Submit Final Report HLTF

High Level Task Force Report

HIGH LEVEL TASK FORCE

REPORTON

HEALTH DEPARTMENT, HARYANA

MDG GOAL 4: REDUCE CHILD MORTALITYTarget 4.A: Reduce by two thirds, between 1990 and 2015, the under-five mortality rateMDG GOAL 5: IMPROVE MATERNAL HEALTHTarget 5.A: Reduce by three quarters the maternal mortality ratioTarget 5.B: Achieve universal access to reproductive health

MAY 2013

1Haryana State Health Resource Centre

http://mdgs.un.org/unsd/mdg/Resources/Static/Products/Progress2012/English2012.pdf#page=34




Content

Chapters

1. BACKGROUND:

2. PROFILE OF HARYANA

2.1 Health Indicators

3. MATERNAL AND CHILD HEALTH

3.1 Maternal Health:

3.1.1 Situational Analysis:

3.1.2. Strategies for Maternal Health for the Last 5 Years

3.1.2.1 Ante Natal Care

3.1.2.1.1 For improvement in number of ANC registration and Early registration

3.1.2.1.2 For improvement in Quality of Ante Natal Checkups

3.1.2.2 Institutional Deliveries

3.1.2.2.1 Promotion of Safe Institutional Deliveries

3.1.2.2.2 Quality improvement in Institutional deliveries

3.1.2.3 Post Natal Care (PNC)

3.1.2.4 Safe MTP services

3.1.2.5 Maternal Death Review & Audit

3.1.2.6 Supportive Supervision for Monitoring & Evaluation

3.1.2.7 Referral Transport

3.1.2.8 Operationalization of Health Facilities FRUs and 24x7 PHCs



3.1.3 Progress So Far

3.2 Child Health

3.2.1 Situational Analysis

3.2.1.1 Major factors responsible for high neo-natal mortality

3.2.2 Strategies for Child Health for the Last 5 Years

3.2.2.1 Mother and Child Protection (MCP) Card

3.2.2.2 Provision for Essential New Born Care

3.2.2.3 Expansion of services for care of sick newborn and free referral transport

3.2.2.4 Home Based Post-Natal Care (HBPNC)

3.2.2.5 Facility Based New-Born Care

3.2.2.6 Immunization

3.2.2.7 Infant and Young Child Feeding Practices

3.2.2.8 Micronutrient supplementation

3.2.2.9 Management of children with malnutrition

3.2.2.10 Management of Diarrhoeal Diseases & Acute Respiratory Infections

3.2.2.11 Integrated Management of Neonatal and Childhood Illnesses (IMNCI)

3.2.2.12 Facility Based IMNCI

3.2.2.13 YASHODA

3.2.2.14 Improving Immunization Coverage & Eliminating Measles related deaths

3.2.2.15 Infant Death Review (IDR)



3.3 Recommendations of the Maternal and Child health sub group

3.3.1 Improvement of Quality of Services

3.3.1.1 Antenatal Period

3.3.1.2 Intranatal Period

3.3.1.3 Postpartum care

3.3.2 Referral Transport

3.3.3 Maternal Morbidity

3.3.4 Safe abortion services

3.3.5 Continuum of care

3.3.6 Acute Respiratory Infection and Acute Diarrheal diseases

3.3.7 Infant Death Review (IDR)

3.3.8 Planning of Manpower and Infrastructure

3.3.8.1 Planning

3.3.8.2 Up gradation of Health Facilities

3.3.8.3 Capacity Building

3.3.8.4 Availability of O positive packed cells

3.3.8.5 Monitoring of JSSK Programme

3.3.9 BCC/IEC

3.3.9.1 Family empowerment to enhance their participation and early care seeking

3.3.9.2 Pre-pregnancy Period

3.3.10 Social Issues

3.3.11 Monitoring & Evaluation:

3.3.12 Separate Cadre for MCH services



4. ANEMIA AND MALNUTRITION

4.1 Anemia


4.1.2 Steps Taken for Management of Anemia

4.1.2.1 Iron Folic Acid

4.1.2.2 Albendazole tablets

4.1.2.3 General therapeutic measures for treatment of moderate & severe anemia

4.2 Recommendations of Anaemia

4.1.1 Clinical screening of anaemia

4.1.2 Testing of cases for Hb status

4.1.2.1 Cases to be tested

4.1.2.2 Method of testing

4.3 Iron Supplementation to all screened case

4.3.1 Therapeutic approach to treat anaemia cases

4.3.2 Enhancing compliance to treatment

4.3.3 Education about Disease

4.3.4 Education about diets

4.3.5 Education about side effects of Iron medicines

4.4 Malnutrition


4.4.2 Strategies

4.4.2.1 Best Mother Award

4.4.2.2 Nutritional Strategy (For Eradication of Malnutrition among Children)

4.4.2.3 Community participation in Growth Monitoring



4.4.2.4 Nutrition Award

4.4.2.5 Formation of VLCs

4.5 Recommendations of Malnutrition

5. GENDER EQUITY AND FAMILY WELFARE

5.1 Gender Ratio


5.1.2 Strategies

5.1.2.1New initiatives

5.1.2.2 Advocacy

5.1.2.3 Efforts of Haryana Government for Women Empowerment

5.2 Family Welfare


5.2.2 Strategies

5.2.2.1 Spacing Methods (IUD)

5.2.2.2 Permanent Methods (Vasectomy & Tubectomy)

5.2.2.3 Community Participation & Capacity Building

5.2.2.4 General

5.3 Recommendations of Gender Ratio

5.3.1 Defining Gender Issues in Health

5.3.2 Strengthening Institutional Capacities

5.3.2.1 Appointment of Gender Nodal Officer

5.3.2.2 Development of curricula and faculty for Gender Mainstream

5.3.2.3 Gender Sensitive HR Policy

5.3.3 Strengthening of Adolescent Health Services



5.3.3.1 Recommendations on Adolescent Health

5.3.4 Sex selection

5.3.5 Violence against women

5.3.6 Community participation

5.3.7 Improved access and information

5.3.8 Access to contraceptive services



1. Background:

Alma Ata Declaration of 1978 declared that the “main social target of governments was attainment of a level of health that would lead to a socially and economically productive life”.

The Millennium Summit of the UN in 2000 adopted the Eight Millennium Development Goals (MDG). Among them Goal 3, 4 and 5 were focused on Gender Equality, Child Mortality Rates and improving Maternal Health.

Although Haryana is one of the leading states of the country in economic terms, it is grappling with social and health indicators. These indicators are not comparable with other states with similar economic status. Therefore Government of Haryana constituted of a High Level Task Force to address the adverse social indicators in the Health Sector during the discussion held in the Planning Commission.

Financial Commissioner and Principal Secretary to Government Haryana, Finance and Planning Department, Chandigarh, Vide his D.O. letter number 807/PS Finance/2012 dated 23-07-2012 had accordingly asked the Dept. of Health to constitute a High Level Task Force to address the adverse social and health indicators and send a report to Hon’ble Chief Minister, Haryana. This issue was approved in the meeting of State Health Mission held on 17-07-2012 under the Chairpersonship of Hon’ble Chief Minister, as this issue had to be reviewed in annual meeting of planning commission.

Government of Haryana constituted a High Level Task Force with the composition and terms of reference as attached as Annexure-I.

The High Level Task Force was to:1. Review the trends of health indicators of Haryana like Maternal Mortality Rate,

Under 5 Mortality Rate (U5MR), Child Mortality Rate, Infant Mortality Rate (IMR), Neonatal Mortality Rate (NMR), Total Fertility Rate (TFR), Couple Protection Rate (CPR), Gender Ratio, Malnutrition and Anemia.

2. Deliberate on the strategies which have been in place for the last five years. 3. Make recommendations on the strategic interventions to be made in the next five

years (Plan period). 4. Assess the trends of malnutrition and anaemia in the State and make

recommendations to improve the nutritional status.5. Recommend specific actions required to be taken by various departments and

measures for improvement of inter sectoral coordination.6. Take into account both rural and urban scenarios, the regional, the socio economic

and cultural factors within the State while making recommendations.



The first meeting of High Level Task Force was held on 23-10-2012 at Haryana Niwas, Sec- 3, Chandigarh under the chairpersonship of Mrs. Navraj Sandhu, Principal Secretary to Govt. of Haryana, Health & Medical Education Department. In this meeting after a general discussion about the adverse social indicators, the group was divided into three sub-groups i.e. Group A (Maternal Health + Child Health), Group B (Anemia + Malnutrition) and Group C (Gender Equity + Family Welfare). Details of members is given in Annexure 1.

The second and third meetings of High Level Task Force were held on 4th - 5th of December 2012 and 16th - 17th of January, 2013 respectively.

Minutes of all three meetings are attached as annexure-II, III and IV.



2. PROFILE OF HARYANA

Haryana is located in north of the country, covering 44212 sq km area, representing 1.4% of total area of the country. Total population of the state is 253.53 lacs (2011 Census), which represents 2% of country’s population, out of this, 165.31 lacs (65.29%) is rural Haryana has about 0.40 crore (15.78%) Schedule Caste population, while the state has no tribal population.

The sex ratio of Haryana is 877 females as against 1000 males (2011 Census). State has an overall literacy rate of 76.64%, while that for males is 85.38% and for females is 66.77%, respectively.

Administratively, Haryana is divided into 4 divisions, 21 districts, 54 sub divisions, 119‐ developmental blocks and 6955 villages.

Table 2.1 Distribution of Health Facilities of Haryana

Number of Districts (RHS 2010) 21

Number of Sub Division/ Talukas 54

Number of Blocks 119

Number of Villages (RHS 2010) 6955

Number of District Hospitals 21

Number of Sub district hospitals (50-100 bedded) 25

Number of Community Health Centres (RHS 2010) 107

Number of Primary Health Centres (RHS 2010) 441

Number of Sub Centres (RHS 2010) 2484

The Total Fertility Rate of the State is 2.5 as per SRS 2009. The Infant Mortality Rate is 48 (SRS 2010) and Maternal Mortality Ratio 153 (SRS 2007-08), as against the



national figures of 212 and 50. The Sex Ratio in the State is 877, as compared to 940 for the country. Comparative figures of major health and demographic indicators of Haryana viz a viz India are as follows‐ ‐

Table 2.2 Comparison of Indicators of Haryana and India

Indicator Haryana India

Total population (Census 2011) (in crore) 2.53 121.01

Infant Mortality Rate (SRS 2011) 44 44

Maternal Mortality Ratio (SRS 2007-09) 153 212

Total Fertility Rate (SRS 2009) 2.5 2.6

Decadal Growth (Census 2011) (%) 19.9 17.64

Crude Birth Rate (SRS 2009) 22.7 22.5

Crude Death Rate (SRS 2009) 6.6 7.3

Natural growth rate (SRS 2009) 16.0 15.2

Sex Ratio (Census 2011) 877 940

Child Sex Ratio (Census 2011) 830 914

Total Literacy Rate (%) (Census 2011) 76.64 74.04

Male Literacy Rate (%) (Census 2011) 85.38 82.14

Female Literacy Rate (%) (Census 2011) 66.77 65.46



2.1 Health Indicators - Haryana

Table 2.1.1 Comparison of Health Indicators of Haryana of 2005 & 2009

SRS 2005 SRS 2009

Indicators HARYANA HARYANA

Infant Mortality Rate 60 44 (2011)

Natural growth Rate 17.6 16.1

Crude Birth Rate 24.3 22.7

Crude Death Rate 6.7 6.6

Maternal Mortality Ratio 186 153



3. Maternal and Child Health

3.1 Maternal Health

Maternal Mortality Ratio of Haryana is better than Indian figure of MMR, however Haryana is quite far from the MDG goal of 100 MMR while some states have already achieved the MDG target. The major causes of maternal deaths are excessive bleeding during child birth, obstructed and prolonged labour, infection, unsafe abortion, disorder related to high blood pressure and anemia.


Table 3.1.1.1 Maternal Mortality Ratio (MMR)-Haryana

MMR (Maternal Mortality Ratio) – SRS (maternal deaths per 1 Lac births per year)Year Haryana India1999-01 176 327

2001-03 162 301

2004-06 186 254

2007-09 153 212

Goal by 2015 100 100Haryana ranks 7th in MMR amongst all states and UTs.

Comment : Haryana has been improving over the years in this regard but not up to the expected levels. From 1999 to 2009 while National MMR has come down by 115 points the MMR of Haryana has come down by 23 points only during this period. The difference of all India average and Haryana average was 151 in 1999 but in 2009 the difference is 69. The progress in other states has been much rapid, but not so rapid in Haryana. One reason could be that after a certain level it becomes difficult to continue to reduce the ratios at the same rapid rate. It is expected that economic development should translate into better access to health care and matching improvement in the health indicators. Reasons of maternal mortality are directly related to availability of facility for institutional delivery, better quality of available services and desire of a patient to access the facility. Therefore, the whole emphasis is on maximizing safe institutional deliveries.

The state has expanded the availability of facilities substantially under NRHM. With this objective in mind the state started the concept of delivery huts and now has 993 delivery points in Government sector. It has dramatically improved its institutional deliveries from 49% in 2006 to 84% in 2013.



Table 3.1.1.2 Progress on Maternal Health Indicators

Indicators (in %)DLHS-III(2007-08)

CES (2009)

HMIS(2010-11)

HMIS(2011-12)

Three plus ANC 52.4% 68.9% 77.03% 81.77%

Registration within 12 weeks 55.1% 57.4% 46.89% 51.15%

TT1 & TT2 Booster - - 100% 100%

Mothers who consumed 100 IFA tablets

29.0% 49.1% 88.4% 79.15%

ANC has improved substantially from 52.4% in 2007 to 81.77% in 2012. The improvement in the figures of ANC indicated that the state is making efforts to improve ANC services in the last few years.

Table 3.1.1.3 Institutional Deliveries as per CRS Data

Year Govt. Inst. Pvt. Inst. Total Inst. Non Inst. Total

200683133 166464 249597 259373

50897016.30% 32.70% 49% 51%

200796948 178273 275221 236752

51197318.90% 34.80% 53.70% 46.20%

2008120042 198053 318095 219224

53731922.34% 36.85% 59.19% 40.79%

2009164388 196864 361252 177658

53891030.50% 36.53% 67% 33%

2010205086 197282 402368 142252

54462037.65% 36.22% 73.88% 26.11%

2011237067 198607 435674 127882

56355642.07% 35.24% 77.31% 22.69%

2012247153 202143 449296 11437

56373343.84 35.86 79.70% 20.30%

Comment : From the above table, it is seen that total institutional deliveries have almost doubled from around 49% to 80%. Furthermore, the institutional deliveries in the private institution have almost remained constant but in the government institution have increased three folds. The number of institutional deliveries in the Govt. institutions have



increases from 83133 to 247153. The staff of Govt facility has not however increased in that proportion. The proportion of home deliveries has declined dramatically during the last 5 years.

