Vikas Samvad Info Pack – 47
Neo-natal Health in Madhya Pradesh (Part - Two): Priorities of Eleventh Plan

Eleventh Plan aims at improvement of health parameters by reducing Maternal Mortality Ratio (MMR) to 125, IMR to 40 and TFR to 2.4 so as to bring them near the all India level. Further it aims to reduce malnutrition to 30% and anemia to 30%.To achieve the led down objectives it emphasizes on establishment of new health institutions & up gradation of existing health institutions & strengthening of Maternal & Child Health Schemes. The total size of the country’s Eleventh Plan is Rs. 69,788.00 crores at current prices. The eleventh plan aims at promoting institutional deliveries up to 85% but Maternal Health budget for 2007-08 & 08-09 constitutes only 16.16% of total RCH II budget of Madhya Pradesh.

Review of Tenth Plan

Review of the Tenth Five Year Plan of Madhya Pradesh & health indicators of NFHS III with high percentage of neonatal & maternal mortality reveals that no special provisions had been implemented under the plan period for neonatal care tenth. Five Year Plan of Madhya Pradesh was formulated keeping in view broad objectives of   improvement of health parameters by reducing the birth rate, death rate, infant mortality rate, maternal mortality to reduce the gap between the state and national average.  But the state is still considered as one of the backward states at the national level in respect of health indices.

A survey estimated that in 2005-06, 29-34% of rural population belonged to households with monthly per capital consumption expenditure (MPCE) less than Rs.365, that is spending less than Rs.12 per person per day on consumption, at 2005-06 prices. For food group average expenditure per person per 30 days on group of items of consumption in rural areas of Madhya Pradesh is Rs.250 only [Household Consumer Expenditure in India,2005-06;NSS,Ministry of statistics & Prog Implementation Govt. of India]. With such less consumption expenditure, how good health  of the people can be secured.

The public health infrastructure in the state is also far from satisfactory. The poor health infrastructure point out the weakness of our health institution to promote institutional delivery & neonatal care. In many tribal areas in the state, the number of PHCs & SHCs is lagging much behind the requirement & poor masses need to travel long distance even in case of emergency.  During the tenth plan period emphasize was made only on making the sanctioned units/institution functional & up gradation of existing ones & not on the established of new infrastructure which are badly needed to improve health indicators in the state. While the target for the established of 845 new SHCs, 100 new CHCs were set in the plan but only one PHC & 44 new CHCs were established & not single SHCs was established. For the Hospital waste management the target of 40 incinerators remained unachieved. Looking at the positive achievement of the tenth plan focused on the established of 12 new district hospital against the target of just 7 district hospital.2484  SHC & 634 PHC building are constructed under 10th plan. As per the Human Development Report 2007, the state had a shortage of 26% in primary health centers, the very basis of primary health.

The Department of Women & Child Development is providing many ICDS services for maternal & early childhood care through Anganwadi centers. ICDS is the foremost symbol of India’s commitment to women & children. But by the end of the tenth plan in M.P. only 69,238 ‘Anganwadi’ centers have been sanctioned against the total need of 0.146 million [Analysis of the Commissioners to the Supreme Court in PUCL vs Union of India and others -196/2001] Anganwadis,  & out of them at present only 49806 are functional. Seeing the vulnerability the Supreme Court of India has ordered that the sanctioned centers should be opened by July 2007.

As per the Human Development Report between 2000 and 2004, while the national IMR reduced from 68 to 58, the IMR of Madhya Pradesh dropped from 87 to just 79. As far as maternal mortality rate is concerned, though the state had witnessed a significant reduction in MMR at 498/1000 (as per the NFHS - II) to 379/1000 as per the MMR data released in 2003, it was still far higher than the national MMR of 301/1000. The RCH goal of the 10th plan for IMR was 45/1000 & 200/100000 remained the dream.

Nothing very significant had been done in Madhya Pradesh during the tenth plan period (2002-2007) to curb MMR & TFR which are basic & foremost causes of high NMR & IMR. The life expectancy for 59 years males and 58 years females in Madhya Pradesh was the lowest among all the major states in India [Human Development Report 2007]. But the TFR  among the reproductive age 15-49 years of state is 3.12 which is much higher then the national average  of 2.68.The TFR shows  in the state shows very slow  decline from NFHS-2 to NFHS-3 from 3.43 to 3.12 only. And TFR for rural M.P. in 2005-06 was still 3.34 [National Family Health Survey (NFHS III), 2005 – 06, India: Volume I, International Institute for Population Sciences, Mumbai]. 5.2% of women given birth during age 15-19years out of the total birth [District Level Household & Facility Survey,India;DLHS-3 2007-08].  Due to high fertility; the number of children born to a couple is also very high. Large size of family & low standard of living further leads to anemia in pregnant women & mother which is major cause of neonatal mortalities in India.

