NATIONAL HEALTH MISSION

 
Special Schemes
 
 
Panchamrit

Introduction

Rajasthan has an extensive physical infrastructure and large manpower engaged in the delivery of health services. The health situation is still far from encouraging.

The situation can be judged from the fact that out of the 90 problem districts identified in India where the birth rate and the infant mortality rate are significantly high, 27 districts belong to Rajasthan. Mothers and children share major mortality and morbidity burden, that too mainly due to preventable reasons.

Sixty seven new born are not able to see their first birth day and as many as 667 women die per 100,000 live births from causes which are preventable by simple interventions. The survival of children in the State is also low. Out 1.6 million children born every year in Rajasthan, 0.15 million die within 12 months of their birth and many more die until they reach five years of age.

Immunization is the most cost effective tool; available, to save mothers and children. Despite of all efforts some areas or sections of population are always left out. Therefore as an additional effort- a special drive to reach the un-reached population, GOI is advocating conduction of Immunization Week every month from January to March 2006. This week will be conducted in states having low coverage; Rajasthan is one of these states.

The Immunization Week is a national initiative to strengthen RI through identification of population without access to or utilization of services; may be remote areas, urban slums or vulnerable groups.

GOR has decided to include few more components to this initiative, considering existing reach and utilization of our health services; taking into account present morbidity and mortality profile of our population and above all, mobilization of resources bound to happen during these weeks, to reach the un-reached more effectively. Rajasthan’s initiative- PANCHAMRIT, thus include five component of health care delivery for the health and welfare of mother and child.

The State decides to continue this activity on sustainable, regular basis in future after every thing is streamlined.

Demographic Profile

In rural areas 30.99 per cent families are BPL compared to 10.79 per cent in urban areas. The data shows that the districts with sizeable population of scheduled tribes, viz., Banswara, Dungarpur, Udaipur and Chittorgarh have the highest proportions of persons BPL. It has been also seen that the incidence of poverty is quite low in desert districts of Jhunjhunu, Sikar, Jodhpur and Nagaur.

The basic demographic characteristics of Rajasthan and India are as follows:_-

Status

India

Rajasthan

Population (Lakhs 2001)

10270

565

Rural Pop’n %

72.22

76.61

Decadal GR % as censes (2001)

+21.34

+28.41

Pop’n Density

324

165

Female Literacy

54 .16

43.9

Sex Ratio

933

921

CBR SRS 2003

25.0

30.3

CDR  SRS 2003

8.1

7.6

IMR SRS 2002

63

75

MMR 1997

408

677

TFR SRS 2002

3.2

4.1

CPR

46.2 (2000)

43.9(2005

Source- Census 2001

Goals Set to be Achieved by 2010-11

Indicator

Vision 2011Goal

IMR

56

MMR

285

CBR

18.5

CPR

65

TFR

2.1

Growth Rate (Annual)

1.2

Immunization TT PW

Children <1 yr. Fully immunized

85

Efforts as on today

1. Maternal Health

  • Antenatal Care – Efforts are being strengthened to increase ANC coverage through MCHN days. CNA have been conducted to identify eligible couples and pregnant women are tracked for ANC through ASHAs and JMC. JSY Scheme has also been included to promote BPL population.
  • Delivery by skilled birth attendant –

Institutional deliveries are being promoted so as to increase the percentage of Deliveries by skilled birth attendant in rural areas

