Progress under RMNCH+A initiative in the State of Rajasthan

Ministry of Health and Family Welfare, GoI has launched RMNCH+A initiative for facilitating the achievement of the MDGs and 12th five year Plan goals for the reduction of Maternal and Infant mortality. On the basis of a composite health index, 184 High priority districts across 29 states have been selected for focused integrated planning and monitoring of RMNCH+A interventions. In the state of Rajasthan, 10 high priority districts have been identified which are Udaipur, Rajsamand, Dungarpur, Banswara, Bundi, Jalore, Barmer, Jaisalmer, Karauli and Dholpur for the implementation of the RMNCH+A initiative. Also, State lead partners have been identified for all the States to facilitate the roll out of the RMNCH+A in partnership with other Development partners and Health Department. For Rajasthan, UNFPA has been identified as the lead partner to coordinate with other Development Partners and provide support in the roll out of RMNCH+A initiative.

2.State, Divisional and District Level Consultations in relation to RMNCH+A

A one day State level consultation was organized on 10th May 2013 to launch the RMNCH+A strategy in the State. It was the first state level consultation in the Country. The consultation was attended by Hon’ble Health Minister, Senior Officials from Government of India & Rajasthan, District Officials and Representatives from the Medical colleges, Development Partners and Civil Society. The state level consultation was followed by Zonal and district level orientation workshops in which Senior Officials from health department, district & block level officials and representatives from development partners participated. The timelines of State, Zonal & District level orientation workshops are given below-

Consultations	Date of Training	Delegates/Participants
State level Consultation	10 May 2013	Senior officials from State/GoI, Representatives from Development Partners/ Officials of 10 districts
Divisional level consultation – Udaipur, Banswara, Dungarpur and Rajsamand	15 May 2013	State officials, Development Partners, District & Block officials of respective districts
District level consultation - Karauli	24th June 2013	State officials, Development Partners, District & Block officials of respective districts
District level consultation - Dholpur	25th June 2013	State officials, Development Partners, District & Block officials of respective districts
District level consultation - Bundi	19th Sept 2013	State officials, Development Partners, District & Block officials of respective districts
District level consultation - Jalore	June 2013	State officials, Development Partners, District & Block officials of respective districts
District level consultation - Jaisalmer	August 2013	State officials, Development Partners, District & Block officials of respective districts
District level consultation - Barmer	June 2013	State officials, Development Partners, District & Block officials of respective districts

Besides that, development partners have also shared about the RMNCH+A initiative with the District officials in their respective districts. As part of the situational analysis, the district officials were also briefed on RMNCH+A.

3.Institutional Mechanism and Division of Responsibilities

A.Division of the districts among development partners

A meeting was conducted under the Chairpersonship of MD, NRHM on 22nd April, 2013 and during the meeting, different development partners were given the responsibility to coordinate implementation of the RMNCH+A initiative in different high focus districts and provide the focused support to the district health officials. The allocation of the districts to the development partners for coordinating the implementation RMNCH+A initiative is given below –

SNo.	Name of District	Development Partners
1	Udaipur, Bundi and Jaisalmer	UNFPA (State Lead Partner)
2	Dungarpur, Banswara, Barmer and Jalore	UNICEF
3	Dholpur and Karauli	NIPI
4	Rajsamand	Earth Institute

B.Formation of State level Task Force:

Constitution of Task Force under the Chairpersonship of the Principal Health Secretary was done in which UNFPA, UNICEF and NIPI are also members. The Task Force discusses policy level issues related to implementation of RMNCH+A initiative and provide guidance for the strengthening the implementation of the initiative.

C.Formation of State level Steering Committee:

Constitution of a steering committee under the Chairpersonship of the Mission Director with representation from UNFPA, UNICEF, NIPI and Senior officials of the CH, MH, FP and Immunisation was done to review the progress on periodic basis. The steering committee regularly reviews the progress of RMNCH+A initiative in state and develop priorities for the initiative.