Table 3.1.1.4 Institutional and Non Institutional Deliveries Year 2012

DistrictGovt.

institution

% Gov

t

Pvt. Instituti

on% pvt

Total institution

% institutio

nal Home

% Home Total

Ambala 10642 51 9400 45 20042 97 685 3 20727

Bhiwani 11011 37 13862 46 24873 83 4999 17 29872

Faridabad 16842 38 20096 45 36938 83 7385 17 44323

Fatehabad 9755 43 7706 34 17461 76 5468 24 22929

Gurgaon 15057 41 18868 51 33925 91 3206 9 37131

Hisar 13941 35 18089 46 32030 81 7725 19 39755

Jhajjar 8114 51 4566 29 12680 80 3161 20 15841

Jind 13370 52 8329 32 21699 84 4202 16 25901

Kaithal 10568 45 8466 36 19034 81 4328 19 23362

Karnal 15474 48 11435 35 26909 83 5441 17 32350

Kurukshetra 7742 37 10392 50 18134 87 2774 13 20908

Mewat 15047 38 2095 5 17142 44 22196 56 39338Mohindergarh 10634 63 4237 25 14871 88 2003 12 16874

Palwal 8556 29 7477 25 16033 54 13398 46 29431

Panchkula 10207 76 2908 22 13115 98 294 2 13409

Panipat 9487 35 11211 41 20698 76 6456 24 27154

Rewari 8681 46 9437 50 18118 95 906 5 19024

Rohtak 16726 63 6535 24 23261 87 3461 13 26722

Sirsa 13736 53 8042 31 21778 84 4288 16 26066

Sonepat 11615 40 10063 35 21678 75 7361 25 29039Yamunanagar 10278 43 9026 37 19304 80 4820 20 24124



247483 44 202240 36 449723 80 114557 20 564280

District wise analysis shows that while districts like Panchkula, Ambala, Rewari and Gurgaon have more than 90% institutional deliveries, and Panchkula, Mohindergarh and Rohtak have 76% and 63 % deliveries in Govt institutions while district like Mewat, Palwal have only 44 % and 54 % institutional deliveries only. The stark contrasts are evident. These factors will have direct bearing on the strategic approach and the regional focus that is required in policies of maternal and child health.

FIGURE 3.1.1.5: Maternal Death Review Data

31%

9%7%15%4%1%

21%

12%

Chart Title

HEAMORRHAGE SEPSISABORTION OBSTRUCTED LABOURHYPERTENSIVE DISORDERS IN PREGNANCY

ANAEMIA

HIGH FEVER SUICIDEOTHERS* UNKNOWN

Comment : If we further group the causes based on period of their occurrence into

1. Ante-natal : Hypertensive disorders and Anaemia manifest during this period and aggressive follow-up during the III trimester can easily help in detection and intervention on these cases.

2. Intra-natal : Obstructed labour, sepsis and Eclampsia (Hypertensive) relate to this period.

3. Post-natal: Though sepsis is caused because of interventions during the natal period but its fatal implications get manifested along with hemorrhage mostly during this period.

4. Related to Unsafe Abortion: Have an implication on the provision of safe and easily accessible MTP services in the state. It is estimated that globally close to 70,000



maternal deaths annually (13 per cent) are due to unsafe abortions UNFPA-SRH framework).

The most common causes of maternal deaths beckon us to improve maternal services during all the three phases of pregnancy. Keeping the above stated generally known causes of maternal death, the state has adopted a comprehensive strategy and series of intervention addressing all the issues/gaps under NRHM. Some of them are highlighted as given below:-

3.1.2 Strategies For Maternal Health For The Last 5 Years

Table 3.1.2.1 Strategies and programs of last five years to decrease MMR:S.No. 2008-09 2009-10 2010-11 2011-12 2012-13

1 Early Registration of Pregnancy

Continued Continued Continued Continued

2 Three ANC Continued Continued Continued Continued

3 Institutional Deliveries


4 Postnatal Care Continued Continued Continued Continued

5 Ensuring Emergency Obstetric care


6 Operationalization of FRUs


7 Referral Transport Continued Continued Continued Continued

8 JSY Continued Continued Continued Continued

9 Delivery Hut Scheme


10 RCH outreach Camps


11 Social Mobilization through ASHA


12 Training of EmOC & LSAS doctors


13 SBA Training of Staff nurse


14 Capacity Continued Continued Continued



Building of ASHA

S.No. 2008-09 2009-10 2010-11 2011-12 2012-13

15 Blood Storage Centres

Continued Continued Continued

16 Provision for extending maternity wards by increasing no. of beds

Continued Continued

17 Provision of 4 staff nurse

Continued Continued

18 Provision of specialists for FRUs

Continued Continued

19 Provision of LT at DH

Continued Continued

20 Equipment & Drugs Continued Continued

21 Infrastructure Continued Continued

22 Operationalization of 24*7 PHCs

Continued Continued

23 Recruitment of staff nurses, LTs, ANMs, Pharmacists

Continued Continued

24 Recruitment of sanitary workers

Continued Continued

25 Monitoring of Health services

Continued Continued

26 Provision of Disposable Delivery kits in PHCs & SCs

Continued Continued

27 Provision of MTP services at CHC, SDH, DH., Training for MTP of MOs

Continued Continued

28 Scheme of social marketing of sanitary napkins for Rural women (since 2009)

Continued Continued



29 Maternal Death tracking

Continued Continued

S.No. 2008-09 2009-10 2010-11 2011-12 2012-13

30 Scheme Janani Suraksha Yojna

Continued Continued

31 Jachcha bachcha scheme

Continued Continued

32 Incentives to DAIs Continued Continued

33 Urban RCH Continued Continued

34 Appointment of 3rd ANM at sub-centres

Continued

35 Prevention of RITs/STIs

Continued

36 Surakshit Maa Award in four Dist.

37 Reverse Tracking of Anaemia

38 Tracking of High Risk Pregnancies

3.1.2.1 Ante Natal Care

3.1.2.1.1 ANC registration and Early registration

As per HMIS data, 81.7% of three plus ANCs are being done while 51% are being done in the first semester. Incentives are to be given under JSY to pregnant women who get her pregnancy registered during early weeks. Surakshit Maa Awards: This award is given to promote early ante-natal registration in 4 districts with poor indicators i.e. Mewat, Palwal, Jhajjar and Bhiwani. Out of all the women registered in the first trimester in a month at the Sub-centre, a draw is conducted at the end of the month and 3 women become eligible for a prize of Rs.300.

Comment: The data of 81.7% registration on ANC needs to be validated by a third party. Even then the first trimester registration is not satisfactory. Quality parameters in HMIS are not properly reported or monitored.



3.1.2.1.2 Reverse tracking of anemic patients

Reverse tracking of anemic patients, arriving in the labor room for delivery, to the concerned service provider/ANM has been started from December, 2011. Online Anemia Tracking System is in process. Doctor in the labor room is required to maintain a list of severe anemic patients and report by email to the State HQ. A return email is then sent by the HQ to the concerned MO-Incharge of the PHC/CHC or PP Centres to take corrective steps to fill the gaps in the service delivery.

Number having Hb less than11 gmYear Survey Number Percentage

2010-11 HMIS 259974 42.71%2011-12 HMIS 298334 49.56%2012-13 HMIS 356999 67.41%

No. having severe anaemia Hb<7 gms treated at Institution:Year Survey Number Percentage of severe anaemic

womento women with Hb level <7gms

2010-11 HMIS 40365 15.52%2011-12 HMIS 39589 13.27%2012-13 HMIS 26571 5.01%

Total 1230 severe anemic patients have been tracked from Dec. 2011 to Mar. 2012 and 1638 anemic patients have been tracked from Apr. 2012 to Sep. 2012.

Comments: This a good initiative of the state which need to be strengthened.

3.1.2.2 Institutional Deliveries

3.1.2.2.1 Operationalization of Health Facilities FRUs and 24x7 PHCs

List of 24x7 Delivery Points

YearDH

SDH

CHC

PHCs

SCs

Medical

Colleges

ESI Hospital

s

Military Hospital

s

Urban

FRUs

Total

2009-10 21 10 53 110460

3 2 3 2 664

2010-11 21 11 54 114 46 3 2 3 2 678



8

2011-12 21 12 56 121469

5 2 3 2 691

2012-13 21 19 97 315469452

5 2 3 2 933

State started with providing deliveries at doorsteps by opening delivery huts in village subcentres. Now state has been focusing on the PHCs to provide 24X7 delivery services conducted by better trained persons. The emphasis is on providing septic and infection free clean environment. Infrastructure and personnel are put in place to improve the services being provided at the health facilities. Equipment and drugs have also been provided in the health facilities. Basic Emergency Obstetric Care (5 types of posters) replicated and provided to all 24x7 health facilities up to PHC level. They include:

– Management of Anaemia in Pregnancy and labour– Management of Ante-partum Haemorrhage– Management of P– PROM (Premature Rupture Of Memberane)– Management of Eclampsia and Pre-Eclampsia– Management of Post-partum Haemorrhage

Number of beds in the Maternity wards have been increased and blood storage facilities have been provided in the FRUs.

Analysis of delivery points show that they are not evenly spread out and the deliveries at such points are not as per the benchmark at all places. State needs to have a [policy about the provision of delivery point for normal deliveries within a reach of 10-15 km , 24 by 7. Services should be evenly spread out.

3.1.2.2.2 Increasing no. of functioning FRUs:

YearDH as FRUs

SDH as FRUs CHC as FRUs Urban

FRUs

Total

2009-10

18 (Except Jhajjar,

Mewat & Palwal)

5 (Nilokheri, Jagadhari, Tohana, Bahadurgarh & Naraingarh)

3 (Meham, Dabwali &

Kalka)2 28

2010-11 19 (Except 6 (Narwana, Nilokheri, 3 (Meham, 2 30



YearDH as FRUs

SDH as FRUs CHC as FRUsUrba

n FRUs

Total

Mewat & Palwal)

Jagadhari, Tohana, Bahadurgarh & Naraingarh)

Dabwali & Kalka)

2011-1220 (Except

Mewat)

8 (Ambala Cantt. Nilokheri, Jagadhari, Tohana, Ballabhgarh,

Narwana, Bahadurgarh & Naraingarh)

4 (Meham, Dabwali,

Shahabad & Kalka)

2 34

2012-13 till Dec.

20 (Except Mewat)

8 (Ambala Cantt. Nilokheri, Jagadhari, Tohana, Ballabhgarh,

Narwana, Bahadurgarh, & Naraingarh)

5 (Meham, Dabwali,

Shahabad, Kalka & Safidon)

2 35

Around 5-10 percent of delivery cases need emergency/elective C-Section for a favorable outcome of the mother as well as the infant. It has been a constant effort under NRHM to operationalise the FRUs so that Caesarean facility to the patients is available within maximum of half an hour to 45 minutes’ drive. As a result the no. of FRUs functioning in the State of Haryana has increased over the years. the no. of caesareans being performed in Govt. and Private Sector has improved considerably resulting in a favourable outcome for both mother and infant.

3.1.2.2.2 Promotion of Safe Institutional Deliveries

ANMs/ASHAs are being utilized to motivate pregnant women for institutional delivery. Strengthening of 24x7 delivery points i.e. 6 SDHs, 77 CHCs, 199 PHCs, 660 Sub-centres and 11 Urban RCH Centres will increase institutional deliveries. Strengthening of 40 health facilities which includes 21 DHs, 11 SDHs and 8 CHCs as FRUs (for providing round the clock services of caesarian section). JSY (GOI Scheme and State Scheme) for promotion of deliveries of SC and BPL pregnant women at the institutions.

Janani Shishu Suraksha Karyakram (JSSK) JSSK scheme is extended to all pregnant women. It provides free delivery, free caesarian section, free drugs and consumables, free diagnostics (Blood, Urine tests and Ultrasonography etc.), free diet during stay (up to 3 days for normal delivery and 7 days for caesarian section), free provision of blood, free transport from home to health institution, between health institutions in case of referrals and drop back home. Exemption from all kinds of user charges is also given.



Janani Shishu Suraksha Karyakram (JSSK) (Implemented on 01.06.2011)

Sr. No.

Free EntitlementsDate of

Implementation

Entitlements for Pregnant Mothers1 Free delivery 01.01.20092 Free caesarian section 01.01.20093 Free drugs and consumables 01.01.20094 Free diagnostics (Blood, Urine tests and Ultrasonography etc.) 01.01.2009

5Free diet during stay (up to 3 days for normal delivery and 7 days for caesarian section)

07.12.2011

6 Free provision of blood 01.01.2009

7Free transport from home to health institution, between health institutions in case of referrals and drop back home

14.11.2009

8 Exemption from all kinds of user charges 01.01.2009Entitlements for sick new born

1 Free and zero expenses treatment 01.09.20112 Free drugs and consumables 01.09.20113 Free diagnostics 01.09.20114 Free provision of blood 01.09.2011

5Free transport form home to health institution, between health institutions in case of referrals and drop back home

01.09.2011

6 Exemption from all kinds of user charges 01.09.2011

Comment : The data and schemes he could also be got validated by a third party. As the Govt. is currently funding institutional deliveries to ensure women have access to safe deliveries it is important to monitor this regularly through facility based monitoring and developing a linkage with outcome such as increase in institutional deliveries.

3.1.2.2.2 Quality improvement in Institutional deliveries

Ensuring good quality Emergency and Obstetric Care. Up-gradation of labor rooms as separate Aseptic Labor Room, separate Septic Labor Room, separate Procedure Room, separate Eclampsia Room and expansion of Post-natal Wards with sufficient number of beds for 48 hours stay of the patient after deliveryCapacity building of the doctors for EmOC, LSA and their posting at FRUs is being done.

Training of service providers for SBA (Skilled Birth Attendant) is being conducted. New incentives and reward schemes to encourage the EmOC and LSA trained doctors.

Comment: All these are good initiatives and need to be followed up aggressively.



3.1.2.3 Post Natal Care (PNC)

ANMs/ASHAs are being utilized for Post Natal Checkups and detection of any post natal complication and their referral to FRUs. Motivation for family planning methods is also being done.

3.1.2.4 Safe MTP services

MTP Services (HMIS Survey)2010-11

2011-12 2012-13

up to 12 weeks of pregnancy 10489 11063 10253More than 12 weeks of pregnancy 191 265 569Total no. in Govt. Facilities 10680 11328 10822Total no. in Pvt. Facilities 16363 16469 11346Total MTPs 27043 27797 22168Total number of Govt. Facilities reporting MTPsTotal number of Pvt. Facilities reporting MTPs 631 631 631Total number of doctors providing MTP services 256 283 283

Trainings of doctors for MTP are being conducted. Provision of Drugs and Equipments for MTP at 24x7 delivery points has been made. IEC regarding safe MTP services is done at Govt. health facilities.

3.1.2.5 Maternal Death Review & Audit

Maternal Death Review (HMIS Survey)2009-10 2010-11 2011-12 2012-13

Maternal Deaths

280 172 260 366

Toll free number 102 is being utilized for reporting of Maternal Death by ASHAs/ANMs/any person. Surveillance system for reporting of maternal death has been started to ensure better reporting. Every maternal death is audited for identification of gaps and timely intervention to prevent such incidence in future.

Comment : The initiative is innovative but state needs to improve its reporting.

3.1.2.6 Supportive Supervision for Monitoring & Evaluation



Supportive supervision inviting teams from PGIMS Rohtak, PGI Chandigarh, PRC (Population Research Centre) and State Head Quarter is being done. Supervision of labor rooms for their up-gradation by the State Head Quarter Officers is being done. Data is analyzed and presented in the Civil Surgeon’s Conference.

3.1.2.7 Referral Transport

Free referral transport services are being provided so as to enable pregnant women to reach PHC or any other higher health facility if necessary and then to come back home after delivery. It is ensured that ambulances are available at all the health facilities.

Referral Transport Scheme under JSSK

YearTotal User

Pregnant

Women

Drop Back

Pregnant

Women

Referral of

Pregnant

Women

Sick New Born

Drop Back Sick New Born

Referral of Sick

New Born

2009-10 36156 25891 N.A. 10265 N.A. N.A. N.A.

2010-1115043

999075 N.A 51364 N.A. N.A. N.A.

2011-1232083

6149246 117904 47014 1776 1118 3778

2012-1331070

4141730 111189 45764 2974 2590 6457

Comments: The state has a unique low cost in house referral transport model as compared to the outsources model being run in the other states wherein the ambulances are outsourced under PPP model to NGOs or business groups. From the time the system was put in place in 2009 the referral ambulances has increased its number of referrals from 36,156 to 310704 in 2012-13 an increase of 274548 almost 9 times in 4 years. The maximum increase has been of pregnant women. State needs to upgrade the quality of services and range of services provided by the referral transport system.

