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Janani Suraksha Yojana (JSY) Assessment MBA (Health Management) Project Report

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					                       CONTENTS

Sr. No.        TITLE                             Page No.

1     ACKNOWLEDGEMENT                                 2

2     DECLARATION                                      3

3     INTRODUCTION                                     4

      A) CURRENT STATUS OF HEALTHCARE IN INDIA         4
      B) NATIONAL RURAL HEALTH MISSION (NRHM)          5
      C) JANANI SURAKSHA YOJANA (JSY)                 13
      D) DISTRICT DODA                                22
      E) NRHM IN DISTRICT DODA                        23
      F) JSY in DODA                                  29
4     BACKGROUND OF THE STUDY                         31

5     DESIGN OF THE STUDY                             33

6     METHODOLOGY AND DATA COLLECTION                 34

7     DATA ANALYSIS AND INTERPRETATION                36

8     SUMMARY AND CONCLUSIONS                         43

9     SUGGESTIONS                                     45

10    ANNEXURE

      i) QUESTIONNAIRE

      ii) REFERENCES

      ii) SOME SNAPSHOTS




                            1
               ACKNOWLEDGEMENT

First of all, I want to thank almighty Allah, the most beneficent and merciful, for everything,
including the opportunity to work on this project. Thereafter I would like to express my
heartiest thanks to Mr. Waseem Raja, District Program Manager, NRHM, Doda, who as my
guide and mentor, helped me, all through this project and without his valuable guidance, this
project would not have been possible.
I am also thankful to Mr. I. A. Shapoo, CMO, Doda, for permitting me to undertake this
study in Doda. I am also grateful to all the staff of BMO offices (BMOs, MOs,
Gynaecologists, Computer-cum-Account knowing Managers, ANMs and ASHAs) of the 5
blocks, I surveyed, for their co-operation and help, and for sharing their views, experiences
and problems with us. These very views, experiences etc, form the backbone of my study’s
findings and subsequent conclusions.
Then, there remain some “Unsung Heroes” in the form of my family members and friends,
and it would be grossly unfair if I do not mention them here, indeed I am indebted to all the
members of my family especially my Mother and Father, for their support and bearing my
absence for “So Long”.




                                                     MOHD.SHOAIB SIDDIQUI
                                                               MBA (Health Management)
                                                         JAMIA HAMDARD UNIVERSITY
                                                                           NEW DELHI




                                               2
                            DECLARATION



I hereby declare that this summer training project entitled “A STUDY TO ASSESS THE
WORKING OF ‘JANANI SURAKSHA YOJANA’ THROUGH THE OPINION OF
HEALTH WORKERS” is a bonafide and genuine research work, carried out by me, under
the guidance of Mr. Waseem raja, District Programme Manager, NRHM, Doda.




                                                    MOHD. SHOAIB SIDDIQUI




                                        3
INTRODUCTION

CURRENT STATUS OF HEALTHCARE IN INDIA
India is undergoing a series of transitions– demographic transition, epidemiological transition
and socio-economic transition. Better socio-economic status and advanced medical facilities
imply that more and more people are surviving longer. However, on the other end of the
spectrum, people are still dying of communicable diseases. Thus one sees the entire spectrum
of both communicable and non-communicable diseases, of people dying of preventable
conditions as well as the elderly struggling with complications of life style diseases, of
patients not being able to access health care because of financial and cultural barriers and of
patients who access a health service that does not have any answer to their problems. Also the
expectations of the people are increasing. There is an increasing demand for better services
and more technology. All this has placed tremendous stress on the health system.
Unfortunately, the response has been unsatisfactory in general. Government health
expenditure has reduced over the years. The existing public health infrastructure has been
steadily demolished and has been replaced by a steady medicalisation of all interventions.
Instead of taking charge and directing the changes, the government has been less than pro-
active. Instead it has shown a remarkable lack of oversight.
Current health scenario is fairly complex and challenging with successful reductions in
fertility and mortality offset by a persistently high levels of child under-nutrition, increasing
inequality in the health status of the rich and the poor (The poorest 20 percent of Indians have
more than twice the rates of mortality, malnutrition, and fertility of the richest 20 percent),
inadequate primary health care coexisting with blooming medical tourism industry! This
situation is further complicated by the presence and practice of multiple systems of medicine
and medical practitioners (several of whom are not formally certified) and very limited
regulation.
Although India accounts for only 16.5% of the global population, it contributes to
approximately a fifth of the world’s share of diseases, a third of the diarrheal diseases,
tuberculosis, respiratory and other infections, parasitic infestations and perinatal conditions; a
quarter of maternal conditions; a fifth of nutritional deficiencies, diabetes, cardiovascular
diseases, and the second largest number of HIV/AIDS cases in the world.

STATE OF PUBLIC HEALTH
      Public health expenditure in India has declined from 1.3% of GDP in 1990 to 0.9% of
       GDP in 1999. The Union Budgetary allocation for health is 1.3% while the State’s
       Budgetary allocation is 5.5%.
      Union Government contribution to public health expenditure is 15%
      while States contribution about 85%
      Vertical Health and Family Welfare Programmes have limited synergy at operational
       levels.
      Lack of community ownership of public health programmes impacts levels of
       efficiency, accountability and effectiveness.



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      Lack of integration of sanitation, hygiene, nutrition and drinking water issues.
      There are striking regional inequalities.
      Population Stabilization is still a challenge, especially in States with weak
       demographic indicators.
      Curative services favour the non-poor: for every Re.1 spent on the poorest 20%
       population, Rs.3 is spent on the richest quintile.
      Only 10% Indians have some form of health insurance, mostly inadequate
      Hospitalized Indians spend on an average 58% of their total annual expenditure.
      Over 40% of hospitalized Indians borrow heavily or sell assets to cover expenses.
      Over 25% of hospitalized Indians fall below poverty line because of hospital
       expenses.




       NATIONAL RURAL HEALTH MISSION
         Recognizing the importance of Health in the process of economic and social
development and improving the quality of life of our citizens, the Government of India has
resolved to launch the National Rural Health Mission to carry out necessary architectural
correction in the basic health care delivery system. The Mission adopts a synergistic approach
by relating health to determinants of good health viz. segments of nutrition, sanitation,
hygiene and safe drinking water. It also aims at mainstreaming the Indian systems of
medicine to facilitate health care. The Plan of Action includes increasing public expenditure
on health, reducing regional imbalance in health infrastructure, pooling resources, integration
of organizational structures, optimization of health manpower, decentralization and district
management of health programmes, community participation and ownership of assets,
induction of management and financial personnel into district health system, and
operationalizing community health centers into functional hospitals meeting Indian Public
Health Standards in each Block of the Country. The Goal of the Mission is to improve the
availability of and access to quality health care by people, especially for those residing in
rural areas, the poor, women and children.
         By 2000, India had not achieved 13 out of the 17 goals laid down in the first National
Health Policy of 1983. Analysis of the 52nd Round National Sample Survey (NSS) on the
utilization of health services showed that during 1986-96, there was a decrease in the
utilization of public facilities for outpatient care from 26% to 19%; a decrease in access to
free care from 19% to 10% and an increase in the number of persons not seeking care due to
financial incapacity. State-wise comparisons show that the poorest in the poorer. To reduce
the disease burden affecting the poor and alarmed by the falling levels in the utilization of
public facilities, the government brought forth the National Population Policy (2000), the
National Health Policy (2002), and the AYUSH Policy (2000), reiterating its resolve and
commitment to achieve a set of goals by 2010. The goals envisaged are to increase public
investment in health from the current level of 0.9% to 2%-3%; to increase the utilization of
primary care facilities from less than 19% to over 75%; to reduce the MMR by three quarters
from the current level of over 540 per 1000; to reduce the IMR from 62 per 1000 live-births
to less than 30, eradicate polio, eliminate leprosy, reduce deaths on account of TB and
malaria by over 50%, etc. Many of these objectives are in consonance with the Millennium
Development Goals (MDGs) for 2015.



                                               5
        National Rural Health Mission (NRHM) was launched in India on 12th April 2005
with a view to bring about dramatic improvement in the health system and the health status of
the people, especially those who live in the rural areas. The Mission aims to achieve goals set
under the National Health Policy and the Millennium Development Goals. NRHM recognizes
the importance of health in the process of economic and social development and improving
the quality of lives of our citizens. The Mission seeks to provide universal access to
equitable, affordable and quality health care which is accountable at the same time responsive
to the needs of the people.
            The Hon’ble Prime Minister launched the NRHM throughout the country with
special focus on 18 States, including eight Empowered Action Group (EAG) States, the
North-Eastern States, Jammu & Kashmir and Himachal Pradesh. The NRHM seeks to
provide accessible, affordable and quality health care to the rural population, especially the
vulnerable sections. It also seeks to reduce the Maternal Mortality Rate(MMR) in the
country from 407 to 100 per 1,00,000 live births, Infant Mortality Rate (IMR) from 60 to30
per 1000 live births and the Total Fertility Rate (TFR) from 3.0 to 2.1 within the 7 year
period of the Mission.


