To ensure parity in resource allocation to the

most backward regions of our country

To fast track improvements in health outcomes
especially in reproductive and child health
indicators.

Poor performing district represent approximately 35% of
our population but account for over 41% of births and
close to 50% of IMR(?60%) and 60% (?75%)of MMR.

Investment in facility development, progress of training,
human resource shortages well below national and state
averages.

Technical and human resources to make the difference
may be insufficient within the districts and would thus
require external ( to the district) assistance.

Geographic, social, economic constraints very high and
would require higher than par investment and support to
overcome.

Visited by 8 teams and
Assam Dhubri Goalpara dialogues with states and
Bihar Muzzafar Samasti districts
Chhattsgh Bilaspur Kawardha Sub-centers: 3292- 1/6476

Those doing delivery- 11.45%:
Jharkhand Deogarh Dumka Sector level PHCs: 525:
M.P Umaria Annupur
Those doing delivery: 24*7=
Orissa Kandmahl Nayagarh 23.2%
Rajasthan Pali CHCs+SDH+ DH= 112
U.P. Kanpur Unnao FRUs= 17- one per 12.54 lakhs
Dehat One functional delivery center per
1,47,044 population: against at
least one per 30,000 aimed for.

Institutional deliveries have increased.

But impact on maternal mortality uncertain/not optimised, because
management of complications in public systems has been very
limited.

Management of complications in private sector not covered for
costs- no JSY or inadequate JSY.

Risk stratification very poor.

Only 10% of sub-centers do delivery and of them only two or three
manage over 70% of the load.
Home SBA delivery- plays a varying contribution.

APHCs need to be functional- but not so in many districts.

Considerable ANM/IMNCI training but often those providing the
services not trained.

Critical shortages of HR- especially of nurses.
1. Invest resources in strengthening those facilities which are functional
and managing case load.
2. Also identify areas where access is the issue and develop/strengthen
facilities there.
3. Estimate precise training load: ExternalTrainers/Training.
4. Prioritise those providers for training who are providing the bulk of the
services and where access has to increase.
5. Work out the facilities where human resource gaps must be closed as a
priority.
6. Strengthen home based care- for deliveries in select sites and for
neonates everywhere.
7. Differential financing- more funds to those facilities which require more.
8. Provider incentives- both for volume of work and for those in
inaccessible areas.
Total Population 22,95,243
CBR 26.1
Expected pregnancies per year 65897
Total reported deliveries in nos. (from HMIS) 64839
Reported deliveries as % of expected pregnancies 98.4%
Actual Delivery as numbers and as % of expected
pregnancies:
Institutional 28398 (43.1%)
Home 36441 (55.3%)
Home deliveries by SBA (assisted by health personnel) 12090 (18.3%)
Home deliveries by non-SBA (not assisted by health
personnel/ unassisted) 24351 (37%)
Total Unreported deliveries 1058 (1.6%)
 INSTITUTIONAL DELIVERIES FACILITY OPERATIONALISATION
2009-10 2010-11 2011-12 2009-10 2010-11 2011-12
No. % No. % No. %
Level 1 facility

PHC - 48/75 PHC - 25/75 PHC - 25/75

Total no. of
5813 8.9 8567 13 9885 15 SCs: 80/357 SCs: 80/357 SCs: 80/357
deliveries
Total – 128 Total – 105 Total – 105
Level 2 facility
CHC-10/11 CHC-7 CHC-5
Total no. of PHC-3/75 PHC-33/75 PHC-45/75
14792 22.5 21088 32 23724 36
deliveries Private - 23 Private – 23 Private - 23
Total – 36 Total – 63 Total – 73
Level 3 facility
DH-1; CHC-1 DH-1; CHC-4; DH-1; CHC-6;
Medical College Medical College Medical College
Total nos. of
7793 11.9 9885 15 12521 19 Hospital-1 Hospital-1 Hospital-1
deliveries
12 Pvt. Hospitals 15 Pvt. Hospitals 20 Pvt. Hospitals
Total-15 Total -21 Total-28

TOTAL
28398 43.3 39540 60 46130 70
 INSTITUTIONAL DELIVERIES FACILITY OPERATIONALISATION
2009-10 2010-11 2011-12 2009-10 2010-11 2011-12
No. % No. % No. %
Level 1 facility