3.1.3 Progress So Far:

MMR has decreased to 153 per lac live births (SRS 2007-09). Millennium Development Goal to be achieved is 100 per lac live births by 2015. There is increase in Institutional Delivery from 49% (2006) to 77.3% (2011). Operationalization of FRUs at 36 Health Facilities and establishing 24x7 delivery points at 421 facilities is being done. Free delivery/caesarean with free referral transport is provided under JSSK Scheme. All Maternal Deaths are reported and audited. Severely anemic patients in district hospital are tracked back to the



Service Provider/ANM. JSY payments to BPL and SC are done regularly. Further matter is being taken up with GOI to relax the BPL requirements.

Comment on maternal Health Interventions:

Since 2006, state has drastically improved its maternal Health services. A large number of initiatives have been taken to provide safe institutional delivery at the doorstep by opening of large number of institutions at subcentres and PHCs, improvement in quality of services and providing services for handling complicated deliveries. The number of delivery points have increased from 664 to 933, which has increased the number of deliveries to 3 times even while private sector deliveries have remained stagnant. The number of PHCs providing 24X7 deliveries have increased from 110 to 315 and number of centres providing services to handle complicated deliveries from 28 to 35. The referral transport system has also drastically improved its services and data of mothers transported is very encoutaging. In order to monitor the causes of maternal mortality state analyses 1/3 of all maternal deaths but it needs to use the analysis for identifying and improving gaps in its services.

The state needs to focus on critical issues like handling of severe anaemia in pregnancy, Hypertension / Eclampsia, post-partum hemorrhage, infection free services and improving access to safe MTP services.

3.2 Child Health:


According to SRS 2011, IMR of Haryana is 44 as compared to 66 in 2001.

Figure 3.2.1.1 Infant Mortality Rate-and Neonatal Haryana Mortality Rate

IMRYear India Haryana

2004 582005 58 602006 57 572007 55 552008 53 542009 50 512010 47 482011 44 44

NMR 2011Indicator India HaryanaNMR Total 31 28



IMR of Haryana has come down from 57 to 44, a fall of 13 points and the decrease is running parallel with improvement in all India figures. However, considering that the state is among the developed states of the country the fall should be faster than all India decrease.

Figure 3.2.1.2 Comparative Status of IMR

Regional Difference



HARYANA IMREASTERN 44WESTERN 54TOTAL 48

The western Haryana includes districts Rewari, Narnaul, Jind, Fatehabad, Sirsa, Hisar, Bhiwani and are showing high IMR and a strategy of the state should focus on these districts.

Figure 3.2.1.2 Causes of Under five deaths in India

More than half of the U5 deaths are in the neonatal age-group. If these are further analyzed further it is seen that Preterm delivery is an important cause of neonatal mortality and this would improve if ANC coverage and quality improves. Asphyxia and infection relate to better labour room infrastructure and practices. The other causes like diarrhea and



pneumonia account for more than 10% of U5 deaths. Malnutrition is an underlying cause in a large proportion of U5 deaths.

3.2.1.1 Major factors responsible for high neo-natal mortality:

• Poor nutrition and anaemia among adolescent girls and women

• Low coverage and quality of ante-natal, intra-natal & postnatal care

• High proportion of unsupervised home deliveries and poor quality of institutional deliveries

• High proportion of low birth weight of newborns

• Delayed initiation of breastfeeding

• Not maintaining adequate warmth of newborns

• Delay in seeking health care for sick newborns

3.2.2. Strategies for Child Health for the Last 5 Years

Table 3.2.2.1 Strategies for Child Health for last 5 Years

S.No. 2008-09 2009-10 2010-11 2011-12 2012-131 Nutrition

supplementation of Pregnant mother & children (0-6 years) through ICDS


2 Immunisation Continued Continued Continued Continued

3 IMNCI Continued Continued Continued Continued

4 Essential New Born care


5 Vit. A supplementation (6 month – 3years)


6 IFA to Primary School children


7 Mid day meal Continued Continued Continued Continued



scheme8 De-worming of

school going children


9 IMNCI Continued Continued Continued

10 School Health Scheme


11 Health promoting school approach


12 IYCF Continued ContinuedS.No.

2008-09 2009-10 2010-11 2011-12 2012-13

13 Management of ARI

Continued Continued

14 Management of Diarrhoea

Continued Continued

15 Establishment of SNCU at DH, Newborn & Child stabilisation units at FRUs, Newborn care corner at 24x7 PHC, Nutritional Rehab. Centres

Continued Continued

16 Monitoring under IMNCI

Continued Continued

17 IEC/BCC Continued Continued

18 NSSK Continued Continued

19 Implementation of F-IMNCI

Continued Continued

20 Facility Based Newborn care

Continued Continued



(FBNC)21 Newborn

Corners at PHCContinued Continued

22 Implementation of community based neonatal care

Continued Continued

23 Implementation of Facility based infant & child care

Continued Continued

24 Infant Death Audit

Continued Continued

S.No. 2008-09 2009-10 2010-11 2011-12 2012-1325 Child referral

unitContinued Continued

26 IBSY Continued Continued

27 Home based Post Natal newborn care (HBPNC)

Continued

28 Measles campaign

Continued

29 Child SNCU helpline established

30 Yashoda introduced

31 Mother & Child Protection cards

3.2.2.2 Provision for Essential New Born Care

Provision for Essential New Born Care is of top most priority. Establishment of New born Care Corners at every delivery point is the planned target of the state. The persons handling delivery are trained in Newborn Sishu Suraksha under the NSSK programme



which provides Essential New Born Care training. New Born Care Corners are established in 81 CHCs/ PHCs / Delivery Huts on the basis of their no. of delivery.

The entire focus is on safe delivery at a specified delivery point. Those newborn who are high risk and need special new born care are referred to higher centres. For the care of sick newborns SNCUs at MCH Level III facilities and NBSUs at MCH Level II facilities have been established. Along with this, arrangement for free referral transport for sick newborns to health facilities has been made improving newborn survival.

Those newborn who are not at risk are sent home along with mother, however to follow up in the newborn period, Home Based Post New born Care (HBPNC) has been started.

3.2.2.4 Home Based Post-Natal Care (HBPNC)

HBPNC contains a range of interventions providing opportunity to identify the danger sign and referral by ASHA. Training of HBPNC for ASHAs for five days has been completed after earlier 2 days training (around 13,000 ASHAs trained) in all the districts in the month of May 2012. 10,000 Salter Weighing Scales digital thermometers & drug kits have been provided to ASHAs.

3.2.2.11 Integrated Management of Neonatal and Childhood Illnesses (IMNCI), Facility Based IMNCI

As per presentation made, IMNCI trainings, booklets and formats have been provided to IMNCI trained workers. During 2012-13, till Sep, 103300 new born babies were visited within 24 hours out of which 13332 were assessed, 11297 were treated & 2561 were referred. Reorientation of MOs using the Multimedia package has been initiated. 9200 health workers & anganwadi workers trained till Sept. 2012.

Comment: The state needstake up the programme district wise and make in fully functional in few districts before moving to the next. It should do a third party evaluation to check the effectiveness of this programme.

3.2.2.12 Facility Based IMNCI is an important training program to bridge the gap in the facility based intervention in child health care. Facility based IMNCI is to empower the Medical Officer and Staff Nurses in managing sick children referred through IMNCI trained workers. F-IMNCI also covers the neonatal care including the resuscitation and management of low birth weight child in the facilities. 2177 health personal trained in facility based IMNCI (F-IMNCI).

3.2.2.5 Specialised Facility Based New-Born Care



State is focusing on improving the child health services to reduce the Infant & Child Mortality. Thirteen SNCUs (Sick Newborn Care Units) have been established and in rest of the district Hospitals they are under process of establishment. Till Sep 2012, A total of 5441 (3304 Inborn & 2137 Outborn) babies were admitted in the SNCUs, out of which 815 were referred to higher centres and 268 died.

New born Stabilizing units are established at 19 CHCs and 11 SDH while in some districts, SUs are under process of establishment. Training of SNCU staff is being done in collaboration with NNF.

3.2.2.3 Free Referral Transport for sick newborn.

ENBC, HBPNC, and IMNCI programmes have lead to identification of sick newborn at their households and improved referral of sick newborns to health facilities. Bringing these two together has resulted in an increased number of sick newborns presenting in referral hospitals. In this situation, Facility-based newborn care has a significant potential to bring favourable impact in newborn survival.

3.2.2.7 Infant and Young Child Feeding Practices

Another important Child Health Intervention strategy adopted to address malnutrition is measures to improve IYCF practices. The IYCF practices reduce malnutrition in infants and young children through:-

Timely initiation of breastfeeding, Exclusive breastfeeding during the first six months of life, & timely introduction of complementary foods, at six months, while breastfeeding continued until 24 months and beyond.Age appropriate complementary feeding, adequate in terms of quality, quantity and frequency for children 6-24 months, with increased quantity, density and frequency as the child grows.

Data from CES 2009 shows that IYCF practices vary widely across the states. Initiation of breastfeeding within half an hour of birth has an all India average of just 33.5% while percentage of children exclusively breastfed for 6 months (among 6-9 months children) is only 37%. In Uttarakhand, Uttar Pradesh and Delhi percentage of exclusively breastfed children is less than 20%, while Himachal Pradesh, Sikkim, Tripura nearing 60% and Jammu Kashmir close to 80%. The percentage of children 6-9 months on complementary feeding and breast milk is an average of 57% for India and ranges from 40-90% in various states. However this age is a critical period when children are likely to falter in growth if the quantity and quality of complementary food is inadequate.

Renewed focus on BCC during home visits, VHND and ANC is required. Mothers should be counselled and supported for breastfeeding during postnatal visits. Most states have



dedicated budget for IEC on Child health, which can be used more effectively for creating awareness on breastfeeding practices.

3.2.2.13 YASHODA

In the state, Yashoda worker was introduced to ensure good IYCF practices, provision of birth doses to the newly born in the facilities and to act as birth companion. The Yashoda facilitates registration of mother at the facility. Ensure Care of new born, recording of birth weight and support to mother, ensures early initiation of breastfeeding, counseling for exclusive breast feeding and watching for post natal risks to mother and new born. Provides counseling. Ensures Zero dose Polio & BCG to the new born before discharge. So far, 128 Yashodas have been recruited out of 148 sanctioned in various districts.

3.2.2.8 Iron supplementation

The NFHS-3 survey highlights widespread anaemia, with prevalence of 69.5 per cent in children between 6 – 59 months. Anaemia remains widely prevalent in all states. Except for a few states, more than half to two thirds of children are anaemic. Despite paediatric IFA tablets / syrup and deworming tablets being supplied as part of Kit A to all sub-centres, twice a year, the coverage of children with IFA remains very low.

3.2.2.9 Management of children with malnutrition

42.5% children under age of five years are underweight (low weight for age). 48% children are stunted (low height for age). In numbers it means that more than 47 million children under 5 are chronically malnourished. 19.8% children are wasted (low weight for height), over 6% of children under five years of age suffer from Severe Acute Malnutrition (SAM). In numbers it translates into 25 million children with wasting and 8 million with severe wasting or SAM. 22% babies are born with low birth weight. SAM significantly increases the risk of death in children under five years of age. It can be a direct or indirect cause of child death by increasing the case fatality rate in children suffering from such common illnesses as diarrhea and pneumonia. Children who are severely wasted or underweight are 9 times more likely to die than well-nourished children.

3.2.2.10 Management of Diarrhoeal Diseases & Acute Respiratory Infections

Intervention is done through the IMNCI programme.

Comment: Currently the state does not have a database on the incidence of ADD and ARI.

3.2.2.15 Infant Death Review (IDR)



IDR is tool to analyze the causes of Infant Death and taking corrective actions. All infant deaths to be reported (surveillance started). State and District level review committees analyze the causes of deaths and fulfill gaps in health system. Total infant deaths reported till Sept 12 were 3533, still births were 2437. Till Sept 12, total no. of Infant deaths reviewed were 948 and no of still births reviewed were 307.

3.2.2.6 Immunization

Table 3.2.1.1 Immunization rates in Haryana

Indicators DLHS-3 (2007-08) DLHS-2 (2002-04)

Child Immunization Total Rural Urban Total1 Rural UrbanNumber of children age 12-23 months 2,111 1,580 531 2,214 1,638 577Children 12-23 months fully immunized (%) 59.6 55.9 70.8 59.1 56.7 66.3Children 12-23 months not received any vaccination (%) 1.9 1.9 1.9 11.8 12.4 10.3Children 12-23 months who have received BCG vaccine (%) 86.5 85 91 83.5 82.5 86.1Children 12-23 months who have received 3 doses of DPT vaccine (%) 69.1 66.3 77.6 73.6 71.6 78.6Children 12-23 months who have received 3 doses of polio vaccine (%) 67.9 65.1 76.2 72.9 70.8 77.9Children 12-23 months who have received measles vaccine (%) 69 66.4 77.2 65.4 63.5 70Children (age 9 months and above) received at least one dose of vitamin Asupplement) (%) 46.3 43.8 53.9 42.2 39.3 49.2

Free Immunization services to all pregnant women & Children to prevent against 7 Vaccine Preventable Diseases. Fully Immunized children are 71.7% (CES 2009), from 59.6% DLHS (2007-08). No Polio Case in state in last two years i.e. Jan 2010. Haryana is the first state in India to complete Measles Catch up campaign in which 48.50 lac children (9M to 10Y) were vaccinated. Unique urban vaccination strategy by providing additional ANM for Immunization at Urban RCH Centre has been started. Hep. ‘B’ vaccination launched from 14th Nov 2011 in all districts. One of the best equipped cold chain in country with four regional vaccine stores & cold chain technician in every district. State launched Pentavalent vaccine in Nov, 2012 and state level workshop conducted for Pentavalent vaccine. It has a special programme to prevent Adverse Events Following Immunization (AEFI).

RAPID i.e. Supportive Supervision for Immunization conducted in 3 districts of Haryana (Palwal, Panipat & Mewat). 52 Immunization Field Volunteers (IFVs) have been recruited for monitoring of Immunization activities in collaboration with NPSP-WHO.

Provision of prophylactic IFA syrup and ORS+ Zinc to all children with Diarrhoea has been made. Ensuring a total of 9 doses of Vitamin A to all children below five years of age.



1,00,000 IU dose of Vit A is being given at 9months and 2,00,000 IU after 9months at 6 monthly intervals upto 5 years of age.

3.2.2.1 Mother and Child Protection (MCP) Card

MCP card has been recently adopted as a tool for monitoring growth of children, assessing key milestones during early years of development and empowering families to make decisions for improved health and nutritional status of children under 3 years. These cards are a joint initiative of the Ministries of Health & Family Welfare and Woman & Child and bring about convergence on the issue of child nutrition.

3.3 Recommendations of the Maternal and Child health sub group

RECOMMENDATION 1: 3.3.1 Defining of Services: State must define, document, upgrade and display the MCH services that it can provide at each level of care. It must also identify and display the services it cannot provide. It must locate its services rationally to ensure access to the rural and urban population.

3.3.1.1 Defining Services, Gap analysis and closure.

a. Level of Care: Care level at each facility should be defined, documented and displayed. Each health facility of the State (Public and Private) must be categorized into MCH level I, II and III on the basis of level of care. State may consider adoption of the classification indicated in Maternal Newborn Health(MNH) toolkit of MOHFW or device its own method of classification. The document of services must be available at State and district levels and on its website. Staff of each facility must be aware of services it has to provide and it cannot provide to prevent vital delays.

b. Uniform spread of facility: Analysis of delivery points show that they are not evenly spread out. State needs to have a policy about the provision of delivery point for normal deliveries within a reach of 10-15 km , 24 by 7. Services should be evenly spread out.



c. Urban Areas: The underserved population specially in slums in urban areas also must be provided better access of care.