NATIONAL RURAL HEALTH MISSION
 THE VISION
 • The National Rural Health Mission (2005-12) seeks to provide effective healthcare to
 rural population throughout the country with special focus on 18 states, which have weak
 public health indicators and/or weak infrastructure.

 • These 18 States are Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh,
 Jharkhand, Jammu & Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh,
 Nagaland, Orissa, Rajasthan, Sikkim,Tripura, Uttaranchal and Uttar Pradesh.

 • The Mission is an articulation of the commitment of the Government to raise public
 spending on Health from 0.9% of GDP to 2-3% of GDP.

 • It aims to undertake architectural correction of the health system to enable it to effectively
 handle increased allocations as promised under the National Common Minimum
 Programme and promote policies that strengthen public health management and service
 delivery in the country.

 • It has as its key components provision of a female health activist in each village; a village
 health plan prepared through a local team headed by the Health & Sanitation Committee of
 the Panchayat; strengthening of the rural hospital for effective curative care and made
 measurable and accountable to the community through Indian Public Health Standards
 (IPHS); and integration of vertical Health & Family Welfare Programmes and Funds for
 optimal utilization of funds and infrastructure and strengthening delivery of primary
 healthcare.




                                               6
• It seeks to revitalize local health traditions and mainstream AYUSH into the public health
system.

• It aims at effective integration of health concerns with determinants of health like
sanitation & hygiene, nutrition, and safe drinking water through a District Plan for Health.

• It seeks decentralization of programmes for district management of health.

• It seeks to address the inter-State and inter-district disparities, especially among the 18
high focus States, including unmet needs for public health infrastructure.

• It shall define time-bound goals and report publicly on their progress.

• It seeks to improve access of rural people, especially poor women and children, to
equitable, affordable, accountable and effective primary healthcare.

GOALS
       Reduction in Infant Mortality Rate (IMR) and Maternal Mortality Ratio (MMR)

    Universal access to public health services such as Women’s health, child health,
   water, sanitation & hygiene, immunization, and Nutrition.

       Prevention and control of communicable and non-communicable diseases,
        including locally endemic diseases

       Access to integrated comprehensive primary healthcare

       Population stabilization, gender and demographic balance.

       Revitalize local health traditions and mainstream AYUSH

       Promotion of healthy life styles



STRATEGIES
(a) Core Strategies:

• Train and enhance capacity of Panchayati Raj Institutions (PRIs) to own, control and
manage public health services.

• Promote access to improved healthcare at household level through the female health
activist (ASHA).

• Health Plan for each village through Village Health Committee of the Panchayat.




                                              7
• Strengthening sub-centre through an untied fund to enable local planning and action and
more Multi Purpose Workers (MPWs).

• Strengthening existing PHCs and CHCs, and provision of 30-50 bedded CHC per lakh
population for improved curative care to a normative standard (Indian Public Health
Standards defining personnel, equipment and management standards).

• Preparation and Implementation of an inter-sectoral District Health Plan prepared by the
District Health Mission, including drinking water, sanitation & hygiene and nutrition.

• Integrating vertical Health and Family Welfare programmes at National, State, Block, and
District levels.

• Technical Support to National, State and District Health Missions, for Public Health
Management.

• Strengthening capacities for data collection, assessment and review for evidence based
planning, monitoring and supervision.

• Formulation of transparent policies for deployment and career development of Human
Resources for health.

• Developing capacities for preventive health care at all levels for promoting healthy life
styles, reduction in consumption of tobacco and alcohol etc.

• Promoting non-profit sector particularly in under served areas.

(b) Supplementary Strategies:

• Regulation of Private Sector including the informal rural practitioners to ensure
availability of quality service to citizens at reasonable cost.

• Promotion of Public Private Partnerships for achieving public health goals.

• Mainstreaming AYUSH – revitalizing local health traditions.

• Reorienting medical education to support rural health issues including regulation of
Medical care and Medical Ethics.

• Effective and viable risk pooling and social health insurance to provide health security to
the poor by ensuring accessible, affordable, accountable and good quality hospital care.

PLAN OF ACTION
COMPONENT (A): ACCREDITED SOCIAL HEALTH ACTIVISTS

• Every village/large habitat will have a female Accredited Social Health Activist (ASHA)
- chosen by and accountable to the panchayat- to act as the interface between the
community and the public health system. States to choose State specific models.


                                             8
• ASHA would act as a bridge between the ANM and the village and be accountable to the
Panchayat.

• She will be an honorary volunteer, receiving performance-based compensation for
promoting universal immunization, referral and escort services for RCH, construction of
household toilets, and other healthcare delivery programmes.

• She will be trained on a pedagogy of public health developed and mentored

through a Standing Mentoring Group at National level incorporating best practices and
implemented through active involvement of community health resource organizations.

• She will facilitate preparation and implementation of the Village Health Plan along with
Anganwadi worker, ANM, functionaries of other Departments, and Self Help Group
members, under the leadership of the Village Health Committee of the Panchayat.

• She will be promoted all over the country, with special emphasis on the 18 high focus
States. The Government of India will bear the cost of training, incentives and medical kits.
The remaining components will be funded under Financial Envelope given to the States
under the programme.

• She will be given a Drug Kit containing generic AYUSH and allopathic formulations for
common ailments. The drug kit would be replenished from time to time.

• Induction training of ASHA to be of 23 days in all, spread over 12 months. On the job
training would continue throughout the year.

• Prototype training material to be developed at National level subject to State level
modifications.

• Cascade model of training proposed through Training of Trainers including contract plus
distance learning model.

• Training would require partnership with NGOs/ICDS Training Centres and State Health
Institutes.

COMPONENT (B): STRENGTHENING SUB-CENTRES

• Each sub-centre will have an Untied Fund for local action @ Rs. 10,000 per annum. This
Fund will be deposited in a joint Bank Account of the ANM & Sarpanch and operated by
the ANM, in consultation with the Village Health Committee.

• Supply of essential drugs, both allopathic and AYUSH, to the Sub-centres.

• In case of additional Outlays, Multipurpose Workers (Male)/Additional ANMs wherever
needed, sanction of new Sub-centres as per 2001 population norm, and upgrading existing
Sub-centres, including buildings for Sub-centres functioning in rented premises will be
considered.



                                            9
COMPONENT (C): STRENGTHENING PRIMARY HEALTH CENTRES

Mission aims at Strengthening PHC for quality preventive, promotive, curative,
supervisory and Outreach services, through:

• Adequate and regular supply of essential quality drugs and equipment (including Supply
of Auto Disabled Syringes for immunization) to PHCs.

• Provision of 24 hour service in 50% PHCs by addressing shortage of doctors, especially
in high focus States, through mainstreaming AYUSH manpower.

• Observance of Standard treatment guidelines & protocols.

• In case of additional Outlays, intensification of ongoing communicable disease control
programmes, new programmes for control of non-communicable diseases, upgradation of
100% PHCs for 24 hours referral service, and provision of 2nd doctor at PHC level (I male,
1 female) would be undertaken on the basis of felt need.

COMPONENT (D): STRENGTHENING CHCs FOR FIRST REFERRAL CARE

A key strategy of the Mission is:

• Operationalizing 3222 existing Community Health Centres (30-50 beds) as 24 Hour First
Referral Units, including posting of anaesthetists.

• Codification of new Indian Public Health Standards, setting norms for infrastructure,
staff, equipment, management etc. for CHCs.

• Promotion of Stakeholder Committees (Rogi Kalyan Samitis) for hospital management.

• Developing standards of services and costs in hospital care.

• Develop, display and ensure compliance to Citizen’s Charter at CHC/PHC level.

• In case of additional Outlays, creation of new Community Health Centres (30-50 beds) to
meet the population norm as per Census 2001, and bearing their recurring costs for the
Mission period could be considered.

COMPONENT (E): DISTRICT HEALTH PLAN

• District Health Plan would be an amalgamation of field responses through Village Health
Plans, State and National priorities for Health, Water Supply, Sanitation and Nutrition.

• Health Plans would form the core unit of action proposed in areas like water supply,
sanitation, hygiene and nutrition. Implementing Departments would integrate into District
Health Mission for monitoring.

• District becomes core unit of planning, budgeting and implementation.




                                             10
• Centrally Sponsored Schemes could be rationalized/modified accordingly in consultation
with States.

• Concept of “funneling” funds to district for effective integration of programmes

• All vertical Health and Family Welfare Programmes at District and state level merge into
one common “District Health Mission” at the District level and the “State Health Mission”
at the state level.