PHC - 48/75 PHC - 25/75 PHC - 25/75

Total no. of
5813 8.9 8567 13 9885 15 SCs: 80/357 SCs: 80/357 SCs: 80/357
deliveries
Total – 128 Total – 105 Total – 105
Level 2 facility
CHC-10/11 CHC-7 CHC-5
Total no. of PHC-3/75 PHC-33/75 PHC-45/75
14792 22.5 21088 32 23724 36
deliveries Private - 23 Private – 23 Private - 23
Total – 36 Total – 63 Total – 73
Level 3 facility
DH-1; CHC-1 DH-1; CHC-4; DH-1; CHC-6;
Medical College Medical College Medical College
Total nos. of
7793 11.9 9885 15 12521 19 Hospital-1 Hospital-1 Hospital-1
deliveries
12 Pvt. Hospitals 15 Pvt. Hospitals 20 Pvt. Hospitals
Total-15 Total -21 Total-28

TOTAL
28398 43.3 39540 60 46130 70

Sub-centers A type: remote areas- train SBAs- but
home is the focus: approximately 5%

Sub-centers B type: sub-center provides outreach
services- not delivery:

Sub-centers C type: approximately 10%: SBA
level -1.

Other PHCs: SBA level - 1

24* 7PHCs(mini/APHCs):50-100%:Bemonc level

CHCs as FRUs: 1/5 lakh at least as Cemonc

All district hospitals: FRUs+ Cemonc

Putting in place the additional HR needed

Defining Training needed and whom to prioritise
for training.

Supportive supervision to see that provider
practices have been revised as per protocols.

Developing infrastructure: equipment and civil
works

Supplies and minor equipment.

Getting the facility quality certified.
1. DH as SNCU 1. DH as SNCU+l FRUs at
2. All FRUs and CHCs as - in protocols
newborn stabilisation 2. All 24*7 PHCs: newborn
unit. Refer more, stabilisation unit- in
resolve less. clinical protocols.
3. All the rest as only 3. All level 1 facilities with
newborn corners. newborn corners only.
4. Home based care 4. Home based care –
based on AWW- limited, universal- resolve more,
refer more resolve less. refer less.

The Current Norm The desired norm


Includes
◦ Repair/ renovation of existing structures:
◦ Construction of new health facilities:
◦ Setting up of blood storage centres,
◦ sick newborn care units/newborn stabilisation units:
◦ ASHA waiting halls in high volume facilities, etc.

EQUIPMENT

Additional beds,

MVA kits (for safe abortion services),

generators,

Blood storage units:.


Preparation of similar sub-plans for other backward districts
◦ Steps already underway to involve development partners and other agencies
to provide support to states in strengthening planning and monitoring

Increasing training capacity to handle increased load
◦ Agencies being recruited nationally to provide training support to these states /
districts

States to prioritise interventions in these districts:
◦ Ensure strengthening of facilities
◦ Rationalise staff to ensure these facilities have fewer gaps
◦ Provide incentives to staff to work in these facilities
◦ Prioritise training
◦ Set up/ strengthen supportive supervision systems

Provision of enhanced / additional financial resources to these districts.

Do we have enough ILR points?

Do we have enough Immunisation points?

Ideally one immunisation point per habitation/ anganwadi – at least
one per 1000 in non tribal areas and one per 700 in tribal areas.

Ideally One ILR point for every 4 to 6 immunisation points.

If the ILR to immunisation ratio is high then need a) larger deep
freezers, b) more vaccine carriers and c) link workers with
alternative delivery mechanisms

If the density of immunisation points is low- additional investment in
demand side support and catch- up rounds.

What is the unmet need?

Are there enough providers to provide the services?

Do we have enough providers and facilities to provide
weekly fixed day sterilisation services- in every FRU? In
every 24*7 PHC?

Is there special care given to reaching spacing to those
on the queue?

What are the HR and training and infrastructure needs to
meet this goal.

Is the access and promotion of spacing methods
optimal.

Lack of human resources in rural and remote
areas is major public health system constraint.

Economic Less, Social and Professional
Isolation:

Regulation: Serevice bonds, mandatory Pre-pG

Incentivisation: compensate economic loss,
provide social recognition.

Positive Practice Environment Strategies.

Educational .

Right service provider in the right place.

8/27/2010

States submit list of facilities so identified

Problems of varying definitions

Loose definitions; inconsistent application of
criteria

Incomplete identification

Facility wise criteria not indicated
Hence impossible to verify on any consistent basis.
Need for a standard criteria for assessing
inaccessibility of facilities across states

8/27/2010
Sl Score Criterion
no
1 A5/ A4 In accessible: PHC is not on road at one has to walk over 2 km to reach it. Over
three hours is an even greater level of inaccessibility. If road gets cut off for
over 6 months in the year
2 A3 Most difficult by itself: Same as A2 add one point each for get cut off for >1
months - one point and /or
no regular public transport – one point
2 A2 Difficult by itself : If distance from DHQ and/or nearest urban center is more
than 60 km and distance from and distance from BHQ is more than 30 km AND
distance from highway is more than 10 kms;
3 A1.5 Not Difficult by itself : If distance from DHQ and /or nearest urban center is
more than 60 km and distance from BHQ is more than 30 OR distance from
highway is more than 10 kms;
4 A1 Not difficult by itself : Only one of the above three criteria is positive: usually
distance from DHQ> 60km.