  • PNC- two postnatal checkups is being done to every delivered mother. It is being promoted through JSY scheme and MCHN days.
  • 24 hrs delivery scheme- Total 1178 PHCs and 194 CHCs are covered in the scheme. There is provision of Rs 100/- for Doctors, Rs 100/- for ANM. Rs 100/- for motivators (Dai, AWW, JMC, SHG, ASHA and others) and Rs 30/- for sweeper for each night delivery.
  • Dai Training scheme- Approx. 50,000 Dais have been identified to be trained for conducting clean and safe deliveries, 20855 Dais have been trained so far.
  • Strengthening Institution for providing emergency obstetric care services –150 new BEmOC and 50 CEmOC have been strengthened so far to handle emergency obstetric care.
  • Development of Model PHC- To provide 24 hrs emergency medical and obstetric services 97 PHCs have been developed as Model PHC.
2. Child Health :
  • Routine Immunization- Routine immunization is being strengthened by increasing access to the un-reached through MCHN days, better monitoring system, safe injection by Auto Disable syringes, effective cold chain system and improved VPD surveillance.
  • Pulse Polio drive- No Polio case reported in the State during last three years. More than 95% coverage in NID and SNID is achieved.
  • MCHN days session – In the State 49000 MCHN sessions have been planned to be held every month, so as to reach every village on a fixed day at a fixed site.
  • IMNCI- More than 50% infant’s death occurs in Neo-natal period. Three home visits by health worker/ANM/Sahyogini for new born during first week after birth is the key strategy for the IMNCI programme. The programme is running in two districts at present and being introduced in another eight districts of the State shortly.

3. Family Planning:

  • Promotion of spacing methods- It is being done through health worker and about 40000 JMC. Social Marketing of contraceptive is being implemented.
  • Promotion of NSV – State level, District level and Block level workshops have been held for the Promotion of NSV. Two Mega camps in each district are being held to popularize NSV among masses. Doctors are being trained to increase service providers.
  • Incentive for sterilization- Incentive and cash award to beneficiaries, Motivators and workers is being provided in the population stabilization programme. Funds have been allotted to improve quality of camps.

4. Adolescent reproductive health:- Life skill education has been included in 11 standard syllabus.

5. Provision of ASHA- Volunteer social worker to assist various activities (MCH/RI) are identified in each village having a population of 1000 and they will be provided incentive for various activities.

6. RCH Camps scheme- To provide various RCH services Camps are being organized at 20 remote PHCs of each districts Bi-monthly. Services provided are ANC, PNC, immunization, RTI, STI and spacing methods.


Why Panchamrit

Fixed day, fixed site outreach sessions (MCHN sessions) are already being held every month in each village in Rajasthan. Ranges of activities; such as immunization, ANC, distribution of contraceptives etc. are performed during each MCHN session. As on today about 70% of sessions are reportedly being held, about 10,000 MCHN sessions are not being held regularly as many of them are in far-flung areas.Their plan has been prepared and will be implemented from june 2006.

Therefore, many villages and hamlets; especially those in remote and inaccessible area, due to difficult geographical terrain or seasonal inaccessibility or villages without Anganwari/ SC or sub centers without ANM or non acceptors due to religious or any other reason and urban slums are not being adequately covered.

It is important to know who the un-reached are, where they are, and why they are underserved, so that managers can develop alternative; effective strategy to reach and serve them. Therefore GOR has planned to intensify MCHN activities along with immunization through PANCHAMRIT drive i.e. a set of five interventions for mother and child, through focused and concentrated efforts; targeting on, so far un-reached areas, for one week each month in next three months i.e. January to March 2006.It has been done successfully.

Objective

Overall purpose of this initiative is to reach the left out and hard to reach area i.e. to promote over all health of the mother and child living in far- flung and vulnerable areas by concentrating efforts and resources; in reaching inaccessible and un-approached areas and improving coverage of MCHN services.

Components of Panchamrit: A 5 point Program for mother and child welfare.

  1. Elimination of Vaccine Preventable Diseases: through universal (100%) immunization.
  2. Elimination of Micronutrient Deficiency: through
    · Elimination of Vit. A Deficiency in children less than five years.
    · Elimination of Iodine Deficiency
    · Reduction of Iron Deficiency in children less than five years and mothers.
    · Promotion of Breast Feeding.
  3. Family Welfare: ensuring · Contraseptive methods
    . Sterilization (Male/Female)
    . Contraseptive (IUD,OP,Condom,E-pils)
    · Safe MTP
  4. Safe Motherhood: ensuring
    · 100% Registration of pregnancy and provision of at least three Ante Natal check ups.
    · Increase institutional deliveries to at least 50% of all deliveries.
    · Promoting deliveries by Skilled Birth Attendant (ANM/ MO)
    · Ensure provisions by Janani Suraksha Yojana
    · Spacing Births- Three year interval between two births.
    · Right Age at marriage through Promotional Activities.