• Provision of Project Management Unit for all districts, through contractual engagement of
MBA, Inter Charter/Inter Cost and Data Entry Operator, for improved programme
management

COMPONENT (F): CONVERGING SANITATION AND HYGIENE UNDER
NRHM

• Total Sanitation Campaign (TSC) is presently implemented in 350 districts, and is
proposed to cover all districts in 10th Plan.

• Components of TSC include IEC activities, rural sanitary marts, individual household
toilets, women sanitary complex, and School Sanitation Programme.

• Similar to the DHM, the TSC is also implemented through Panchayati Raj Institutions
(PRIs).

• The District Health Mission would therefore guide activities of sanitation at district level,
and promote joint IEC for public health, sanitation and hygiene, through Village Health &
Sanitation Committee, and promote household toilets and School Sanitation Programme.
ASHA would be incentivized for promoting household toilets by the Mission.

COMPONENT (G): STRENGTHENING DISEASE CONTROL PROGRAMMES

• National Disease Control Programmes for Malari a, TB, Kala Azar, Filaria, Blindness &
Iodine Deficiency and Integrated Disease Surveillance Programme shall be integrated
under the Mission, for improved programme delivery.

• New Initiatives would be launched for control of Non Communicable Diseases.

• Disease surveillance system at village level would be strengthened.

• Supply of generic drugs (both AYUSH & Allopathic) for common ailments at village,
SC, PHC/CHC level.

• Provision of a mobile medical unit at District level for improved Outreach services.

COMPONENT (H): PUBLIC-PRIVATE PARTNERSHIP FOR PUBLIC HEALTH
GOALS, INCLUDING REGULATION OF PRIVATE SECTOR




                                             11
• Since almost 75% of health services are being currently provided by the private sector,
there is a need to refine regulation.

• Regulation to be transparent and accountable

• Reform of regulatory bodies/creation where necessary

• District Institutional Mechanism for Mission must have representation of private sector

• Need to develop guidelines for Public-Private Partnership (PPP) in health sector.
Identifying areas of partnership, which are need based, thematic and geographic.

• Public sector to play the lead role in defining the framework and sustaining the
partnership

• Management plan for PPP initiatives: at District/State and National levels




            NRHM’S EXPECTED OUTCOMES
 • Infant Mortality Rate to be reduced to 30/1000 live births

 • Maternal Mortality Ratio to be reduced to 100/100,000

 • Total Fertility Rate to be brought to 2.1

 • Malaria mortality reduction rate –50% up to 2010, additional 10% by 2012

 • Kala Azar to be eliminated by 2010.

 • Filaria/Microfilaria reduction rate: 70% by 2010, 80% by 2012 and elimination
     by 2015

 • Dengue mortality reduction rate: 50% by 2010 and sustaining at that level until
    2012

 • Japanese Encephalitis mortality reduction rate: 50% by 2010 and sustaining at
     that level until 2012

 • Cataract Operation: increasing to 46 lacks per year until 2012.

 • Leprosy prevalence rate: to be brought to less than 1/10,000.

 • Tuberculosis DOTS services: from the current rate of 1.8/10,00, 85% cure rate to
    be maintained through the entire Mission period.




                                            12
          JANANI SURAKSHA YOJANA (JSY)
        Janani Suraksha Yojana (JSY) is a safe motherhood intervention under the National
Rural Health Mission (NRHM) being implemented with the objective of reducing maternal
and neo-natal mortality by promoting institutional delivery among the poor pregnant women.
The Yojana, launched on 12th April 2005, by the Hon’ble Prime Minister, is being
implemented in all states and UTs with special focus on low performing states.

2.     JSY is a 100 % centrally sponsored scheme and it integrates cash assistance with
delivery and post-delivery care. The success of the scheme would be determined by the
increase in institutional delivery among the poor families

3.     The Yojana has identified ASHA, the accredited social health activist as an effective
link between the Government and the poor pregnant women in l0 low performing states,
namely the 8 EAG states and Assam and J&K and the remaining NE States. In other eligible
states and UTs, wherever, AWW and TBAs or ASHA like activist has been engaged in this
purpose, she can be associated with this Yojana for providing the services.

3.1 Role of ASHA or other link health worker associated with JSY would be to:

        Identify pregnant woman as a beneficiary of the scheme and report or facilitate
         registration for ANC,
        Assist the pregnant woman to obtain necessary certifications wherever necessary,
        Provide and / or help the women in receiving at least three ANC checkups
         including TT injections, IFA tablets,
        Identify a functional Government health centre or an accredited private health
         institution for referral and delivery,
        Counsel for institutional delivery,
        Escort the beneficiary women to the pre-determined health center and stay with
         her till the woman is discharged,
        Arrange to immunize the newborn till the age of 14 weeks,
        Inform about the birth or death of the child or mother to the ANM/MO,
        Post natal visit within 7 days of delivery to track mother’s health after delivery
         and facilitate in obtaining care, wherever necessary,
        Counsel for initiation of breastfeeding to the newborn within one-hour of delivery
         and its continuance till 3-6 months and promote family planning.

Note: Work of the ASHA or any link worker associated with Yojana would be assessed based
on the number of pregnant women she has been able to motivate to deliver in a health
institution and the number of women she has escorted to the health institutions.

4.    Important Features of JSY:




                                             13
4.1 The scheme focuses on the poor pregnant woman with special dispensation for states
having low institutional delivery rates namely the states of Uttar Pradesh, Uttaranchal, Bihar,
Jharkhand, Madhya Pradesh, Chhattisgarh, Assam, Rajasthan, Orissa and Jammu and
Kashmir. While these states have been named as Low Performing States (LPS), the
remaining states have been named as High performing States (HPS).

4.2 Tracking Each Pregnancy: Each beneficiary registered under this Yojana should have
a JSY card along with a MCH card. ASHA/AWW/ any other identified link worker under the
overall supervision of the ANM and the MO, PHC should mandatorily prepare a micro-
birth plan. Please see Annexure – I. This will effectively help in monitoring Antenatal
Check-up, and the post delivery care.

4.3   Eligibility for Cash Assistance:

         LPS States           All pregnant women delivering in Government health
                              centres like Sub-centre, PHC/CHC/ FRU / general wards of
                              District and state Hospitals or accredited private institutions
         HPS States           BPL pregnant women, aged 19 years and above
         LPS & HPS            All SC and ST women delivering in a government health
                              centre like Sub-centre, PHC/CHC/ FRU / general ward of
                              District and state Hospitals or accredited private institutions



Note: BPL Certification – This is required in all HPS states. However, where BPL cards
have not yet been issued or have not been updated, States/UTs would formulate a simple
criterion for certification of poor and needy status of the expectant mother’s family by
empowering the gram pradhan or ward member.

4.4   Scale of Cash Assistance for Institutional Delivery:

         Category Rural Area                   Total    Urban Area               Total
                  Mother’s         ASHA’s      Rs.      Mother’s ASHA’s          Rs.
                  Package          Package              Package  Package
         LPS      1400             600         2000     1000     200             1200
         HPS      700                          700      600                      600

Note 1: Importantly, such woman in both LPS and HPS states, choosing to deliver in an
accredited private health institution will have to produce a proper BPL or a SC/ST
certificate in order to access JSY benefits. In addition she should carry a referral slip from
the ASHA/ANM/MO and the MCH - Janani Suraksha Yojana (JSY) card.

Note 2: ANM / ASHA / MO should make it clear to the beneficiary that Government is not
responsible for the cost of her delivery. She has to bear cost, while choosing to go to an
accredited private institution for delivery. She only gets her entitled cash.

4.5 While mother will receive her entitled cash, the scheme does not provide for ASHA
package for such pregnant women choosing to deliver in an accredited private institution.



                                              14
4.6        Limitations of Cash Assistance for Institutional Delivery:

             In LPS States                      All births, delivered in a health centre –
                                                Government or Accredited Private     health
                                                institutions. Refer to para (b).

             In HPS States                      Upto 2 live births.

4.7 Disbursement of Cash Assistance: As the cash assistance to the mother is mainly to
meet the cost of delivery, it should be disbursed effectively at the institution itself.

4.7.1 For pregnant women going to a public health institution for delivery, entire cash
    entitlement should be disbursed to her in one go, at the health institution. Considering
    that some women would access accrediting private institution for antenatal care, they
    would require some financial support to get atleast 3 ANCs including the TT injections.
    In such cases, atleast three-fourth (3/4) of the cash assistance under JSY should be
    paid to the beneficiary in one go, importantly, at the time of delivery.

4.7.2 To Beneficiary:

      a.     The mother and the ASHA (wherever applicable) should get their entitled money at
            the heath centre immediately on arrival and registration for delivery.

      b.      Generally the ANM/ ASHA should carry out the entire disbursement process.
            However, till ASHA joins, AWW or any identified link worker, under the guidance of
            the ANM may also do the disbursement.