D.State RMNCH+A Unit (SRU): In order to coordinate and support the roll out of RMNCH+A initiative in the state, a state level RMNCH+A unit is supported by the Development partners. It is an independent unit consisting of technical experts responsible for the technical backstopping of the RMNCH+A initiative at the state and in 10 high priority districts in the State. The State RMNCH+A Unit is located in the DMH&FW and it helps in regular coordination between the department & SRU. In the RMNCH+A Unit, following positions are supported –

SNo.	Name of the Consultant	Designation	Status
1	Ms. Shibumi Prem	State RMNCH+A Co-ordinator	In Position
2	Ms. Shibumi Prem	State Maternal Health and QA consultant	In Position
3	Dr. Sushila Saharan	State Family Planning Manager	In Position
4	Ms. Vaidehi Agnihtori	Community system Consultant	In Position
5	Dr. Pushpita Dutta	Demographer	In Position
6	Dr. Sanjeev Gupta	Newborn Consultant	In Position
7	Dr Kovalan	Nutrition Consultant	In Position
8	Mr.Vinod Rathore	Data Manager	In Position
9	Existing consultant has left and recruitment is under process	Logistics and Commodities officer	Will join by December

E.District Facilitators

In order to provide quality technical support to the districts and strengthen implementation of the RMNCH+A initiative in High Priority Districts, the positions of District Facilitators are supported in the HPDs. The following position of DFs are supported-

SNo.	District	District Lead Partner	Names of the District Facilitator	Status
1	Bundi	UNFPA	Aditya Singh	In Position
2	Karuli	NIPI	Managed from NIPI State office	Managed from NIPI State office
3	Jaisalmer	UNFPA	Mr Paramsukh Saini	In Position
4	Udaipur	UNFPA	Dr. S.M. Yadav	In Position
5	Rajsamand	EARTH Institute	-	-
6	Dholpur	NIPI	Managed from NIPI State office	Managed from NIPI State office
7	Jalore	UNICEF	Mr.Inderpal Singh	In Position
8	Barmer	UNICEF	Mr.Sashank Pathak	In Position
9	Banswara	UNICEF	Mr. Ali Akbar	In Position
10	Dungarpur	UNICEF	Dr.Kapil Agarwal	In Position

4.GAP Analysis

A.Situational Analysis

As part of the RMNCH+A initiative, a comprehensive situational analysis exercise was undertaken in all the 10 districts. The objective of the exercise was to identify the existing gaps/ challenges at State, District, Block and Facility level. The findings from the situational analysis helped in developing an action plan for addressing the existing gaps and also helped in development of PIP for these 10 districts. The existing tools/ checklists were reviewed for development of tools and also a series of consultations with the State, District officials & with the Development Partners were undertaken to finalize the tools. In order to facilitate the SA exercise, district level workshops were conducted. The SA exercise is completed in all the districts -

SNo.	District	Status of completion SA exercise	Status of availability of district wise SA report
1	Bundi	Completed	Available
2	Rajsamand	Completed	Available
3	Karauli	Completed	Available
4	Dhaulpur	Completed	Available
5	Barmer	Completed	Available
6	Jaisalmer	Completed	Available
7	Udaipur	Completed	Available
8	Banswara	Completed	Available
9	Dungarpur	Completed	Available
10	Jalore	Completed	Available

B.District Profiles of the 10 high priority districts:

The District Profiles of the 10 high priority districts have been developed. The profiles provide brief information about the socio-economic characteristics related to district and also about the availability of health services.

C.Assessment of Water and Sanitation situation in the health facilities and facility specific action plans:

In UNICEF supported high priority districts assessment of Water and Sanitation facilities in the heavy loaded health facilities were conducted. This assessment covered institutions catering to around 75% of total institutional delivery load of the District.

D.Bottleneck Analysis

Bottleneck analysis has been conducted in the five districts that i.e. Banswara, Dungarpur, Barmer, Jalore and Udaipur. The BNA exercise helped in identifying the bottlenecks in provision of health services. Also, as the district officials were involved in conducting BNA hence they owned the findings from BNA. Also, a state level workshop with the Development Partners was organized on 1st October 2013 to discuss on the various nuances of the BNA.

E.Community Level Assessment

In order to identify the gaps in accessing services by community and challenges in delivering services at community level, community level assessment is planned. The tools for same has been developed and it will be initiated in December starting onwards.

5.Monitoring and Supportive Supervision

A.Monitoring Visits

– Regular monitoring visits were undertaken by the department officials, consultants from State RMNCH+A Unit and representatives from development partners. These visits have contributed in strengthening of RMNCH+A initiative in the state.

B.Supportive Supervision

Supportive supervision visits are ongoing in all 10 HPDs. These visits are undertaken by trained mentors from the health facilities and also by the retired officials. During the visits, mentors provide handholding support to the facility staffs.

