, early identification of bacterial infections and diarrheoal disease followed by appropriate treatment and early referral. Enabling the health care personnel in providing the integrated services to children from 2 months to 5 years for severe illnesses, diarrhoeal diseases, nutrition care through exclusive breast feeding, introduction of complementary feeding at appropriate time, management of malnutrition followed by appropriate treatment, early referral and counseling of the mothers and attenders for proper care. 68

Enbling the health workers and ASHA in providing home care to new borns and sick children. Enabling the medical officers and staff nurses of 24x7 PHC's and CHC's in providing essential services to new borns and sick children at facilities. Out come: by effective implementation of IMNCI, Facility based new born care and home based new born care by the skilled health care personnel will facilitate in reduction of neonatal, infant and child hood morbidity and mortality and there by achieving the NRHM goals of reducing the IMR by 30 at the end of 2009-10. Strategies under IMNCI training ; Integrated management of Neonatal and child hood Illness is proposed for Medical Officers, Staff Nurses of PHC/CHC and health and nutrition training of field health functionaries along with AWW. The programme is under taken in 14 districts of Gulburga division, Belagaum division and 2 tribal districts namely Chamarajanagara and Kodagu. Strategies under Facility based new born care training : MO's and Staff nurses of the 24x7 PHC's and CHC's will be trained under this programme. . Home based new born care: ASHA workers will be trained under this programme as per Gudchoroli Model with certain modification as per the local need. Care of sick child and severe Malnutrition: training under this programme is given to MO's of CHC/FRU's so as manage the these children appropriately at institutions in absence of the paediatricians. Immunization training: capacity building of MO's in immunization programme along with management and surveillance of AEFI is under taken. 3.9.6.3. Strategies under Family Planning Programme trainings : Specific Objectives: o Up grading the skills and knowledge of the Obstetricians and Surgeons in conducting laproscopic tubectomy, counseling the clients and maintenance of quality and standard of operating procedures. o Up grading the skills and knowledge of the MBBS doctors in providing minilap tubectomy services, no scalpel vasectomy services and IUCD services along with counseling of clients, provision of quality service at 24x7 PHC and CHC's. o Up grading skills and knowledge of staff nurses and ANM/LHV's in providing the IUCD services along with counseling and follow up services. Out Come: Provision of quality service along with proper counseling and follow up services by the health care providers will increases the client satisfaction and there by lesser rejection rate, more demand and acceptance and long sustenance of FP methods. This will in turn results in increase in use of spacing methods, increase in coverage of unmet needs and there by increase in CPR and reduction of TFR to less than 2.08 by 2009-10. Strategies under FP Training: · Laproscopic training: Gynecologist or Surgeons along with staff nurse and OT attender is given this training for 12 working days as per the GOI 69

guidelines. These Gynecologist and Surgeons are also oriented about quality assurance in standard procedures in male and female strerilization technique. Minilap Tubectomy training : MO's of 24x7 PHC's and CHC's along with staff nurses and OT attender is given this training for 12 working days as per the GOI guidelines. NSV training: It is proposed train MO's of 24x7 PHC's and CHC's in NSV for 6 days so as to provide NSV services to the clients whenever necessary. As the state do not have institution with good case load required for the training , it is proposed to train the doctors during special camps held for NSV or at neighboring state where the NSV services provided in good number. IUCD training: As per the GOI guidelines, an alternate method of IUCD insertion technique training is provided to MO, Staff Nurse, LHV and ANM with help of anatomical pelvic model provided. 3.9.6.4. Adolescent Reproductive Sexual Health: Specific Objective: -up gradation of skills and knowledge of the health care providers in counseling of adolescent, providing nutrition and health education, life skills development -and provision of nutrition and anemia care to adolescent, and RTI/STD services - providing carrier and educational couselling - special clinical, counseling service provision to vulnerable, marginalized and high risk adolescents. Out Come: Adolescent forming the 23% of the population arebig strength or threat to the community if they are not taken care at appropriate time and place. They being the future parents need to be properly educated about the roles and responsibility and health care. Strategies: ARSH programme is taken up in 12 district of Karnataka in this phase and Capacity building of the all category of staff. The objective of the training under ARSH is to develop the skills of the health functionaries in counseling, in rendering health education, nutrition education, education regarding RTI/STI and in providing counseling for carrier and education to small extent through 24x7 PHC's and CHC's and also at community via Adolescent meetings. 3.9.6.5. ASHA training: Nearly 39000 ASHA's are identified in 29 districts. 11200 ASHA's from 9 districts in 1st phase were trained by 2 NGO namely Narayana Hrudayalaya and Karuna Trust. During 2nd phase 16000 ASHA's from 11 districts are under going training through SIHFW, 12000 ASHA's from rest of the 9 districts will be trained during 2009-10 with help of SIHF and NGO's. AYUSH training: as process of mainstreaming the AYUSH under NRHM, AYUSH medical officers working in PHC's will be trained for multi skill mainly: maternal health SBA, IMNCI, Immunization, Disease Control programmes and other national health programmes. 6. Other National Health programmes; Capacity building of the health personnel in other heath programmes also been done as per the national guidelines. Monitoring and Evaluation of the training programmes: Evaluation of the trainings are done before , during process of and after thebtrainings. Different checklist and monitoring mechanism developed with help of NIHFW, UNICEF and WHO is used for the process. On the place evaluation of the health worker 3 to 6 months after the 70

training is also built in the system. Evaluation is been carried out interanal as well external agencies to under stand the lacunae. 3.9.7 Infrastructure available for Training: Table Showing the Training Institutions in the state with staff and Infrastructure available Name of the Sl No. Faculty Infrastructure Remarks No Institution 1 SIHFW 1 Director, Joint 1 Administrative Need for Director, 10 Block and 1 Training Up Deputy Directors Block with 1 Conference gradation and supporting Hall, 5 class rooms with and staff LCD, Over Head renovations Projector, Slide Projector, well equipped library and Hostel facility for 35 members. 2 HFWTC 4 Principal, MLCD, 3 Class rooms, with all Epidemiologist, teaching aids, library and Communication field demonstration faculties and station, Bus and jeep/ supporting staff tracks. In house facility for 40 members. 3 DTC 19 Principal, HEO 1 class room, and in and DNO and house facility for 30 supporting staff persons with library and all teaching aids. Principal, 6 tutors 1 class room, in house with supporting facility 40 trainees, staff library with adequate teaching aids TOT OBG, Skin etc TOT OBG, Skin etc trained Pediatrics, specialists trained Pediatrics, specialists For Hands on practice in skill Training For Hands on practice in skill Training & Field visits. For Hands on Training