Gap analysis and : On the basis of categorization, State should take an exercise at beginning of every year to identify gaps. The gaps identification should be specific and time bound including infrastructure, equipment, personnel and training. The state may consider GIS mapping for visual display of its critical facilities and services.

d. Reallocation of resources and Upgradation/ Reclassification of facilities On the basis of gap analysis, the state must upgrade its facilities appropriate to the level of care. The health resources including manpower and equipment should be reallocated depending upon the gap analysis of health facilities. Trainings should also be deferentially targeted based on identified gaps. Budget allocation, construction of buildings and postings of personnel should be made accordingly. In case of non availability of adequate manpower, infrastructure or budget, the facilicity should be reclassified on the basis of available resources. Resources can be reallocated according to the need of each district. Some performance based indicators and total population covered can be used as parameters for decising needs of each district. Primary care should be designed in such a way to decrease the load of tertiary care.

RECOMMENDATION 2 : 3.3.2 Improvement of Quality of Services: Quality of antenatal, intranatal and postnatal services needs to be improved and monitored.

3.3.2.1 Antenatal Period

a. Quality of Antenatal Checkup (ANC):

i) Promoting quality ANC should be foremost priority. Quality of antenatal care is the most important step that will determine the survival of child at birth. ANC Guidelines as specified in “Guidelines for Antenatal care and skilled Birth Attendance at Birth” of MOHFW, GOI (April 2010) should be adopted formally in the MH programme.

ii) Indicators to check the quality of services being provided at every step must be developed. Indicators should be structural, process and outcome indicators (eg – availability of examination table, Number of pregnant women referred with major risk factors after ANC; Number of severe anaemia/ high BP identified). It would be difficult to monitor quality amongst the large number of indicators, therefore selected few key indicators as a starting point. These key indicators



should be evidence based, nationally and internationally recognized. The clinical practices related to these key indicators should be modified so as to contribute to the reductions in mortality and adverse outcomes. Reverse tracking of maternal deaths should be done as a tool to identify gaps in ANC.

iii) State should device a system of annual accreditation of ANMs skills. It should regularly identify gaps in their knowledge, skills and practices specially those that would enable them to identify high-risk pregnancies and conduct specific trainings to fill these gaps. ANMs can be certified on the basis of these training. State must define and document the high risk obstetric cases and this information should be available with all care providers.

iv) Atleast one ANC should be done by an MBBS doctor especially in the last trimester. ASHAs should do home based pregnancy care with atleast one home visit for birth preparedness. She should also be trained to carryout Antenatal checkups.

v) Sub centres should be equipped with BP apparatus, Hb testing equipment, digital thermometer, weighing machine and examination table. Weighing machines, BP apparatus etc should be regularly checked and calibrated. ANC should be done in clean environment offering privacy to the women.

c. Mobile Teams for ANC: State should provide Mobile Teams providing ANC services for underserved areas. It could comprises of a team of nurses, SBA trained ANC health workers, lab technicians etc equipped with BP Appratus, weighing scales and lab facility can visit the underserved areas/villages following a fixed schedules and provide basic antenatal services and identify high risk cases and complications. They could also schedule and conduct check-ups at the health centres/hospitals in remote areas or where the coverage is unsatisfactory due to paucity of staff.

d. Camp Approach for ANC: A camp approach for first trimester MTP as well as third trimester ANC of all cases of PHC may be started in which Gynecologist from DH will visit PHC on pre scheduled dates. The Gynecologist may be given incentive.

e. Anaemia in Pregnancy: Anaemia in pregnancy is an important factor related to maternal health so should be detected and treated promptly. At present health workers are not able to diagnose anaemia clinically or by testing methods. Capacity building for clinical and lab diagnosis of anaemia should be done. Reverse tracking of anaemia cases coming at facility level already being done by the state should be done more aggressively to find out the reasons of cases being missed out at peripheral level.



3.3.2.2 Intranatal Period:

a. Setting standards and Infrastructure improvement: State must improve the quality, safety and privacy of its labour rooms, caesarian OTs and delivery services at all levels of care. “Guidelines for Antenatal care and Skilled Attendance at Birth” and MNH guidelines of MOHFW, Govt. of India, April 2010 should be adopted formally as standards for providing intra-partum care. Every labour room and caesarian OT should be provided with facility to handle essential new born care. Safe practices should include standard infection control and Biomedical Waste disposal practices. Best practices could be less number of PV examinations; not giving Inj. Oxytocin before delivery; maintaining Partographs to monitor progress of labour. These can be painted on the wall of Labor Room.

b. Availability of Blood and Blood components: Every delivery point must have easy access to blood in timely manner. O negative packed cells should be present at all Blood storage facilities as it can be transfused to any patient with any blood group. Blood Storage centers at CHCs should be identified and availability of blood should be ensured.

c. Monitoring: Indicators to check the safety and quality of services being provided must be developed, analysed and monitored. Documented preventive and corrective actions must be taken after each set of analysis.

d. Accreditation of Nursing Skills: State should device a system of annual accreditation of nurses obstetric skills. It should regularly identify gaps in their knowledge, skills and practices specially to enable them to conduct normal deliveries adopting best practices and enable them to identify high-risk deliveries in time. They also must have complete knowledge of manner of dealing with high risk deliveries. State should conduct specific trainings to fill gaps in knowledge and skills. All Nurses who conduct deliveries must undergo atleast 15 day attachment in a district level hospital under a Gynecologist and SNCU each year to upgrade their knowledge and skills.

e. Patient Rights: State should treat every women coming for delivery with utmost respect in terms of conduct, cleanliness and privacy. Right of women for respectful care should be displayed. Labor room abuses should not be tolerated. State should document all types of labour room abuses and educate the personnel handling deliveries about them.

3.3.2.3 Postpartum care:



a. Improve Quality: State must take steps to improve quality of the post-partum care. Standard protocols for care should be used. “Antenatal care and skilled Birth Attendance at Birth” should be adopted by the State as Standard Guidelines for Postpartum care. Indicators to check the quality of services being provided must be developed and monitored.

b. 48 hour stay and Discharge: State should ensure a mandatory stay of 48 hours in institutional deliveries. High risk mothers & neonates should be kept for a longer period. An exercise of calculating the number of PN beds should be done for every delivery point based on the delivery and population load. If there are inadequate number of beds in the PN wards then the number of beds should be increased to meet the objective of 48 hour stay on priority basis. Food, clean water and toilet facilities should be ensured in the PN wards.

Till adequate number of beds are made available and at times of heavy rush low-risk cases can be discharged after complete examination of the mother & baby by a doctor earlier than 48 hours to ensure that focus is there on the high risk group.

c. State may consider providing monetary incentive to BPL and SC/BC women for 2 days at the rate of minimum daily wages to encourage 48 hours stay. This incentive may be provided in leiu of loss of wages suffered on account of longer stay in the facility.

d. Post partum anemia: Anaemia after delivery is quite common and often ignored. It contributes to adverse outcome following delivery. Addressing postpartum anaemia and its treatment should be made integral part of postpartum care. This comprises of Haemoglobin testing before discharge in institutional deliveries. In all the patients with severe anemia in last trimester and after delivery, Inj. Iron sucrose can be given in the hospital.

e. Continuing postpartum care: Continued PP care should be done at home by ASHA. ASHA must be trained to carry out postpartum care at home. Free transport must be ensured for postpartum complication services. Postpartum contraception services must be integrated with Family Planning Programme.

RECOMMENDATION 3 : 3.3.3 Improvement of Referral Transport: Adequacy and quality of referral transport needs to be improved. It should be labeled as “Accompanied Transfer” of patients based on standard protocols to the facility providing services needed for that patient.



3.3.3 Referral Transport:

a. State must ensure that adequate number of ambulances are available to transport serious cases (mother/children) at appropriate level in timely and safe manner. State can consider augmenting its existing fleet of ambulances. It should integrate its ambulance services with other state agencies/NHAI/private players. It could consider having a single call number in case of emergencies for police/NHAI and health dept. ambulances.

b. State should define the type of cases and the level to which referral has to be made on priority basis depending on specific signs and symptoms. A GIS mapping exercise of facilities as indicated earlier is required to be done to help locate higher referral facilities without delays to prevent maternal and child mortality eg Basic Obstetric Care (BeMOC), 24X7 care (including night deliveries), Emergency Obstetric Care (EmOC) facilities. For emergency care private facility should also be mapped.

c. Knowledge to the community and ASHAs and the health workers who refer the patients, about the facility where that patient needs to be referred must be provided. The information needs to be disseminated widely so that the people can make the right choices with the help of ANMs and ASHAs regarding places to go for seeking emergency care. The ambulance drivers have to be trained to take them to the right place based on the needs. Referral maps must be available with ambulance drivers.Standard guidelines should be prepared so that the referral can be safer and training should be given to staff to follow the standard guidelines according to their roles and responsibilities.

d. A Standard referral note with details on diagnosis, blood group, reasons for referral, condition at time of referral, treatment given, date and time of referral should be given to the family. A trained person (EMT,ANM, GNM or a doctor) should accompany the person who is sick to render first aid and provide basic medical support during travel. The staff (including drivers) accompanying a sick patient must be trained in BLS: The ambulance must be equipped with life support equipment and medicines which should be checked on periodic basis as per check list. The ambulance must also have equipment for conducting delivery and staff including drivers should be trained for same in case delivery occurs while transferring mother from one facility to another facility.

e. The referral facility staff should be informed in advance and should be ready to prevent any further delays.



f. A system of auditing referrals could be started to find any deviation from above stated standards.

RECOMMENDATION 4 : 3.3.4 Improvement of Trainings: Quality of training needs to be improved and monitored

a. Appropriate Training: State must provide training appropriate to the need. It may conduct a gap analysis of training need, make an annual plan and budget based on gaps identified and follow the plan. The training need should be linked to the need of the programmes.

b. Improving Quality: State must improve the quality of trainings provided to all cadre involved in MCH services. Before and after each training a written and oral test must be conducted and certificate issued.

c. Practical Experience: The medical as well as paramedical staff of peripheral health facilities like Medical Officer, ANM, Staff Nurse and ASHA should be deputed for 3-4 days in a month at respective District Hospital. This would help them learn and practice the key skills through observation and practice. It will provide helping hands in busy hospitals and also facilitate in rapport building which will then help in cases of referred patients. Support and hand holding is needed for SBA trained personnel. Doctors under going EmOC/LSA training should be posted at DH and their follow up indicators after completion of training should be developed.

d. Monitoring: It should develop indicators to monitor the quality of trainings. The indicators must be analysed and acted upon. Training could be monitored by means of a third party monitor.

e. Posting of trained staff: All trained staff must be posted in a rational manner keeping in view the gaps and level of facility, so that the skills that they acquire are properly utilized and not lost.

f. Retraining: Each category of MCH staff must undergo retraining after every 3 years to upgrade their skills.

RECOMMENDATION 5 : 3.3.5 Review of Maternal Mortality and Morbidity:- There is a need to strengthen the existing process of Maternal Death Audit. Apart from maternal mortality audits, maternal morbidity audit or near miss audit should also be included in Maternal Health Programme.

3.3.3 Maternal Mortality and Morbidity:



a. Maternal Mortality/Death Reviews (MDR): MDR should be strengthened. At present MDR in the state is capturing only one-third of total maternal deaths. It is recommended that all maternal death in the state should be reviewed intensively to find out the cause. Preventive and corrective actions should be taken and documented after each analysis.

b. Medical complications: Complications like hypertension, anaemia, TB during pregnancy are also important cause of maternal deaths. Strategies to address these medical problems should be devised. Horizontal integration of maternal health with existing programmes for RNTCP, NVBDCP, Anaemia Control Programme etc. should be done.

c. Community Audit: The community/civil society involvement in MDRs to look at the social determinants of maternal deaths including any discrimination on the basis of gender is recommended. Many times, the cause of maternal death like anaemia, late transport, emanates from causes which can be corrected by the community itself. The engagement of the community is also useful step in prevention of deaths and improvement of quality of care.

d. Morbidity Audits and Audit of Serious Adverse Events: There is also a need to study morbidity outcomes. Certain deliveries result in serious adverse events which compromise quality of life of a women after delivery for example, genital and uterine prolapse, infertility, fistulas etc . Data on maternal morbidity needs to be generated. A list of morbidity conditions that need reporting may be made which will be further reviewed and focused on, for policy interventions. For every maternal death it is estimated that approximately 30 women suffer a long or short-term morbidity (UNFPA-SRH framework))

e. Specific efforts to ensure management of severe chronic morbidity, such as uterine prolapse and obstetric fistula, should be made where prevalence is high and access to treatment care is low.

f. Near Miss Audit: Along with death audits state may consider conducting “Near Miss Audits”. These refer to audit of care provision and delays in care to women who survived after life threatening conditions related to pregnancy and child birth (WHO definition). These audits at times can be more useful in learning about gaps in care because the women would have survived to tell her story.



RECOMMENDATION 6 : 3.3.6 Safe abortion services:- Health system should provide better access to quality and safe abortion services for unwanted pregnancy both in married and unmarried women at primary and secondary level of care.

a. MTP Services: Illegal abortions are one of the leading causes of maternal deaths. Provision of safe and quality MTP services are as important as providing good institutional delivery services. The state must ensure that better access to MTP services is provided through the public health system at primary and secondary health care level. There is a need to conduct mapping of the available MTP services in the State (Private and Government) and close the geographical gaps in the services to provide better access.

b. Better access of MTP services: MTP services should not be limited to pregnancies in married adults. Teenage and unmarried girls should also be provided abortion services to prevent mortality and morbidity. Care should be taken to be ensure confidentiality of personal identity in such cases. Provision should be made for counselling of such cases in order to reduce mental trauma. Abortion services should be provided free of cost at Govt. health facilities without too many formalities and in a user friendly manner.

c. Better quality of MTP services: State must invest in improving the quality of MTP services by formulating and implementing standard clinical protocols and following standard infection control practices.

d. Better Training of MTP services: There is a need to evaluate the training skills of services providers performing Manual Vacuum aspiration MVA and other abortion services. The availability of MVA kits should also be ensured.Training of medical officers in modern methods of medical abortion, MVA should be done.

e. Better reporting of MTP services: The reporting of MVA in both public and private facilities should be ensured under MTP Act. This information should be analyzed and collated periodically. Preventive and corrective action must be taken after each analysis.

Detailed data about unsafe abortions in Haryana should also be compiled. This could include number of abortions in each trimester, places at which these abortions are taking place, whether in private/govt. sector. Interventions should be accordingly planned.



f. MTP Pills : MTP pills under unsupervised care could lead to incomplete abortions and sepsis. Sale of MTP pills should be strictly monitored. No such pills should be available to user without prescription of registered medical practitioner to avoid misuse.

g. Right to safe abortion: Women’s awareness about abortion services has to be enhanced. Access to Safe abortion should be recognized as a right of every pregnant women irrespective of age, caste, or marital status.