C.Block Monitoring visits

Block level monitoring visits (BMVs) were started in all districts from the Month of January, 2014. Till October 2014, all the blocks have been visited once and second round of visits have been started. The details of blocks covered till the month of October is as below:

District	No. of Block	Number of blocks Visited so far
Barmer	8	13
Banswara	8	11
Bundi	5	13
Dholpur	4	9
Dungarpur	5	15
Jaisalmer	3	12
Jalore	8	10
Karauli	5	5
Rajsamand	7	13
Udaipur	12	16
Total	65	117
BMV in two blocks in a district started in July onwards

6.Steps taken for addressing the gaps

Based on the gap analysis, the steps taken for improvement, include the following:

A.Identification and Management of High risk pregnancies:

In HPDs efforts have been started for started for identifying and line listing of high risk pregnancies.

This also helps in early identification of danger signs and timely referral to institution. In district Bundi the identification of high risk pregnancies have been initiated with the intensive monitoring and follow up of district collector. Under her guidance the identified household (where the high risk pregnancy has been identified) the RED dot has been made, for continuous monitoring and follow up.

B.ANC Strengthening:

After the review meeting under the chairpersonship of AS&MD, Ms Anuradha Gupta, a checklist has been prepared in Hindi for ANMs on actionable points, which will be referred by ANM during the MCHN days. The checklist has been shared with state officials for review and further circulation. Regular monitoring visits have been done by the district monitors during MCHN days and the feedback of the same is shared with district and state level officials. Each district monitor is supposed to visit 3-4 MCHN days in a month. The efforts are being made to revise the MCHN checklist, so that apart from immunization, other quality aspects of maternal health could be measured.

C.Hand holding support to facility staff:

During the supportive supervision visits to the districts, the state consultant along with the district officials, orient ANMs at their facilities, on the best practices and the labour room protocols. If the labour rooms are not as per MNH protocols, the team facilitates the same. The labour rooms of district hospital karauli and Dholpur were among those which were rearranged as per MNH toolkit and protocols.

D.Capacity building at Sector level:

As part of the follow up of gap assessment done for 10 HPDs, one of the important interventions by the state government, is the capacity building of ANMs during the sector meetings. In these meetings the BCMHOs were given responsibility to train the ANMs on basics like BP, Urine testing and HB estimations. The district monitors visits the sector meeting and feedback is being provided to the district CMHOs for the improvement (If needed)

E.Capacity Building of delivery point and labour in-charges:

In order to strengthen the capacities of delivery point in-charges and labour room in-charges on evidence base maternal & new born care, capacity building workshops are being conducted in 8 HPDs.

These workshops are done in coordination with DMH&FW, SIHFW and UNFPA. The workshops are already conducted in Udaipur, Dholpur, Jaisalmer, Rajsamand, Jalore, Bundi, Barmer and Karauli. During these workshops, Labour room in charge and other staff nurses, including Districts CMHO, BCMHO, RCHO and PMOs were oriented on key evidence based practices. To gauge the impact of these workshops, a one day reorientation has been planned for the same participants for all the districts. So far Dholpur and Karauli workshops have been undertaken.

F.Annual work plan with SIHFW

- In order to provide technical support for strengthening of RMNCH+A initiative in the State, UNFPA state office developed an AWP with State Institute of Health & Family Welfare (SIHFW). The AWP was initiated from the month of April, 2014. Under the AWP, orientation workshop for delivery point and labour room in- charges were conducted in 6 districts. Also, protocols for labour room were printed. Besides that a pool of resource is developed to provide supportive supervision support to 6 districts. Also tools were developed to undertake community assessment in HPDs.

7.Other Initiatives

A.District level orientation of the Master trainers on the Home Based Newborn Care:

With the support of NIPI, Department has initiated the orientation of the Master trainers on the Home Based Newborn care in the 10 high priority districts. After district level orientation, the orientations of field level staffs were undertaken. The status of district level orientation are given below-

B.Facility Based Newborn Care:

UNICEF in partnership with Child health division in the Department has initiated the computerisation of FBNC data through online software.

The orientations of the SNCU staffs are already completed and report from the districts have started coming.