4

ANMTC

28

5 6

LHVTC District Hospitals

4 26

7

CHC, TH 352 and GH

8

Medical college hospitals

30

TOT trained OBG, Pediatrics, Skin specialists etc

71

3.9.8.Training cost : Training cost is calculated as per the GOI guidelines. SlNo Item Cost 1 Per diem to Trainees or participants Guidelines awaited 2 Honorarium to resource persons To Guest resource persons @Rs.500 per session not more In house faculty than 2 per day @ Rs. 200/ session 3 Training materials @Rs. 250/participant/day 4 Refreshment @Rs. 250/participant/ day 5 IOH- Institutional Over Heads 10% of 1+2+3+4 6 Travelling cost as per State rules 3.9.9 Table Showing line item wise training budget Planned under Budget Head KHSDRP Strengthening of Training Institutions (SIHFW, HFWTC,DTC,LHVTC and ANMTCs, etc.) 1 Carry out repairs/ renovations of the training institutions: 28 institutions - 19 old ANMTC, 4 LHVTC and 3 HFWTC' s 2 Provide equipment and training aids to the training institutions 28 institutions - 19 old ANMTC' 4 s, LHVTC' 4 HFWTC"s and s, SIHFW 3 Contractual staff recruited and in positionDevelopment of training packages 1 Development/ translation and duplication of training materials and Manuals 2 Other activities - Vehicle Hiring and Maintainance Cost in lakhs 560

56

188 25 50

72

Training programme under RCH Flexipool 11.3 Maternal Health Training 11.3.1 Skill Attendance At Birth / SBA 11.3.2. EmOc training 11.3.3. LSAS training 11.3.4. MTP training 11.3.5. RTI/STD training including Blood storage training 11.3.6. IMEP training 11.5 Child Health Training 11.5.1. IMNCI training 11.5.2. FBNC training 11.5.3 Home Based Newborn Care / HBNC 11.5.4 Care of sick children and severe malnutrition Following GOI guidelines 11.6 Family Planning Training 11.6.1 laproscopic training 11.6.2. Minilap Training 11.6.3. NSV training 11.6.4. IUCD training 11.7. ARSH training 11.8. Programme Management training 11.9 Multi skill training to AYUSH Doctors ( 4 wks training) GRAND TOTAL

258.5 66.41 55.2 20 247.1 33.2 255.57 129 117.9 12.9 10 20 0.3 165 121.35 18 20 1550.43

After NPCC meeting the budget has been revised to Rs.1288.74 in place of Rs.1550.43.

Under NRHM Addionalities ASHA- 5200 remaining ASHA' from 9 districts and 27000 a ASHA' from remaining districts s

2209.68

After NPCC meeting the budget has been revised to Rs.1767.74 in place of Rs.2209.68 lakhs.

3.9.10 Comprahensive Training Plan enclosed as Annexure-I

73

ORGANIZATION DEVELOPMENT Organisational Development, is a process to improve and strengthen the role of Government in the Public Health Sector with an objective to move the Department of Health & Family Welfare Services towards a result-based approach. Acquisition of new skills and knowledge, requires external technical assistance and internal capacity building for an organization. Organisational Development envisages the adoption of doing things in a new, more effective and result oriented ways. Apart from the communicable diseases, the non-communicable diseases like diabetes, CVD (Cardio Vascular Diseases), Psychiatric illnesses etc., have become a significant entity in health. The public health system has to gear up to cater to noncommunicable diseases preventive and curative care along with its vast on-going National Health Programme. The orgnizational set up in the Public Health Sector needs to be improved and strengthened to meet the present need of the people. Thus the concept of ` organization development' has been envisaged. In order to move towards the result-based approach, a process of planning, implementation, supportive supervision periodical effective monitoring and replanning for the better would be necessary. Keeping in mind the role played by the Private Sector in delivering health care services to the masses, their potential can be used for the improvement of health care delivery systems. Scope in organization development : 1. 2. 3. 4. 5. 6. Capacity building through the HRD programme. Re-organising the department. Formation of a Public Health Act. Strengthening of a Strategic Planning Team & Senior Management Team. Drafting of Medical manual for Medical Officers. Providing schemes of incentives to encourage, for further improvement in Health care service delivery.

These when well planned and effectively implemented would set the wheel in motion for achieving a result based approach. Objectives: 1. a. To improve IPC and resolving issues that hinder affective functioning. b. To bring about awareness, co-operative and co-ordination in achieving the MDGs 2. To bring about transparency, clarity and confidence in Procurement State Procedures World Bank Procedures 3. To established effective documentation, analysis and corrective actions for maximum usage of allotted funds. 4. To inculcate confidence, resilience and have positive attitude to move ahead towards achieving the MDGs. 5. Up to date computer knowledge, to improve documentation, effective dissemination of information and analysis, in co-ordination with HMIS wing.

74

The strategies for Organization Development would be : 1. Bringing about an ` attitudinal change' in the personnel delivering health care services. 2. A behavioural change communication would strengthen the integrity of the H.R.D. in DoHFW. 3. Development in the skill and knowledge of the people through trainings, workshops, meetings, group discussions, tele conferencing study tours and visits etc. 4. Recognising marked achievement and rewarding would encourage and uplift the enthusiasm of the health care personnel. 5. Counselling for recruitment and transfer along with timely eligible promotions would facilitate people to give their best services for health care. 6. Refurbishing method of accountability of services rendered would drive the organization towards a result oriented approach. A well studied change in The Cadre and Recruitment Rules would be effective to achieve the target, objective and the goal of the Department. Similarly the drafting of Public Health Laws and Rules would stream-line the department. A comprehensive public health act would keep the department in a disciplined and systematic form. Thus Organization Development would cater to the wholesome development of all levels of Health Care Providers in the Public Sector , with encouragement for the PPP concept in public health. 3.9.9. SIHFW Plan (under KHSDRP)

