2 nd Common Review Mission (CRM) under NRHM in Rajasthan

1. 2nd Common Review Mission (CRM) under NRHM in Rajasthan (December 16-22, 2008) Districts: Jaipur and Dungarpur Team: Dr. Gian Chand (Retd. DHS, Govt. of HP) Gautam Chakraborty (NHSRC) Dr. Rajib Dasgupta (JNU) Sanjay Saxena (NIPI-UNOPS) Dr. Ute Schumann (EC)

3. Major Findings Increase in institutional deliveries (70% of ANC registered) 10% of SCs conducting institutional deliveries in Dungarpur Mothers reportedly staying in CHCs and PHCs for 24-48 hours after delivery Critical functions missing in FRUs / CHCs C-sections, blood transfusion, management of complicated APH/PPH cases, routine surgeries Significant numbers of non-communicable disease including heart disease, diabetes mellitus, cancers and degenerative disorders being diagnosed Rapid diagnostic kits (malaria), IDD kits, haemoglobin testing kits and pregnancy testing kits available with ANMs  utilisation very low Adequate supply of medicines, expensive antibiotics, out-of-stock for 2 weeks to 4-5 months; ‘stock-outs’ more in higher level facilities (DH/SDH)

4. Major Findings • 25% BPM posts still vacant, most have joined in last one month • Untied grants transferred and available all levels  utilisation 20-30% • Block level health “Society” not formed; Block Health Plans prepared • VHSCs being formed: • Not active to their full potential; however, village health plans were prepared • Money lying with SC, mostly unused • VHSC members need greater orientation/training to utilize untied funds • Adequate accounting personnel in place; more IT enabled solutions, focus on internal controls, further rationalization of delegation of powers, communitization of audit process of VHSC / RKS necessary • An operational study to review financial management – staffing, training, bank account and flow of funds, auditing and Internal control, in details is recommended • Design specific interventions to address neonatal mortality – like National Newborn Infection control programme; incentivize home based ASHA visits during neonatal period • Focus on immunization programme by identifying more vaccination sites, vaccinators, regular supply of vaccines and tracking of child.

5. Major Findings • Shortage of specialists at FRU/CHC/DH; 3/4 posts vacant in Dungarpur • Rural Medical Officer (RMO) cadre has increased availability at PHC levels: • No pre-induction training; post-induction training in small batches • RMOs lack adequate programme management experience • Multi-skilling training in progress; utilisation inadequate • In Dungarpur, training (anaesthesia) given to 4 MOs; services not utilized owing to shortage of surgeons/obstetricians, equipments and transfusion • ANM Training School, Dungarpur: • Very few refresher courses for ANMs • Curriculum content of ANM training courses not updated since long • Human resource training is fragmented and requires strengthening: • SIHFW currently under ad hoc funding • Regional Institutes at Jaipur and Ajmer are under the Directorate; not under SIHFW; no ‘regional’ distribution • Schools for LHV and ANM training are operating under the RCH

6. Major Findings • ASHA Sahayogini model is unique in Rajasthan • Attempted convergence between ICDS and Health • WCD controls recruitment and termination; fixed payments • Health department lacking administrative control and ownership • Cabinet approval for separate monitoring structure for ASHA • Referral transport: • Mostly hired by patients/families from the market • Utilisation of 102 ambulance service is limited • In some cases, payment being made from untied/VHSC funds • Inter-institutional referral transport arrangements working well • Pregnancy Tracking System (Dungarpur) requires adaptation and upscaling • Integrated reporting system modules available for RCH, NDCP, IDSP; to be expanded in 2009-10; need to integrate ‘C to E’ forms • Several collaborations, including PPPs and social marketing: need for better management of contracts at district level • Health insurance is in crisis Rajasthan Swasthya Bima Yojana stopped after launch of RSBY (Ministry of Labor); Bhamashah scheme stopped due to non-compatibility of cards with RSBY software