C.Launching of Rashtriya Kishor Swasthya Karyakram (RKSK)

- Government of India has launched Rashtriya Kishor Swasthya Karyakram (RKSK) for improving the health and well being of adolescents in the Country. In order to orient the officials in the State on the framework of RKSK and to facilitate inter & intra department convergence, a one day state level orientation workshop on RKSK was organized on 22nd May 2014 by DMH&FW with the support of UNFPA. The workshop was attended by around 130 participants including Senior Officials from GOI and Health, Education, DWE departments in the state. Besides that, CMHOs, RCHOs and DPMs from all 33 districts attended the workshop along with representatives from Civil Society Organizations & UN Agencies.

D.Vision 2020 - Family planning -

In 2012, a FP2020 international workshop was organized at London and it was attended by Ministers & Senior Officials from several countries. India was one of the main contributors to conference and Government of India committed to improve the provision of quality FP services. In order to orient the State Officials on the outcome of FP2020 workshop and also to develop state specific action plan, Orientation & Dissemination Workshop on FP-2020 was conducted in Jaipur on 6th & 7th June. In order to give more focus on understanding and addressing district specific issues, districts were invited in two batches on 6th and 7th June (half district attended the workshop on 6th June and other half of the districts attended the workshop on 7th June).

The workshop was conducted under the Chairpersonship of Mr. Niraj K. Pawan, Additional Mission Director, NHM and Dr. S.K. Sikdar Dy. Commissioner (FP), MoHFW, GoI. The workshop was also attended by Director (RCH), Senior Officials from DMH&FW at state level and representatives from Development Partners. From the division and districts, CMHOs, Additional/ Deputy CMHOs, DPMs and Divisional Family Planning Managers attended the workshop. During the workshop, Dr. Sikdar and GoI team presented on overview of FP2020 workshop, strategies for achieving the goal of FP2020 workshop and using HMIS for monitoring of FP programmes. It was followed by development of district specific plan by district team to strengthen the FP programme at the district level.

E.Regional child health review

Regional Child Health Review meeting of 8 EAG States was held during 8th-10th May 2014 under the chairpersonship of Dr. Rakesh Kumar, Joint Secretary (RCH), and attended by Deputy Commissioners and Consultants of Child Health Division, Ministry of Health and Family Welfare, Govt. of India, Delhi, State level Nodal Officials in field of Child Health, ASHA nodal officers, RBSK nodal officers from all 8 EAG States and representatives of Development Partners working in these States. The aim of the two day workshop was to: 1)Review the progress of key components of Child Health Programme; namely facility based and home based newborn care, nutrition, common childhood illnesses, JSSK, RBSK; for the period 2013-14 in the context of RMNCH+A approach. 2)Discuss the HPD Gap Analysis and importance of intensification of the efforts and recommendations with special focus on Newborn Health and Nutrition

F.Monthly Newsletter for ASHAs:

with the objective to establish the continuous dialogue with ASHAs in the field, with the support of SIHFW a monthly newsletter started for ASHAs.

The first newsletter was shared with ASHA in the month of August.

G.Development of Training Management Information System:

UNFPA in partnership with SIHFW supporting in development of comprehensive Training Management Information System (TMIS) for the monitoring of the various trainings happening in the state. The TMIS developed by MoHFW will be also studies and if found appropriated, will be adapted.