Study Tours / Workshops / Seminars Sl. No 1 2 3 4 5 Study Tours Training institution Study Public Health Directorate Other Study tours Seminars/Symposium Study tours Total 2009 ­ 10 2010 - 11 2011 - 12

In lakhs In lakhs In lakhs 10,00,000 10,00,000 10,00,000 20,00,000 10,00,000 20,00,000 5,00,000 5,00,000 30,00,000 40,00,000 20,00,000

75

Capacity Building Sl. No 1 2 3 4 5 6 7 Capacity Building 2009 ­ 10 2010 - 11 2011 - 12 In lakhs 1,00,00,000 20,00,000 50,00,000 90,00,000 1,00,00,000 60,00,000 30,00,000 1,00,00,000 50,00,000

Distant Education Courses at IGNOU Sponsoring issues in the 5,00,000 country Abroad Courses sponsoring 25,00,000 Personality Development and 5,00,000 Stress Management 30 Districts @ Rs. 3 lakhs /District Distant Education Courses Soft Skill Development @ Rs. 3.5 lakhs/ District Skill Based training @ Rs. 2L/District Post doctorate training (MD) 25,00,000.00 fellowship in nephroUrology recognized by Rajiv Gandhi University oh Health Sciebces for newly commenced renal dialysis wards in District Hospitals (5 candidates per annum) Total 65,00,000

In lakhs In lakhs 5,00,000

3,00,00,000

3,00,00,000

Incentives ­ Cash Sl. No 1 2 Incentives Institution 1/Dist/yr. @ 20 k /yr Individual 1/Taluk/yr @ Rs. 50K/yr a. MO 1/176/yr. b. Stf Nrs. c. JHAF i.e. 176X 50 = 88,00,000 d. 8 individual JHAM e. Supervisor (1) M/F = 90,00,000 f. Pharmacist. g. Lab Technician. h. + 2 individual Group D i. ASHA j. AWW Total (2009-10) (2010-11) (2011-12) 6,00,000 90,00,000

96,00,000

76

Guidelines:1. In the `Organization Development' component of KHSDRP, the above activities are to be planned the district level, for implementation and capacity building of the personnel of the dept of H& FW. 2. The needed financial allocation/budgeting also had to be estimated, talking into account the no. of people to be trained. 3. The venue for the training/workshop should be convenient of the participants, rather than the resource people. 4. District could add any other particular workshop /training /activity, which is felt to be necessary. 5. All the planned workshop/training/activity has to have the consent ­ approval of the District Health Society and District Health Mission. Then sent to SPMU, NRHM ­ KHSDRP, at the Directorate of H & FW, for guidance, approval and allocation of budget. 6. It is to noted that capacity ­ building is to be catered to all the cadres of the department not restricting to clinical ­ paraclinical aspects of training. 7. Innovation, new ideas are to be encouraged, which would move the services of the department towards achieving the Millennium Development Goals. 3.10 Health Management Information System (Costing is detailed in 3.10.4) A comprehensive Health Management Information System will be developed. Apart from integrating the flow of health data of various levels from different units, it will facilitate in regular and effective monitoring of the physical and financial components. Objectives of HMIS : To improve the management of public health care services by computerization of the Department, from PHC to the State level. To enable optimum utilization of the resources and integration of all national health programmes. Key Concepts: Establishment of State Health Informatics Centre. Design and development of comprehensive need based health information system. Strengthening of the existing system. Networking in the Department. Functions proposed in HMIS: · · · Training of health personnel Development of application software and procurement of hardware for the Department Networking in the Department 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter

Sl. Activities planned from No. April 2009 to March 2010 1. Selection of 4 districts to have HMIS in an 77

2. 3. 4. 5 6.

integrated fashion ­ BOOT module In all other districts to have HMIS from Taluk level Development and Integration of Application Software for programmes and planning from PHC level to State level Development of web application software ­ NRHM format aggregated level at PHC and taluk level Integration of web based software for NRHM format with GOI software of NRHM Basic computer and HMIS software training to health staff (ongoing) Input/Budget Description 1 2 3 4 5 Hiring of IT Professionals Training for health staff Networking Printing of User Manuals and other guidelines Miscellaneous Total Unit Cost 20000 1,00,000 10,00,000 200 Number 8 100 batches 1 unit 5000 Budget required for 2009-10 i.e. from 01-04-09 to 30-03-10 19,20,000 1,00,00,000 10,00,000 10,00,000 10,00,000 1,49,20,000

HMIS under KHSDRP

78

79

In order to upgrade the IT facilities in different Program offices in the RCH wing, the following proposal is prepared and placed as under. SL Description No 1 Desktop Computers to Computer Centre (Data Entry, Report Generation, Internet usage, e-mail, scanning of documents, etc, (Hardware with O/s, Anti Virus and MS Office Software Desktop Computers to be provided to different Program offices Server to store all the data collected from PHC, THO, DHO and other offices related to Health sector Un Interrupted Power supply to support the regular Power supply Quantity 10 Rate per unit 45,000/Estimated Total Cost (Rs. In Lakhs) 4.50

2 3

15 1

45,000/3,00,000/-

6.75 3.00

4

Network connection between 10.00 different program offices under RCH (including Switch, Router, network components and Wireless connectivity, etc, ) 6 Software Development for 15.00 different activity under D&E cell, MCH, FW, etc programs 7 Multimedia Projectors for 3 50,000/1.50 presentation Total 48.75 Total Estimated Cost : Rs. 48.75 lakhs (Rs. Forty Eight Lakhs eventy Five Thousands only)

5

Different capacity to different Program offices

8.00

80

PRINTING OF REGISTERS OBJECTIVE: The ANM's at the field level are loaded with lot of work both in the field as well as noting down the services provided in the register. At present they are maintaining around 30 registers of various kinds. By streamlining, we may downsize the No of registers maintained by the ANM's and also Information pertaining to single ANC case will be available in the single register. SCOPE: Authenticated information may be obtained from the grass root level, since only one register will be maintained. Easy to cross check whenever necessary, and comprehensive report may be prepared every month based on the information. DETAILS: It is planned to downsize the number of registers maintained by field staff at the SUB_Centre level. At present around 30 registers are maintained by ANM at the field level. Discussions were held with programme officers, field level staff and Doctors of PHC's to know about the existing registers and its usefulness. These registers are to be printed and supplied to all the subcentres for maintaining the records properly, and also to forward the data to D & E cell in the Directorate. ESTIMATE There are around 8000 and odd subcentres, need about 10,000 registers for the year 2009-2010. Each ANC case will have 80 columns ie., 5 pages, assuming 25 ANC,s in a month and 5 cases can be entered in 5 pages we require around 30 pages in a month, and for 1 year it works out to be360 pages, and for external cases we may require approximately around 200 pages, and Each register will be printed using A3 size paper. According to the above assumption we require 10,000 registers of A3 size having 600 pages each. Assuming each register to cost Rs 500, total cost works out to be 50 lakhs .