8/27/2010
Sl no Score Criterion
1 H0 Housing in government building or rent available, with
electricity > 8 hours per day and water.( tube well with hand
pump at least). HS school within 30 km of the place, and
primary school within 2 km of the place.
2 H1 One of three criteria above not available.
3 H2 Two of three criteria above not available.
4 H3 All three not available- available house is kutcha house and/or
inadequate to keep family for four. And also if there is no
housing facility either in government and rent.

Though H1 scores range from H0 to HI for calculating total

scores we take only one point for any level of H difficulty.

8/27/2010
Sl Score Criterion
no
1 E1 Part of LWE district/block by definition
OR
Any Hilly over 3000 ft/ any tribal area or any desert area or within 3 km of any
forest area- 1 pt.
OR
Any island.
2 E2 E1 plus
Police stations managed as in LWE areas,, free movement not possible( in
holding phase)
OR
Tribal and forested/hilly or desert area with Falciparum malaria with API>5
3 E3 E1 plus Active conflict for most of the year, with armed special police forces
placed there( in clearing phase).
4 E0 When there is favorable environment.
The maximum score for Environment and Social and Natural is 5
8/27/2010
Sl Score Criterion
no
1 V0 If all MO posts sanctioned are filled in respective facilities

2 V1 If MO posts sanctioned are vacant for one year

3 V2 If MO posts sanctioned are vacant for two year

4 V3 If MO posts sanctioned are vacant for 3 or >3 years

Vacancy refers only to Medical Officers , MBBS ( MO): Though scoring is

given for extent of difficulty- we take only one point for any level of
vacancy when calculating total difficulty classification.

8/27/2010
Inaccessible
•Any primary health centre which is not on the Any A5 or Any A4
road, and doctor/nurse/ staff member have to irrespective of
walk more than 1 or 2 kilometres to reach the other scores.
facility is considered as inaccessible. Those who
have to walk more than 3 hours to reach is a A3 or A2 or A1
special subcategory of inaccessibility in it with any E3

•If it is on the road head, but the road is cut off for A3 with
more than six months irrespective of the public E2HnV0
transport it is classified as inaccessible. E2H0Vn
Where n is more
•If it is on the road head, but the road is cut off for than 0
more than one month in a year and there is no
public transport in any part of the year it is also in
the same category of inaccessible.

•If it is classified as most difficult by access

criteria(see next cell) but is part of the LWE
affected block and has a problem in housing or
vacant for more than a year

8/27/2010
Most Difficult
•Any PHC which is in a rural area and more than 60 Any A3
kilometres away from the district head quarters, or Any A2 with EHV
any urban area of more than 100000 and more scores totaling to
than 30 km away from the block head quarters three or more. (
and more than at least 10 kilometres away from give maximum of 1
the national high way or any other busy highway for any level of
and if public transport is non existent or poor(less housing and
than 2 buses/share taxis per day)will be difficulty or
considered most difficult vacancy)
Any E3
•These criteria apply irrespective of the
environment, housing or vacancy factors.

•If road cut off for less than 6 months but more
than a month, then irrespective of public transport
it is most difficult.

•If a PHC is categorised as difficult by accessibility

criteria but it has additionally other criteria of
environment+ housing + vacancy adding up to
three points at least then it can be considered as
most difficult. (E2H1 or E1,V2,etc ) 8/27/2010
Difficult
•Motorable road to facility; more than 60 Any A2
Kms from DHQ and/or >60 kms from nearest Any A1 or A 1.5
urban centres and >30 kms from BHQ, >10 with E scores or V
scores or H scores
kms from nearest state/national highway;
greater than 0
with public transport in place, housing
available either in government /or rented
building and no vacant position of doctors.

•desert/island/hilly/forest/tribal

8/27/2010
Rural but not difficult
•Motorable road to facility (>60 Kms from DHQ Any A0
and/or >60 Kms from nearest urban center); and Any A1
one of the criterion (>30 kms from BHQ or >10 With no adverse E,
kms from nearest state/national highway) with V or H score.
public transport in place, housing available either
in government /or rented building and no vacant
position of doctors.

8/27/2010

Should there be provider incentives to reach these
homes?

Should there be differential financing- more
incentives to reach the institution, more costs of
careK

Should there be special support for providers-
telemedicine, teleconferencing Klocal positive
practice environments.