4.7.3 At accredited private institution: Disbursement of cash to the mother should be done
through the ANM/ASHA/ Link worker channel and the money available under JSY should be
paid to the beneficiary only and not to any other person or relative.

       Should ensure that:
       Such accredited private institution would also be responsible for any postnatal
        complication arising out of the cases handled by them.
       They should not deny their services to any referred targeted expectant mother.

            Note: Every month, accredited private health centers would prepare a statement of JSY
            - delivery / ANC/ obstetric complication cases handled by them and send it to the
            Medical officer, along with the referral slips for sample verification by the concerned
            ANM / ASHA.

       In the District / Women’s Hospital / State Hospital etc :

       State / District should allocate sufficient amount of money (based on the load of
        deliveries in these institutions) for each of these institution. This money should be kept
        in a separate account under the supervision of the Rogi Kalyan Samity.




                                                    15
       The residency of the beneficiary would determine entitlement of cash benefit in such
        institutions, to be verified based on the referral slip from the ANM, carried by the
        beneficiary.

                   Format of Referral Slip: State should prepare a format of the referral slip,
                   which should mainly indicate, identification details of the beneficiary, JSY
                   registration number in the register of the ANM, reason for referral
                   (including medical complications), name of ASHA, amount already
                   disbursed, amount due, including referral transport money (if applicable),
                   amount due to ASHA and to be paid, signature of MO/ANM.

       It is therefore, essential that all targeted expectant mother should carry a referral slip
        from the ANM/MO where she generally resides. This will, infact, help all such
        pregnant woman who go to her mother’s place for delivery.
       Disbursement of money to expectant mother going to her mother’s place for delivery
        should be done at the place she delivers. The entitlement of cash should be
        determined by her referral slip carried by her and her usual place of residence.
       A voucher scheme may be introduced in such a way that along with admission slip
        for delivery, a voucher amounting to mother’s package plus the transport assistance
        money is given to the expectant mother and that she should be able to encash the same
        at the Hospital’s cash counter, at the time of discharge.

4.8     Flow of Fund:

              i. State/ District authorities would advance Rs. 5000/- and Rs. Rs.10,000/- to each
              ANM in HPS /LPS States respectively as a recoupable impressed money from the
              JSY fund.



              ii. This money could be kept in the joint account of ANM and Gram Pradhan,
              as in case of untied fund placed with sub-centers so that the ANM could ‘roll’ the
              entire amount by advancing Rs.1500 to Rs. 2,500/- to ASHA / AWW per delivery
              and later she could recoup it from the PHC or CHC, where JSY fund is parked by
              the authorities.

                 Expenditure Monitoring: ASHA / AWW should provide an expenditure
                 statement of money advanced to her in previous month to the ANM in the
                 monthly meeting held by ANM.



              iii. There should be a clear authority for ANM to withdraw cash from this
              account for advancing it to the ASHA or AWW / any other health link worker,
              needed for ready use towards disbursement to the pregnant and also for arranging
              the referral transport for escorting the pregnant women to the institution.




                                                 16
Note: Where an elected body of the Panchayati Raj Institution (PRIs) exists, the State
Governments/Health society may keep the money in a joint account of the Gram Pradhan and
the ANM (like that of the untied fund). The process of recoupment of fund should be so
simple to be able to disburse the cash to the pregnant women in time.

4.9 ASHA Package: This package, as of now, is available in all LPS, NE States and in
the tribal districts of all states and UTs. In rural areas it includes the following three
components:

      Cash assistance for Referral transport to go to the nearest health centre for
       delivery. The state will determine the amount of assistance (should not less than
       Rs.250/- per delivery) depending on the topography and the infrastructure available
       in their state. It would, however, be the duty of the ASHA and the ANM to organize
       or facilitate in organizing referral the transport, in conjunction with gram pradhan,
       Gram Sabha etc.

           Note: This assistance is over and above the Mother’s package.

      Cash incentive to ASHA: This should not be less than Rs.200/- per delivery in
       lieu of her work relating to facilitating institutional delivery. Generally, ASHA should
       get this money after her postnatal visit to the beneficiary and that the child has been
       immunized for BCG.
      Transactional cost (Balance out of Rs.600/-) is to be paid to ASHA in lieu of her
       stay with the pregnant woman in the health centre for delivery to meet her cost of
       boarding and lodging etc.. Therefore, this payment should be made at the hospital/
       heath institution itself.

Note 1: In Urban areas, ASHA package consists of only the incentive for ASHA, for
providing the services, as at para 3.1

Note 2: In case ASHA fails to organize transport for the pregnant woman to go to the health
institution, transport assistance money available within the ASHA’s package should be paid
to the pregnant woman at the institution, immediately on arrival and registration for delivery.

Note 3: In case ASHA is yet to join, transport assistance money may be kept with the
institution and a voucher scheme may be introduced for disbursement.

4.10 Payment to ASHA: ASHA should get her-

      First payment for the transactional cost at the health centre on reaching the
       institution along with the expectant mother.
      The second payment should be paid after she has made postnatal visit and the child
       has been immunized for BCG.

All payments to ASHA would be done by the ANM only. In this case too, a voucher
scheme be introduced in such a manner that for every pregnant woman she registers under
JSY, ANM would give two vouchers to ASHA, which she would be able to encash on
certification by ANM.


                                              17
Important: It must be ensured that ASHA gets her second payment within 7 days of the
delivery, as that would be essential to keep her sustained in the system.

4.11 Special Dispensation for LPS states:

      Age restriction removed
      Restricting benefits of JSY up to 2 births removed. In other words, the benefits of
       the scheme are extended to all pregnant women in LPS states irrespective of birth
       orders.
      No need for any marriage or BPL certification provided woman delivers in
       Government or accredited private health institution.

Important: The state / UTs would be responsible for instituting an appropriate monitoring
mechanism and ensure that a proper accounting procedure is put in place for all transactions.

4.12 Subsidizing cost of Caesarean Section or management of Obstetric complications:
Generally PHCs/ FRUs / CHCs etc. would provide emergency obstetric services free of cost.
Where Government specialists are not available in the Govt’s health institution to manage
complications or for Caesarean Section, assistance up to Rs. 1500/- per delivery could be
utilized by the health institution for hiring services of specialists from the private sector. If
a specialist is not available or that the list of empanelled specialist is very few, specialist
doctors working in the other Government set-ups may even be empanelled, provided
his/her services are spare and he/she is willing. In such a situation, the cash subsidy can be
utilized to pay honorarium or for meeting transport cost to bring the specialist to the health
centre. It may however be remembered that a panel of such doctors from private or
Government institutions need to be prepared beforehand in all such health institutions
where such facility would be provided and the pregnant women are informed of this facility,
at time of micro-birth planning.

4.13 Assistance for Home Delivery: In LPS and HPS States, BPL pregnant women, aged
19 years and above, preferring to deliver at home is entitled to cash assistance of Rs. 500/-
per delivery. Such cash assistance would be available only upto 2 live births and the
disbursement would be done at the time of delivery or around 7 days before the delivery
by ANM/ASHA/ any other link worker. The rationale is that beneficiary would be able to
use the cash assistance for her care during delivery or to meet incidental expenses of delivery.
It should be the responsibility of ANM/ASHA, MO PHC to ensure disbursement. It is very
important that the cash is disbursed in time. Importantly, such woman choosing to deliver at
home should have a BPL certificate to access JSY benefits.

5. Compensation Money: If the mother or her husband, of their own will, undergoes
sterilization, immediately after the delivery of the child, compensation money available
under the existing Family welfare scheme should also be disbursed to the mother at the
hospital itself.

6. JSY Benefits in Accredited Private Health Institution: In order to increase choice of
delivery care institutions, at least two willing private institutions per block should be
accredited to provide delivery services. State and the district authorities should draw up a
list of criterion / protocols for such accreditation. (Please see a model criterion at



                                               18
Annexure-2) Such beneficiaries delivering in these institutions would get the cash benefits
admissible under the JSY.

7. Equip Sub-centers for Normal delivery: For women living in tribal and hilly districts, it
becomes difficult to access PHC/CHCs for maternal care or delivery. A well-equipped sub-
center is a better option for normal delivery. Deliveries conducted in sub-centers, which are
accredited by the state / district authorities will be considered as institutional delivery and
therefore, women delivering in these centers would be eligible for all cash assistance under
JSY.

Important: All States and UTs to undertake a process of accreditation of all such sub-centre
located in Govt. buildings and having proper facility of light, electricity, water, and other
medical requirements of basic obstetric services including drugs, equipments and services of
trained mid-wife for the purpose of conducting normal deliveries in these institutions.