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PRINTING OF FORMATS OBJECTIVE: Government of India has introduced the new web enabled data transfer system throughout the country to have uniformity of data flow from all the states. Eventhough the data transfer is through web portal, hard copies are to be maintained in the respective institutions for future reference, and also for data capturing from the field level formats designed by GOI has to be printed and supplied to all the health institutions. SCOPE: Collecting data in a standard format supplied by GOI enables us to have a uniform reporting system, and also helps us in co-ordinating in a better way with the Central Government.

DETAILS: Implementation of WEB-ENABLED reporting system, as per the requirement of Govt Of India, the data has to be captured from Sub Centre level and upwards in the new format supplied by Govt Of India. The new formats have to be printed and Supplied to all the Institutions for capturing the data in the new format. ESTIMATE: Total no of Health Institutions of all levels right from SubCentre level works out to be 10675, say around 11,000, and each institute require 25 formats for 1 year and assuming each format is having around 5 sheets (10 pages), and cost of printing each format to be around Rs 10/= per format. The total cost works out to be Rs 27,50,000/= Say 30 lakhs

82

TRAINING PROGRAMME: OBJECTIVE: All field level staff are not computer literate, further the web based data transfer system itself is a new concept, which has to be understood properly, unless and untill we train the lower level staff, the very purpose of web portal will be defeated, as such Training programme to educated the field level staff is a must. SCOPE: By Training the lower level staff we will have uniform flow of data from all the lower health institutions, which will help in accurate consolidation and preparing required reports, further it helps in faster flow of data and helps in analysing the data. DETAILS: The WEB-ENABLED reporting system is a new computerized reporting system, wherein the data flows from the lower level to the State through WEB PORTAL. The lower level staff should be oriented towards the new system and exclusive training has to be imparted. Regular training programes at the state level, Division level, and at the District level has to be organized. ESTIMATE: It is assumed that 2 training programmes are arranged in a month from April 2009 onwards for various field level staff and estimating approximately around 50 trainees in each training programe and each programme on an average for 2 days the total cost for each training works out to be Rs 15,000 + Sundry expenses (100 people at Rs 100 per day +Rs 5,000 for logistic support). Total cost works out to be 3,60,000 (4Lakhs)

83

EVALUATION STUDY: OBJECTIVE: Evaluation of ongoing and implemented scheme in any department is a must, for effective planning of other schemes in the department. It helps in identifying the loop holes and problems faced while implementing the programmes, so that best strategy can be worked out to implement the scheme in the right direction. SCOPE: Evaluation studies will have a cross-check and cross verification of various developmental schemes implemented in the department. The lower level staff will work with caution and take extra care while implementing the programmes. DETAILS: The Health department is implementing several beneficiary oriented and development oriented schemes, for the health care of the people. It is mandatory to know how these schemes are reaching the people, and how successful the schemes are for the welfare of the people, further the assessment has to be done based on the feed back from the people. Evaluation studies on some of the Important schemes may be taken up for Evaluation both Inhouse and through External agency. ESTIMATE: Two evaluation studies on important schemes of the department may be considered to be done by external agency, for which an amount of Rs 10 lakhs may be earmarked and further sample check and sample studies can be taken up by the inhouse personnel of demography cell, for which an amount of Rs 15 lakhs may be earmarked.

INFRASTRUCTURE SUPPORT: OBJECTIVE: To have the latest statistical packages and latest computers and printers for the demography wing will help in analysing the data in a better way.

84

SCOPE: Adopting the latest technology available in the market, the demography cell personnel will be equipped and armed with latest technology for providing accurate reports, and also helps in generating the reports on time without delay. DETAILS: The infrastructure has to be updated keeping in mind the latest developments on the field, Since the D & E cell will be collecting the WEB based reports in near future latest computers and printers has to be procured for the section, further since the D & E cell is planning to take up sample check on various schemes of the department additional Vehicular support is required for the section. ESTIMATE The total estimated cost of Rs 10 Lakhs may be earmarked for purchasing computers, software and printers. Also 5 lakhs may be earmarked for vehicular support for the section which may be outsourced, which will help the D & E cell to take up the sample check survey effectively. Budget SL NO 1 2 3 4 5 PARTICULARS PRINTING OF REGISTERS PRINTING OF FORMATS TRAINING PROGRAMME EVALUATION STUDY INFRASTRUCTUR E SUPPORT TOTAL UNIT Nos Nos Nos Nos schemes Nos Nos UNIT COST (RS) 500 10 15,000 5,00,000 Total requirement 10,000 registers 2,75,000 formats 24 programmes ESTIMATE D COST (Rounded of) 50 LAKHS 30 LAKHS 4 LAKHS 10 LAKHS 15 LAKHS 10 LAKHS 5 LAKHS 124 LAKHS

2 studies Lumpsum lumpsum Computers, software,printer lumpsum Outsourced vehicle

85

86

3.11. PC & PNDT (Costing for activities under 3.11.2) Current Scenario: The state of Karnataka is also affected by the phenomena of reduction in child sex ratio. However the situation is not as alarming as that of the situation in Punjab and Haryana. In spite of this fact the PC and PNDT Act is being implemented strictly through out the state of Karnataka. The child sex ratio in Karnataka (district wise). is given below. Sl. No. District 1 Belagaum 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Bijapur Mandya Gulbarga Bagalkot Bidar Bangalore ® Bangalore (U) Dharvad Davangere Chitradurga Uttar Kannada Ballary Tumkur Gadag Dakshina Kannada Koppal Shimoga Haveri Hassan Udupi Chikkamagalur Kolar Mysore Raichur Chamarajnagar Kodagu 1991 955 956 959 959 NA 962 957 950 952 NA 960 949 957 970 NA 956 NA 961 NA 967 NA 978 971 966 965 NA 957 945 2001 921 928 934 938 940 941 942 943 943 946 946 946 947 949 952 952 952 956 957 958 958 959 959 962 964 964 977 927