5. Ensuring Healthy New Born:

· Reduce Neonatal Mortality by ensuring 100% registration of new borns and providing check ups.

Activities for Each Component:

AWW/ Sahyogini/ ASHA and ANM will ensure presence of all beneficiaries by informing them well in advance about session site, time and services available

1. Elimination of Vaccine Preventable Diseases:

  • Vaccination of All Targeted beneficiary by All antigens (BCG, Polio, DPT, Measles for children and TT for mothers) at Right Age.
  • i.e.- BCG & Polio at birth to all institutional deliveries,
  • BCG (if not given at birth); Polio and DPT at 6 weeks of age,
  • Second and third dose of OPV & DPT at 4 weeks interval and
  • Measles vaccination at completion of nine months.
  • BCG can be given during any visit, before one year of age, if not given previously.

2. Elimination of Micronutrient Deficiency:

  • Elimination of Vit. A Deficiency in children less than five years: through administration of Vit A solution (1,00,000 IU) with Measles vaccination at 9 completed months of age. This improves measles sero-conversion as well as helps eliminate Vit A deficiency. Vitamin- A deficiency is the main cause of night blindness.
  • Second dose of Vit A (2,00,000 IU) should be given with Booster dose of OPV/ DPT at 16-24 months of age and there after three more doses of Vit A (2,00,000 IU) at six moths interval.
  • Elimination of Iodine Deficiency: Families are asked to bring sample of salt they are using to the session site, on MCHN day. ANM is supposed to carry iodine-testing kit. She will test salt samples and using the results as reference emphasizes up on the importance of using iodized salt and consequences of iodine deficiency.

Iodine deficiency causes goiter, mental retardation , Stunted growth, miscarriages etc.

  • Reduction of Iron Deficiency in children less than five years and mothers: all pregnant and lactating mothers and children below 5 years will be given prophylactic IFA Tab. (100 tablets per beneficiary to be taken one daily after meals). For identification of anemia physical check up (pallor of eyes, tongue and nails) will suffice and therapeutic dose will be given as per norms. Advocacy for balanced diet and right cooking practices will follow.

Iron deficiency is the main cause of nutritional anemia which leads to loss of energy and physical efficiency, it’s the main cause of low birth babies, pre-mature delivery (Common cause of IMR) and hemorrhages (APH/PPH) related to pregnancy.

  • Promotion of Breast Feeding: All pregnant mothers, preferably during early pregnancy, will be examined by ANM for retracted nipples and advised exercise for its correction.

ANM will talk about benefits of feeding First Milk (Colostrum) to the newborn; as early as possible (within half an hour of birth) and over all benefits of breast-feeding to all pregnant and lactating mothers. She will use local evidence to stress up on her point.

She will tell, when to start, how to feed and what to do in special conditions like cracking nipple, mastitis, indurations, nodule or breast abscess.

She will counter ensure breast-feeding by telling disadvantages of bottle-feeding.

3. Family Welfare:

  • Spacing Births- Three year interval between two births: Distribution condoms and oral pills, advocacy for IUD insertion including and use of E-Pill.
    ANM / AWW/ ASHA will talk with persons present including male members about importance of small family and ways to achieve it. She can use Flip- book, poster or any other IEC tool as per need and availability.
    She will ensure participation of Jan Mangal Couple, AWW and ASHA.
  • Right Age at marriage: Since early marriages are common tradition in most of the communities of Rajasthan and early pregnancy i.e. before full development of organs, is the major cause of maternal and child morbidity and mortality.
    She will arrange group meeting after the session, with opinion leaders/ religious leaders/ PRIs/ JMCs/ any social organization working there/mothers and other family members and talk to them about physical, social and mental problems associated with early marriages as well as legal implication associated.
    If any young mother death has occurred in her or neighboring area or any mentally retarded child has born to a young mother, she will use this as evidence to impress up on the gravity of right age at marriage..