8. Provision of Administrative Expenses: Upto 4 % and 1% of the fund released could be
utilized towards administrative expenses like monitoring, IEC and office expenses for
implementation of JSY by the district and state authorities respectively.

9. Essential Strategy: While the scheme would create demand for institutional delivery, it
would be necessary to have adequate number of 24X7 delivery services centre, doctors, mid-
wives, drugs etc. at appropriate places. Mainly, this will entail

          Linking each habitation (village or a ward in an urban area) to a functional health
           centre- public or accredited private institution where 24X7 delivery service would be
           available,
          Associate an ASHA or a health link worker to each of these functional health centre,
          It should be ensured that ASHA keeps track of all expectant mothers and newborn.
           All expectant mother and newborn should avail ANC and immunization services, if
           not in health centres, atleast on the monthly health and nutrition day, to be
           organised in the Anganwadi or sub-centre:
          Each pregnant women is registered and a micro-birth plan is prepared.
          Each pregnant woman is tracked for ANC,
          For each of the expectant mother, a place of delivery is pre-determined at the time of
           registration and the expectant mother is informed,
          A referral centre is identified and expectant mother is informed,
          ASHA and ANM to ensure that adequate fund is available for disbursement to
           expectant mother,
          ASHA takes adequate steps to organize transport for taking the women to the pre-
           determined health institution for delivery.
          ASHA assures availability of cash for disbursement at the health centre and she
           escorts pregnant women to the pre-determined health centre.

10. Possible IEC strategy:

           To associate NGO and Self Help Groups for popularizing the scheme among
            women’s group and also for monitoring of the implementation.
           To provide wide publicity to the scheme by:



                                                 19
       Promoting JSY as a component of total package of services under RCH along with
         programmes like Pulse polio programme, Monthly Village Health Day, Health Melas
         etc,

        Printing and distributing JSY guidelines, pamphlets, notices in local languages at
         SC/PHCs/CHCs/ District Hospitals/ DM’s and Divisional Commissioner’s office and
         even in at the accredited Pvt. Nursing Homes, in abundance,
        Supporting printing of state’s stationery, specially for State’s Health Secretary, DMs /
         SDMs/ Block/ PHC/ CHC/ District Hospital, advocating on Institutional Delivery and
         cash benefits of JSY,
        Facilitate organizing workshops and meetings in villages / blocks - by women’s
         group, local leaders (PRIs), Opinion Maker, at functional health institutions on
         promoting maternal health in general, Institutional Delivery and JSY,

       Undertaking wall painting in all sub-centers, PHCs and CHCs, District & State
         Hospitals and the accredited private institutions,

       Supporting women self help Groups and NGOs for promoting the scheme,

       Facilitating woman Panchayat member to take review of Janani Suraksha Yojana (JSY)

11. Establish a grievance redressal cell in each district, under the District Project
Management Unit, mainly to facilitate meeting people’s genuine grievances on -

        Eligibility for the scheme,
        Quantum of cash assistance,
        Delays in disbursement of the cash assistance,

An officer, supported by an assistant, if necessary, may be made responsible to supervise the
grievance cell. However, proper information about the grievance cell, giving the officer’s
name, postal address and his telephone number should be displayed prominently at all health
centers and institutions. If necessary, fund available under administrative expenses could be
utilized for this purpose.

12. Display of names of JSY beneficiaries: The list of JSY beneficiaries along with the
date of disbursement of cash to her should mandatorily be displayed on the display board at
the sub-center, PHC/CHC/District Hospitals (from where beneficiaries have got the benefit),
being updated regularly on month-to-month basis. Wherever necessary, display boards may
be procured.

13.     Guidelines For urban areas: The state shall prepare detailed guidelines by stating a
simple procedure of implementing the Janani Suraksha Yojana (JSY) in the urban areas
through the Municipalities/local bodies ((where an elected body exits) and quickly obtain
approval of the state Government/SHS. The guidelines should bring out clearly, the chain of
fund flow as well as disbursement of the benefits to the ultimate beneficiaries. The quantum
of grants to be placed at the disposal of the Municipalities shall be in proportion to the BPL
families in the Municipal area. The district annual plan will also include the plan of the
municipalities in the districts wherever applicable. The Chief medical Officer of such an



                                                20
authority should be the implementing authority. It must be ensured that basic objectives and
the scale of disbursements are not altered. A copy such plan along with necessary
Government’s order should be sent to the GOI.

14. Monitoring:

14.1 Monthly Meeting at Sub-centre Level: For assessing the effectiveness of the
implementation of JSY, monthly meeting of all ASHAs / related health link workers working
under an ANM should be held by the ANM, possibly on a fixed day (may be on the third
Friday) of every month, at the sub-center or at any of Anganwadi Centres falling under the
ANM’s area of jurisdiction. If Friday is a holiday, meeting could be held on following
working day.

14.2 Prepare Monthly Work Schedule: In the monthly meeting, the ANM, besides
reviewing the current month’s work vis-à-vis envisaged activities, should prepare a Monthly
Work Schedule for each ASHA / village level health worker of following aspects of the
coming month:
      Feed back on previous month’s schedule -
               (a) Number of pregnant women missing ANCs,
               (b) No. of cases, ASHA/link worker did not accompany the pregnant women
               for Delivery,
               (c) Out of the identified beneficiary, number of Home deliveries,
               (d) No. of post natal visits missed by ASHA,
               (e) Cases referred to Referral Unit (FRU) and review their current health
               status,
               (f) No. of children missing immunization.
      Fixing Next Month’s Work Schedule (NMWS): To include -
   (i) Names of the identified pregnant women to be registered and to be taken to the health
       center/Anganwadi for ANC,
   (ii) Names of the pregnant women to be taken to the health center for delivery (wherever
        applicable),
   (iii) Names of the pregnant women with possible complications to be taken to the health
         center for check-up and/or delivery,
   (iv) Names of women to be visited (within 7 days ) after their delivery,
   (v) List of infants / newborn children for routine immunization,
   (vi) To ensure availability of imprest cash,
   (vii) Check whether referral transport has been organized.

16. Any deviation from the above process will not be accepted by the Central Government
and that such expenditure will not be treated as legitimate utilization of the fund given under
JSY. It may be noted that all payments before or after seven days of delivery will be treated
as illegitimate subject to audit objection.



                                                21
     INTRODUCTION TO DISTRICT DODA
    Earstwhile District Doda is further Divided into three new District viz Doda, Ramban &
Kishtwar.

SOCIO-DEMOGRAPHIC PROFILE
Geographic Area (1981)                                                  11691 sq.km

Population                                                             7,78,683 lacs

Density of Population                                                      59/sq.km

Sex ratio                                                   945 female /1000 male

Inhabited Villages                                                               655

Literacy Rate

    Total                                                                   46.92%

    Male                                                                    63.56%

    Female                                                                 28.35%

Health Blocks                                                                     10

Tehsils                                                                           10

Community Blocks                                                                 19

Panchayats                                                                      262




                                             22
                NRHM IN DISTRICT DODA
In District Doda NRHM started functioning from the month of February, 2006 after the
Registration of District Health Society(DHS), Doda which got Registered under societies
act No 4847 of 2006 Dated 27-01-2006.

            MEMBERS OF DISTRICT HEALTH SOCIETY
 District Development Commissioner, Doda                                  Chairman

 Chief Medical Officer, Doda                                           Vicechairman

 Deputy Chief Medical Officer, Doda                                         Member

 Chief Education Officer, Doda                                              Member

 Medical Superintendent, Distt. Hospital, Doda                               Member

 District Health Officer, Doda                                              Member

 District Immunization Officer, Doda                                        Member

 District Social Welfare Officer Doda                                       Member

 District Program Officer ICDS Doda                                         Member

 District Information Officer, Doda                                         Member

 Executive Engineer,RDD Doda                                                Member

 Executive Engineer, PHE Doda                                               Member

 District Panchayat Officer Doda                                            Member

 Block Medical Officers (10 Med Blocks)                                    Members

 District Programme Manager                                                Convener



MEETINGS OF DISTRICT HEALTH SOCIETY
After the registration of DHS Doda, during the year 2005-06 1 meeting of DHS was held,
then in the year 2006-07, 3 meetings of DHS were held and during the year 2007-08 2 DHS
meetings are held so far.