All India average

87

Karnataka average

960

946

As seen from the figures given above, only in Belgaum District the child sex ratio is lesser than the national average. The child sex ratio is lesser than the Karnataka average in 13 Districts of Karnataka. In Kodagu district of Karnataka, the child sex ratio has actually increased by 20 points. 3.11.1 Objectives: 1. To maintain equal sex ratio by creating awareness among publics by more & more IEC activities. 3.11.2 Activities: 1: The public at large is still unaware of the provisions of PC & PNDT Act and also regarding the ban of female feticide. It is necessary to reach the public through the electronic and print media, hence adequate provisions are made in the PIP in this regard. Apart from electronic and print media, it is also proposed to conduct a state level workshop and several district level workshops. Suitable provisions are also made in the PIP for carrying out these activities. 2: It is proposed to conduct State level Workshop for Health Professionals to create awareness of the hazards of Sex ratio and at the District level for Health Staff as TOT to carry on the Programme to the Taluk level and Hobli level. 3: It is proposed to conduct Work shops at Taluk level four per year at the rate of ten thousand rupees per event involving the Health staff, PRI's members, NGO's and Media representatives. 4: It is proposed to carryout the above strategies with the aid of Audio-Visual media and print media and Electronic media along with the integrated work with NG ... 3.11.3. Budget 1. Honorarium and TA of Legal Assistant a) Honorarium of legal assistant 25000x12 a) Towards traveling allowance of legal Assistant b) Wages for Data Entry Operators x2 II III 3,00000x1 2500x12 1,44,000 2,00,000 5,00,000 5,50,000/300000 1,74,000

Provision towards establishment working of separate 200000x1 cell for PNDT Towards IEC activities by NGO's 5,00,000 1) Electronic media: c) Towards tele casting of TV spots at Rs 1000/-x55 weeks 88 5,50,000/-

2) Print media a) News paper advertisements(state level) 3,00,000/3,00,000/1,50,000/c) Advertisements in magazines and periodicals 1,50,000/(Kannada) 4. Workshop at state level Organising State/District Level workshop for Health 12,64,000/Staff 176 Taluks x 4 camps per year x Rs 10,000/Total Total Cost: Rs.104.78 lakhs 3.12. PROGRAMME MANAGEMENT 3.12.1. BACK DROP: Health & Family Welfare Services has been implementing various service activities under Maternal and Child Health and Disease Control Programs from the time of inception of these programs. It has been a felt need of the department to have services of professional managers at various levels of implementation in order to improve the performance of various programs. The traditional Health Programs along with the NRHM initiatives and innovations in terms of programmatic support, schemes & innovative financing have to be professionally managed at all levels if tangible results have to be achieved within the mission period including the attainment of Millennium Development Goals. 3.12.2. OBJECTIVE: a. b. Providing managerial experts of general, financial and accountancy at Various level of service management. Rearrange such of the programs related to each other but otherwise under different systems of administration & service management, under a unified umbrella of command thereby optimizing the implementation and monitoring. 70,40,000 83,04,000 1,04,78,000

89

3.12.3. STRATEGY : a. Establish functional program management units at State, District & Block level. b. In-sourcing of various experts in technical management of the different initiatives. c. Functional integration of different program divisions at the Directorate of Health and Family Welfare Services. d. Strengthening of Block / Taluk Health office through provision of additional manpower, infrastructure, and logistics over the coming years. e. Make the taluk health office as a fully functional unit of implementation of not only NRHM activities but also the different National Health programs 3.12.4. PROGRAM IMPLEMENTATION STRATEGY: a. Recruitment of MBA qualified persons at State & District. b. And BBM qualified person at the Block / Taluk level. c. Empowering the Deputy Commissioners to recruit Block Program Managers in order to accelerate the implementation and encourage local talent to participate in the management of health activities. d. Training & continuous hand holding of all the managerial staff so recruited. e. In-sourcing of qualified technical persons who are experts in their field of operation as consultants. f. Strengthening the financial system management through in-sourcing qualified & competent experts in financial management. g. Creating "BLOCK HEALTH RESOURCE CENTRE" (BHRC) out of the BPMUs by further strengthening them. The BHRC will consist of different officers at Taluk, NGOs who are active in the field of health and have an community acceptable presence in the taluk, IMA and local donors. h. Creating such a cadre of Taluk Health Officers and train them and groom them so that over a period of time they can take up greater responsibilities at Taluka, District and at State level. 90

i. Involve the Regional Commissioners and the Assistant Commissioners of revenue sub division in monitoring the NRHM implementation as well as monitor the convergence activities of the Health and Health related departments like Women & Child development, Rural drinking water supply, total sanitation campaign(all under RDPR) Education and Tribal development etc at the implementation level. j. Finding suitable place in the Directorate of Health & Family Welfare Services to relocate the blood blank JD / DD from KSAPS and integrate with the NRHM and Director of Health & Family Welfare Services.

