SHRC ANNUAL REPORT 2009-10 - State Health Resource Centre ...

Bringing EnergyintoPublic Health Scenario in ChhattisgarhAnnual Report 2009 – 10State Health Resource CentreAdditional Technical Capacity to Department of Health and Family WelfareGovernment of Chhattisgarh

Chair of the Governing BoardSHRCPrefaceChhattisgarh was long a region of extreme poverty, and in its remote hamlets peopledied every year, because they were deprived of basic health care. It seemed a problem sointractable, that governments and people accepted such recurring epidemics and thehigh levels of mortality and morbidity due to preventive ailments, as fate that could notbe altered.The Mitanin Programme changed this forever, by truly placing 'People's Health inPeople's Hands'. When it was initially conceived, it seemed an utterly audacious idea,that unlettered women volunteers in 60,000 plus hamlets in the state would learn andpractice knowledge of how to prevent ailments, and to treat them when they occurred.But this happened, through a unique collaboration of Government, CommunityWorkers, Public-spirited professionals and Non-Government Organisations.The results are there for all to see. Independent data establishes that theseinterventions saved tens of thousands of lives - especially of children, women and theaged. There were many learnings from the Mitanin Programme which fed into theNational Rural Health Mission.The annual report reflects the programme in its state of consolidation. There are stillfailings and mistakes. But overall it is a programme which has demonstrated that thebest way to save lives is to enable people to recognise, utilise and harness their owninnate strengths.Harsh ManderCentre for Equity StudiesNew Delhi

MessageDr. T. SundararamanExecutive Director NHSRC, New DelhiI take great pleasure in greeting the State Health Resource Center, Chhattisgarh,on the occasion of publication of the Annual Report for the year 2009-10. This is aunique institution which acts as a bridge between what is academic and what isoperational in Public Health. It is also a great source of inspiration and innovation forbuilding effective Public Health Systems. When it was created, few were willing to bet onits sustainability. But now, 8 years of its creation, despite a large number of changes inits leadership and changes in the environment, the SHRC continues to grow and breakfresh ground in Health Systems strengthening. The Mitanin Programme is no doubt theflagship of the institution, but it has now made its mark in many other areas of PublicHealth as well.Growth brings with it, its own challenges. It is difficult to increase institutionalcapacity at the rate at which the demands for its services and contributions grows.Administrative mechanisms and experience take time to develop. Yet, SHRC hasstruggled to overcome these challenges. This report is a testimony to how much hasbeen achieved by such a small team. We look forward in the coming years to a renewal ofits commitment to serve the cause of people's health and its continued contribution tobuilding an equitable, effective and efficient Public Health System.With greetingsDr. T. Sundararaman

From the desk of the Director…Dr. Antony K. R.Director, SHRC, ChhattisgarhWhere are our people and how to reach them were the questions asked jointly by Health Department aswell as Civil Society Organizations when Chhattisgarh was born. These questions that were asked to“reach the unreached,” brought forth a partnership and set in motion a Health Sector Reform process.State Health Resource Center came into existence with that Health Sector Reform agenda in 2002.The main thrust of the reform agenda was “Communitization” and the hallmark of Communitization inHealth Sector was 'Mitanin'. It has become an international brand item from Chhattisgarh. ASHA evolvedacross many states under NRHM. Mitanin in every habitation carried messages and services from HealthDepartment to Community and she brought the demands and aspirations of Community to theGovernment. Understanding where they stand on development indicators each village communitymeaningfully stepped towards a Swasth Panchayat.Jeevandeep Sammittis fostered participatory approach to quality maintenance in curative care inhospitals. Standardizing case management and drug supply, rationalizing human resource deployment,generating need based health human resource generation like innovative multi-skilled Doctors for SafeMotherhood, Rural Medical Assistants etc. are ongoing reforms agenda SHRC got fully involved in andsteered through.Our “think tank team” reflected on problems and challenges in the field, suggested viable solutionsevolved after meetings and consultations with various stake holders in a participatory mode resulting invarious policy formulations, government orders and Acts. We worked hard in building capacity in PublicHealth Management at State / District level.This annual report is only a short glimpse of the varied activities our team toiled through.We are proud of our Mitanins, their Trainers and Mentors, at Block and District level and the Centralteam working day and night at Raipur.We are immensely grateful to Government of Chhattisgarh listening to us and valuing our input andcontribution. We are encouraged by Govt. of India and International Public Health Experts quoting SHRCand Chhattisgarh innovations.Let us march on till the poorest man is reached and made happy in Chhattisgarh.Warm regardsDr. Antony K. R.