The institutional deliveries have improved at very slow pace from 22% in 1998-99 to 29.7% in 2005-06.The percentage of safe deliveries in rural area in the state even after the end of tenth plan is only 43.4% & 52.1% deliveries are still conducted at home [District Level Household & Facility Survey,India;DLHS-3 2007-08].The percentage of pregnant women under the reproductive age 15-49 years who are anemic has increased from 49.9 % to 57.9%.Even if the breast feeding practice is common in India & state but only 15.9% children are given breastfeed within an hour in M.P. Percent distribution of children under age 3 years by Exclusive breastfeeding status, Madhya Pradesh, 1998-99 up to 6-7 month is 24.2% & it is 9.7 for the children up to 6-8 months

Low birth weight babies among the live birth with the birth weight less than 2.5 Kg for M.P was 32.2% [National Family Health Survey (NFHS II), 1998-99, India] in 1998-99 & reduced only to 23.4% [National Family Health Survey (NFHS III), 2005 – 06, India] in 2005-06.The chance of survival of such low birth weight babies within the first month of birth is very low.

Even if we look at the basic requirement of the health centers i.e. the manpower, we will find that the Health Institutions of the State are having a significant short fall of the staff members. The numbers of position sanctioned to functionalize health services at different levels are lying vacant. In Community health centers 60 percent of sanctioned posts of specialists are vacant. The vacancy position in district and civil hospitals is relatively better with 16 percent of sanctioned posts being vacant [M.P. Draft Health Sector Reform Strategy,Aug 2006].

Source: www.health.mp.gov.in (Health Institutions in Madhya Pradesh, as on August' 2007)

If we sit by to analyze the budgetary allocations and its outcome in Madhya Pradesh from 2001 and 2005, one clearly see a sorry state of affair. This period, – being the transitional period between 9th and 10th Five Year Plans, funds to the tune of Re.1685.64 crores were allocated and disbursed to the Department for Women & Child Development.  However, the Department could utilize only a sum of Re.1210.34 crores (71.80%) and the balance amount of Re.475.30 crores (28.20%) remained unutilized [Report of the Comptroller and Auditor General of India - 2005].

As far as financial outlay in the health sector is concern, it is declining at a steady pace. In the year 2000-01 budgeted figure of health sector was 2.98 percent of total State budget which has come down to 1.89 percent in the year 2004-05. Then further it shows upward trend in 2005-06 & 2006-07 to 2.84% & 3.06% respectively. Such a low outlay on the health sector along with the non utilization of the allocated budget results in grave situation affecting the health condition especially of the vulnerable women & infant population during the tenth plan period.

Thus the health indicators shows the improvement trend  during the tenth five years plan but they still fall short to reach the national average & thereby achieving the millennium development goals  by 2011.So now the need of the time is to put special emphasize on  maternal & child health indicators. Proper allocation & complete utilization of the budget & available resources should be checked & taken care.

Thrust Areas for Maternal & Child Health in Eleventh Plan

Improvement in the health status of the population is one of the major thrust areas of the five year plan of the country. This can be achieved through improving the access to and utilization of Health services with special focus on maternal & child health.

Major thrust area regarding the maternal & child health in the eleventh five years plan is the reduction of Neo-natal Mortality, Infant Mortality and Maternal Mortality Rates in the state through quality services. For this integrated comprehensive primary healthcare services leading to population stabilization in high fertility districts to reduce TFR are needed on priority basis.

The thrust area for state plan would be to provide medical facilities to cope up with the increasing demand of institutional deliveries, increasing access to rural health services by way of establishing new health institutions as per population norms and to provide buildings for all the primary health care institutions.

Many initiatives are planed during XI plan to improve the health indicators significantly. One of the major interventions that the state is pursuing is promotion of institutional delivery. The strategy involves two major kinds of interventions –one, creating demand by providing incentives to pregnant women of disadvantaged sections to come to  institutions for delivery through the promotion of  new schemes like Janani Suraksha Yojana, Vijayaraje Janani Kalyan Bima Yojana, Prasav hetu Parivahan Yojana,Janani Express. Another strategy is to improve infrastructure, facilities & services of the health institution by strengthening Sub-Centres, PHCs & CHCs. The prime focus concerning the institutional deliveries is to provide 24-hour services to pregnant woman within 15 km.

Training of the traditional birth attendants, ANMs for the normal deliveries & for early detection & timely referral   of the complicated cases is one of the major priorities of the eleventh plan. Another initiative needed to be taken is to increase the drug supply by almost three times to improve the availability of the medicines to poor outdoor patients significantly.

Another important thrust area is to improve the survival rate of the neo-nates, infants & children under 5 year through the universal immunization against major childhood illnesses, providing supplementary nutrition to curb malnutrition & by establishing neo-natal care units within the village. In 2007-08, 43.1% of children under the age of 3 years are breastfed with an hour of birth [District Level Household & Facility Survey,India;DLHS-3 2007-08]. So the eleventh plan thrust area is to increase the level of breastfed within an hour of birth.

Only 33.8% of women had received antenatal check-up in the first trimester & in rural Madhya Pradesh only about 56.8% women had received any ANC check-up. To ensure the registration & coverage of all pregnant women, lactating women & children under 5 years in the AWCs & providing them all the benefits under ICDS is another major concern of the eleventh plan.

During the eleventh plan more emphasis was given on decentralized planning for the involvement of all the stakeholders in the planning process. The planning exercise will be done from the micro level to macro level. Firstly action plan will be prepared at the panchayat level and then every district will have an integrated district health action plan based on such grassroot planning.

The major objective of the eleventh five years plan & the National Rural Health Mission (NRHM) is to improve the basic maternal & child health to reach the MDG by the end of the plan in 2011.