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3.12.5. JOURNEY SO FAR: a. The State Program Manager and State Finance Manager have been appointed during the year of 2007-08 and are provided supporting staff & necessary logistics. The State Accounts Manager has also been recruited and placed in the SPMU. The Management intricacies of the entire NRHM program is being streamlined with the constitution and strengthening of the SPMU under the overall supervision of the Chief Administrative Officer of the KHSDRP who has been given an additional responsibility of the SPMU. The Financial Management also has been streamlined with the Chief Finance Officer (CFO) of KHSDRP being given the additional responsibilities of managing the NRHM finance. The FMG at the state level has been constituted and functioning under the overall leadership of CFO. b. The finance management has been further strengthened by opting for core banking system with SBI & SBM which has resulted in easy flow of funds from the State upto the facility. The release as well as the expenditure is being closely monitored through EFT and monthly balance MIS report obtained from the banks respectively. c. State has got 176 blocks / talukas which have been strengthened by constituting BMPU with the provision of Block Program Manager & Block Accounts Manager. d. At the district level the MBA qualified District Progam Managers have been appointed during 2006-07. The qualified District Accounts Managers have also been selected and placed in all the district DPMUs. They have been provided necessary supporting staff in accounting and data entry. The DPMU is headed by the District Program Management Officer (DPMO) there by merging and unifying the NRHM & KHSDRP functions which has been giving a much needed thrust to the program implementation of NRHM activities at and below the District level. This has also resulted in relatively young officers assuming responsibilities which is a welcome and needed change for the development of the department. e. Five state level consultants who were planned and recruited under RCH-II program are assisting the NRHM program division / SPMU very effectively and efficiently. SPMU has been further strengthened by the provision of two more NRHM consultants to improve the quality and effective management through providing necessary directional inputs to the SPMU. 3.12.6. MILESTONES IN THE JOURNEY: It is worth recollecting here and placing on records some of the decisions and actions in the NRHM implementation over the past years which have made significant and perceptible impact on the integration of the Mission with the general health activities and sensitizing the entire Department of Health & Family Welfare and other departments in the Government, so also the elected representatives and general public. Though the journey was naturally arduous in the beginning, these decisions have helped in gathering the momentum in implementation in the recent past.

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a. Integration of KHSDRP and the Mission at state and merger at District level has resulted in providing the synergy and avoiding duplication in implementation and bring about economy in all the activities, since the KHSDRP & NRHM are working for the achievement of the same millennium development goals. b. To this effect the world bank was convinced the usefulness and utility of integrating the two programs and the bank has given permission to utilize the KHSDRP funds for training of members of 23,000 VHSCs, members of the Community Health planning and monitoring comities of various levels, Arogya Raksha Samithi members and other related PRI members. c. The Mission Director, NRHM office has been setup in the premises of Directorate of Health & Family Welfare Services to bring about close, regular and intensive interaction with all the state level officers which will finally lead to the ownership of the NRHM activities by the Directorate and assured sustainability. d. All procurement of NRHM & KHSDRP have been internalized with the Commissionerate of Health & Family Welfare and Directorate of Health & Family Welfare Services by creating a functional need assessment committee under the chairmanship of JD planning, thereby avoiding multiplicity of procurement of goods, equipments and works. e. Procurement has been further internalized in the sense that all the RCH procurement has been given to Karnataka Drug Logistics and Ware House Society under the chairmanship of Commissioner of Health & Family Welfare, which has been developed on the model of TNMC. f. The program officers of the RCH thus can devote their full time in program planning and implementation. g. The engineering division which existed with the KHSDRP has been given the responsibility of civil works, both of fresh and repairs of different physical infrastructures taken up by the State, NRHM & KHSDRP which has resulted in unified execution of civil works, accountability and cost cutting. h. "What is not monitored does not get implemented" is the time tested management philosophy which has been fully practiced in the state. 1. The Executive Committee meeting of the State Mission is conducted every month without fail under the chairmanship of Secretary, Health & Family Welfare, wherein the different components of NRHM are reviewed in totality of all stages of planning, programming, process and implementation. 2. The responsibility of technical monthly review of the officers of the Directorate of Disease control programs has been given to the Director of Health & Family Welfare Services and that of MCH, to the Project Director, RCH thereby monitoring the quality of supervision and implementation. 3. Divisional and District review meetings are happening regularly at the respective head quarters by involving the heads of the Districts, both revenue and ZP administration which has given the necessary pace for the NRHM implementation.

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4. The officers working in the different program divisions of the Directorate of Health & Family Welfare Services have been given the responsibility of mentoring and monitoring one district each as "NODAL OFFICERS OF THE DISTRICT" to not only visit for 3 days in a month or as often as necessary to these districts and closely monitor the implementation of NRHM activities at different facilities but also interact with the Chief Executive Officer of the Zilla Panchayat & the Deputy Commissioner of the District. They also have been given structured review formats so that the quality of the review is uniform, and have been asked to be present in the District Health Society and District Health Mission meeting as observers from the State Directorate. 5. Elaborate guidelines of implementation of all the line items under RCH-II & NRHM Additionalities have been prepared in kannada language and issued to the districts for guidance under the joint signature of Commissioner and Mission Director, thereby providing right signals to the implementing units with the much needed unity and clarity in command. 6. "Group SIMs" have been provided to all the officers of the Health Directorate, NRHM, KHSDRP and SPMU at the State and all the officers of the District for trouble free communication and continuous monitoring. 3.12.7. ROAD MAP AHEAD: a. Integrating the RTI & STI / Blood bank / TB with the MCH. b. Strengthening of SPMU, DPMU & BPMU through training, regular structured review of programs through the analysis of feedback from the report of nodal officers and through data based management. c. The Group SIM facility is going be extended to all the Taluka Health Officers and BPMU in the year 2009-10. d. Further consolidating the different management activities, expertise and gains accrued so far. e. The "BLOCK HEALTH RESOURCE CENTRE" (BHRC) at Taluk level is a new concept to effectively decentralize the planning, programming, implementation, review and evaluation of all the NRHM and other Health activities, through the participation of the locally positioned manpower, both Government & Non-Government, but under the overall programme goal, objective and direction and further made accountable for the output and outcome rather than input, infrastructure and process. 3.12.8. Budget: in lakhs Sl.No Budget Head Programme Management (State level) State Programme Manager & State Finance Manager Untit Mesure Base Line Target Rate Amount (Rs: In Lakhs

1

Number

2

25000.00

6.00

94

2 3 4 5

State Accounts Manager & State Data Number Manager 3 Administrative Asst, 4 Accounts Asst, 2 Statistical Assist. 3 computer Asst for SPMU Mission Director 3 group ' Employee D'