ObituarythDr. Premanjali Deepti Singh, born on 17 July 1955, an MBBS had worked in the hospitalsector for more than two decades as a General Practitioner and Deputy MedicalSuperintendent. She was invited to join the SHRC in 2003 in the capacity of a SeniorProgramme Coordinator. With her vast experience in health sector she went on to work forPublic Health with utmost zeal and dedication.During her 7 years sojourn at SHRC, Dr. P.D. Singh contributed enormously inconceptualizing and preparing training modules and guidelines for varied cadres of medicalpractitioners. Some of her major contributions towards Public Health involves in theformulation of the Essential Drug List, DAI training Modules, ANM training modules, Multiskilling of Doctors, policies ofMaternal Health issues, PHRN modules besides development of various Audio-Visual resources and other researchand publications in health. Her forte was in Maternal Health.Her dedication, attention to details and perfection coupled with utmost professionalism in her work earned the respectthof all her Supervisors, Colleagues and Subordinates alike. She breathed her last on 26 October 2009.Mehrunnisa, Nisha started her cultural life through India Peoples Theatre Association andthen extended her space to entire theatre horizon of Chhattisgarh. She worked very closelywith almost all leading theatre figures ranging from Habib Tanwir. She also got into massmedia through Chhattisgarhi films and TV programmes. Many of the Chhattisgarhi ruralpeople remember her for her role in well-watched regional movie called Chhaiyya-Muiyya.Her talent as a sweet voiced singer would be there vividly in the memory of many.She was socio-cultural activist too. She was the soul of Kalajatha movement in MadhyaPradesh for literacy, child education, health, women empowerment and various issuesrelated to upliftment of vulnerable and poor. Many remember her as a sensitive social worker. She worked restlessly forstreet children, geriatric and women in distress...Since the very inception of SHRC, she joined as the senior among field coordinators of Mitanin Programme. She foundthis as an opportunity to further extend her reach to the needy, more than a job- giving the necessary motherly touchneeded for such an initiative. Hence, she was the inspiring team player for not only to the youngsters and beginnerswithin the team right from state level to village level, but also to the senior team members and the senior healththadministrators. She breathed her last on 7 Dec'2003.As the Psalmist writes… 'A time to live and a time to die', Dr. P.D Singh and Mrs. Nisha Gautam left for the heavenlyabode. The void they left behind is irreplaceable but, in their sweet memories, the SHRC family thrives and rededicatesto carry the beacon forward.

Table of Contents...PageChapter 1: An Overview 1SHRC – Background information 2Activities 2Chapter 2: Report on Programmes & Initiatives 41. The Mitanin (ASHA) Programme 52. Nutrition Security Programme 103. Home Based Neonatal (Newborn) Care 124. Swasth Panchayat Yojna and Capacity Building of VHSCs 155. Jeevan Deep Samittee 196. Strengthening FRUs - Enhancing Quality in Primary Care 237. Mainstreaming AYUSH 268. Chhattisgarh Health and Equipment Management System 319. Rural Medical Assistant (RMA): Viable solution for Primary Health Care 3410. Establishment of Chhattisgarh Medical Services Corporation (CGMSC) 3411. Leprosy Cell: 'Accelerating the NLEP programme' 36Chapter 3: Policies, Strategies & Proposals Contribution under Health Sector Reforms 37i Policy/Drafts formulation 38ii Review and inputs 38iii Project Proposal Formulation 38Chapter 4: Research and Studies 40Chapter 5: Publications 45Chapter 6: Audio-Visual Library 49Chapter 7: Workshops and Seminars 52Chapter 8: Training and Capacity Building 59Chapter 9: Centre for Training and Exposure 62Chapter 10:Impact of SHRC on the Health Sector Reforms – A critical Appraisal 64Annexure/Appendices:1. SHRC Governing Body 712. Executive Committee 723. SHRC Team 724. Partner Agencies for collaboration 765. Abbreviations 77