4. Safe Mother-hood:

  • Register all pregnant mothers of her area and provide Ante Natal check up on the spot i.e. she will confirm pregnancy by history taking, take weight; blood pressure and do physical examination for Anemia and edema feet, do per abdominal examination for checking lie and verify gestational age with period of amenorrhoea. and advocate for at least three ANC check ups in pregnancy (preferably one in each trimester)
  • Increase institutional deliveries to at least 50% of all deliveries: she will talk with all pregnant mothers and their mother in law, any other member of community about- 1) un-predictability of pregnancy outcome, 2) importance of preparedness (how crucial are first two hour in saving life of mothers), 3) value of institutional delivery, and 4) Institutions in vicinity where round the clock Emergency Obstetric Care services are available, where they should go in case of emergency. 5) She will inform community about availability of funds with her or with medical officer for Referral Transportation for mothers in emergency to higher institutions.
  • Promoting deliveries by Skilled Birth Attendant: she will inform community about her availability (where about) so that, people can approach her in case of needs. She will conduct normal deliveries and before referring emergency obstetric cases, will provide first aid services.
  • Ensure utilization of provisions by Janani Suraksha Yojana for BPL Families: giving all needed information and informing people of the locality about ASHA and her role.
  • 5. Ensuring Healthy New Born:

    Reduce Neonatal Mortality by ensuring institutional deliveries and 100% registration of newborn. She will create environment for registry of all births and at least three check-ups within 7 days of birth. She will provide on the spot check-up to all newborn babies of her area during the session and advocate for future check-ups.

Targeted Areas:

· All Urban Slums
· Desert and Tribal Areas
· All C- Category Villages i. e. > ½ hour distance from the nearest sub-center, villages under SC where ANMs are not available (either not posted/ or deputed/ or on leave for three or more months), Villages with no SC or AWC.
· Left out villages/ hamlets during MCHN sessions.
· Reported case of vaccine preventable disease in last 2 years.
· Vaccination coverage less than 30%
· Areas of hard core Non- Acceptors due to religious or any other reasons.
· Areas where activities are either irregular or not provided at all.

Dates for Action:

  • First MCHN week – 26th January to 1st February 2006
  • Second MCHN week – 23rd February to 1st March 2006.
  • Third MCHN week – 4th April to 10th April 2006.

Scheduled Activities:

10th  January 2006

State level Orientation meeting at SIHFW

  • Orientation of district officials
  • Guidelines and Directives
  • Urban area plan

10-12th January 2006

District level orientation and planning

14-16th January 2006

PHC/CHC orientation and planning

Supervisory plan for PHC/CHCs & Urban area

17th January 2006

Submission of PHC/CHC plans at Block level

18th January 2006

Submission of Block plans at District level

20th January 2006

Submission of District plans at State Level

20-26th January 2006

Management of Logistics and supplies

26th  Jan.–01st Feb. 2006

Field activities –MCHN weeks

Strategy

The MCHN weeks will be observed with the joint coordination of Medical & Health Department and Women and Child Health Department. Principal Secretary, Medical & Health had requested Principal Secretary, WCD for their cooperation vide letter number dated 16th January 2006 .

1. Preparation of Micro-plan:

Sub-center, PHC and District Micro-plan shall be prepared and submitted to the State headquarters on 20th January 2006. The formats of the micro-plans have already been provided to all the districts on 10th January 2006. The guidelines for preparation of Micro-plan is as under:

(i) Sub-center Micro plan:

  • MO In-charge PHC shall identify the name of ANM who shall prepare the Sub-center Micro-plan. The ANM shall further identify the un-reached area (name of village/Mohalla) and its population.
  • ANM shall decide the fix session site for observing the MCHN day in each targeted village. In case of Dhanis/ pockets of few houses, mobile team consisting ANM & two to three social mobilizer shall be formed to observe the MCHN week house-to-house.
  • The ANM shall further identify the name of social mobilizer who shall mobilize the mother and children to the session site for MCHN activities. The mobilizer shall be AWW, Sahyogini, Sahayika, JMC or any other lady who can mobilize the beneficiaries to the session site.
  • All the information shall be entered in the appropriate column, for the full week. In case of the villages having population of less than 500, two session sites in a day can be planned but it should not be more than 30 minutes distance by vehicle.
  • The Micro-plan shall be submitted to the MO in-charge PHC before 15th Jully 2006, furnishing complete information in the formats.