Health Provisions under Eleventh Plan

To achieve the goals & objectives of the eleventh five year plan, the state has launched number of new schemes along with the continuation of some of the existing schemes for improving the health status of vulnerable, under privileged & marginalized section of the society in Madhya Pradesh. Emphasize is also on the construction & up gradation of the health infrastructure.

Establishment of New Health Institutions

Health institutions are established as per population norms. At present 1991 population norms are being followed to establish primary health care institutions i.e. SHCs, PHCs and CHCs.

• As per 2001 population norms 60 new CHCs need to be established.
• 250 new PHCs are proposed to be established with staff sanctioned at block headquarter CHC during entire plan period. This will enable block CHC to function with more efficiently too. 100 PHCs would be taken up during the annual plan 2007-08.
• To fulfill the population norms of 1991, it is proposed to establish 200 new SHCs during first year of the five year plan and a total of 600 new SHCs are proposed to be established during entire five year plan period.

UP-gradation of Existing Health institutions:

• During the 11th five year plan period, 30 district/civil hospitals are proposed to be upgraded.
• Re-construction of ruined PHC buildings at 300 places and re-construction of ruined SHC buildings at 1500 places.
• Some of the district hospitals have already been sanctioned with construction of additional wards and OPD buildings. 48 institutions are proposed to be upgraded as CHCs during 2007-08.

Enhancement of capacity:

Enhancement in the capacity of the hospital will lead to construction of additional wards, OPD building, Operation theatre, Labor room etc.

1. In many district hospitals, ICCU, Burn unit, NICCU, Neonatology unit and trauma centre have been established.
2. During five year plan, it is proposed to support 20 district hospitals to establish and to operationalize these facilities by providing medical and paramedical staff.
3. Diagnostic facilities in some district hospitals such as high capacity/ digital X-ray machines need to replaced the old machines and Ultra sonography need to be established for advance diagnostic facilities and to handle emergency obstetric cases.
4. X-ray machines with 300 ma capacity would be provided for 200 CHCs during the entire plan period.

Bringing uniformity in bed capacities

At present there is no uniformity in sanctioned beds of district and civil hospitals. District hospitals shall be categorized as 100 beds, 150 beds, 250 beds, 300 beds and above. Similarly civil hospitals shall be categorized as 20 beds, 40 beds, 60 beds and 100 beds and above.

• During 11th five year plan, bed capacity of total 30 hospitals (20 district and 10 civil hospitals) would be enhanced.
• During the plan 60 PHCs are proposed to be upgraded into 30 bedded CHCs to fulfill the population norms.
• To meet the increased patient load in some of the CHCs, these CHCs would be further upgraded to 60 bedded CHCs.

Continuation of Schemes of X plan

1. Up gradation of 11 districts hospital & 11 civil hospitals started during the X plan to be continued in the XI plan period.
2. Establishment of 44 new CHCs which were not established during X plan.
3. Building construction of 12 new District Hospitals.
4. Construction & re-construction of 100 buildings of CHCs & Civil Hospitals.
5. Construction of 280 PHCs & 500 SHCs building. 

Strengthening of Maternal & Child Health Schemes

It is well established that care during or immediately after birth plays an important role in preventing deaths in the early neonatal period. During eleventh plan period efforts have to be made to tackle & curb the high rate of neonatal deaths in a much focused manner. Many new schemes has been planned to be launched during the plan period & continuation of the existing schemes to secure maternal & child health .Maternal health has direct impact on the neonatal health as only a healthy mother can give birth to a healthy child. The IMNCI, ICDS  & Bal Sanjeevni Campaign are targeted towards the special attention & care of children under five year; whereas the schemes like Janani Surksha Yojana,Janani Express, Vijaya Raje Janani Kalyan Bima Yojana & Dhanwanti Yojana  aims at promotion of institutional deliveries & their by securing immediate medical check-ups & care  of newborn. The other schemes like Deendayal Antyodaya Upchar Yojana & mobile clinics are meant for providing medical services especially for population below poverty line in rural & tribal districts of Madhya Pradesh with the objective to improve the health indicators.

Integrated Management of Neonatal and Childhood Illnesses (IMNCI)

IMNCI is a Child Health Intervention implemented as a part of NRHM/RCH-II. IMNCI implementation would integrate, build on and improve the quality of the existing approaches for early childhood illness. It brings health and nutrition interventions (breastfeeding, complementary feeding, vitamin A supplementation, care of the severely malnourished) together into one package. 

Home visits are an integral part of this intervention. Three home visits are to be provided to every newborn starting with first visit on the day of birth (day 1) followed by visits on day 3 & day 7.For low birth weight babies, 3 more visits (total 6 visits) are to be undertaken before the baby is one month of age. Improving household behaviors for newborn and child care is an important objective of IMNCI.

IMNCI has been implemented in 12 districts in 2007. During 2007-08 Medical officers-425, supervisors-302, ICDS officers-146, ANM-639 & AWW-2930 were trained. The target of 2007-08 includes the implementation of IMNCI in 13 more districts & establishment of sick newborn care units in 10 IMNCI districts. It is planned to train all frontline workers, including ANMs, AWWs and community volunteers on infant and young child feeding practices.