Chapter 1 : An OverviewThe State Health Resource Centre, Chhattisgarh (SHRC) isa unique state-civil initiative registered as a Society under theSocieties Registration Act, India. The SHRC is designed asan “Additional Technical Capacity to the Department ofHealth and Family Welfare”, Government of ChhattisgarhState. Its main role is to provide support to the government inthe process of Health Sector Reforms.This includes support in:Policy Planning and Strategic ThinkingCapacity BuildingDevelopment of innovative and adaptiveprogramme designsCommunity based health programmesHealth Systems ResearchAssisting the department to developnew strategiesSHRC has an innovative work charter, a specialorganizational structure and an appropriate positioning. In2002 SHRC was established under a Memorandum ofUnderstanding signed between the State Health Society ofthe Government of Chhattisgarh and the Action Aid. Since2004 SHRC has been functioning as a fully autonomousinstitution.ActivitiesSHRC has contributed significantly to:Policy DevelopmentThe SHRC has contributed significantly to the developmentof the State Health Departments' Human Resource Policy,Transfer and Posting Policy of Doctors, Policy of Placementand others, besides, the Information-Education-Communication (IEC) - Strategy as well as theimplementation of this framework. Other policy draftsprepared by SHRC – which are in the process of approval –are the State's Integrated Health and Population Policy, theDrug and Supplies Policy, and the Policy for Public PrivatePartnership.Strategy DevelopmentFurthermore, the SHRC has evolved the drafting of theHealth Sector Reform Agenda under the Sector InvestmentProgramme and under the State Partnership Plan with theEuropean Union. It has also contributed to the developmentof the Reproductive and Child Health Programme and theNational Rural Health Mission Programme ImplementationPlans of the State Government.Leading the Implementation of ProgrammesIn collaboration with the Department of Health and FamilyWelfare, CG, the SHRC has led the Mitanin Programme andthe Swasthya Panchayat Yojana. It has played a significantrole in shaping and supporting the Jeevandeep Programmeas well as the piloting of multi-skill-training of MedicalOfficers.StudiesThe SHRC's studies on rationalization of health services andon workforce development have defined much of healthsector reform moves aimed at strengthening public healthsystems.Further Studies are:Control of MalariaPattern of Illness and Household Expenditure inrural ChhattisgarhUnaccountedNewborn - Issues of BirthRegistration in Chhattisgarh: AStudyWorkforce ManagementPrivate Sector in Emergency Obstetric CareMitanin EvaluationIndicator Based Village PlanningPrescription AnalysisStudy on JSYStudy of PHCs in Chhattisgarh2

All studies are significant works which have been used toshape policies. It is currently guiding performance appraisalsof public health facilities.Training and Capacity buildingIn order to improve and strengthen the health system of thestate, the SHRC has initiated trainings which are ongoingthroughout the year. For example more than 60,000 women(Mitanin Programme) were trained as community healthworkers in Child health and nutrition, Women's health,Community control of malaria, Waterborne diseases etc.,Medical Officers are multi-skill trained in EmergencyObstetric Care as well as in Life Saving Skills in Anaesthesia,and at Panchayat Raj Level the Panch/Sarpanchs aretrained to be able to put health at the village level with theSHRC's specific programme called Swasth PanchayatYojana.Institutional Strengthening:SHRC has also been actively involved in providing technicalsupport and inputs for institutional strengthening like settingup of the SIHFW, CGHEMS, Drug Ware House Design forState, Districts and Blocks and PHRN; a networking oflikeminded people for advocacy and influencing theGovernment. Besides, technical support in new designs andlayout of Public Health Infrastructures like the Sub Centers,CMHO Office, CHCs and BMOs Office.PublicationsThe SHRC has undertaken various publications of healthsector reforms.Besides, the Government of Chhattisgarhhas published books which were authored and designed bythe SHRC. These books include training/reading material for60,000 Mitanins and, in addition, guidelines for the trainersand programme organizers.Change ManagementThe SHRC actively supports a wide variety of Governmenteffort for change management. It has for example assisted ina major expansion in sanctioned health facilities and inexpanding budgetary allocations for the department. It hadassisted resource mobilization through well articulated PIPsfor funding from European Union, NRHM, 13th FinanceCommission etc.3

