1 Dr. H. Bhushan Assistant Commissioner Maternal Health MoHFW-GOI

MH Interventions in RCH-II  Essential Obstetric Care :  Ensuring Quality ANC Care.  Institutional and Safe Delivery (promotion by Janani Suraksha Yojana).  Prophylaxis and treatment of Nutritional Anemia.  Provision of 24 Hrs Delivery Services at PHC.  Post natal care for mother and newborn.  Skilled Attendance at Birth (domiciliary & health facilities): Training of SNs/LHVs/ANMs in SBA. Orientation of MBBS Doctors in SBA.  Emergency Obstetric and neonatal Care Operationalization of First Referral Units (FRUs). Training of MBBS doctors in Life Saving Anaesthetic Skills and Emergency surgical interventions.  Referral Services at both Community and Institutional level. 2

MH Interventions (Contd..)  Other MH Interventions: Expand early Safe Abortion Services- introduce MVA at PHC level Strengthening RTI/ STI services at sub-district level. Setting up of Blood Storage Centers (BSC) at FRUs Village Health and Nutrition Day 3

RCH-II ( ): Operational Targets  Operationalize FRUs in the country;  Make at least 50% PHC operational for 24 hours  Management of common obstetric complications by MOs o Capacity building of MBBS doctors for Anaesthetic Skills at FRUs o Training MBBS doctors for Emergency Obstetric Care including caesarean Section.  Provision of Early and safe abortion; and  RTI/STI services at Sub District level  Train and empower MOs/ ANMs /LHVs as Skilled birth attendants  Develop referral linkages 4

Issues with Operationalization of facilities  Skewed priorities and fragmented efforts by the States. Need to prioritize strategies/interventions.  State RCH II PIPs do not reflect targets as prescribed in NPIP.  State and District Action Plans (training centres/cells, drugs, equipment, funds etc.) not in place.  Shortfall of specialist Manpower.  Irrational deployment and posting of trainers and trained manpower.  Improper mapping of resources.  Shortage of Blood Storage Centers. 5

6

FRU-Definition An existing facility ( district hospital, sub-divisional hospital, Community Health Centre etc. ) can be declared fully operational First Referral Unit (FRU) only if it is equipped to provide round the clock services for Emergency Obstetric and New Born Care, in addition to all emergencies that any hospital is required to provide. 7

Requirements of FRU § Critical Requirements :  EmOC including surgical interventions like Caesarean Section and other medical interventions.  Blood Storage facility  New-Born Care.  24-hour delivery services including normal and assisted deliveries. § Desirable Requirements :  Emergency Care of sick children.  Full range of family planning services including Laparoscopic Services.  Safe Abortion Services  Treatment of STI/RTI  Essential Laboratory Services  Referral (transport) Services 8

Selection of a facility as FRU 9

Format for Selection of FRUs 10

Format 2: Listing of resources Category/Facility123 1Name and Address 2No. of Sanctioned Bed 3No. of Operational Beds 4Doctors (Total) 5OBG Specialist 6Surgeon 7Anesthetists 8Pediatrician 9Staff Nurses 10Lab Technicians 11Blood Storage Facility 12Utilization level AFunctional delivery room BNo. of deliveries conducted in previous year(Jan-Dec) CNo. of CS conducted in previous year(Jan-Dec) DTotal Surgeries done in previous year(Jan-Dec) 13Availability of Equipments AAnaesthetics BC-Sections CNew Born care 14Availability of Infrastructure AGenerator B24 hr water Supply 15Availability of Investigational facility AFunctional Laboratory BFunctional Radiology CAvailability of Functional Ambulance DStaff Quarters 11

Format 3: Human Resource Summary Level and CategoryNumber SanctionedIn positionRecruitment on Contractual basis ADistrict Hospital or Equivalent 1MBBS Doctor (M) 2MBBS Doctor (F) 3Surgeons 4OBG Specialist 5Anesthetist 6Pediatrician 7Lab technicians 8Staff Nurses BCHC/ Sub DH 1MBBS Doctor (M) 2MBBS Doctor (F) 3Surgeons 4OBG Specialist 5Anesthetist 6Pediatrician 7Lab technicians 8Staff Nurses CBlock PHCs, PHCs and Dispensaries etc. 1MBBS Doctor (M) 2MBBS Doctor (F) 3Surgeons 4OBG Specialist 5Anesthetist 6Pediatrician 7Lab technicians 8Staff Nurses 9LHVs 10ANMs 12