Eleventh plan draft proposed the establishment of sick newborn unit in 10 IMNCI district hospitals & Level-1 units in 2 [www. wcd.nic.in/icdsimg/ICDS] CEmONC each of these districts & operationalization of two already existing units (18 DH & 20 CEmONC institutions).It is also proposed to establish 50 additional NRCs in the state & addition of 250 Newborn Care Corner in BEmONCs as FRUs. Establishment of SNCU at 6 district hospitals is also proposed during the plan period. First SNCU is established in District Hospital, Guna on 14 Dec 2007.

According to DLHS-3 report 86.2% FRUs under CHCs having new born care services on 24 hour basis & 32.3% of PHCs having newborn care services.

Integrated Child Development Services (ICDS) The programme of the ICDS was launched in 1975 seeking to provide an integrated package of services in a convergent manner for the holistic development of the child. The Scheme targets the most vulnerable groups of population including children up to 6 years of age, pregnant women and nursing mothers and adolescent girls belonging to poorest of the poor families and living in disadvantaged areas including backward rural areas, tribal areas and urban slums. To achieve the above objectives, the ICDS aims at providing a package of services, consisting of Supplementary Nutrition; Immunization; Health Check-up; Referral Services; Non-formal Pre-school Education; and Nutrition & Health Education.

The total number of aaganwadi center (AWC) sanctioned & operational up to 31st march’07 is 69239 & 56737 repectively.11569 more AWC became operational during 2007-08 & the number of operational AWCs reached to 68306 as on 29th Feb ’2008 [NRHM,Department of Public Health & Family Welfare www.healh.mp.gov.in/nrhm]. It is worth mentioning that a total of 367 integrated child development projects are functioning in the state including 313 in blocks and 54 urban integrated child development projects.  

Bal Sanjivani campaign has been launched to prevent, control and manage malnutrition amongst children, the state government launched the state-wide Bal Sanjivani campaign. Under the campaign, the weight of all children below 5 years is monitored at 6 month's interval to track their growth. This is followed by focused attention on severely and moderate malnourished children through nutritional and health counseling, and treatment under Bal Shakti programme.

Under programme severely malnourished children of grade 3 and grade 4 are provided free medical treatment through hospitalization and during the period of hospitalization, the parents of the malnourished child are imparted nutrition and health counseling.

As a result of this campaign, severe malnutrition in the state came down dramatically from 5.7% in the year 2001 to 0.96% by 2006 [NRHM,Department of Public Health & Family Welfare www.health.mp.gov.in/nrhm] .9403 [State PIP NRHM 2008-09 Department of Public Health & Family Welfare] malnourished children of grade 3 & 4 are treated in 61 functional NRCs under the Bal Shakti Yojana under the eleventh plan.

Project Shaktiman: Shaktiman Project launched on 29th Sep’2007 under the government Bal Sanjeevani Scheme to address the critical issue of malnourishment in the predominantly tribal areas of Madhya Pradesh. The project had initially covered 1,000 villages in 38 development blocks of 19 districts. Thus the Project Shaktimaan has been implemented in 997 villages under 39 Integrated Child Development Schemes in 40 clusters of 19 districts. Under Shaktiman scheme, the centre gave Rs.2 per child while the state government added Rs.4 to it for providing nutritious food to the children in the affected areas. This means that the daily expenditure per child for providing nutritious diet to children would be Rs. 6 against the normal Rs.2 being spent by anganwadis. In Sep ’2008 Madhya Pradesh government had declare to implement the project Shaktiman in all the tribal villages in the state.

Janani Suraksha Yojana (JSY) is a safe motherhood intervention under NRHM being implemented with the objective of reducing maternal and neo-natal mortality by promoting institutional delivery among the poor pregnant women in Low Performing States (LPS) .JSY is a 100 % centrally sponsored scheme and it integrates cash assistance with delivery and post-delivery care. The success of the scheme would be determined by the increase in institutional delivery among the poor families.

The eleventh plan focuses on increasing demand for institution deliveries under the JSY. During 2005-06 the percentage of institutional deliveries under JSY was only 11.39% which raised to 48.47% in 2006-07 & further up to 86.50% (8,04,955 beneficiaries) in 2007-08  till dec,2007 due to mass promotion of JSY under eleventh plan [State PIP NRHM 2008-09 Department of Public Health & Family Welfare].

Janani Express Scheme; Under the Janani Express Scheme the provision of 24 hours transports availability at field level in order to bring the pregnant women to CEmONC & BEmONC institutions. Since the vehicles are being hired from the private sector, therefore there would be two units of the fair. Rs. 150 would be payable for 25 kilometers while Rs. 250 for more than 25 kilometers. However, no fair would be taken from the expectant mothers of the families of below poverty line. On the other hand, the women do not belong to this category would pay cash amount of the fair prescribed. Janani Express would be used for institutional deliveries in both government and private sector.

Janani Express Yojana was introduced in 90 hospitals of 47 development blocks. In selected areas, an ambulance is ready round the clock for providing conveyance to expectant mother for delivery. Under Janani Sahyogi Yojana, 118 private sector institutions have been authorized. Under the scheme to provide conveyance and treatment for delivery of expectant mothers, 2, 13, 860 women have been benefited [www.mpinfo.org/mpinfonew/english/articles/2007/091207lekh85e.asp].

Dhanvantari Yojana: Dhanvantari Yojana has been launched in the 50 blocks of the state from August 15, 2005. The Dhanvantari Yojana aimed at reducing the morality rate of expectant mothers and infants. With this objective, the institutional deliveries are being encouraged as the only effective measures for the purpose.