RECOMMENDATION 7: 3.3.7 Essential Newborn care (ENBC): As newborn period (0 to 28 days/ 4 weeks) is the most vulnerable period and many lives are lost in this period, the State should put more focus on Essential New Born Care.

a. Infrastructure: All delivery points must have facility for ENBC which include warmth, resuscitation facility, and infection prevention.

b. Protocols and Practices: State must formally adopt or develop and implement standard clinical protocols for ENBC services. The protocols should specifically focus on quality and safety. Practices such as Kangroo Mother Care (KMC), Early initiation of Breast feeding etc should be promoted aggressively.

c. Referral Linkages: State must provide appropriate facilities in the ambulances for referral of sick new-born and sick children. The staff should be trained to quickly identify danger signs which may need refferal. The referral cases must be given proper treatment before referral and given details of the treatment given on their referral slips. Facilities which can provide referral support from primary, secondary and tertiary level must be mapped. Staff should be aware of the level of these services and make rational referrals and separately pass on information to the referred facility. A proper log of referral communication must be maintained and audited.

d. Monitoring : State should develop indicators and monitor them regularly to ensure these services are properly given. The state may consider withdrawing the status of a delivery point if it does not provide the facility of ENBC.

e. Training: The accreditation process of Staff nurses providing delivery services should include testing their skills and knowledge on ENBC and issue certificates as evidence of the particular staff having undergone. Gaps in skills should be supplemented by retraining.



RECOMMENDATION 8 : 3.3.8 Special Newborn care (SNBC): Since certain percentage of newborn like low birth weight, premature newborn, need to be provided intensive care environment for survival State should also focus on Special New Born Care.

a. Structure : State must create appropriate infrastructure for providing graded levels of SNBC. The structure should include proper infrastructure, trained personnel and equipments. State may consider creation of Level 1 SNBC facilities at appropriate locations with ventilation facilities to cater for referrals from existing SNCUs.

b. Protocols : State must formally adopt or develop and implement standard clinical protocols for SNBC services. The protocols should specifically focus on quality and safety.

c. Training Facility: State may develop some of its SNCUs as training facilities for its staff providing SNBC by contracting trainers from agencies like NNF/PGI/AIIMS and training infrastructure. State may consider starting special courses of neonatal care for doctors and nursing staff in its medical and nursing colleges and provide them with special incentive in service rules.

RECOMMENDATION 9 : 3.3.9 Home Based Post Natal Care: State should strengthen its HBPNC programme for early detection, and referral of sick newborn .

a. In the first 48 hours state must properly identify at risk newborn and retain them after delivery.

b. After 48 hours the programme should address Post natal visits at homes of newborn and at-risk new-borns must be promptly identified and referred appropriately to prevent mortality in the newborn period.

RECOMMENDATION 10: 3.3.9 Care of post neonatal infants and under 5 children and specially for acute respiratory infection (ARI)and acute diarrheal diseases (ADD):- Timely detection and management of acute respiratory infection (especially pneumonia )and acute diarrheal diseases is needed to reduce mortality in neonate, infants and children.

3.3.9 Care of Post Neonatal infants and under 5 children specifically for Acute Respiratory Infection and Acute Diarrheal diseases.



a. In the post-neonatal period Pneumonia, diarrhoea and under nutrition are the top causes of deaths. The deaths due to these illnesses are preventable. State should adopt standard protocols for early detection, treatment and referral of these cases. The health workers have to be trained in IMNCI. The field level health workers must be able to recognize early signs of dehydration in diarrhea, respiratory distress in pneumonia and growth retardation. \

b. IMNCI (Integrated Management of New-born Care and Child Illness) : State should strengthen its IMNCI programme. This can be done by making a few districts fully functional in IMNCI and gradually extending to all districts. There is a need for focus rather than spreading it across the state.

c. IMNCI v/s HBPNC :State should resolve duplication in IMNCI programme component for infants between 0 to 2 months of age and the HBPNC programme which is also for newborn between 0 to I months of age. Both the programmes are being run concurrently.

d. Supportive Supervision: Quality improvement through external and internal quality assessment and quality improvement through supportive supervision and concurrent evaluation should be strengthened.

e. Availability of drugs: State should manage its drug supply chain in a scientific manner to ensure first line treatment like ORS, Zn and antibiotics should be available at all levels.

RECOMMENDATION 11:

3.3.10 Infant Death, still birth and Child death Reveiw(IDR):- The process of Infant Death and still birth Review needs to be strengthened along with community involvement and morbidity review. The state could consider introducing under 5 mortality review

3.3.7.1a. Infant Death Review (IDR): The process of Infant death and still birth audit needs to be

strengthened. The review should not be a fault finding but a fact finding exercise and result in corrective and preventive systemic actions without assigning blame to any individual. The systemic action could be structural or process related. Reverse tracking of deaths and severe cases of diarrhea and pneumonia should be carried out.

b. Community Involvement: The community/civil society involvement in IDR to look at the social determinants of infant deaths and still birth including gender related causes is recommended.



c. Near Miss Audit: Along with death audits state may consider conducting “Near Miss Audits” in cases of newborn as per the UNFPA guidelines. These audits at times can be useful in learning about gaps in care.

d. Morbidity Audit : Many of the conditions of disability including Mental Retardation, spasticity and developmental delays in children have their origin in the antenatal and inter-natal period. State may consider conducting audits of such cases to arrive at process gaps in the ante-natal and delivery services.

e. Under 5 Audit : State may like to audit some number of its U5 deaths to identify gaps in the services for the under five age gp.

RECOMMENDATION 12 : 3.3.11 Continuation of care:- Health Care should be provided as a continuum starting from preconception period up till the child reaches 5 years of age including adoption of family planning .

3.3.10 Continuum of care:a. in terms of different critical stages (conception, delivery, early neonatal care,

infancy, childhood, and adolescence) and various delivery channels (district, sub district, CHCs PHCs Sub centers and ASHAs) as well as stakeholders in the community (e.g. ICDS, Women and Child Development) should be the way forward. The state should put in place appropriate mechanism to ensure that the beneficiary of RCH and FP programme are provided the services in continuum despite the programmes being run by different branches and department through inter-branch and inter-sectoral coordination.

b. To facilitate the implementation of continuum of care, mother child protection card (MCP card) is required for covering the period from pregnancy upto 5 years age of child. The record should serve as the base for the delivery of essential maternal and early child health services in an integrated manner. Innovative use of Information Technology (IT) can be done to send messages to the clients during different phases of care.All ANMs and SNs must be trained to fill the MCP Card. It has to be ensured that all the elements in the MCP card are properly filled.

RECOMMENDATION 13: 3.3.12 BCC/IEC:- BCC is needed to address various issues related to maternal and child health. Public needs to be sensitized regarding danger signs so as to access the health facilities timely.



3.3.9.1 Family empowerment to enhance their participation and early care seeking - Change mind set of people for early intervention in neonatal sickness and need to take children early to hospital. Health Department should be in continuous contact with the family till the child is 3 years old. Families need to be educated about recognition of danger signs for early and appropriate care seeking. Printing of “Safe Motherhood booklets” with all interventions and pictures, which should be started at preconception till the baby is 3 years old.Message should be given to the community and educate them to identify symptoms which are need hospital level care and to take women directly to District Hospital to avoid crucial delays. Health department can start its first contact by sending letters to women right after their marriage for their diet counseling and family planning methods.

3.3.9.2 Pre-pregnancy Period: BCC should be done to improve the nutritional status of the women right after marriage. This is more important during first pregnancy. Decision makers in the family should be motivated to give good nutritional food to the woman before, during and after the pregnancy. Time in between pregnancies is equivalent to pre pregnancy so counseling is required in this period for use of spacing method and good nutrition.

RECOMMENDATION 14 : 3.3.13 Social Issues:- Social issues like caste problems in delivery of health services should be identified and addressed accordingly.

3.3.10 Social Issues: Group recommended that social issues like neglecting lower socio-economic group. Group also felt the need to address caste problems like some ANMs of upper caste don’t visit the areas where people of lower caste reside and vice versa is also true. State should map out pockets within villages and urban areas and specific groups which are vulnerable to neglect on account of caste or religious factors and closely monitor these areas for service delivery.

RECOMMENDATION 15 : 3.3.14 Monitoring & Evaluation:- Routine Monitoring and Evaluation as well as third party evaluation of all programmes should be strengthened.

3.3.11 Monitoring & Evaluation: Routine Monitoring & Evaluation of all the services and programs should be done. This can be done internally and also by third party.



3.3.8.5 Monitoring of JSSK Programme:- The State should put in place a regular mechanism of third party evaluation of implementation of JSSK.

RECOMMENDATION 16 : 3.3.15 Separate Cadre for Public Health services:- A Separate Cadre like public health cadre should be made to look after all functions of public health including MCH services.

3.3.12 Separate Cadre for Public Health services: A Separate Cadre should be made to look after the public Health services including MCH services being provided in the state. State needs to clearly delineate its clinical, administrative and public health functions and assign the works to persons who are specialists in their respective areas. The health department has the responsibility for implementation of various national and state programmes including MCH Programme, Family Planning prog, Immunization programme, Adolescent Health Prog, large number of Communicable and Non-communicable Disease control programmes, School Health Programme, Disease Surveillance etc. These programme address preventive health in large population groups. The state has also to provide curative services in its various hospitals. Currently the public health programs are being managed by specialists like surgeons, anaesthetists, pathologists but very few persons with Public Health degrees. Absence of a separate public health cadre results in wastage of specialist clinical manpower to run the public health preventive programmes who are not trained in public health. State may consider adopting models of Tamil Nadu and Maharashtra for a Public Health Cadre.



4. Anemia and Malnutrition

4.1 Anemia

4.1.1 Background & Situational Analysis

Iron deficiency Anemia (IDA) in Haryana is a serious public health problem and is a reflection of undernourishment and poor dietary intake of iron.

World Declaration and Plan of Action for Nutrition in December 1992 pledged

“to reduce substantially within this decade important micronutrient deficiencies, including iron”

but the exalted objective has eluded the policy makers despite efforts.

The WHO in its Iron Deficiency Guidelines, 2001 has made a clear distinction between iron deficiency and iron deficiency Anaemia (IDA). Iron deficiency has been defined as a condition where there are no iron stores in body with or without anemia. It has considered IDA as a continuum from iron deficiency to iron deficient blood formation (erythropoiesis) to IDA. This differentiation has an important programme implications when dose schedules are planned.

MOHFW, GOI, National Iron + Initiative adopting this concept identifies Iron deficiency as a consequence of decreased iron intake, Increased iron loss from the body and Increased iron requirement by the body.

As per NFHS-III data 2005-06, gives prevalence of anemia in Haryana among selected groups and shows that state position does not fare well vis-à-vis all India figures.

Table 4.1.1.1 Prevalence of anaemia in Haryana and India

Selected Group Condition Haryana India6 months to 3 years Any Anaemia Hb < 11g/dl 82.3% 79%6 months to 5 years Any Anaemia Hb < 11g/dl 72.3% 69.5%6 months to 3 years Severe Anaemia Hb < 07g/dl 4.3% 03.0%All women Any Anaemia Hb < 12g/dl 56.1% 55.3%Ever married women Any Anaemia Hb < 12g/dl 56.6 56.0%Pregnant women Any Anaemia Hb < 12g/dl 71.1% 58.7%Lactating women Any Anaemia Hb < 12g/dl 63.5% 63.2%Adolescent girls Any Anaemia Hb < 12g/dl 57.7% 55.8%Adolescent boys Any Anaemia Hb < 12g/dl 26.0%



The anaemia in all groups is very quite high and has ben resisting all programme interventions.

WHO has classified public health significance of Anaemia as Mild, Moderate and Severe. According to its IDA report, 40 % and above prevalence of anaemia in a population has been classified as a severe public health problem.

Table 4.1.1.2

Reports of Hb Testing Under IBSY (Fy 2012-13) till 14th Jan 2013

S.No.

District Schools

No of children whose Hb testing done

Mild Anemia

Moderate Anemia

Severe Anemia

Total no. of anemic

Abendazole tablets distributedSchool

s covered

1 Ambala 476 56439 25247 10787 451 36485 1017002 Bhiwani 415 41449 15159 5814 49 21022 1512103 Faridabad 64 14594 5175 1199 131 6505 978214 Fatehabad 136 27597 10857 3727 323 14907 983705 Gurgaon 189 24672 10949 4788 110 15847 1270006 Hisar 10824 4720 1701 86 6507 1586777 Jhajjar 500 64000 17000 46860 140 64000 738528 Jind 365 58509 32551 11194 482 44227 728199 Kaithal 422 80614 16388 8425 248 25061 44298

10 Karnal 530 78344 34221 17199 215 51635 22273511 Kurukshet

ra496 53484 17718 9788 340 27846 138691

12 Mewat 58 28189 14925 5148 47 20120 4100013 Narnaul 498 39707 17130 6170 385 23685 5780814 Palwal 237 26899 11849 5731 97 17677 4643815 Panchkula 159 20979 9533 2699 114 12346 2073816 Panipat 236 64992 32830 11947 795 45572 2699817 Rewari 98 30058 14773 8716 148 23637 8062318 Rohtak 298 44857 19496 17025 28 36549 8021019 Sirsa 225 19967 10150 6232 176 16584 3297520 Sonipat 158 27813 10169 6326 202 16605 9740021 Y.Nagar 262 28055 16455 3568 85 20108 55365

Total 5822 842042 347295

195044 4652 546925

1826728



IBSY is a flagship program of Government of Haryana launched in 2010. It covers all the children between 0-18 years in the Govt. schools and Anganwadis in terms of disease, deficiency and disability including anemia. In 2012-13 out of 8.4 lac school children tested 5.5 lacs (65%) were found to be anemic.

4.1.2 STEPS TAKEN FOR MANAGEMENT OF ANEMIA:

4.1.2.1 Iron Folic Acid:

One Small IFA tablet daily for 90 days to all child given in all the Govt. schools for classes 1st to 5th by the class teachers after mid day meal under IBSY having 20mg elemental Iron and 100 microgram folic acid. The children of classes 6th to 12th are covered under WIFS (weekly Iron and Folic Acid supplementation) giving 100mg elemental iron (fersolate) and 500 micro gram Folic acid. It also includes creating awareness about importance of personal hygiene and sanitation.

4.1.2.2 Albendazole tablets:

Albendazole tablets to school children by class teachers biannually for classes 1st to 5th

under IBSY and 6th to 12th under ARSH.

4.1.2.3 General therapeutic measures for treatment of moderate & severe anemia:

The PBF slides for the severely anemic children is made for knowing the cause of anemia and further treatment. Reporting of the number and name wise list of severe anemia cases at District level and compilation at state level is being done.

List of anemic children is made and is made available to ASHA’s and ANM’s for proper follow up of these cases. ASHA is incentivized at Rs 25/- on completion of IFA tab course for 90 days for each child with moderate and severe anemia (only for govt. school children) on prescription by the MO. Education and counseling material on dietary changes in form of manuals has been provided to schools to create awareness among the children by the teachers about prevention of anemia.

Comments: The IBSY initative and through it the data generated by state is commendable and it is not far from the data of NFHS. State is able to cover around 6000 schools and test 8.4 lac children for anaemia is itself a herculean task. But state needs to move ahead in interventions in addition to providing iron and albendazole tablets. It may like to focus to analyse the data microscopically to look at certain schools which have more cases of anaeimia and have severe anaemia for effective follow up as a pilot. The state also needs to adopt a policy to treat iron deficiency in addition to anaemia cure.