                                          23
          MEMBERS OF DISTRICT HEALTH MISSION
 Hon’ble Minister for Rural Development Department      Chairman

 District Development Commissioner Doda              Vicechairman

 Chief Medical Officer, Doda                            Convener

 District Social Welfare Officer Doda                    Member

 District Program Officer ICDS Doda                      Member

 Assistant Commissioner (D) Doda                         Member

 District Superintendent Engineer, PHE Doda              Member

 District Information Officer Doda                       Member

 Ho’ble MLA Doda                                         Member

 Ho’ble MLA Bhaderwah                                     Member

 Kichloo Ho’ble MLA Kishtwar                              Member

 Ho’ble MLA Inderwal                                      Member

 Ho’ble MLA Ramban                                        Member

 Ho’ble MLA Banihal                                       Member

 Member of Legislative Counsil                            Member

 Chairman MC Doda                                         Member

 Chairman MC Bhaderwah                                    Member

 Chairman MC Kishtwar                                     Member

 Chairman MC Batote                                       Member

 Chairman MC Ramban                                       Member

 Chairman Municipal Committee Banihal                     Member




                                         24
         NRHM Unit (DPMSU and BPMSUs), DODA
S.No.   NAME                  DESIGNATION                     PLACE OF
                                                              POSTING

1.      WASEEM RAJA           District Programme Manager      CMO Office, Doda


2.      ASHOK KUMAR           District Accounts Manager       -do-

3.      TARIQ HUSSAIN         District Data Officer           -do-

4.      MOHD RAFI             Computer Assistant              DDC Office, Doda
                              (Immunization)

5.      MASHOD LATIEF         Computer cum Accounts Knowing   Block Ghat
                              Managers


6.      NAZISH ANJUM          -do-                            Block Banihal

7.      ANIL KUMAR            -do-                            Block Kishtwar

8.      SHUHAB SYED           -do-                            Block Bhaderwah

9.      ASHOK KUMAR           -do-                            Block Assar

10.     TARIQ AZIZ            -do-                            Block Ukheral

11.     BHANU UDHAY           -do-                            Block Padder

12.     MANOJ KUMAR           -do-                            Block Ramban

13.     Amad-ud-din Mansoor   -do-                            Block Dachhan

14.     Mushtaq Ahmed Khan    -do-                            Block Gandoh




                                         25
SOME ACHIEVEMENTS UNDER NRHM IN DODA
A) MO Outreach Sessions:
  (One camp at S/C level per month @ Rs 600 per camp)

   Conducted during the year 2005-06 = 242

   Conducted during the year 2006-07 = 711

   Conducted during the year 2007-08 = 736

B) ANM Outreach Sessions/Immunization of Children by ASHA:
  Attended by ANM and AHSA

  (Four sessions outside the S/C per month @ Rs 50 per sessions)

   Conducted during the year 2006-07 = 890

   Conducted during the year 2007-08 = 4417

   Conducted till 30th May, 2008 = 864

C) Village Health and Nutrition Days:
  (Attended by ANM/ASHA/AWW/etc under the supervision of CHO/HE/LHV)

   Conducted during the month of September, 2007 = 168

   Conducted during the 1st Quarter Ending June, 2007 = 203

   Conducted during the year 2007-08 = 2836

   Conducted till 30th May, 2008 = 906

   Calendered for the month of June, 2008 = 479

D) Constitution of Rogi Kalyan Samities CHC/PHC level as per
norms/Guidelines:
   The Samiti is a registered society which primarily acts as a group of trustees for the
    district, sub-district hospitals and PHCs to manage the affairs of the hospital in such a
    way so as to meet the expectations of the people especially for quality curative
    services. The RKS will not function as a government agency, but as an NGO as far as
    functioning is concerned.

   35 RKSs were constituted at CHC and PHC level




                                            26
Status of RKSs
       Target = 35

       Registered = 35

       Bank Accounts opened = 35

       Pending RKS registration = 0

      District Hospital                                    1

      No of CHCs                                           8

      No. of PHCs                                          26

      Total                                                35



              LIST OF ROGI KALYAN SAMITIES FOR DISTT. DODA
S.         Name of Block   Rogi Kalyan Samiti   Registration     Account    Bank
No.                                             No.              No.

      1.   Bhaderwah       CHC Thathri          5574-S of 2007   CD-519     J&K Bank Ltd, Thathri

                           PHC Bhella           5575-S of 2007   SG-5756    J&K Bank Ltd, Pull Doda

                           CHC Bhaderwah        5245-S of 2007   SG-14356   J&K Bank Ltd, Bhaderwah


                           PHC Prem Nagar       5248-S of 2007   CD-518     J&K Bank Ltd, Thathri

                           PHC Chinta           5246-S of 2007   SG-14637   J&K Bank Ltd, Bhaderwah


                           PHC Bhalla           5247-S of 2007   4032/G3    J&K Bank Ltd, Bhalla

      2.   Assar           PHC Assar            5249-S of 2007   13226      J&K Bank Ltd, Doda

                           PHC Goha             5250-S of 2007   13225      J&K Bank Ltd, Doda

      3.   Kishtwar        CHC Kishtwar         5578-S of 2007   CD1389     J&K Bank Ltd, Kishtwar

                           PHC Chatroo          5261-S of 2007   CD 1381    J&K Bank Ltd, Kishtwar




                                                27
               PHC Keru            5262-S of 2007   SB 24117   J&K Bank Ltd, Kishtwar

               PHC Nali            5263-S of 2007   SB 24122   J&K Bank Ltd, Kishtwar

4.   Ghat      PHC Ghat            5241-S of 2007   SG 13220   J&K Bank Ltd, Doda

               PHC Bhagwah         5242-S of 2007   SG 13219   J&K Bank Ltd, Doda

               PHC Bharath         5244-S of 2007   SG 13222   J&K Bank Ltd, Doda

               PHC Gundna          5243-S of 2007   SG 13221   J&K Bank Ltd, Doda

5.   Ukheral   PHC Ukheral         5253-S of 2007   3884/G     J&K Bank Ltd, Ukheral

               PHC Kheri           5254-S of 2007   15146      J&K Bank Ltd, Banihal

               PHC Trigam          5255-S of 2007   15147      J&K Bank Ltd, Banihal

6.   Banihal   CHC Banihal         5268-S of 2007   SB 15145   J&K Bank Ltd Banihal

               PHC Mangit          5269-S of 2007   SB 15144   J&K Bank Ltd Banihal

7.   Ramban    CHC Ramban          5256-S of 2007   SBG-190    J&K Bank Ltd Ramban

               PHC Rajgarh         5259-S of 2007   SBG-189    J&K Bank Ltd Ramban

               PHC Bhatni          5258-S of 2007   SBG-188    J&K Bank Ltd Ramban

               CHC Batote          5257-S of 2007   SBG-187    J&K Bank Ltd Ramban

8.   Gandoh    CHC Gandoh          5577-S of 2007   5484/G9    J&K Bank Ltd Gandoh

               PHC Changa          5266-S of 2007   5476/G9    J&K Bank Ltd Gandoh

               PHC Malanoo         5265-S of 2007   5475/G9    J&K Bank Ltd Gandoh

               PHC Tipri           5267-S of 2007   5477/G9    J&K Bank Ltd Gandoh

9.   Dachhan   CHC Marwah          5576-S of 2007   CD 13      J&K Bank Ltd Dachhan

               PHC Dachhan         5271-S of 2007   CD 11      J&K Bank Ltd Dachhan

               PHC Afti            5272-S of 2007   CD 12      J&K Bank Ltd Dachhan

10. Padder     PHC Padder Atholi   5251-S of 2007   5835/G     J&K Bank Ltd. Gulab Garh

               PHC Massu           5252-S of 2007   5834/G     J&K Bank Ltd. Gulab Garh




                                   28
           JANANI SURAKSHA YOJANA in DODA
    JSY is a safe motherhood intervention under NRHM, as discussed previously, with the
objective of reducing maternal and Neo-Natal mortality by promoting institutional deliveries
among the poor pregnant women. The JSY is a programme to strengthen the institutional
deliveries through provision of escorts and referral services by ASHA and subsidized hospital
services. The cash assistance in our J & K (LPS) is Rs. 2,000/- per delivery (Rs. 1,400 to
beneficiary and Rs. 600/- to ASHA). Rs 500/- is given for home deliveries in case of BPL families
up to two live births. JSY is also running successfully along with other programmes of NRHM.