Monitoring of FRU operationalization Dissemination findings FRU Checklist FRU Critical Services 13

Monitoring of Skilled Based Trainings to Augment Availability of Manpower Anesthesia Training: EmOC Training: 14

Issues in operationalizing FRUs  Infrastructural: o Operation Theatres, o Labour rooms; o water supply  Logistics : o Shortage/lack of Em. Drugs  Lack of Blood transfusion facilities  Lack of skilled manpower, particularly Anaesthetists and Gynecologists 15

Steps taken by GOI :  Civil works for operationalizing OTs and Labour rooms undertaken;  Emergency drugs were supplied to FRUs  Different Equipments were supplied to FRU  Drugs and Cosmetics Act amended to facilitate establishing blood storage units at FRUs;  Guidelines for blood storage units issued to states;  Funds for Hiring of private specialists Anesthetists and Gynecologists were made available Newer Initiatives :  Short training programmes in anesthesia & Obstetric  Training of ANM/ Staff Nurses in Skilled Birth Attendance and basic obstetric care along with New born care. 16

Steps to be taken by the state…… Completing facility survey and identifying the gaps and thereby formulating an operational plan for 2 nd Phase of RCH. Deployment of Skilled manpower and rationalizing HR policies e.g. transfer policies, cadre reviews etc. Enabling environment especially adequate residential facilities. Focused strategies for capacity building of identified training institutions for nurses and ANMs. Orientation of all health personnel including medical and para medical and all programme managers. Procurement policies and systems in place. Developing an accreditation criteria for regular monitoring of the facility and coordinating in its smooth co-ordination. 17

Guidelines for Setting Up Blood Storage Centres At First Referral Units 18

License for approval of Blood Storage Facility :  The Drug and Cosmetics Act, has been amended with the objective of setting up blood storage facilities at the FRUS / CHCs / PHCs.  Approval from the licensed blood bank from which the storage centre will get the supply.  State Licensing Authority will then approve the Blood Storage Centre after inspection of the facility. Approval will be for a period of two years.  Blood Storage centre can be affiliated to more than one Blood Bank.  License of the Blood Storage centre will automatically be cancelled if the license of the issuing blood bank is cancelled. 19

Criteria for Approval Of Blood Storage Centre : Following requirements be available :  Space : just 10 sq.m., well lighted and clean  Manpower : No additional staff. Trained medical Officer or LT can be made overall incharge.  Electricity: 24 hour supply with back up.  Equipments : o Blood Bag Refrigerators having a storage capacity of 50 units of Blood. o Deep Freezers. o Insulated Carrier Boxes. o Microscope and centrifuge.  Consumables like gloves, glass tubes etc.  Reagents  Disinfectants. 20

 Quantities of Blood Units to be available at any time :  5 units each of A,B,O (positive)  2 units of AB (positive)  1 units each of A,B,O ( negative) * Medical officer in-charge should ensure that unused blood bags should be returned to the Linked Blood Bank at least 10 days before the expiry of the blood and fresh blood obtained in its place. 21

 Training : A Standard Operating Procedure Manual (SOPM) has been developed for a 3 day training of doctors and technicians, which will include :  Pre-transfusion checking i.e. patient identify and grouping  Cross- matching  Compatibility  Problems in grouping and cross matching  Troubleshooting  Issue of Blood  Transfusion Reactions and its management  Disposal of Blood Bags.  Maintenance of Cold chain. It would be desirable for the states to follow those guidelines and protocols. 22

Guidelines for Operationalizing a Primary Health Centre for Providing 24-Hour Delivery and New born care 23