Under the scheme the number of such deliveries has increased from seven to ten thousand in June 2006 alone. Under the scheme 80147 in 2004-05, 140185 in 2006-07 & 223891 in 2007-08 institutional deliveries were registered. Dhanwantri Yojana has been successful in raising the percentage of institutional deliveries from 30% in 2005-06 to 55% in 2006-07 & during eleventh plan it went up from 55% to 79% in 2007-08 & further to 82.36% in 2008-09(up to June 2008) [NRHM, Department of Public Health & Family Welfare; http://www.mp.gov.in/health/nrhm/dy-graph-2008-09.pdf].

Deendayal Antyodaya Upchar Yojana: The Government of Madhya Pradesh has designed and implemented an innovative scheme for socially and economically disadvantaged people of the society for providing access to quality health care to the needy people like SC, ST and BPL families. The Scheme, known as Deendayal Antyodaya Upchar Yojana was instituted on 25th September 2004. It was further modified in the month July, 2006 to extend the coverage to all below poverty line (BPL) people in the state. Under the scheme, one family health card is issued to each BPL family & free of charge health services up to the maximum limit of Rs. 20000/- in a financial year in government health institutions is provided to them.

So far upto July 2007 the 5, 22,413 patients have availed of this scheme's benefits. As on March, 2008 about 9, 58,141 BPL households are estimated to have benefited from the DAUP from the initiation of the schemes in Sep, 2004 up to March, 2008. Family Health Card is being provided to 51 lakh families under this scheme.

Deendayal Mobile Hospital Scheme (Mobile Health Clinic): The Madhya Pradesh Government launched a mobile health clinic scheme popularly known as Deendayal Aroygya Rath on 29th may 2006 to provide health services in remote tribal areas. Private Service providers are engaged in management of the mobile health clinic to render free of cost services for medical examination, treatment, consultation and necessary medicines. Eleven tribal blocks have been selected for the first phase of the scheme. In the second phase the State government has decided to extend the facility of mobile health clinic scheme to further 80 tribal blocks of 16 tribal districts.

From 29th May,2006 to 31st March,07  total 4,69,659  & in  2007-08 1605997 were benefited  under DMHS. Thus total 20, 75,656 people from the 91 tribal blocks of Madhya Pradesh have been benefited so far [Department of Public Health & Family Welfare; www.healh.mp.gov.in].

Social Inclusion under Eleventh Plan

Social exclusion is an extreme consequence of what happens when people don't get a fair deal throughout their lives, often because of disadvantage they face at birth, and this disadvantage can be transmitted from one generation to the next. Social exclusion leads to deprivation, marginalization, exploitation and oppression.

Efforts are needed to integrate them into the mainstream society. The concept of Inclusion and Equality is one the state need to work for. Once this is achieved, people can all have better living in a barrier free environment with better access. But this cannot be a passive exercise but a well planned and programmed inclusive mechanisms need to be put in place. Inclusion has to analyze and understand the processes and outcomes of exclusion and work out mechanisms for inclusion.

The thrust of the Eleventh Five Year Plan is social inclusion coupled with provision of improved livelihood opportunities. This approach calls for renewed emphasis on education, health, and other basic public facilities. Many of these programmes like NREGP, NRHM, are implemented especially only in rural areas. Even the programmes that are implemented across the country tend to favour rural and backward areas in terms of resource allocation.The eleventh plan envisaged the objectives to promote the social inclusion of excluded communities like SCs, STs, & OBCs as

• To achieve the 5% growth in agriculture and allied sectors
• To reduce poverty levels from 38% to 25%
• To achieve the literacy rate of 84% by the end of the Plan
• To improve health parameters-reduce Maternal Mortality Ratio (MMR) to 125, IMR to    40 and TFR to 2.4 so as to bring them near the all India level.
• To improve the sex ratio (0–6 years) to 950 females per 1000 males.
• To reduce malnutrition to 30% and anemia to 30%.
• To empower women through their socio-economic development and increased participation in decision making on matters that directly affect them.
• To strengthen social, economic and political empowerment of weaker sections of the society through welfare of SCs/STs, OBCs, minorities and poor.
• To provide adequate and improved quality of power to all the villages.
• To provide a minimum single connectivity roads to all villages with population over 1000 in general and 500 in tribal areas.

During the eleventh plan, the State needs to redefine its relationship with the poor. Rather than make the poor targets for charity, there should be an emphasis on enabling them to help themselves. Efforts are needed to generate new source of livelihood for them & their inclusion to mainstream social, economic & political life & establish attitudinal change on the part of service provider to become more sensible towards the need of these excluded communities. Though the broader objectives of the eleventh plan undertakes the key issue of facilitating the access of the rural & tribal masses in the institutions but no specific measures or plans has been framed for bringing inclusion of tribes to the mainstream life.

Bottlenecks in the implementation of  Maternal & Child Health Schemes in MP

The state government has initiative number of innovative schemes to promote safe motherhood & health development of children in M.P. & is spending a lot of fund to under these schemes. But unfortunately various bottlenecks & constraints come in the way of their effective implementation which results in the failure to achieve the targets.

The ICDS services aims at holistic development of the children under 6 years & for serving pregnant women & nursing mother of deprived & marginalized section of the state.