   Following are some achievements under JSY in DODA:
                 PHYSICAL & FINANCIAL ACHIEVEMENTS UNDER JSY

Financial Achievement:

Opening Balance1-4-07                                                         =            98,600

Funds received during the year                                                =          1955000

Total funds in hand                                                           =         2,053,600

Expenditure during the1st Qtr                                                 =           948,850

Expenditure during the 2nd Qtr                                                =           105116

Expenditure during the 3rd Qtr                                                =              2134

Expenditure during the 4th Qtr                                                =           169180

Expenditure during March, 2008                                                =           203180

Total Expenditure during the current year                                     =         1,245,280

Balance                                                                       =           808,320

Physical Achievement:

No of Institutional Deliveries for the 1st Quarter ending June, 2007          =              1459

No of Institutional Deliveries for the 2nd Quarter ending Sep., 2007          =              1646

No of Institutional Deliveries for the 3rd Qtr ending December                =              1176

No of Institutional Deliveries for the 4th Qtr ending December                =              1150

No of Institutional Deliveries for the month of March, 2008                   =               479

Total No of Institutional Deliveries for the year 2007-08                     =              5431

Beneficiaries paid during the year                                            =               581


                                                 29
From 655 Villages, 700 ASHAs were nominated and selected.
ASHA, as a health activist, create awareness in the community on health and its social determinants
like:
    Sanitation,
    Safe drinking water,
    Hygiene
    Mobilize the community towards local health planning and increased utilization and
     accountability of the existing health services.
    She will also make timely referrals of all antenatal cases, sick children, and other diseases
     like Tuberculosis, Malaria, Leprosy, AIDS etc.
    And shall ensure immunization of children against six killer diseases.
TRAINING OF ASHAS
    273 ASHAs were trained in Module 1st in the previous year and the rest of 27 were trained
     in the financial year 2007-08
    All the 10 Medical Blocks have trained 651 ASHA as of now. So a total of 651 ASHAs
     have been trained in Module 2nd.

                      STATUS OF ASHAS IN DODA
Name        of Selected     Trained    in Trained IN Already                     To be Trained
Block                       06-07         2007-08    Trained                  in in Mod II
                            (Module I)    (Module I) Mod II

Banihal         45          45                0                45                0

Ukheral         52          52                0                52                0

Ramban          65          65                0                65                0

Assar           41          41                0                41                0

Ghat            104         91                13               100               4

Bhaderwah       137         127               10               125               12

Gandoh          95          95                0                76                19

Kishtwar        98          94                4                84                14

Padder          33          33                0                33                0

Dachhan         30          30                0                30                0

Total           700         673               27               651               49




                                                   30
            BACKGROUND OF THE STUDY
The stagnant maternal mortality rate (MMR) in India over the years is a serious concern
(See table below). The national population policy 2000 has acknowledged the need to
undertake effective programmatic interventions to reduce the MMR to less than 100 by
2010. Keeping in view of the importance of MMR and IMR as health indicators the
Government of India launched JSY in 2005 under its flagship program NRHM.



MMR, ANNUAL DEATHS AND % BIRTHS ATTENDED BY
          SKILLED HEALTH PERSONNEL (SEAR)




        Country Estimated                  MMR % births
                 annual                        by skilled
                 deaths                        attendant
     Nepal             210                 830        9.7
     Bangladesh     20,000                 600      14.3
     Bhutan            360                 500      15.1
     Indonesia      22,000                 470      46.6
     India        136,000                  440      42.5
     Maldives           30                 390        95*
     Myanmar         1,500                 170      56.4
     Sri Lanka       6,300                  60      95.0
     Thailand          450                  44      84.6

     Total                   187,020




                                           31
       Reproductive and Child Health Programme (RCH-II) was launched in 2005 as a
part of the Mission as the principal vehicle for reducing IMR, MMR and TFR as
envisaged in the original Cabinet Note. Upgradation of Community Health Centres as
First Referral Units (FRUs) for dealing with Emergency Obstetric Care, 24x7 delivery
services at the PHCs, operationalising of Sub-Centres multi-skilling of doctors,
contractual appointments of MOs and AMOs, training medical officers in Anesthetic
skills, training doctors/ANMs/Nurses as Skilled Birth Attendants (SBA) permitting
ANMs to administer certain drugs in emergency, partnerships with voluntary
organizations, RCH camps accreditation of non profit organizations, IEC activities are
the major interventions in reducing MMR.


                                      For reducing neo natal mortality programme for
Integrated Management of Childhood illnesses(IMNCI) is being extended at the
community and facility levels. Activities of ASHAs, Anganwadi workers and ANMs,
preraks of continuing Education Centres and SHG groups at the village level with focus
on both preventive and promotional aspects of health care accelerated immunization
programme, advocacy on age of marriage/ against sex selection, spacing of births,
institutional delivery, breast feeding, meeting unmet demands for contraception, besides
providing a range of RCH services are to have impact on reducing the health indicators.
Efforts are being made to integrate HIV AIDS programme with the RCH at the district
and sub-district levels. Convergence of disease control programmes, integration of
services, combined awareness generation, education and the advocacy at community and
facility levels, taking care of preventive, promotive and curative health care are expected
to bring down IMR/MMR/TFR and the disease burden as stated in the proposal.




                                            32
                  DESIGN OF THE STUDY
Considering the importance of JSY as discussed earlier, I decided, in consultation with
Mr. Waseem Raja, District Program Manager (DPM), NRHM, Doda, to assess the
functioning of JSY through the opinions of health workers, as my summer training
project.

STATEMENT OF THE PROBLEM
A study to
  1. Take opinions of health workers about functioning and current status of JSY in
Distt. Doda, J&K.

OBJECTIVE

    To assess the awareness, and evaluate the functioning of JSY, among Health
     workers in District Doda.

OPERATIONAL DEFINITIONS

    Awareness: It refers to the information that the sample population has, about JSY
     on the basis of their response to the questionnaire.



ASSUMPTIONS
The study assumes that:
   Awareness and attitude play an important role in caring for pregnant women.
   Sample population differs in their awareness.

LIMITATIONS
The study is limited to:
   Adults above the age of 18 years.
   Health workers (BMO, MO, Gynaecologist, Account Manager, ANM, ASHA
      from each block) in 5 blocks (Ghat, Assar, Batote, Kishtwar, Bhaderwah) of Distt.
      Doda.




                                          33
  METHODOLOGY AND DATA COLLECTION

Methodology indicates the general pattern of organizing the procedure for gathering valid
and reliable data for investigation, it also includes the study approach, development of tool,
and description of tool, data collection procedure and plan for data analysis. The present
study to is basically designed to know the opinions of health workers about JSY in terms of
effectiveness, difficulties faced etc. in 5 blocks namely Ghat, Assar, Batote, Kishtwar,
Bhaderwah of Distt. Doda, J&K.

STUDY APPROACH
The study approach is the basic procedure for collecting data in a particular situation. The
choice of the method of study is determined by the nature of the problem. Present study is
aimed at identifying the awareness and opinion about JSY, among sample population. The
survey approach was found to be most appropriate for this study.

SURVEY DESIGN
The survey design is concerned with the overall plan for conducting the study. It involves
making decision about the setting of the study, target population, sampling technique,
sample size, selection and development of tool. Basically it is an overall plan for collection
and analyzing data.

POPULATION
Population refers to the entire set of individuals having some common characteristic(s). The
population of the present study is the adult population consisting of both males and females
in a selected community of Doda.

SETTING
The setting is the physical location of condition where the data is collected. The study was
conducted in 5 blocks (Ghat, Assar, Batote, Kishtwar, and Bhaderwah) of Distt. Doda.

SAMPLE AND SAMPLING TECHNIQUE
A sample is a small portion of population selected for observation and analysis. Sampling
refers to the process of selecting a portion of the population to represent the entire
population. Sampling is necessary because it is more economical and efficient to work with
a small group of subjects.

In the present study, the sample was drawn from the selected blocks. Convenience sampling
technique was used keeping in view the nature of problem, objectives of the study and

                                              34
study design. A sample size of 25 people was drawn out of health workers, which included
both males and females.

DATA COLLECTION TOOLS AND TECHNIQUES
The most important aspect of any investigation is the collection of appropriate information,
which provides necessary data for the study. Selection of tool depends upon the objectives
of the study and the sources of information required. I used a Questionnaire as my data
collection tool to take in-depth interview of sample.

DESCRIPTION OF THE TOOL
The interview schedule starts with seeking information on demographic data of the
respondents. It then proceeds to collection of data on awareness. The tool consists of two
sections:-
Section 1: Analysis of demographic data
Section 2: Analysis of awareness data
Section 1
It consists of five items to collect the demographic information of the sample subjects.
Section 2
It consists of 10 questions to collect information about the awareness and opinion of the
sample population (Health workers) about JSY.
The format of the questionnaire used, is given in Annexure.

DATA COLLECTION PROCEDURE
To collect the data with the help of questionnaire I went to the selected 5 blocks on different
days as follows-
    Ghat                   1/6/2008
    Assar                   2/6/2008
    Batote                  3/6/2008
    Kishtwar                4/6/2008
    Bhaderwah                6/6/2008

There I met with the intended health workers (i.e. Block Medical Officer, Medical Officer,
Gynaecologist, Computer cum Accounts Knowing Manager, ANM and ASHA) in each
block.Then with the help of the Questionnaire I interviewed them one by one. We discussed
all the questions in-detail but due to limitations of the study only relevant information was
recorded as per questionnaire’s format. Some other points, which I thought as inseparable
from the study but could not be incorporated in the questionnaire, were also recorded.Not
all the health workers could be approached on a single day so I had to revisit all the blocks
several times until I interviewed all of them.