4.2 RECOMMENDATIONS OF ANAEMIA:

RECOMMENDATION 17: State should formulate a comprehensive policy and programme for

reducing Iron, folic acid and B12 deficiency, Anaemia control and constitute appropriate

administrative structure to achieve objectives laid out in the policy.

a. As of today Anaemia programme is component of several programmes of health

Department like Maternal Health (MH), Child Health (CH) and Indira Bal Swasthya Yojna

(IBSY) and Adolescent Health Programme to take care of anaemia in mother, children and

adolescents and also Women and child department. However in order to monitor anaemia

across the programmes state should create an independent Cell for Anaemia Control at the

state level. State may consider naming its programme with a catchy name like “Operation

Red “ so as to focus on the issue.

b. The Anaemia Cell should be provided with appropriate structural support and its function

should include devising and adopting standards and policies, intersectoral coordination and

monitoring of anaemia across programmes.

c. Programme should be expanded to cover all age groups and both genders as anaemia is

prevalent in all age groups affects both genders. So policy should address broader coverage

in a more comprehensive manner. In the Maternal Health Programme instead of focusing

only on the pregnant and lactating mothers, all women is reproductive age group should be

focused.

d. intervention should target mainly Iron deficiency anaemia but also other deficiencies like

folic acid and B-12 deficiency anaemias. State may also like to address the issues of various

other types of anaemia like haemolytic anaemias and make a comprehensive policy for all

types of anaemias.

RECOMMENDATION 18: Diagnostic protocol to detect anaemia:- A definite clinical and

laboratory protocol to diagnose type as well as extent of anaemia in individuals and

population groups should be put in place. The state should define the lab protocols for each

level of facility.



a. Diagnostic Protocols : State may adopt or formulate diagnostic criteria for anaemia for all

age groups and gender.

b. The state may either adopt a 2g band system for classifying anaemia starting from 4 g/dl

means that there would be 5 bands viz

Band 1 < 4

Band 2 4-6 g/dl

Band 3 6-8 g/dl

Band 4 8-10 g/dl

Band 5 10-12g/dl

c. Or the following criteria as recommended by the GOI in its Iron + initiative with addition of

very severe category recommended by WHO. State may consider adoption of these

protocols. “Very severe anaemia in pregnant women is a medical emergency due to the risk of

congestive heart failure; maternal death rates are greatly increased”.

Table 4.1.1 Haemoglobin levels to diagnosis anaemia (g/dl)

Age Group No

Anaemia

Mild Moderate Severe Very

Severe

Children 6-59 months of

age

>11 10-10.9 7-9.9 <7 < 4

Children 5-11 year of age >11.5 11-11.4 8-10.9 <8 < 4

Children 12-14 year of age >12 11-11.9 8-10.9 <8 < 4

Non pregnant women

(15 year of age and above)

>12 11-11.9 8-10.9 <8 < 4

Pregnant women >11 10-10.9 7-10.9 <7 < 4

Men >13 11-12.9 8-10.9 <8 < 4

d. Clinical screening of anaemia:- Before undertaking laboratory testing Clinical

screening of all children from 6 months to 5 years should be done by ASHA and

AWW. School and college teachers should screen the children and adolescents (boys

& girls both) under IBSY & ARSH. ANMs should screen all women in reproductive



age groups. All cases irrespective of their age and gender having any degree of

anaemia should be referred for further testing.

e. Suggested Cases to be tested:-

1. All cases of irrespective of their age and gender referred after screening having any

degree of anaemia should be tested for Hb status.

2. Following cases should be tested for their Hb status irrespective of clinical status:-

a) All pregnant women ( at least 3 times during pregnancy)

b) All postnatal cases before discharge from health institute including Hb

testing at home by ANM in case of home delivery.

c) All lactating mothers (At least 6 monthly).

d) All women of reproductive age group having IUD in place (At least 3

monthly).

e) All OPD cases of any age and both genders should be assessed clinically and

tested for Hb at all health facilities as a routine investigation.

f. Training: A training module to train the field workers on clinical assement with

pictoral chart (comparing the degrees of red colour) should be put in place for

ensuring good clinical assessment. At the end of training the health workers should be

able to atlest identify all cases of severe anaemia.

g. Method of testing:- Depending upon the expertise and facilities available the method

of testing of Hb may be as following:-

Sr. No. Facility Method of Testing

1 Sub Centre Haemoglobometer (Sahli’s Method)/ Color Scale

Method and dry dot method for pregnant

women

2 PHC, CHC and

SDH

Calorimeter (Cyanmeth Hb meter)

3 DH Haematological cell counter for complete

Haemogram



*Note: All pregnant women should undergo their Hb testing by calorimeter method at PHC

or higher level.

Haematology counter and Anaemia Clinic should be set up in every District Hospital and

must be provided with Cell counters. All cases which come to these counters a complete

profiling of their anaemia should be done to detect type of anaemia and given complete

treatment at the Anaemia clinincs.

Category of cases :

Pregnant women : There are about 5.5 -6 lac pregnant women in the state every year.

Every pregnant women must be tested 3 times during her pregnancy with cynemet

method. At subcetntre level dry dot may be prepared and filter paper may be sent at the

PHC level for testing. All cases of severe anaemia should be immediately referred to district

hospital at the Anaemia Clinics.

Children: There are more than 40 lac children in schools being tested for anaemia. The

state may consider revising its strategy of testing every child for Hb. Rather it should

clinically screen the children and test those suspected to be anaeimic that too only for the

purpose of follow-up on the effectiveness of treatment.

Provision of Equipment and personnel : State must upgrade its anaemia testing facilities

at all levels of care as recommended in the table above.All DH must have haematology

counters, all SDH, CHCs, PHCs must have calorimetry. All facilities from PHC and above

must have atleast one LT who must do Hb testing. The aim of the state should be to provide

accurate method of testing Hb upto the level of PHC. Subcentres can continue to have

Sahli’s method or any other colour comparison method.

Capacity Building of Personnel involved in testing:-

ANM as well Lab Technicians must be trained with manual publication for a small number

of tests being carried out by them. NIN lab manual may be used as reference.

RECOMMENDATION 19: Iron Supplementation and Treatment Protocol:- All cases being

screened and detected as anaemia should be treated as per standard protocols. The

protocols must define the prophylactic and therapeutic methods for treatment. It should also

define the policy of the state towards injectable iron preperations.



a. Iron supplementation would be the key intervention of the state for treating iron

micro-nutrient deficiency. While adopting any protocol especially of dose duration,

state should adopt a general principal of treating iron deficiency in addition to iron

deficiency anaemia. Therefore, all iron supplementation should be broadly divided

into prophylactic and therapeutic.

b. Anaemia prophylaxis should start as early as at age of 6 months as per the IMNCI

Guidelines. While in IBSY (WIFS component) Weekly iron supplementation is given

to boys and girls both but in anaemia campaign of ARSH component only adolescent

girls are tested and treated for anaemia. Boys should also be included in anaemia

campaign.

c. Therapeutic Approach : Every case of iron deficiency must be given iron

supplementation beyond 90 days to replenish the stores. Principal of test and treat

should be followed.

d. State should consider formal adoption of Govt. of India’s “Guidelines for Control of

Iron Deficiency Anaemia” in its Anaemia programme or develop its own protocols.

The protocols should include prophylactic and therapeutic approach included doses

and duration for all categories of anaemia, age groups and gender.

e. Vit B12 and Folic acid : State should continue to give folic acid in pregnant women

and also consider adding vit B12 and Vit C in some cases.

f. Ayush department may consider promotion of preparations based on ayurveda,

homeopathy etc in some of the PHCs on experimental basis and then arrive at a

comprehensive strategy for anaemia treatment the state based on Ayush based

treatments.

g. Enhancing compliance to treatment: - Every case should be educated accordingly

to the compliance with treatment regimen. A list of warning about expected side

effects and dietary education to enhance absorption should be made and handed

over to each and every patient. Vitamin C may be added to increase bioavailability of

Iron.



RECOMMENDATION 20: -Dietary Interventions:- Dieting interventions are very important

aspect in case of Iron deficiency disease. Dietary intervention should include availability and

better access to iron rich food for vulnerable population and bring about change in feeding

practices. These intervention should be listed out and public should be educated accordingly.

The govt should promote effective iron food fortification diets through an iner-departmental

approach.

a. Dietary intervention is the most cost effective and sustainable way to improve

status of deficiency diseases and Iron deficiency anaemia is one of them. ICDS and

Mid day meal at AWC and Schools should be made iron rich. They can consider

Amla Candy in their mid day meals.

b. Availability and Accessibility of Iron Rich Food : Iron rich foods should be made

available in the state by involvement of agriculture, forest and panchayat

departments. Fruit trees like amla, Jamun, drum stick, Amrood, ber and olives

should be promoted on Panchayat lands. Forest departments should make wild

fruits available to population at affordable rates. Health department must grow all

these trees in its PHCs and CHCs. Coarse cereals rich in iron like ragi should be

promoted.

c. Ayush Department may be asked to identify and popularize the iron rich foods like

jiggery, gur chana, gur ke chawal among population at large.

d. Food practices : Availabilty of food to vulnerable sections within family and

community should be exhorted. Education about selecting iron rich and iron

absorption enhancing foods, avoiding foods which inhibit iron absorption should be

spread.

WHO has listed iron enhancers as haem iron, present in meat, poultry, fish, and

seafood., ascorbic acid or vitamin C, present in fruits, juices, potatoes and some

other tubers, and other vegetables such as green leaves, cauliflower, and cabbage;

and some fermented or germinated foods.

And iron inhibitors as phytates, present in cereal bran, cereal grains,high-extraction

flour, legumes, nuts, and seeds; foodsthat contain the most potent inhibitors

resistant tothe influence of enhancers include tea, coffee,cocoa, herbal infusions in



general, certain spices(e.g. oregano), and some vegetables; and calcium, particularly

from milk and milk products.

Tea coffee coco and milk should be avoided for 2 hours after meals as they inhibit

iron absorption.

e. Schools and colleges syllabus should include a chapter of nutrition giving emphasis

of Iron rich balanced diet. Health Wall should be painted in school emphasizing

health and nutrition.

f. Fortification of foods with iron:- state should identify important items of food

which can be fortified with iron. Iron fortified Salt, flour other cerials should be

considered for universal coverage and methods of making powdered form of iron

rich foods be explored to be used in mid day meal.

RECOMMENDATION 21: -Public education about disease and drugs:- A precise public

education material should be made by experts including all aspects of anaemia and

treatment. Community should be involved directly in each and every public health problem as

without their participation no goal can be achieved.

4.3.3 Education about Anaemia:- As a large number of cases detected with low Hb level

are asymptomatic because development of symptom depends upon the rapidity of

development of anaemia . In chronic anaemia cases even severe anaemia will not lead to

any major symptomology. A women with chronic onset o severe anaemia would be able to

do normal activities of daily living without any complaints. Therefore, public should be

educated about this fact and sensitized about the adverse outcomes of anaemia to make

them responsive to the interventions.

4.3.4 Education about diets:- A list of traditional iron rich diets like jaggery should be

prepared and included in public education campaign. Cooking in iron utensils should also

be emphasized. Role of food items which affect absorption of Iron should be taught and list

of both enhancers and inhibitors of iron adolescent should be included in the training

modules/BCC strategy..



4.3.5 Education about side effects of Iron medicines:- All person given iron preparation

should be cases should be educated about actions, expected side effects to enhance

compliance with the treatment.



4.4 Malnutrition:


Child malnutrition is mostly the result of exposure to infection and inappropriate infant & young child feeding and caring practices, and has its origins almost entirely in children between 0-3 years. However, the commonly held assumption is that food insecurity is the primary cause of malnutrition which is erroneous. Consequently the existing response to malnutrition in India has been skewed towards food based interventions and has placed little emphasis on schemes addressing the other determinants of malnutrition and bringing about a behavioural change to address the problem of undernutrition in children.

Table 4.4.1.1 Nutritional Status of Children as on July, 2012NUTRITIONAL STATUS OF (0 to 6 years) CHILDREN AS ON July, 2012

Sr. No.

Name of District Total population of children

Total Children weighed

Normal Grade

Moderate Severely Underweight

1 Ambala 86329 86329 52878 26967 64842 Jind 127348 127262 84960 34829 74733 Bhiwani 130866 124526 86323 31380 68234 Hissar 141932 129500 80894 40569 80375 Karnal 132549 109495 67857 34302 73366 Narnaul 85932 85932 56510 24193 52297 Rohtak 93240 88509 65401 23108 08 Gurgaon 124236 116078 79944 26176 99589 Faridabad 144647 141997 83241 47271 1148510 Kurukshetra 73739 69422 47805 18516 310111 Sonepat 138675 138543 108383 30107 5312 Sirsa 94858 83665 57510 24197 195813 Y.Nagar 97041 96575 68540 24564 347114 Rewari 80536 80483 51646 24148 468915 Panipat 119647 119647 84521 30086 504016 Kaithal 102955 102844 71991 24683 617017 Panchkula 31660 31660 23306 7921 43318 Fatehabad 92655 84518 55654 23511 535319 Jhajjar 86672 79521 48951 23587 698320 Mewat 182021 154634 81230 64877 852721 Palwal 140487 126112 75549 46719 3844

Total 2308025 2177252 1433094 631711 112447

Comments : The data indicates wide scale malnutrition in the state which is specially so in certain districts.



4.4.2 Strategies:

Keeping the above in view, the department of WCD has introduced several initiatives and awards like improving infant & young child feeding practices, Nutrition Award, Best Mother Award, Nutrition Strategy, Ladli, etc to combat malnutrition in the State.

Supplementary Nutrition Program: Under the Supplementary Nutrition Program of ICDS, State is now providing hot cooked food to children, Adolescent Girls , pregnant and lactating mothers through Village level women SHGs and that is being monitored by VLCs.

Most of the Rural children are being covered under ICDS. Of the 33.35 lac children in Haryana, 23.66 lac children are being provided ICDS services. As the coverage of the urban children is low, efforts are being made to cover all the urban slums through opening of new Anganwadi centers in the 3rd Phase of expansion of ICDS so that there is complete universalization of ICDS in Haryana. Unfortunately the scheme at present ignores the coverage of children 0-3 years age who suffer from undernutrition and the risk of death maximally. The attendance of children in this age group and of the undernourished children is very low even though their needs are maximal.

Food intake is not the only determinant of child’s nutritional status. The effect of the feeding efforts can decline if environmental hygiene and domestic health management practices are poor. In this context, Convergence with public health department regarding total sanitation campaign and drinking water supply is being carried out to cover 100% Anganwadi’s with these facilities.

New attractive and acceptable recipes have been introduced to ensure the consumption of micronutrients and other nutrients in the Anganwadi’s. The food items like Aaloo Puri, Stuffed Prantha, Dalia (sweet as well as salty), Khichri, Gulgule / Sevian etc have been introduced by the department. These recipes have a flavor of festivity among the target group and have evoked great response among the community. It is likely to facilitate the increase in the number of beneficiaries in the Anganwadi’s.

4.4.2.1 Best Mother Award: - To encourage women for proper rearing of the children especially girl child. The scheme of best mother award has been started from the year 2005-06. Under this scheme from each circle and each block of ICDS Scheme , 3 Mothers having at least one Girl Child are selected for 1st, 2nd and 3rd Prizes of Rs. 1000/- , Rs. 750/- and Rs. 500/- respectively at block level and Rs. 500/- , Rs 300/- and Rs 200 respectively at the circle level.

4.4.2.2 Nutritional Strategy (For Eradication of Malnutrition among Children) : A nutritional strategy has been implemented with effect from January , 2003 under which , each Anganwadi worker adopts 4 families/ children( on the basis of nutritional status) and



visits each family thrice a week for 3 months to provide information and knowledge about child care , nutritional health and 100% weight measurement is being done quarterly and Diet chart being provided to adopted children by supervisors and parents committee meeting are being conducted fortnightly.

To involve the community in growth monitoring and to have sense of community ownership of ICDS Programme, further the component of community participation in growth monitoring under the nutritional strategy was added.

4.4.2.3 Community participation in Growth Monitoring: - VLCs and SMS are involved in monitoring nutritional status of the children at the village level from September 2007. Incentives to 3 best mothers in each village, 3 VLCs and SMS in each block are given to motivate the community for better health of the child. Under this strategy, weighment of the children is carried every month on weight day and weekly nutritional education day through SMS is conducted to counsel / motivate the mother for proper care, health and hygiene of the children.