Sufferings of Poor Women!

Hemlata, a BPL card holder has to pay the prize of being poor. Hemlata w/o Devi Singh from Ajera Village of Suhagpur block, Hosangabad district gave birth to a baby at the government hospital, Hoshangabad through caesarian operation. Hemlata was very weak lean & thin during her pregnancy & after the delivery her blood pressure roused very much & soon she became very unconscious. In such a critical condition, she was referred to Hamidia Govt. Hospital, Bhopal. Her total treatment cost Rs.16, 000.

As per the government “Deendayal Antyodaya Upchar Yojana” the treatment up to Rs.20, 000 is free for the BPL families. But Hemlata’s family was forced to bear the treatment cost as they do not possess the DAUY card in spite of continuous efforts due to administrative defaults.

But the state has 69,238 approved integrated child development centers but only 49,806 are functional against the total need of 0.146 [Analysis of the Commissioners to the Supreme Court in PUCL vs Union of India and others -196/2001] million aaganwadi centers. It indicates that ICDS have been unsuccessful in reaching out to thousand of children & mother in the state.

In one of study it is revealed that only 37% Anganwadi’s are having their own building while 63% centers are running in rented structure or panchayat bhawans temporarily and these structures fail to provide the basic facilities like sufficient space for children to sit, play rooms, proper cooking space and toilet facility. 28% of the AWC lacking the Salter machine required for growth monitoring of the children.

Though the Supreme Court has ordered that every anganwadi center must provide services and should be open for 300 days in a year but the ground reality came out of the survey study shows that only 43 % anganwadi centers are providing services for 26 days a month which is in accordance to the orders of Supreme Court while 40 % centers provide services for 21 days, 15 % centers provide services only for 15 days in a month and 2 % of the surveyed centers hardly provide services for 7 days in a month [Study by Right to food campaign, Sep,2008].

Only 34.9% mother received financial assistance for delivery under JSY in Madhya Pradesh [District Level Household & Facility Survey,India;DLHS-3, 2007-08]. And even the mere financial assistance will not solve the problem. JSY does not address the nutritional needs for women during pregnancy. One woman dies every seven minutes in India due to pregnancy-related complications and these are conservative estimates since more than 30 per cent of maternal mortality cases go unreported, according to estimates. Very little effort is being put to strengthen quality of services and hardly any on improving human – human interaction of the health delivery staff.

Key posts continue to remain vacant. Only 137 posts of gynecologists and obstetricians are approved in entire state and of these 38 are vacant since several years, according to information unearthed by the Right to Food Campaign in M.P., from Department of Health and Family Welfare. Only 20.8% CHCs have obstetrician/gynecologist & only 6.3% FRUs in CHCs are having blood storage unit [District Level Household & Facility Survey,India;DLHS-3, 2007-08]. Also only 66.6% of PHCs in the state having at least 4 beds & 57% sub health center are within the average distance of 3kms [District Level Household & Facility Survey, India; DLHS-3, 2007-08]. How institution can ensure safe child birth, if it does not have sufficient doctors, other medical staff & are not within the easy reach of the people?

The number of vehicles available under the Janani Express is inadequate to transportation of expected mother to hospitals in time. As per the norms of Janani Express would reach to mother within an hour of call received but most of the blocks have either one of two Janani Express and very critical situation arises when the demand increases.

Utter Negligence!

Shahnaz gave birth to twins, both baby boys on Dec 3, 2008 at the government hospital, Betul.

Unfortunately, one of the babies died within 3 days of the birth after he was severely bitten by red ants that even made a hole in his left ear in the hospital’s ICU.

The newborn’s parents alleged that despite of repeated complaints, the medical staff paid no attention, resulting in the death of their newborn.

Adopted from Hindustan Times, Bhopal Dec 8,2008

he total population of the people below poverty line in Madhya Pradesh is 61 lacs while under the government scheme only 47, 90,668 poor are given the “Below Poverty Line” (BPL) card & those who do not possess the BPL card do not have the access to the benefits of these schemes.

Though wide publicity has been made by state of the Bal Sanjeevni campaign‘s Bal Shakti Yojana & project shaktiman but the malnutrition is still a biggest curse for small children in Madhya Pradesh. Still, there are around 63 lakhs malnourished children in Madhya Pradesh in the 0-5 age-group, according to National Family Health Survey (NFHS III) data while Madhya Pradesh government has admitted having only 48,000 malnourished kids in the state. Right to Food Campaign and its partner’s survey report reveals the death of 384 children due to malnourishment just with the four months time since May, 2008.This indicates the failure of state’s effort to prevent malnutrition [Study by Right to food campaign in M.P. 2008].

According to NFHS-III only 40.3% of the children are fully immunized in Madhya Pradesh. In comparison 69% children under 5 years of urban area only 32% children in rural area are fully vaccinated.  13 % children in Madhya Pradesh are not vaccinated at all. Only 36.2% children under the age 12-23 months are fully immunized & 11.3% children in the same age had not received any vaccination in rural areas in Madhya Pradesh [District Level Household & Facility Survey,India;DLHS-3, 2007-08].

The death of newborn in government hospital’s intensive care unit due to ants bit shows the utter negligence of the medical staff & all the claims of state of promoting neonatal care proved false. 