Chapter 2 : Programmes and Initiatives1. Mitanin (ASHA) Programme:Background :The Mitanin Programme was initiated by Government of Chhattisgarh in 2002as a component of the Health Sector Reforms undertaken under the SectorInvestment Programme (SIP) supported by the European Commission. SHRCwas born along with the Mitanin Programme and has been playing the keyfacilitation role in the programme right from its beginning. Mitanin, literallymeaning a lifelong friend in Chhattisgarhi dialect, is a Community HealthWorker selected by local communities at the habitation level. Nearly 60,000Mitanins thus cover almost all the rural habitations of the State. MitaninProgramme has the following stated objectives:To provide health educationTo mobilise communities for prevention of infectionsTo provide primary curative services at the habitationlevel for common ailmentsTo link communities with formal healthcare servicesTo empower women and other socially excluded sectionsTo promote grassroots health planning by bringing healthon agenda of PanchayatsAll the Mitanins have been recognized as ASHA after the start of NRHM. ThusSHRC has always played the role of an 'ASHA Resource Centre' as visualizedin NRHM. SHRC provides hands on support to the Mitanin programme bydesigning its curriculum, conducting required Training of Trainers (ToTs),building quality in field level training, building capacity of Mitanin supportstructure, monitoring its outcomes and coordinating between community andGovernment agencies. Thus SHRC supports all the key processes in theprogramme i.e. training, home visits, habitation and cluster level meetings ofMitanins. With Village Health and Sanitation Committees (VHSCs) coming in asa key strategy for communitisation under NRHM, Mitanin Programme alsoplays the role of capacity building of these newly emerging institutions at thevillage level.“Mitanin” in Chhattisgarhi meansa friend. In fact she is muchmore than a friend. It is an ageold tradition in the villages ofChhattisgarh, that people makeother people their “Mitan” or“Mitanin”. It is customary in thevillages of Chhattisgarh for girlsto become Mitanin of their closegirl friends. This is doneceremoniously. Once the twogirls have become Mitanins, theyare closer to each other thanreal sisters. This relationshipcontinues for the rest of their life,even after they are married, andbecomes a bond betweenfamilies. The “Mitan” or the“Mitanin” is a friend not only inthis life, but even in heaven. The“Mitans” and “Mitanins” areready to sacrifice everything foreach other.Mitanin Programme is credited as a significant contributor to the dramaticdecline witnessed by the state in its rural Infant Mortality Rate (IMR). It hasmade a huge difference to rates of early initiation of breastfeeding, institutionaldeliveries and first contact care for child illnesses like diarrhea, fever andrespiratory infections.5

The main strategies employed by the programme include:Continuous training and support to the Mitanins along with the social mobilization.Reduction of malnutrition with the application and practices of learnt skills by strengthening and deepening thehealth education and counseling work at the household level and by means of equipping the Mitanins with BCC kit.Special focus for neonatal visits to reduce the neonatal mortality along with strengthening the Mitanin helps deskand newborn corners in CHCs/24X7 PHCs.Facilitating Mitanins instrumental for Inter-sectoral convergence among the related sectors at the habitation andPanchayats levels and strengthening local planning at Panchayats and village level.Strengthening the access of the poor to essential curative care through adequately provisioned women healthvolunteers. They are also linked to improved peripheral primary and secondary medical care facilities, through afunctional referral system, Mitanin help desk (MHD). They enable the public health system to respond promptly andadequately to needs of institutional care of sick children, referred in by Mitanins.To develop the logistic system for timely drug distribution under Mukhya Mantri Dawa Peti Yojana across districts.Supporting and encouraging the Mitanins to take local leadership through PRI.Facilitating the career path way for volunteer Mitanins for B.Sc. nursing, GNM, ANM courses.To recognise the social and system level problems faced by the Mitanins. This is to motivate them and to advancethe solidarity among the Mitanins. District and block level “Mitanin Sammelans” or “Mitanin Diwas” of the womenhealth volunteers to increase their motivation, ensuring their timely and correct incentive distribution, sustainingmaintain their spirit of volunteerism and to strengthen their identity.Highlights of Mitanin Programme in the year 2009-101. Mitanin Trainingth th th thThe year started with backlog of 10 , 11 and 12 round of training and ended with the 13 round of the Mitanin training. Incurrent year training was mainly accomplished on:th10 Round Part II of training based on 'IMNCI' –of three days on child illnesses - conducted in 55 blocks.th11 Round of training on 'strengthening VHSCs and Village Health Planning' – of two days -conducted in 28 blocks.In addition to nearly 55,000 Mitanins, around 70,000 VHSC members, mainly PRI representatives were also trainedin this round.th12 Round of training on 'Infant and Young Child Feeding' and focused on strengthening counseling skills – of twodays- conducted in 113 blocks.th13 Round of training on 'Behavioral Change Communication tools' – conducted in 100 blocksthAlso the ToT for around 3500 participants was conducted for the 13 Round.ththDraft Modules for 14 and 15 Rounds of training on strengthening skills related to Malaria, Leprosy, TB and HIVwere also prepared in the current year.6