4.4.2.4 Nutrition Award: - To motivate the people and to give recognition to the districts who have brought improvements in the nutrition and health status of children. Nutrition Awards have been initiated from year 2006-07 and so on which will be awarded to 3 best districts for showing maximum improvement in the nutritional status of the children below six years. The first prize of Rs. 2.00 lacs , 2nd Prize for Rs. 1.00 lac and 3rd prize for Rs. 50000/- will be given to the districts standing first, second and third position respectively.

4.4.2.5 Formation of VLCs:- Govt. of Haryana has set up village level committee (VLC) in every village in the state for supervision of Anganwari Centres. These VLCs, has been created as sub committee of panchayats, and given wide ranging administrative and financial powers like appointment of AWW, monthly reviewing of working of anganwari centres, maintenance of child tracking records and monitoring of child birth, survival, health, education in the true spirit of devolution of powers to PRIs. The Steps being taken by State Govt. under Women and Child Development (WCD) Department Haryana for the improvement of nutrition intake in the children of 0-3 years of age are:

Improving Infant and Young Child Feeding Scheme (IYCF):- As more focus is required for younger children ie. Under 3 years. IYCF scheme has been introduced in the State from the year 2005-06 with the objective to impart training to Supervisors/AWW/SMS Members, ASHA workers to equip them with skills for better communication of knowledge to mothers and care takers encouraging mothers to adopt appropriate Child Care Practices.

4.4.2.6 Midday Meal Programme : The elementary school Department MDM programmes are being carried out in all Govt schools to provide nutrition to all School going children..



Comments: As of today nutrition programme is mainly handled by the WCD department in case of under 6 children, adolescent girls and Pregnant women through its ICDS programme and the School Departments through it MDM programmes. Under the ICDS programme children are being weighed and their protein calorie malnutrition (PCM) is monitored through the Weight for Age Graph. This has also been integrated in the MCH card now. The school Department are carrying out any assessment of nutrition status of each child by weight and height measurement as is being done by ICDS NRHM is identifying the nutrition deficiencies in school children in its IBSY programme but they donot follow a uniform diagnostic criteria for classification of anaemia. also planning to set up NRC at few disreicts to intervene in cases of mal-nutrition under its child health programme



RECOMMENDATIONS OF MALNUTRITION:

5. RECOMMENDATION 22: State should formulate a comprehensive policy and

programme on nutrition and malnutrition and constitute an appropriate

administrative structure to achieve the objectives set out in the policy.

a. State policy should be comprehensive to cover all vulnerable groups and all forms of

undernutrition (refereed as malnutrition) including micronutrient deficiencies like

iron, Vit A, iodine etc. The policy should translate into a comprehensive programme

of implementation to address the objectives of the policy.

b. As there are mainly three departments viz the WCD, School Dept and the Health

Dept coordinating an appropriate structure in the form of an independent Nutrition

Cell for nutrition at the state level with inter-departmental coordination should be

formed.

c. The Nutrition Cell should be provided with appropriate structural support and its

function should include devising and adopting standards and policies, intersectoral

coordination and monitoring of malnutrition across all departments of the state.

d. Programme should be expanded to cover children of all ages (0- 18 years) and both

gender and pregnant women. as malnutrition is prevalent in all age groups affects

both genders.

e. It should have a focus on the backward districts and urban slum areas and other

underserved pockets.

RECOMMENDATION 23: Classification :- State must adopt criteria and method for

classification of malnutrition in different age gp and target groups.

a. State must adopt a uniform method of nutritional assessment, whether it can

be weight for age, weight-for height, Body Mass Index (BMI) etc.



b. State may consider addition of length/height measurement of children in its

Anganwadi Centres and Schools along with age and weight so as to record the

indicators such as weight for height as an indicator of acute malnutrition (wasting)

in children and height for age as an indicator of chronic malnutrition (stunting) and

BMI in adolescent. State may also collect data on Low birth weight newborn at birth.

c. It must also adopt a uniform criteria for classifying malnutrition among

children various age groups of children (upto 18 years) and pregnant women which

should be followed across the state and departments. The target age groups should

include newborn and under 5 children.

RECOMMENDATION 24 : State must plan its intervention in a more integrated manner and include community and facility management of cases of all cases of malnutrition and low birth weight newborns.

a. Lifecycle approach covering newborn children, adolescents, and women in the reproductive age groups. Best practices in Breast feeding and providing maternal nutrition should be adopted by the state. State can follow a stategy of community based and facility based rehabilitation of acute under-nourished children through a special programme which could be led by the health department. The state could adopt the MOHFW “operational guidelines for facility based management of children with Severe Acute Malnutrition”

b. Better content planning for nutrition programmes While deciding on contents of Supplementary Nutrition Programme (SNP) (ICDS) and Mid Day Meal programme (MDM) (SME), there should a proper representation from Health Department. To improve the content of nutrition, recipe prepared by institutes like National Institute of Nutrition (NIN) may be looked at for Supplementary Nutrition Programme (SNP) and Mid Day Meal programme.

c. Improved nutrient intake with focus on micro nutrients Seasonal menu may be prepared instead of fixed menu to make SNP and MDM for more cost effective, rich in micronutrient and more interesting for the child. The micronutrient (iron) can be extracted from any possible method to make it powder and may be used to sprinkle before eating in SNP and MD.M Salt, sugar or flour fortification could also be considered.

d. Better Policy Decisions:- The syllabus may be examined for the content of nutrition, anemia and malnutrition and revisions could be made if required.



Growth Chart (WHO new growth charts) should be made available for all Anganwadi Centers and Schools. The MCP card has been approved by the government of India It should be distributed widely and should be kept with the family to empower them and to guide them about feeding growth and nutrition during pregnancy and child under the age of 3 years.Group suggested to look for the possibility to give the wages without work to lactating mothers through MNREGA scheme. The groups suggested considering lactation as a work.Food pyramid could be put in Anganwadis. Supplementary feeding activities need to be better targeted towards those who need it most and growth monitoring activities need to be performed with greater regularity, with an emphasis on using this process to help parents understand how to improve their children’s health and nutrition.

e. Strengthening of Human Resources:- ASHA should be used in nutrition education.Feasibility of second anganwadi worker should be worked out to facilitate work. Improvement in worker skills is required as it is inadequate. This new Anganwari should be solely responsible for children 0-3 years age in order to address their special needs.

f. Reverse Tracking:- Reverse tracking for malnutrition could also be considered.

g. Strengthening of VHND:- The Village Health and Nutrition Days (VHND) should be targeted and monitored by both Health and, Women and Child Development Department. The Health, Nutrition education and other activities in VHND if done properly can make people aware and healthy. Greater convergence with health sector and intersectoral coordination.

h. BCC/IEC:- FM radio may be added as the media for the campaign against anemia/ malnutrition. The youth may be influenced for the cause using the modern media like FM and setting modern trends. A separate website or some page in the current website may be developed to reach the youths of the state for anemia, malnutrition and healthy practices.

i. Use of Mother and Child Protection Card (MCPC) should be promoted and monitored at field level. As MCPC enable the care giver and service providers to make comprehensive nutrition and health information in pictorial and written form.

j. Capacity Building:- Efforts should be made to build the capacity of mothers/ caregivers through counseling and support to identify the nutrition and health problems in their child. Demonstration and practice by doing on the preparation of energy dense child foods using locally available, culturally acceptable and affordable food items. Enough attention should be given to improve child care behavior and on educating parents how to improve nutrition using the family good budget. Special focus should be given on timely, adequate and appropriate feeding for children and on improving skills of mothers and caregivers on



complete age appropriate caring and feeding practices. Facility based care for malnourished should be provided and it can be done through establishing facilities like Nutritional Rehabilitation Centers (NRC).

k. Targeting the determinants of malnutrition. ICDS activities need to be refocused on the most important determinants of malnutrition, programmatically this means emphasizing disease control and prevention activities, education to improve domestic child care and feeding practices and micronutrient supplementation.

Service delivery should be more focused on the youngest children (under three), who could potentially benefit most from ICDS interventions. Emphasis should be there on changing facility based feeding and caring behavior. Children should be given sensory stimulation and emotional care.

l. Strengthening of Monitor and Evaluation:- Monitoring and Evaluation activities need strengthening through the collection of timely, relevant, accessible, high quality information and this information need to be used to improve program functioning by shifting the focus from input to results, informed decisions and creating accountability for programme. Involving communities in the implementation and monitoring of ICDS can be used to bring in additional resources into the Anganwadi centre, improve quality of service delivery and increase accountability in the system.



5. GENDER EQUITY AND FAMILY WELFARE

5.1 GENDER RATIO:


The sex ratio of patriarchal States of Haryana & Punjab has been tilted heavily in the favour of males since 110 years as compared to the matriarchal States of Kerala & Tamil Nadu.

With advent of ultra sonography for Pre-natal detection of sex, people shifted to the sex selection and sex selective abortion in comparison to the option of female neglect and female infanticide. Again this effect of the modern technology was evident in the child sex ratio (0 to 6 years) in all the states including the patriarchal states as well as matriarchal states of Kerala and Tamil Nadu.

Table 5.1.1.1: Inter temporal trends in Sex ratio in India: A State wise Decomposition

Sr. No.

Name of the State

1901

1911

1921

1931

1941

1951

1961

1971

1981

1991

2001

2011

1. Haryana

867 835 844 844 869 871 868 867 870 865 861 877

2. Punjab

832 780 799 815 836 844 854 865 879 882 874 893

3. Kerala 1044

1008

1011

1022

1027

1028

1022

1016

1032

1036

1058

1084

4. Tamil Nadu

1044

1042

1029

1027

1012

1007

992 978 977 974 986 995

India (Av)

972 964 955 950 945 946 941 930 934 927 933 940

(Source 2011 census)

Table 5.1.1.2 STATE WISE CENSUS CHILD (0 TO 6 YRS.) SEX RATIO

Sr. No. State 1991 2001 2011

1. Haryana 879 819 830

2. Punjab 875 793 846

3. Kerala 958 963 959



4. Tamil Nadu 948 939 946

The enactment of the PNDT Act in 1996 and proactive subsequent enactment of amendment to PCPNDT Act has yielded some improvement in the sex ratio as per the CRS system of Haryana.

Table 5.1.1.4 District wise sex ratio at birth 2012 (CRS)

DistrictSex Ratio excluding Delay Registration year 2012

JanUpto Feb

Upto Mar

Upto AprUpto May

Upto Jun

Ambala 869 834 860 849 840 841Bhiwani 903 877 882 880 884 884Faridabad 897 890 898 895 891 884Fatehabad 834 862 849 867 865 861Gurgaon 859 846 838 840 843 830Hissar 862 870 867 853 853 859Jhajjar 883 861 852 845 839 826Jind 834 819 813 837 835 840Kaithal 823 827 824 823 818 823Karnal 829 836 853 861 865 852Kurukshetra 827 846 831 810 789 779Mewat 897 945 946 951 952 937Mohindergarh 782 773 755 765 755 747Palwal 831 834 828 834 833 841Panchkula 990 946 936 906 902 886Panipat 853 863 804 829 837 830Rewari 728 754 786 786 788 779Rohtak 824 831 849 833 822 813Sirsa 814 829 833 853 864 861Sonepat 918 896 880 851 838 826Yamunanagar 831 818 816 803 802 801

Haryana State 854 855 852 852 849 844

5.1.2 Strategies: In Haryana, till June 2012, under PC & PNDT Act, 1315 centres have been registered, out of which 54 are in Government sector. 14576 inspections done, 194 ultrasound machines seized and sealed, 346 licenses suspended /cancelled, 74 court cases



launched, 3o persons convicted out of which, 24 are doctors. 1111 District Advisory Committees and 28 District Task Force meetings were held.

5.1.2.1 New initiatives: Registration of Veterinary ultrasound machines, incentive for informer up to Rs. 20,000/- , Mandatory Residence ID proof for ultrasound of pregnant ladies, Registration and tracking of pregnancies between 12 to 20 weeks (ideal period of sex selection), Constitution of District Task Force to review PNDT activities in the districts and awards for District PNDT teams are new initiatives to curb the female foeticide and sex determination.

5.1.2.2 Advocacy: Fortnight Pakhwara by SMS Groups from 1st to 15 March dedicated to prevention of sex selection to create awareness and various forms of IEC activities like seminars/workshops, street plays, painting competitions, Radio jingles, press advertisements and T.V. programmes telecast on the issues of skewed sex ratio from time to time. Health Wall is being painted in villages on prominent places displaying number of girls out of 1000 boys during the year. Training /workshops of various stakeholders at State and district level to create awareness about PC & PNDT Act. Adolescent Health

Adolescents (10-19 years age ) comprise more than 30 lacs in Haryana. This is the critical turning point and period of vary rapid transition when very large number of physical, mental and sexual changes are taking place very rapidly; This is a period of great opportunity as well as challenges. The seemingly good health of adolescents is deceptive since health in this age shows up in the form of numerous reproductive and sexual health problems, early onset of adult life style diseases like diabetes, hypertension., Obesity Heart disease chronic obstructive lung disease related to tobacco use and cancers.

This is a period of great opportunities and challenges many adolescents practice risk behaviour and these risk factors have a cumulative as well as clustering effect in later life. This is also the period of pre conception.

Health sector cannot do it alone. Cooperation and collaboration with department of education and ICDS is important At the same time behaviour change through engagement of peers and parents is required and can have very positive results.

Haryana has already started mitrata clinics in the state and is undertaking a program for the training and engagement of peer educators. Support will be provided through the counsellors.

The strategy should be more be more broad based than the sole focus on Reproductive and sexual health alone.



5.1.2.3 Efforts of Haryana Government for Women Empowerment :

The various stakeholders like NGOs, Media, politicians, religious leaders, Panchayati Raj Department, Women and Child Department, Education department etc. have been roped in to given their inputs, create awareness and change the mind-set of the people towards gender equality. Some of the major steps taken to address the issue in Haryana are as under:-

Concession of 10 Paisa per unit is being given to women for domestic electricity connection in the name of woman, in case the property is owned by woman.

2% rebate is being given on stamp duty in respect of purchase of immovable property in name of women.

5% concession on education loan to girls for higher education. 33% seats are reserved for women in direct recruitment quota in teaching

category in Education Department, Haryana. 30% seats are reserved for girls in I.T.I. 33% seats are reserved for women in Panchayati Raj elections. 50% rebate is being given in bus fare for women more than 60 years age. “Ladli Scheme” was launched in 2005 by Women & Child Development

Department. Under this scheme, the Government provides benefit/ financial assistance of Rs. 5000/- on the birth of 2nd girl child for 5 years or till the scheme is continuedd. This amount will be deposited in the bank and is given when the second girl child attains the age of 18 years (approximately Rs. 86927/- depending on the present rate of interest).

Balika Samridhi Yojna scheme has been launched by the State through Women and Child Development Department. Under this scheme, the cash assistance for below poverty line families has been given with Ante-natal care, institutional care during delivery and immediate post-partum period.

Delivery huts have been set up for safe delivery in neat and clean environment, especially in rural areas, thus reducing the Infant Mortality & Maternal Mortality.

A prize of Rs. 5.0 lac, Rs. 3.0 lac and Rs. 2.0 lac is being given to first three districts showing improvement in the child sex ratio by Department of Woman & Child.

An exclusive University and Medical College for women has been set up for girls at Khanpur Kalan in district Sonepat.

Haryana Govt. has announced awards in the name of females, Rs. one lac for Indira Gandhi Mahila Shakti Award, Rs. 51000/- for Kalpna Chawla Shorya Award and Rs. 51000/- Shanno Devi Panchayati Raj Award.