Thus the issue of survival & betterment of women and children is extremely crucial in the state of Madhya Pradesh & there is need of immediate attention in the state.  It  is not at all enough to frame policies of neonatal care but the bigger concern is that of effective implementation of polices & programme to promote neonatal care in real sense to reduce neonatal mortalities in Madhya Pradesh.  Aaganwadi workers, ANM, medical staff & others service providers need to become more generous to the needs to the people.

Eleventh Plan Budget & Neonatal Health

Budget is the critical but the most important part of any planning process. The eleventh plan of Madhya Pradesh shows significant improvement in public finance. The total size of the Eleventh Plan is Rs. 69,788.00 crores at current prices as against the Tenth Plan approved outlay of Rs. 33,724.96 crores. The size of the Eleventh Plan is 2.07 times compared to Tenth Plan while the Annual Plan 2007-08 is 1.33 times that of the approved outlay of the Annual Plan 2006-07. Budgetary provision on health indicates the states commitment for the health of its citizens. The Percentage of total health budget out of the state budget for 2007-08 was only 3.73% & it increases slightly in 2008-09 to 3.82%.Neonates & infants are more prone to infections & chronic diseases & need immediate & special care which requires special budget for neonatal, infant & maternal healthcare.  Key points of eleventh plan which has direct & indirect bearing on the neonatal & maternal health are:

• The sectoral distribution of plan outlay on Rural Development has increased from 4760.42 Crore during the tenth plan to   8457.57 Crore in the eleventh plan. However the percentage distribution has decreased to 12.12% from 14.12% in tenth plan.
• Though the maternal & child health is the most important component of RCH II program, still the budget is very low. Maternal Health budget is 3138.69 lacs & 3266.50 lacs only for 2007-08 & 08-09 respectively which constitute 16.16% of total RCH II budget of Madhya Pradesh. The child health budget of RCH II has increased to 3170.47 lacs in 2008-09 from 1079.59lacs in 2007-08.Tribal RCH budget for 08-09 3095 lac (15.78% of 08-09 budget).
• The eleventh plan aims at promoting institutional deliveries up to 85% with the proposed budget of Rs.18950.02 lacs for 2008-09. It includes JSY being run with the support of union government .However the budget provision of the state government is so little that only 50 to 100 women per block can be benefited.
• An outlay during 2008-09 is Rs.50 lacs has been proposed for care & support of 10000 deliveries done at home, but the number of home deliveries in Madhya Pradesh is still much higher & budget outlay is comparatively low.
• To promote the breast feeding practices (including training & BCC activities) has proposed outlay of Rs.30.0 lacs.
• Proposed outlay of Rs.14.19 lacs for information dissemination (BCC activities) for the management of diarrhoea by promoting the use of ORS & zinc.
• Out of the 48 districts in Madhya Pradesh implementation of IMNCI has been planned only in 13 districts with an outlay of Rs.571.78 lacs which also includes cost of training, logistic support & follow-up.
• During the whole plan period from 2007-12 Sick new born units to be established in 10 IMNCI districts (18 DH & 20 CEmONC institution) with a budget of Rs.578  lacs  & it also  includes operational cost of 2 already existing sick new born units (it also includes civil work, equipments & staff & training).
• Rs.328.94 lacs budget outlay for operationalization of 120 CEmONC & an outlay of Rs.1183.16 lacs for 455 BEmONC operationalization during 2008-09.
• Major civil work for operationalization of  FRUs & BEmONCs with addition of 250 new Born Care Corner@20,000 in BEmONCs with the proposed budget of Rs.50 lakhs.Rs.90 lakhs budget outlay proposed for establishment of SNCU at 6 district hospitals.
• Special focus on tribal health with the provision of mobile dispensaries for quality RCH & FP services in 91 tribal block with the proposed budget of Rs.1820 lakhs & for 91 SC populated blocks @ Rs. 166667/- per unit for 33 units with the budget of Rs.595 lakhs.
• To improve the access & quality of health care the up gradation & construction of district hospital, PHCs, CHCs & SHCs of the tenth plan continued during the eleventh plan with budget allocation of Rs.33010 lacs out of which 7750 was estimated to be utilized during the annual plan 2007-08.
• It aims at expansion of capacity of only 30 units of existing District Hospitals and Civil Hospitals with the budget of Rs.7500 lacs. Up gradation of facilities (in 10 units) in District/Civil hospitals & provision of staff (for 10 units)  has the total  provision of Rs.4000 lacs,Rs.2000 lacs for facilities up gradation & Rs. 2000 lacs for the provision of staff for ICU, Trauma center etc. Almost all the district & civil hospitals of the state need expansion of capacities & facilities but very few are considered during the whole plan period.
• Eleventh plan aims at the establishment of 250 PHCs & 600 SHCs in rural area & allocated Rs.1200 lacs each for PHCs & SHCs. Rs.3000 lacs has been allocated for expansion of existing PHCs & CHCs in rural area, this budget is itself short as against the need.
• Social welfare schemes like Bal Shakti/Health insurance schemes were given the allocation of Rs.1200 lacs only. Establishment of 50 additional NRCs with the budget of Rs.472.50 lacs is proposed.
• Budget of Rs.1500.00 lacs has been allocated for incentive to BPL families for child health (immunization).
• NRHM additionalities for strengthening of SHCs, PHCs & CHCs with the budget outlay of Rs.4181.94 lakhs, Rs.1400.11 lakhs & Rs. 2450.21 lakhs respectively for SHCs, PHCs & CHCs.
• Major source of tribal livelihood, Agriculture & allied activities also called the backbone  of Indian economy  has sectoral distribution of 4.86% only while during the tenth plan it was 1908.64 crore i.e. 5.66% of total budget.
• Rural roads which directly affect the access of rural & tribal people to the health institutions have been given consideration under eleventh plan. The proposed outlay for rural roads for the plan period has an outlay of Rs.50000 lakhs & state rural road connectivity budgeted Rs.8647.60 lakhs. 
•  The state government has decided to provide an allocation of Rs. 62.00 crores under Mukhya Mantri Awas Yojana for constructing houses on the same pattern as IAY for SC and ST houseless families.
• The outlays reflect the public investment in different sectors out of the state plan. However, they do not communicate the correct and complete picture of 33 the total public investments in different sectors e.g. the central support through Centrally Sponsored Schemes (CSS) like National Rural Employment Guarantee Scheme (NREGS) etc. in Rural Development Sector adds up to about Rs. 22,025.70 crores, which is more than double the size of state plan in Rural Development. Similarly, support under National Rural Health Mission (NRHM) is also not reflected in the social services plan size.