(ii) PHC- Micro-plan

  • MO in-charge PHC shall collect the Micro plan of all the sub-centers and prepare the Micro-plan of PHC.
  • Day and sub-center wise information shall be entered in first nine columns with the help of sub-center micro plan. Similarly day and sub-center wise vaccine requirement shall be calculated. Minimum one vial of each antigen shall be calculated and entered in the appropriate column of the micro-plan. In the last total requirement of vaccine shall be calculated and entered.
  • The mobility support plan and the route charts shall be prepared by the MO PHC looking to the time required in the travelling. The Vaccine and Logistics should reach at the session site before 10 AM. In case more than one vehicle is required, it should be indicated in the mobility support plan but more than two vehicles in a PHC shall not be allowed.
    The Micro plan shall be submitted to the CMHO/RCHO latest by 21st Jully 2006.

(iii) Urban Micro-plan

  • Detailed Micro-plan for the urban slums is prepared by the RCHO and send to the Directorate latest by 15th Auguest 2006.
  • For services in urban slums staff can be mobilized from nearby dispensary/MCWC/UFWC/Hospital or urban revamping scheme. Staff can be mobilize from the area where MCHN week actually is not been carried out during the MCHN week. In case of shortage of staff one ANM per 10000 urban slums population can be hired. Hired ANM will conduct services in the identified uncovered areas and will be paid Rs 350/- per session. One social mobilizer for each session site is also be identified who shall mobilize the beneficiaries to the session site. Rs 150/- per session will be paid to the mobilizer. The ANM will carry vaccine, Kit-A, Medicines and other logistics from the cold chain depot herself at the session site.
  • RCHO would be Nodal officer , responsible for preparing Micro-plan and implementation of activities in urban slums at districts.
  • Dy. CMHO, MO Subdivision will likewise be responsible for activities and micro-planning of Sub-division level urban slums.
  • Doctors monitoring the pulse polo programme at district control room be made responsible to monitor Urban Slums MCHN week activities.

(iv) District Micro Plan

  • District Micro Plan of the districts shall be prepared by the CMHO/RCHO after compiling the Micro-plans of the PHC .
  • District Micro plan shall be submitted to the State before 1st week of Auguest 2006 through Fax.

(iii) Monitoring of MCHN days:

  • The 32 State Monitors who have been allotted to the Districts shall reach in their districts on first day to start the programme and monitor the activity.
  • Seven State Monitors of immunization cell who have been allotted the zone shall visit in their zone and monitor the activity through out the week.
  • The orientation and the Check list to the State Monitors shall be given on 23rd January 2006 in the Directorate.
  • The Check-list and the report of the Monitor shall be collected by the Dy. Director (Immunization) who shall identify the shortcoming and report shall be submitted to the Director (FW) with in three days of completion of the activity.
  • Dy. Director (Immunization) will be the key person of for MIS along with his assistants and persons from NPSP Jaipur Head quarter. NPSP shall support Dy Director Immunization in collecting the reports through net/fax etc.

2. District Level:

The concerned Joint Directors of the Zone will co-ordinate the activities and human resources in their respective zones.
CMHO, Additional CMHOs, RCHO, and Dy. CMHOs shall monitor full MCHN week in their area. All the officers shall visit at least three MCHN sessions per day and the report be submitted to the CMHO on same day.
CMHO shall submit his consolidated report to the Directorate control room on same day.

(3) PHC level:

MO in-charge PHC shall Monitor 100% MCHN days of his area and report shall be submitted to the CMHO/RCHO on the same day.

Roles and Responsibility:

Responsibilities

Officer in-Charge

Link Officer/Officials

Over all in Charge

Director (FW)

Director (WCD)

Mobility matters and logistics

State Cold Chain Officer

T.A (Cold Chain)

Human Resources management and supervision

Joint Director (RCH)

-

IEC Activities

Director (IEC)

Dr Sunil Singh

Vaccine arrangement and supply

Dy. Director (Immunization)

Shri Surender Singh, TA (Vaccine)

MIS collection & submission of report

Dy Director (Immunization)

Shri Ghanshyam Agarwal, SA

Control Room will work from 8 AM to 8 PM. Any assistance required can be sought from here and reports be sent on following phone/fax number:-

Phone/ Fax- 01412225715.