Education Department provides rewards to the girls coming first, second and third in matriculation examination as Rs. 2000/-, 1500/- & 1000/- respectively.

To promote sports in rural females in Haryana, Government has started annual sports competition at State and District level.

17 working women hostels have been set up by Government for working women to provide protective stay at concessional rate.

Two years child care leave is being given to female employees in Haryana. Pension of widows of ex-serviceman has been increased from Rs.6000/- to

11000/- by Haryana Government. Rs. 500/- per month pension is being given to parents after the age of 45 years

having two girls under the scheme Ladli Samajik Surkhsha pension Yojna by Women and Child Department, Haryana.

Free Bus service is being provided to girls and women on the eve of Raksha Bandhan by Transport department, Haryana.



5.2 Family Welfare


Population of State as per 1991 census was 1.64 crores as per 2001 census it was 2.11crores (increase by of 46.8 Lacs) and as per 2011census it is 2.53crores. Thus there was an increase of 42.1 lacs in last ten years as against 46.8 lacs in previous decade. The decadal growth in Haryana as per 2001 census was 28.06% which was much higher than the National increase (21.38 %). The decadal growth rate of Haryana has come down from 28.06% to 19.9% as per 2011 census, which is still higher than the National increase (17.7 %). The Birth Rate in Haryana, which was 42.1 per thousand in 1971 and 36.5 per thousand in 1981, has been brought down to 22.3 per thousand as per SRS 2010.

Table 5.2.1.1 Demographic trends of the state

The State Govt. is implementing the National Family Welfare Programme as an integral part of total health care delivery system.


DEMOGRAPHIC TRENDS OF THE STATE


Trends of Family Planning indicators

Table 5.2.1.2 Birth Rate

Year Haryana India1971(Census) 42.1 36.91981(Census) 36.5 33.92001(Census) 26.8 25.42007-SRS 23.4 23.12008-SRS 23.0 22.82009-SRS 22.7 22.52010-SRS 22.3 22.1

Table 5.2.1.3 Total Fertility Rate (TFR)

Total Fertility Rate (TFR) is a useful indicator for analyzing the prospects for population stabilization Total Fertility Rate (TFR) signifies the total number of children an average woman will produce in her child bearing years. In Haryana the TFR is 2.3 (SRS-2010).

Table 5.2.1.4 Current use of family planning methods (%)

Sr. No. Indicators DLHS-II (2002-04) DLHS-III (2007-08)1. Any method 60.3 62.02. Female sterilization 35.6 36.33. Male sterilization 1.0 1.04. Oral Pill 3.1 2.85. IUD 4.5 3.86. Condom 10.0 10.47. Any traditional method 6.0 7.48. Emergency contraceptive pills NA 0.5



Table 5.2.1.5: Acceptance of family planning methods as per couple having no. of children.

Year

Percentage of sterilization acceptors after No. of the children

Percentage of IUD Acceptors after No. of the children

0-2 3 and more 0-2 3 and more2005-06 40.28 59.72 63.89 36.112006-07 41.12 58.88 68.04 31.962007-08 42.43 57.57 67.47 32.532008-09 41.81 58.19 69.32 30.682009-10 41.68 58.32 71.66 28.342010-11 47.69 52.31 69.43 30.572011-12(up to Dec.11)

49.68 50.32 70.36 29.64

Table 5.2.1.6: Trends of Sterilization (Tubectomy& Vasectomy) for last years

Ster. Tubectomy Laparoscopic Vasectomy NSVTotal

% of Ster.

Total

% of Ster.

Total

% of Ster.

Total

% of Vas.

2011-12(up to Dec.11)

56623

51639

91.213293

25.74984

8.804984

100.0

Table 5.2.1.7: Current Status & Indicator Targets for 2012-13

Sr. No. Component Current Status Target1. Contraceptive Prevalence Rate 2005-06(NFHS-3) 2012- 13(%)

Over all 61.0 NFHS-3 Change allSC/ST NA 70



Sr. No. Component Current Status Target2. Contraceptive Prevalence Rate(limiting

methods)Male Sterilization 1.0 - NHFS-3 15Female Sterilization 38 –NHFS-3 64

3. Contraceptive Prevalence Rate (spacing method)Oral Pills 3% - NFHS-3 4.5IUDs 5% - NFHS-3 9.5Condoms 12% - NFHS-3 7.0

4. Unmet need for spacing methods among Eligible Couples

3.2 - NFHS-III 1.5

5. Unmet need for terminal methods among Eligible Couples

5.1 - NFHS-III 2.0

Total Unmet need- 8.3 - NFHS-III 3.5

5.2.2 Strategies

5.2.2.1 Spacing Methods (IUD)

Extra emphasis on spacing methods is being under taken for which service delivery point are being increased, personnel are being trained and supply line is being maintained.

IUD insertion services are being provided at all sub centres on all working days.

PPIUCD is being promoted aggressively and special trainings are being held for the officials/Officers at DH, SDH & CHC level.

PPIUCD is required for mother and child’s optimum health growth of the child survival of the child and also to maximize the potential for child development lack of child spacing is a major factor in the birth of low birth weight babies (about a quarter of babies are born low birth weight) For the success of PPIUCD the pregnant women have to be convinced their concurrence for adoption of IUCD obtained and the insertion of IUD should be done while the child is still in the hospital the credibility of IUD and its acceptance has to be improved in order to make it more acceptable This is potentially a powerful intervention in the programme and should be prioritized in the strategy.

5.2.2.2 Permanent Methods (Vasectomy & Tubectomy):

More stress on couples with 2 children to adopt Permanent Methods.



Younger age couples (less than 35 years) are being motivated to adopt Permanent Methods.

Organise special camps for Vasectomy & Tubectomy in addition to fixed day static services.

Additional Mobility Support to Surgeon’s team (if required) has been provided for in PIP 2012-13

5.2.2.3 Community Participation & Capacity Building:

Capacity building by training of personnel and providing needed equipments is being under taken at all level.

IEC activities are being under taken to bring behavioural changes and demand generation among community by creating awareness about availability of services.

5.2.2.4 General:

Regular monitoring on monthly basis at all levels.

Monitoring and supervisory visits by State, district and sub district level officers are being under taken.

Dedicated FW counsellors are being appointed in each district to address unmet need of the society.

For providing Terminal/Limiting Methods Fixed Day Static (FDS) approach in sterilisation Services i.e. “providing on fixed day, throughout the year on a regular and routine manner is being implemented.

A scheme of Home delivery contraceptive by ASHA’s is being implemented in district Mewat as a pilot project which would be extended to other districts also in near future.

An action plan for providing/strengthening Postpartum sterilisation services including PPIUCD services at Health facility in district has been formulated and being implemented.

A rational human resource development and deployment plan for Minilap, NSV and IUD services is being formulated and implemented



Intra and Inter departmental co-ordination is being promoted and ensured at all level to achieve the common goal of population stabilization.



5.3 RECOMMENDATIONS OF GENDER RATIO:

RECOMMENDATION 25:

5.3.1 Defining Gender Issues in Health :- Gender issues in health go beyond the issue of adverse sex ratio and implementation of the PNDT Act. For mainstreaming of gender, issues like violence against women, teenage pregnancies, early marriage, reproductive and sexual evaluation etc should also be focused upon through intersectoral coordination.

For intersectoral coordination there would be a State level and district level committees which would meet every month/quarter. The members of the committee would be from the WCD Department, Education Department and Health Department. Health Department should appoint a Nodal Officer to coordinate these meetings, draw up agendas and minutes. The proceedings of these meetings should be monitored by the Principal Secretary, Health.

The group was of the opinion that gender issues in health should not be restricted to adverse sex ratio. This is a narrow lens and it could rather broaden the issues to bring about mainstreaming of gender in the state, not merely looking it as implementation of PNDT Act. The group suggested that other gender issues like violence against women, teenage pregnancies, early marriage, reproductive and sexual education etc should also be focused upon. The group further felt that issues go beyond the domain of the health department and should be addressed in a comprehensive manner through several departments.

The sub group identified the following broad objectives, which should become part of entire discourse:

1. Sex selection2. Neglected daughters.3. Adolescent health targeting both girls and boys.4. Women and nutrition.5. Unmet needs of contraception.6. Addressing women health needs beyond reproductive life stage.7. Women and HIV.8. Crime/Violence against women as a health issue.9. Dowry related deaths.10. Community mobilization for changing mindsets towards gender equality.

The group felt that these issues have only been identified as issues concerning gender mainstreaming. However, instead of discussing all these issues, the group decided to discuss issues relevant to the scope of sub group of the task force.



RECOMMENDATION 26:

5.3.2 Strengthening Institutional Capacities:- For mainstreaming of gender institutional capacity of Health Department has to be strengthened.

5.3.2.1 Appointment of Gender Nodal Officer

The Health Department should appoint a Nodal Officer at State level to ensure the implementation of Gender mainstreaming. His/Her role would be to integrate a gender perspective in key programmes like Declining Sex Ratio, Adolescent Health, Family Welfare/Contraceptive Services, planning for other Gender and Health issues like Violence against Women as a Health Issue.

5.3.2.2 Development of curricula and faculty for Gender Mainstream

SIHFW/HSHRC should develop a gender mainstreamed training curricula and faculty.

5.3.2.3 Gender Sensitive HR Policy

State should develop an Annual Plan for Gender Mainstreaming and gender sensitive Human Resource Policy at state level. Senior Nursing professionals (Nursing Directors/ Principals of Nursing Colleges etc) should be included at all levels of Health planning. District level gender mainstreaming through orientation of district health officers and a district health plan which is gender sensitive. The role and job descriptions of MPW Male in RCH and Adolescent Health services for male involvement should be reworked. State should consider studies on issues and concerns of women health workers- ANMs, Staff Nurses (e.g. Safety, career opportunities etc) and corrective measures implemented.

RECOMMENDATION 27:

5.3.3 Strengthening of Adolescent Health Services:- The State should promote a well designed Adolescent Friendly Health Services. The Adolescent Reproductive and Sexual Health (ARSH) Programme should be broad based and renamed as Adolescent Health Programme (AHP)to address overall issues of the Adolescents.

5.3.3.1 Adolescent Health:

a. It was recommended to rename it as - Adolescent Health Programme to address overall health issues of the adolescents.

It should include the following:

Reduction of tobacco use and substance use.



Prevention of injury and violence including gender based violence (especially violence against women)

Prevention of early onset of adult onset ;life style diseases through healthy eating and regular physical activity.

Mental and emotional well being.

b. This cannot be done by health sector alone Partnerships are required with ICDS and schools and colleges.It was suggested to have a Question Box for clarification of queries of adolescents for maintaining confidentiality in schools and health facilities.

c. There should be counseling of adolescents regarding sexual, mental health and misuse of substances like alcohol and drugs.

d. Access and availability of all contraceptive services to adolescents should be ensured. There is a need to cater to the unmet needs like more focus on unmarried girl.

e. Importance of media for adolescent education was emphasized. It was suggested that communication material should be in form of radio, T.V., newsletter and advertisements.

All cadres of health care providers should be trained to address Adolescent Health issues.Intersectorial coordinator with Women and Child Development Department, Youth Affairs and Education Department to promote Adolescent Health and Development.

f. The State should generate data on Adolescent Health issues to take informed decision about design of Adolescent programme.

RECOMMENDATION 28:

5.3.4:- Appropriate measures to prevent sex selection by any means should be taken.

5.3.4 Sex selection:

A suggestion was made that central data base of all ultrasound machines in Haryana should be compiled by collecting information from companies that manufacture and sell ultrasound machine including vetenary ultrasound machines. There should be strict implementation of PC & PNDT Act. in the State. As regard the PNDT Act, an observation was made by the state team that registered clinics were not so much a problem but problem lies in unregistered machines, which operate from houses, mobile vans, go-downs etc. The people who carry out the illegal sex determination, work through various types of middlemen. The Health Department needs to use decoys to catch them. A suggestion was



made that all second trimester abortions should be tracked to generate evidence on reasons and profile of women requiring second trimester abortion. However, some members opposed that all second trimester abortion should be tracked. Rather, they felt that it would divert the women to illegal and unsafe abortion providers. Instead of tracking the second trimester abortion, data of all second trimester abortion should be collected, compiled and analyzed to fund out the reasons for abortions.

RECOMMENDATION 29: -

5.3.5:- Violence against women should be viewed as a health issue to be addressed by the Health Department by means of specific strategies in place.

RECOMMENDATION 30: -

5.3.6:- Community awareness has to be created by means of effective BCC/IEC strategies to make community aware about gender equity.

5.3.6 Community participation:

There is a need to make community aware about gender equality. There is a need for better IEC/BCC strategy. Promote community awareness about value of girl child through awareness campaigns i.e.

Wall paintings in the villages depicting health and nutrition indicators & sex ratio (health wall).

Folk media to give the required information about equal value of girls and boys, men and women.

Posters, Flip Charts, T.V., Radio, Documentaries, Advertisements in Newspaper to deliver health messages in an understandable manner.

However the contents and quality of all the communication material is to be scrutinized before use to prevent repercussions on access to safe abortions under MTP Act.

There should be amendments in the Panchayat Act, enhancing the role of Panchayat in reporting maternal, child death and birth, nutrition status of children, sex ratio of the villages to involve them in health related activities.



RECOMMENDATION 31: 5.3.7 Improved access and information:- There is a need to provide better information and access to the family planning services.

Access, information and adoption of appropriate family planning methods should not be viewed only as a method of population control but also as an essential instrument for gender empowerment and promoting maternal and child health.

Quality of Family Planning services needs to be improved.

5.3.8 Access to contraceptive services:

“Family planning services are essential to enable women to delay, space and limit pregnancies, potentially reducing maternal deaths by 20 to 35 per cent” (UNFPA).

“Access to comprehensive modern contraception, emergency obstetrical care and skilled birth attendance can prevent abortion, and complications of unsafe abortion, including mortality and morbidity” (UNFPA SRH framework).

a. Poor access to and quality of family planning services are two important issues in catering to the unmet demand.

b. State must invest adequately in providing adequate information about safe contraceptives including emergency contraceptives to all individuals and couples including adolescent groups.

c. State must provide adequate access to safe contraceptives including emergency contraceptives to facilitate informed choice. It must include in its facility mapping exercise, facilities providing three modern methods of contraceptives and reproductive health services.

d. There is a need to ensure a sufficient supply of contraceptives through a reliable logistics system is available within the health system.

e. State should conduct training of frontline health workers on the available range of safe and effective modern methods of contraception including emergency contraceptives, to enable them to educate prospective users to choose the method that best suits their perceived needs. This will facilitate informed choice for choosing a method and for continuing or for switching the method currently being used.



f. There should be effective contraception campaign to change the attitude in society to avoid teenage pregnancy by delaying first pregnancy.

g. Contraception should be seen as an important instrument for preventing maternal and infant mortality for pregnancies in teenage groups.

h. There is a need to increase male participation by accepting NSV and for mental preparation of males to changing roles of gender and democratization of the family.

i. There should be strengthening of counseling about postpartum and post-abortion IUCD and postpartum and post-abortion tubectomy and evaluation of counseling by mechanisms like stamp on antenatal card.

j. There should be effective use of family planning counselors to ensure proper timing and efficient use of family planning services.

k. Injectable contraceptive could be considered for introduction but only after some pilot study with proper counseling and follow up.

l. There is a need to develop better IEC material to cater to the needs of the population. A Pictorial booklet or other communication material for contraception could be used to impart knowledge and bring behavior change.

m. There is an urgent need of strengthening of evidence based monitoring and evaluation of family planning services.

n. State must improve the quality of services in the family planning services especially sterilization and IUDs by officially adopting standard protocols and guidelines.


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