The budget provision for promoting institutional deliveries, BCC activities, establishment & operationalization of health institutions, expansion of facilities & capacities of district hospitals, civil hospitals, CHCs, PHCs & SHCs along has direct bearing on the neonatal & maternal health whereas budget outlay for infrastructure development in rural & urban areas, road connectivity, provision for housing, education, livelihood has indirect bearing on the health status of the children.

Positive Trends – from Tenth to Eleventh Five Year Plan

• The total size of the Eleventh Plan is Rs. 69,788.00 crores at current prices as against the Tenth Plan approved outlay of Rs. 33,724.96 crores. The size of the Eleventh Plan is 2.07 times compared to Tenth Plan while the Annual Plan 2007-08 is 1.33 times that of the approved outlay of the Annual Plan 2006-07.
• Maternal & child under RCH-II for Madhya Pradesh  in 2008-09 are Rs.3266.50 lacs & Rs. 3170.47 lacs respectively which constitutes 16.16 percent of RCH-II budget for 08-09,Child Health Budget of Madhya Pradesh has raised from Rs.1079.59lacs to Rs.3170.47 lacs, which indicates positive efforts for child survival & development.
• Eleventh Plan aims at the establishment of Health Institutions as per the population norms of 2001. It provides for the establishment of 60 new CHCs, 250 new PHCs & 600 new SHCs & up gradation of existing health institutions along with their capacity enhancement. While during X plan efforts were made for the operationalization of the existing health institutions & during the plan period only 1 new PHC, 44 new CHC [11th Five year plan, Department of Public Health & Family Welfare Madhya Pradesh] were established & not a single SHC was established against the target of 845.
• During the Tenth plan period the percentage of institutional deliveries rise at agonizingly show pace from 30% in 2005-06 to 55% in 2006-07 but during the very first year of the Eleventh plan it went up from 55% to 79% in 2007-08, & further to 82.36% in 2008-09 (up to June 2008) [NRHM, Department of Public Health & Family Welfare; http://www.mp.gov.in/health/nrhm/dy-graph-2008-09.pdf]. The total number of institutional deliveries in 2008-09 from April-Nov 2008 is 906869 out of the total deliveries 1166950 registered in the year.
• During the Tenth plan no effective steps are taken to curb neonatal mortality under IMNCI. Eleventh plan focuses on operationalization & implementation of Integrated Management of Neonatal & Childhood Illness (IMNCI) in 12 districts of Madhya Pradesh with 50 additional NRCs & 250 Newborn Care Corner in BEmONCs as FRUs. It further proposed the establishment of Sick Newborn Care Unit (SNCU) at 6 district hospitals is also proposed during the plan period. First SNCU is established in District Hospital, Guna on 14 Dec 2007.
• During the Tenth Plan period no state level program had been implemented with special focus on inclusion of socially & economically excluded communities like SCs, STs, & OBCs in the mainstream. The thrust of the Eleventh Five Year Plan is social inclusion coupled with provision of improved livelihood opportunities along with the resource reallocation in favour of excluded communities. This approach calls for renewed emphasis on education, health, and other basic public facilities.

Missing Link for Inclusion of HIV Positive in Mainstream Society

Social exclusion factors also increase the risk of ill-health amongst people with HIV positive people. The stigma associated with the infection also means that such people are socially excluded. As a result of such exclusion, often coupled with direct discrimination, many people develop very low self-esteem that may in turn lead to degradation of socio-economic capacities of people living with such stigmatic infections & diseases.

In the Eleventh plan of Madhya Pradesh no special provisions has been made for the social inclusion of HIV positive, the most excluded  & marginalized community.  Social inclusion efforts need to integrate the HIV/AIDS programme & establish linkage with the livelihood programmes for the mainstreaming of these communities. It further needs even positive discrimination in favour of them. People undertaking health program for prevention and information work should ensure that materials and methods are culturally appropriate to the groups. It needs to endorse a mass campaign to reduce stigma and prejudice about HIV.

Seema Jain