Our Partners:

Department of health and FW

Department of Women and Child Development

Department of Panchayat Raj.

UNICEF

WHO-NPSP

UNFPA

EC-SIP

CARE

NGOs

IMA and IAP

FOGSI

Parinche

Rajasthan faces a severe challenge in combating health care and its related issues like malnutrition, inadequate sanitation and the growing incidence of communicable diseases. The problems in access to health care are related to the harsh terrain and lack of efficient communication system. Since all these dimensions of human development needs improvement, the pilot project on Empowering Rural Communities through provision of additional health inputs in difficult areas of Rajasthan has been initiated in one sector PHC of five district namely Harsani, Barmer, Manohar Thana – Jhalawar, Losal – Sikar, Ajan – Bhartpur and Kalinjara – Banswara.

Under this project a community health worker/volunteer will be identified. This female volunteer will act as a change agent for overall development of the village. It attributes that they will not restrict their activity to health sector but make efforts for all-round development. These volunteers would regularly visit schools, help solve all veterinary poultry services required by villagers, take villagers in confidence to sustain a cleanliness and sanitary movement in the village. They will educate people to restrain from child marriage and educate them on better nutrition practices and mobilize the community to reach the point of self sufficiency in preventing common diseases.

Capacity building of these volunteers is critical in enhancing her effectiveness. It has been envisaged that training will help to equip her necessary knowledge and skills resulting in achieving of scheme objectives.

After the selection of volunteers, they will undergo nine months training process (2 days in a week i.e. 8 days in a month) to acquire necessary skills and confidence for performing her spelled out roles. A cascade model of training has been proposed where trainers for trainings will be trained at state and thereafter the teams will train volunteers at PHC level of each district, simultaneously. Each district has a training team, which may comprise of officers from various departments including animal husbandry, doctors / health activist of NGOs, officers of medical and health department or other related departments.

Social Marketing

Despite a longstanding social marketing programme for condoms and pills, there has not been a marked increase in the use of these methods. Experience of neighboring countries suggests substantial potential for greater use of pills by younger couples, if supported by counselling and BCC activities. The social marketing programme has suffered from:

  • A strong urban bias in the distribution network.
  • Low incentives for commercial participants.
  • A limited range of products.
  • The simultaneous presence of a wasteful, free distribution system.

Strategic Interventions

Social marketing of contraceptives, especially in rural areas will be strengthened. A strategy for Social Marketing is being developed and will include marketing of products and also the processes through social franchising. The creation of service availability through social franchising would enhance the availability in rural areas. The range of methods will be broadened. Community based depot holders and distributors will be part of the social marketing strategy. Social franchising would be the method to franchise the processes by franchising services of acceptable quality at affordable prices to the community. Condom vending machines are being introduced on a pilot basis in 54 HIV high-prevalence districts. The project has been promoted jointly by National AIDS Control Organization (NACO) and Department of family Welfare on a cost-sharing basis.

Involving Panchayati Raj Institutions, Urban local bodies and NGOs:

Establishing depot holders to increase coverage of family planning services, as many women are unable to leave their homes to attend health facilities. This is a major barrier even in life-threatening situations. Involving PRIs, ULBs and NGOs to mobilize the community, sensitizing community members to gender issues and training community members will enable women to access contraceptive services closer to home and support them in increasing their mobility.

Strategic Interventions

One couple (JJan Mangal couple) from each village will be selected by the villagers themselves and will be trained to provide counselling and services for non-clinical FP methods such as pills, condoms and others. They will be supplied with pills and condoms by the ANMs for free distribution and act as depot holders for these supplies. They will also procure pills and condoms from social marketing agencies and provide these contraceptives at the subsidized rate. They will provide referral services for methods available at medical facilities. They will assist in community mobilization and sensitization.