2 9 3 3

25000.00 7500.00 7500.00 5000.00

6.00 8.10 8.10 1.80

95

6

Hiring of 5 vehicles for SPMU staff to undertake tour for monitoring & inspection of district health society and programme implementation at Rs. 40000/- per month per vehicle Contingency expenses for stationary, post, telephone, TA/DA, meetings, office expenses etc., Furniture, Equipments, Computers, Xerox, Computer Networking, Scanner, Printing, UPS, etc Training of District Accounts Manager, Accounts Asst. @ state, Districts, Block level Management unit i.e.around 1920 members Monotiering NRHM Activities by state nodel Officers Programme Asst Salary State Untied fund Total Programme Management (Dist level)

Number

5

40000.00

30.00

7

Lumsum

65.00

8

Lumsum

100.00

9

Lumsum

48.20

10 11 12

Lumsum 1 15000.00

25.00 1.80 100.00 400.00

1 2 3 4 6 8 10

DPM Salary District Accounts Manager Salary Account Assst Salary Dist Data Asst Salary D group Employee Contingency expenses for stationary, post, telephone, TA/DA, meetings, office expenses @the rate ofRs.3 lakhs. Dist Untied fund Total Grand Total Lumsum

29 29 29 29 29 29

20000.00 15000.00 7500.00 7500.00 5000.00 300000.00

69.60 52.20 26.10 26.10 17.80 108.20 100.00 400.00 800.00

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3.13.QUALITY ASSURANCE PROGRAMME 3.13.1 Background: Quality Assurance can be defined as mechanism / process that contributes to defining designing, assessing, monitoring and improving the quality of health care. These activities can be performed as part of the accreditation of facilities, supervision of health workers or other efforts to improve performance of health workers and the quality of health services. Hence QA applies broadly to an entire cycle of assessments which extends beyond problem identification, to verification of the problem, identification of what is correctable initiation of innervations / improvement and continual review to assure that identified problems have been adequately corrected, quality of services improved and no further problems have been engendered in the process. 6.2 The Quality Assurance Programme is made up of two main components: · · Quality Assessments Quality improvement

The Monitoring and Evaluation (M&E) framework of the Ministry of Health and Family Welfare (MOHFW) for the National Rural Health Mission (NRHM) has proposed to introduce the Quality Assurance (QA) program for assessing and improving of the quality of services at public sector health facilities. FRONTIERS program of Population Council and UNFPA jointly developed a QA manual and tested in Gujarat and Maharashtra to demonstrate that QA could be easily integrated at district level management (Leila. Khan, Agarwal and Sharma, 2006). Subsequently, QA program has been scaled-up in all the 25 districts of Gujarat (Khan, Mishra, Sharma and Varkey, 2008). Appreciating the potentiality of QA checklists in improving quality of care, the MOHFW is currently pilot testing slightly modified version of QA tools in six states, including Karnataka and Maharashtra. The revised QA manual also covers a wider service delivery network by including sub-centers and RCH camps in the QA program. FRONTIERS Program of Population Council with financial support from UNFPA is providing technical assistance to the states of Maharashtra and Karnataka in implementing the QA program and helping its institutionalization in the district level management. During first round of visits, the DQAG had established the mechanism to monitor and assess the extent the facilities have taken initiative to address the gaps identified by QA visits. The review of the `actions taken' showed that facilities were using findings of the QA visits for improving functioning of their facilities. For example, analysis reveled that 48 percent of the suggested actions at CHC/PHC in Tumkur have already been taken. 97

Similarly, in case of sub-centers, the process of filling service delivery gaps has started in the district. A review showed that half of the gaps (50 percent) identified in Tumkur subcenters have already been addressed (Khan et al, 2008). Analysis of the activities executed indicates that no-cost actions, which are mostly to be taken at facility level, can be quickly executed as compared to the cost actions for which the district or state require more time for allocating resources or taking approval before executing them. It is encouraging to note that beside no-cost actions many cost actions had also been attended. For example, in Tumkur more than one-third (37 percent) of the cost actions for CHC/PHCs had been executed. After initial difficulties, now the QA activities have been fully linked with NRHM and the required resources for quality improvement are obtained through district program Implementation program (DPIP) mechanism. The revisits to facilities had started from February 2008 in Tumkur district. Quality of QA Visits FRONTIERS staff regularly accompanied the QA teams on rotational basis to monitor the quality of QA visits and to provide hands-on TA to team members. The attributes for classifying `good' quality visit are given in Box 1. Absence of two or more of the quality attributes were classified as `average' or `poor' visit. During the first quarter FRONTIERS staff accompanied 9 QA visits, the analysis shows that majority of the visits (88 percent) were of `good' quality and rest (12 percent) were marked as `average'. On an average five facility staff attended the pre-assessment briefing. During all 9 visits, the QA team leader debriefed the facility in-charge. In general, the observations on the debriefing sessions with facility in-charge were generally precise, all gaps were pointed out and action points were listed and discussed. All this indicate that QA visit to a great extent has institutionalized in the district health system and the capacity of district officials has adequately developed to conduct and use QA visits for quality improvement. Key Service Delivery Gaps during Second Round of Visits The key gaps identified at CHC/PHCs and sub-centers are as following (a) Gaps observed at PHCs Training · MOs need training in EmOC, sterilization and MTP Infrastructure · Functional OT to conduct sterilization operations to be made available, · Vehicle and Generator with POL need to be arranged Equipments and Supplies · Equipments required such as Autoclave, Oxygen cylinder, MVA syringe, · Reagents such as gram staining and RPR kits are required · Short supply of medicines and consumables such as Tab. Azithromycin, Inj. Magnesium Sulphate, Glutaraldehyde concentrate and ECPs. Records · Records need to be properly maintained and regularly updated such as ECP usage, vehicle log book

98

(b) Gaps observed at Sub-centers Equipments and supplies · Short supply of equipments such as Baby Ambu bag, Centchroman, ECPs etc. Service delivery process · Providers need to be instructed to use Parthograph, counseling of women. Records · Referrals register for the low birth weight newborns need to be maintained. Number of Actions Identified and Responsibility Assigned The analysis of gaps identified and actions suggested by QA teams during the QA visits made in the first quarter (Feb­March) of 2008 indicates that in Tumkur, on an average 26 action points ­ nine at facility level and 17 at district level­were suggested for RH/PHCs. Similarly on an average 13 action points for sub-centers ­ nine at facility level and four at district level were identified to improve the quality of service delivery. Analysis of QA Data Overall Facility Grades: The analysis of overall facility scores from first and second round of visits shows remarkable improvements in facility grades. While during first round only nine percent of CHC/PHCs in Tumkur were in Grade A (scored more than 75 percent of the total score), 48 percent in Grade B (scored 51-75 percent of the total score), and remaining 43 percent were in Grade C (26-50 percent of the total score), in the second round the facilities scoring grade A increased to 38 percent and 62 percent scored grade B (Figure 1).