Essential service package to be provided by a 24- hour functional PHC  Essential Services : hour delivery services, both normal and assisted 2. Essential new born care 3. Referral for emergencies  Desirable Services : 1. Ante- natal care and routine immunization services for children and pregnant women ( besides fixed day services). 2. Post-natal care. 3. Early and safe abortion services (including MVA) 4. Family planning services. 5. Prevention and management of RTIs/STIs. 6. Essential laboratory services. 24

Selection of the PHC as 24 hour Delivery and New Born Care in RCH-II  A scoring system has been developed, which are being used to prioritize the PHCs.  The PHC with maximum scoring is operationalized first.  The criteria for scoring include : o Location and Accessibility o Presence of Staff and Staff Quarters o Labour Room o Number of deliveries conducted in one year o Referral services. 25

Scoring System Category/Facility123 1Name and Address 2Location and Accessibility ARoad BPopulation Size COther health Facilities DMarket Place 3Staff AMedical Officer BStaff Nurse/ANMs CStaff Quarters 4Labour Room 5Deliveries 6Referral Services 7Total Score 26

Scoring Criteria A Location and Accessibility 3. If facility connected with an all weather road link 1. If facility connected by a kuccha road 0. If facility not connected by road 3. Population size catered to > 35,000 ( or > 25,000 in hilly/tribal areas) 2. If Population size catered to 25, ,000 (or 15,000-25,000 in hilly/tribal areas) 1. Population size catered to < 25,000 (or < 15,000 in hilly/tribal areas) 3. If no private/charitable/trust hospital/health facility in a radius of 15 Kms 2. If no private/charitable/trust hospital/health facility in a radius of 10 Kms 1. If no private/charitable/trust hospital/health facility in a radius of 5 Kms 0. If private/charitable/trust hospital/health facility present in a radius of 15 Kms 1. If a market place is present within 2 Kms radius of facility 0. If no market place is present within 2 Kms radius of facility B Presence of Staff and Staff Quarters 5. If 2 Medical Officers are posted and working at facility 3. If 1 Medical Officer is posted and working at facility 0. If no Medical Officer is working at facility 5. If > 3 Staff Nurses/ANMs are posted and working at facility 3. If 1-2 Staff Nurses/ANMs are posted and working at facility 0. If no Staff Nurse/ANM is working at facility Staff Quarters 5. Residential quarters for Doctors, Nursing Staff, and other paramedical staff 3. Residential quarters for only Doctors and Nursing Staff 1. Residential quarters for either Doctors OR Nursing Staff 0. No residential quarters C LR 10. If the facility has a functional labour room with Electricity Supply (and power back-up) and 24 hour water supply 8. If the facility has a labour room in use, with either Electricity Supply (and power back up) or 24 hour water supply 5. If the facility has a labour room in use with no/intermittent electric supply and/or no/intermittent water supply 1. If facility has a space earmarked as the labour room, but not in use 0. If facility has no labour room D Deliver y 10. If > 500 deliveries conducted annually 8. If deliveries conducted annually 5. If deliveries conducted annually 2. If deliveries conducted annually 0. If < 20 deliveries conducted annually # Referral Services 3. Established Referral Linkage with sub-centres, villages and FRU (Government or Private) 2. Established Referral Linkage with FRU (Government or Private) only 1. Established Referral Linkage with Sub-centres and/or villages only 0. No Referral Linkage with either the community or sub-centres nor the CHC or FRU (Government or Private) 27

24 X 7 PHCs Monitoring Dissemination findings. Dissemination findings 24 X 7 Checklist. 28

Monitoring of Skilled Based Trainings Site Assessment Checklist SBA Training Monitoring Format 29

Steps to be taken by the state…… Completing facility survey and identifying the gaps and thereby formulating an operational plan for 2 nd Phase of RCH. Effort for shifting from incentive on per delivery basis to the deployment of personnel Deployment of Skilled manpower and rationalizing HR policies e.g. transfer policies, cadre reviews etc. Enabling environment especially adequate residential facilities. Focused strategies for capacity building of identified training institutions for nurses and ANMs. 30

Steps to be taken by the state contd…… Orientation of all health personnel including medical and para medical and all programme managers. Procurement policies and systems in place. Developing an accreditation criteria, regular monitoring of services available. Incentive may be given for accomplishing group work 31

32