                                              35
  DATA ANALYSIS AND INTERPRETATION

The analysis is based on the following objectives of the study


       To assess the awareness among health workers about JSY and


       To know their opinions about functioning of JSY.




Analysis is the categorizing, ordering manipulating and summarizing of
data to obtain answer to the study question. The purpose of analysis is to
reduce data to an intelligible and interpretable from so th at the relation of
study problem can be studied and tested. Accordingly, the data was first
tabulated, and analyzed in accordance with the above objective.

Interpretation is the task of drawing conclusions or inferences and of
explaining their significance, after careful analysis of the collected data .In
other words, it refers to the process of making sense of the results and of
examining the implications of the findings within a broader context.
The present study was undertaken to assess the awareness of health workers
about JSY .The data for the study was collected through an Interview schedule
and then analysed by descriptive statistics. The report is organized under the
following sections:
 (i) Analysis of demographic data of sample subjects
 (ii) Analysis of awareness data of sample subjects about JSY.




                                            36
37
                 “EFFECTIVENESS OF JSY IN REDUCING MMR”

Degree of effectiveness                                                 %age of population
A) Very effective                                                                           24
B) Effective                                                                                60
C) Somewhat effective                                                                       16
D) Not effective                                                                             0




                                                                   A) Very effective
                                                                   B) Effective
                                                                   C) Somewhat effective
                                                                   D) not effective




                 “IMPORTANCE OF AWARENESS CAMPAIGNS”

A) More important than cash assistance                                                 28%
B) Both are equally important.                                                         48%
C) Cash assistance attract more effectively than awareness campaigns.                  24%



                                                               A) More important than
                                                               cash assistance


                                                               B) Both are equally
                                                               important.


                                                               C) Cash assistance attract
                                                               more effectively than
                                                               awareness campaigns.




                                               38
    “BENEFITS OF JSY SHOULD EXTEND TO ALL PREGNANT WOMEN”

A) Yes                                                        88%
B) No                                                         12%
C) Cannot say                                                   0


                                                   A) Yes




                                                   B) No




                                                   C) Cannot say




“CURRENT PROCESS OF JSY IN TERMS OF TIMELY RELEASE OF FUNDS
                             etc”

A) Excellent                                                    0
B) Good                                                       36%
C) Not satisfactory                                           56%
D) Cannot say                                                  8%

                                             A) Excellent


                                             B) Good


                                             C) Not satisfactory


                                             D) Cannot say




                              39
                         “IMPROVEMENT NEEDED IN THE AREA”

A) More funds are needed                                              60%
B) More workforce is needed                                           40%
C) Efficient delivery of services                                     16%
D) Any other, please specify                                           4%


      A) More funds are needed




      B) More workforce is needed




      C) Efficient delivery of services




      D) Any other, please specify




                    “NEED AND SCOPE OF IMPROVEMENT IN JSY”

A) Yes, very much                                                     60%
B) Yes, to some extent                                                40%
C) No                                                                   0
D) Cannot say                                                           0




                                                  A) Yes, very much
                                                  B) Yes, to some extend
                                                  C) No
                                                  D) Cannot say




                                          40
               “VIEW REGARDING INCENTIVE GIVEN TO ASHA”

A) It is sufficient                                                 40%
B) It is insufficient                                               56%
C) Cannot say about this                                             4%




                                            A)   It is sufficient



                                            B) It is insufficient



                                            C) Cannot say about this




                                  41
 INTERPRETATION OF RESPONSES TO DESCRIPTIVE
                 QUESTIONS



     A) The first descriptive question was to describe JSY briefly. Analysis of responses to this
question show that all, except one (ASHA) respondent knew JSY in considerable detail.
Interestingly one of the BMO had to consult the JSY manual before answering this question.


   B) The second question was about the difficulties faced by health functionaries in
implementation of JSY. Analysis of responses to this question reveal following findings


    Funds are either delayed (For ASHAS) or not coming at all(For mothers beneficiaries)

    A substantial no. of sub-centers is running in private rented buildings.

    There is a shortage of staff.

    Transportation difficulties in approaching far-flung, remote areas.

    ASHA just bother to drop the gravida to the hospital (According to one Gynecologist).

    Poor education status and awareness among women.

    Incentives are inadequate.

    Infrastructure is grossly inadequate at most of the sub-centers.

    Local culture and customs sometimes hinder the proper functioning.


   C)   The third descriptive question was about suggestions for improvement in JSY. The
   responses to this question are dealt with in subsequent sections of this report.




                                                42
             SUMMARY AND CONCLUSIONS

Summary Of The Study
The purpose of the study was to assess the awareness and opinion about JSY
among health workers in Distt. Doda. The study approach selected for the study
was Descriptive Survey Approach. The study setting was in 5 blocks namely
Ghat, Assar, Batote, Kishtw ar and Bhaderwah of Distt. Doda, J&K. The
sampling technique used for the study was convenient sampling. The final data
collection was carried out on a sample of 25 health workers; 5 from each of the
selected 5 blocks. A structured interview schedule was developed and used for data
collection.
The tool used for collecting information was a questionnaire to interview the sample.


The tool had 2 sections:


Section 1: It consisted of 5 items to collect demographic information of Sample subjects.

Section 2: It consisted of 10 items to assess the awareness of sample population
(Health workers) about JSY.

The study was completed within the specified time frame and without any significant
glitch. All the staff in all 5 blocks co-operated with me in every aspect. All 5 of the
BMOs gave me whatever information I asked, freely and without any fuss.

They also discussed at length, other health related issues with me. Some of the lower
rank health workers were sceptical in giving their opinions at first but after some
assurance they got ready. It was a little difficult to interact with some lower rank
women workers due to their hesitation. This is understandable considering the
cultural values prevalent in the region.




                                            43
                        CONCLUSIONS
The following conclusions were drawn on the basis of the findings of the
Study:

     JSY is currently working in all 5 blocks under study.

     Most of the ASHA’s are not trained in obstetric care.

     Certain problems were pointed out by health workers viz. delay in
      reimbursement of incentives to ASHAs, transportation problems due to
      topography of far-flung areas.

     Most of the BMOs demanded more work-force in implementation of JSY.

     Some ASHAS and other health workers perform below standard or don’t work
      at all, this adversely affects the performance of other workers and de-motivate
      them.

     Some workers perform above par, but do not get the deserved recognition or
      any extra incentives, this de-motivate them to work.




                                        44
                         SUGGESTIONS

 To increase awareness about JSY among the target population, more efforts are
  needed in the form of—regular, frequent and well crafted Awareness Campaigns,
  advertising, regular door-to-door visits by health workers.

 ASHAs should be given training of Emergency Obstetric Care (EOC) also, so that
  they can perform uncomplicated deliveries whenever needed in emergency
  situations.

 Infrastructure need to be upgraded urgently at sub-centers for smooth functioning of
  services under JSY.

 Cash should be disbursed to ASHAs at right time to keep up their motivation and
  dedication.

 Transport facility should be available at blocks as well at sub-centers and remote
  areas should get some facility nearby.

 More ASHAs should be recruited in some areas as there is more population. The less
  the number of ASHAs in an area the less is the awareness among people.

 ASHAs should be given certain targets so that they can have a feeling of
  responsibility.

 Presence of all the ASHAs should be ensured in the monthly meeting, so that their
  progress can be tracked. They should be asked about the problems and other issues
  related with the work, and all possible steps should be taken to solve the same at the
  earliest.

 The underperforming health workers should be identified and strict action be taken
  against them at the earliest to ensure proper work environment.

 The star performers i.e. the ASHAs (for example Khursha Begum, an ASHA of
  Ghat Block, in addition to her usual duty, even perform deliveries in
  emergencies in her area, motivates and bring even NSV cases and perform a
  host of other activities) or other health workers who work above average level,
  should be identified and given proper rewards for their work, to keep up their
  motivation. This would also inspire other workers to perform well.




                                         45
 Infrastructure in terms of buildings, equipments, vehicles etc should be
  strengthened and arranged on a priority basis where required (and not blindly
  sanctioning something for everywhere) especially in areas with difficult terrains and
  high altitudes.

 Involvement of other departments-Other departments specially Education Dept. &
  Road Transport Dept. must be involved to spread awareness in the case of former
  and facilitate timely delivery of services (by constructing new roads to link remote
  areas with health-centers and repairing the damaged roads) under JSY, because
  sometimes few saved minutes can save a life in an emergency.

 There should be at least a van, fully equipped for Emergency Obstetric Care, ready
  for emergencies, in the areas which are very far from any health facility. ASHAs
  should be trained in Emergency Obstetric Care for this purpose.

 Regular, impartial and strict monitoring is necessary to achieve the goals within the
  stipulated time frame.




                                         46

				
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Description: A study assessing the awareness of general public and health workers regarding JSY in Doda, J&K