99

Figure 1: Overall Grades of CHC/PHCs in First and Second Round of QA Visits First round of QA visits (n=35)

Grade A 9%

Second round of QA visits (n=16)

Grade C 43% Grade B 48%

Grade B 62%

Grade A 38%

The overall scores for sub-centers revealed that while majority of sub-centers were in B or lower grades during second more than thirds (69 percent) of sub-centers scored A grade (Figure 2). Figure 2: Overall Grades of Sub-centers in First and Second Round of QA Visits First round of QA visits (n=47)

Grade D 4% Grade A 19% Grade B 31%

Second round of QA visits (n=16)

Grade C 34% Grade B 43% Grade A 69%

At individual facility level analysis shows that that all the facilities in the district scored higher grades during second visit as compared to their corresponding grades obtained in the first visit. Average score of the facilities visited increased by 25 percent points in CHC/PHCs (from 49 to 74 percent) and 27 percent points in sub-centers, from 53 to 80 percent (See figures 3 and 4). Figure 3: Overall facility Scores from First and Second Round of QA visits (CHC/PHCs)

100

CHC/PHCs (n=16)

100 75

Per cent

50 25 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Facilities

First QA visit

Second QA visit

from First and Second Round of QA visits (Sub-centers)

Figu re 4: Over all facili ty Scor es

To get insight into the gaps causing lower facility grades, the `input' and `process' scores have been separately analyzed and presented below. The elements relating to facility readiness such as, human resources, infrastructure, equipments and supplies and availability of service delivery protocols have been grouped together as `inputs'. Similarly, the elements relating to the service delivery environment and procedures are have been grouped together as `processes". These include cleanliness, infection prevention practices, maintenance of records and maintaining the hygiene and asepsis among others. Inputs: The analysis of input grades of CHC/PHCs shows facility readiness and availability of human resources to provide quality RCH services have improved significantly in the district between first and second round of visits. While during first round of visits, only 6 percent of CHC/PHCs scored input grade A, it increased to 31 percent in the second round of visits (Figure 5). The facilities scoring C grade reduced from 43 percent in the first round to 6 percent in the second round.

First round of QA visits (n=35)

Grade A 6%

Second round of QA visits (n=16)

Grade C 6% Grade A 31%

Grade C 43% Grade B 51%

Grade B 63%

The inputs score of sub-centers also increased significantly in between first and second round of visits. While during first round majority of sub-centers (87 percent) scored B

101

grade or lower, three-fourths of them achieved A grade during second round of visits (Figure 6).

Figure 6: Input Grades of sub-centers in First and Second Round of QA Visits First round of QA visits (n=47)

Grade D 4% Grade A 13%

Second round of QA visits (n=16)

Grade C 6% Grade B 19%

Grade C 40%

Grade B 43%

Grade A 75%

6.7 State's Decision to Scale-up the QI initiative in Five More Districts Impressed by the QA visits bringing improvements in quality of service delivery, Principal Secretary, Health and family welfare, Government of Karnataka has decided to scale-up quality improvement activities in the entire state in the phased manner. As the first step, the state health department has decided to scale-up the QA program in five more districts of Karnataka and remaining CHC/PHCs and sub-centers of Tumkur district. The state health department has also asked the districts to allocate resources required for conducting the QA visits and initiate actions identified by these visits in their district PIP. The state health department has requested the Population Council to extend the technical assistance in scaling up of QA in five districts. Although the Population Council is willing to extend the TA to state health department, the resources required for TA such as field staff salary, travel cost. Etc. are the constraints and it need to be arranged either by the government through making provision of TA in NRHM program implementation plan, or through support from development partners. Presently with limited resources, Population Council is providing TA to the state to constitute and train the district quality assurance groups (DQAGs) in the scale-up districts.

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6.8 Conclusions Readiness (infrastructure supplies and trained human resources) of the health facilities at all level has shown significant improvement which is an important requisite for providing quality services. The process component which actually address to the quality of delivering services has also shown improvement but at a lot more initiative from district health management is required. It is primarily because it demands behavioral change, adherence to clinical standards and adoption of good practices. To accelerate the improvement in the processes, supportive supervision need to be strengthened and more attention should be given to review the process part. Scaling up of quality improvement initiatives to five more districts of Karnataka shows state health department's commitment to provide quality services from public health facilities in the entire state. The state health department has requested for TA from Population Council to scale-up the QA program in these five districts. Population Council is willing to provide the TA to state but the resources required for TA provision need to be worked out. We feel that either the Ministry of Health and Family Welfare should allocate the resources for TA in the NRHM program implementation plan or the ministry collaborates with the donor agencies to support the TA cost of Population Council staff. Integration of the QA program with DPIP and drawing resources from NRHM to conduct QA activities is an important achievement. It ensures that available fund with state/district/facility level is being used for improving the access and quality of services.

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ANNEXURE-11 FINANCIAL MANAGEMENT REPORT (FMR) LINE ITEMS PLANNING AND FINANCIAL ESTIMATION NORMS SHEET (A Guide and ready reckoner to the District Health and Family Welfare Officer for Preparing the Program Implementation Plan, filling up of FMR and monitoring of the NRHM Activities) Financial Plan and First Final Target Moderaition Estimation Activity Estimation Estimation Estimation Estimation Officer Norms in Level Officer Officer Norms lakh 6 Dist are selected in 48.00 QA Programme A 8.5 Quality Assurance DHO DHO RO(RCH) PD (RCH) (800000*6) Following districts are to implementing in 5 Dist are QAP in 09-10: selected in 1) Gulbarga DHO DHO RO(RCH) PD (RCH) QA 40.00 2) Bellary Programme 3) Chitradurga (800000*5) 4) Gadag 5) Raichur Total 88.00 FMR Code

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