SNo.	Date	Status of completion Meeting/ Consultations/ Workshop	Major Discussions Points & Decisions	Participants
1	22nd April, 2013 at 10.30 am. Venue - DMH&FW, Jaipur	Meeting under the Chairpersonship of Mission Director, NRHM to discuss the roll out of RMNCH+A initiative in the state	•Constitution of a steering committee under the Chairpersonship of the Mission Director with representation from UNFPA, UNICEF, NIPI and Senior officials of the CH, MH, FP and Immunisation divisions. •Divisions of the responsibilities of 10 high priority districts among the development partners. •It was decided that UNFPA will support five consultants at the State level. UNFPA will also support District Facilitators for 2 other HPDs along with 1 existing DF and the 7 DFPMs. UNICEF will support four consultants at State level and also the District level Coordinators in the assigned Districts. •In terms of Gap analysis of the 10 districts, DPs will develop a framework for undertaking the assessment in the districts. UNFPA will lead the exercise. •The district level meetings will be undertaken for all the high priority districts. •A core team of DPs was constituted and it was decided that DPs will meet regularly to coordinate their efforts. •On monthly basis, progress of the districts will be tracked on 16 indicators.	MD (NRHM), Director (RCH), Senior Officials from DMH&FW and representatives from UNFPA, UNICEF and NIPI
2	24th May 2013 at 11:00 am. Venue - DMH&FW, Jaipur	Meeting under the Chairpersonship of Secretary and Mission Director NRHM to discuss on the Udaipur Division	•The key findings from the Udaipur visit were shared. •CMHOs were instructed to regularly review the performance of the districts and organize the review meetings. •Civil Engineer was asked to provide status of civil works in all the districts especially in 10 HPDs.	MD (NRHM), Director (RCH), Senior Officials from DMH&FW and representatives from UNFPA, UNICEF and NIPI
		Visit (15-17th May 2013)	•Instructions to improve the quality of MCHN days were given. •Orientation for District OICs and on newborn care for two officials from each district was planned.
3	10th September 2013 Venue - DMH&FW, Jaipur	Working group meeting under the Chairpersonship of MD NRHM and Secretary FW	•Discussion on the progress of the RMNCH+A situational analysis •Discussion on the critical thematic interventions related to newborn care , maternal health , birth spacing , immunisation and adolescents •An online system of FBNC reporting to be initiated •Monitoring visits to be initiated •Capacity Building of the Programme officers of the 10 districts planned in Oct/November 2013	Senior Officials from health department and Development partners
4	24th October 2013 – DMH&FW,Jaipur Venue - DMH&FW, Jaipur	Review of the RMNCH+A under the Chairpersonship of Mission Director NRHM	•HBPNC training of all the District Master trainers •FBNC software online preparations initiative •Training Management Information System in SIHFW to be established •Training of Programme Managers initiated •Score cards developed for the 10 high priority districts	Senior Officials from health department and Development partners
5	15th November 2013 Venue – Venue - DMH&FW, Jaipur	Review of RMNCH+A initiative under the Chairpersonship of Additional Mission Director, NRHM	•A review meeting was organized to review the progress of implementation of RMNCH+A initiative. During the meeting, Deputy Regional Coordinator, National RMNCH+A Unit, also shared the feedback from Barmer Visit. •The different issues identified during the visit will be addressed by the Department.	AMD (NHM), Director (RCH), Deputy Regional Coordinator (NRU), Senior Officials from DMH&FW and representatives from UNFPA, UNICEF and Earth Institute
6	25th January 2014	Review of RMNCH+A initiative under the Chairpersonship of Additional Mission Director, NRHM	•Discussion on the RMNCH+A progress in the state •Deputy Regional Coordinator, National RMNCH+A Unit, shared the feedback from Rajsamand visit. •The different issues identified during the visit will be addressed by the Department.	AMD (NHM), Deputy Regional Coordinator (NRU), Senior Officials from DMH&FW and representatives from development partners
7	7th March 2014	Review of RMNCH+A initiative under the Chairpersonship of Additional Mission Director, NRHM	•The progress of the RMNCH+A initiative in the state was shared •Key findings from block monitoring visits were shared	AMD (NHM), Senior Officials from DMH&FW and representatives from development partners
8	20th June, 2014	Review of RMNCH+A initiative under the Chairpersonship of Additional Mission Director, NRHM	•The quality of family planning services needs to be monitored, especially the training quality •The MCHN sessions needs to be improved •Supportive supervision visits needs to be strengthened .	AMD (NHM), Deputy Regional Coordinator (NRU), Senior Officials from DMH&FW and representatives from development partners
9	8th July 2014	Review of RMNCH+A initiative under the Chairpersonship of Additional Mission Director, NRHM	•The District health plans needs to be developed •The delivery point functionality needs to be improved	AMD (NHM), Senior Officials from DMH&FW and representatives from development partners
10	9th September, 2014	Review of RMNCH+A initiative under the Chairpersonship of Mission Director, NHM	•PPIUCD services to be made available till CHC level •NSSK trainings for the untrained staff needs to be planned •An analysis on the reasons for non functionality needs to be made available to state officials for further action	Senior Officials from DMH&FW and representatives from development partners
11	21st November 2014	Review of RMNCH+A initiative under the Chairpersonship of Mission Director, NHM	•Discussion on non performance of delivery points were undertaken •Decisions were taken to make the non-functional delivery points functional	MD (NHM), Senior Officials from DMH&FW and representatives from development partners

9.District level review meetings

•District level review meetings are being held on a regular basis in all the 10 districts.

•The meetings are included as part of the DHS review meetings.

•The challenge is that in many districts, the meeting is not held under the chairpersonship of the district collector.