2. Achieving critical process outcomes in community healthMitanins continued their field level action in all the key outcome areas. The MIS of Mitanin Programme shows that theproportion of Mitanins active in various aspects achieving various important outcomes are:Aspect% of Active MitaninsFirst day newborn visit 73%Facilitating family's preparation for Delivery 76%Using Drug kit 92%Counseling malnourished children 78%Attending Immunisation Day 84%Conducting hamlet level women's meeting 66%Some of the strong features of Mitanin's work this year were:An estimated number of 5 million patients (mostly diarrhea, fever, respiratory infections) came in contact withMitanins for help this year. Mitanins provided support to these patients with a combination of counselling, homeremedies, drugs from thheir drug kits and referral to health facilities.Mitanins strengthened participation of women in around 30,000 monthly Village Health and Nutrition Days inconvergence with efforts of Anganwadi workers and ANMsMitanins contributed towards increasing coverage under Shishu Sarankshan Maah (two rounds of Child ProtectionCampaigns).Mitanins helped in screening and motivating suitable cases for Institutional Delivery, Family Planning, Cataractoperations, Malaria testing, Sputum examination for suspected TB and so on.3. Initiating Career pathways for Mitanins - Joining Nursing CourseThe 60,000 Mitanins have been leading and serving their hamlets for the last six to seven years. During this period theyhave gained skills and competence in areas of child health, maternal health, first contact curative care, local herbalremedies, local health planning, management of newborn and childhood illnesses, infant and young child feedingpractices, women's empowerment and behavior change communication. It is visualized that they should have diversecareer pathways. One of these is to gain formal medical education and become skillful nurses and ANMs in under-servedththareas facing manpower crunch. Around 1200 Mitanins have 12 standard qualification and another 3000 are 10 pass.thIn August 2009, a state level drive was organized to mobilize the 12 class passed (biology group) Mitanins to appear for awritten test organized by a group of private nursing colleges recognized by the Department of Medical Education (DME),Chhattisgarh. More than 125 Mitanins appeared in this test and 55 Mitanins qualified successfully. SHRC facilitated theprocess of listing, motivating, screening, counseling of candidates and coordinating with Nursing colleges, DME and7

NRHM State Unit. As a result of the above process, 24 Mitanins, 10 Mitanin trainers and 4 District Resource Persons ofMitanin program have finally joined the 4 year course of B.Sc. Nursing. NRHM is providing scholarship support (Rs. 65,000per candidate per annum) to cover the expenses for these candidates. SHRC has provided counseling support to theMitanins so that these new entrants are able to adapt to the academic environment.The State now is aiming to expand this initiative by according first priority to Mitanins for ANM Training course (for up to 50%of seats in private colleges). SHRC has started preparing a draft methodology for this important process.4. Mitanin Data Base PreparationA data base of 59489 Mitanins, 2920 Mitanin trainers and 437 District Resource Persons initiated in the previous yearreached close to final completion stage in this year. More than 80% of the information collected has been fed into a softwarespecially designed for the purpose this year. This database provides very detailed and valuable information on socioeconomicbackground of Mitanins and would also help in further research on Community Health Workers. This would alsohelp in creating Identity Cards for all the Mitanins.5. Dialogue on Infant DeathsThis new activity was started this year across the State through Mitanin cascade. It involves identification of infant deathsby Mitanins, organizing a dialogue on the issue in the community and informing the block health authorities through theVHSC. This way dialogue has taken place on more than 3,000 infant deaths. This has helped in sensitizing the Mitanincascade, service providers as well as the communities on this critical issue. An analysis of age of infant at the time of deathwas done for 655 cases and it helped in bringing the focus on newborn care.6. Development of BCC kitSHRC had started developing a toolkit for Behavioral Change Communication (BCC) with support from UNICEF in 2007­08. The final design and production of the kit was completed this year. This kit will help health workers especially Mitaninsand Anganwadi workers in effectively delivering messages on Integrated Child Survival, Health and Development. Theinitial 5000 sets were produced with support from UNICEF. Subsequently, Department of Health and Family Welfare,Chhattisgarh is producing 65,000 sets of the BCC Kit using European Union State Support Programme funds for wider useby Mitanins across the state. The feedback received from the various stakeholders including the Mitanins has been veryencouraging. Women and Child Development (WCD) department has shown keen interest to adopt it for Anganwadiworkers in the State. It also has the potential to be used as resource material for ASHA communication kit at the nationallevel.The BCC kit has five types of toolsThis new activity was started this year across state through Mitanin cascade. It involves identification of infant deathsby Mitanins, organizing a dialogue on the issue in the community and informing the block health authorities through theVHSC. This way dialogue has taken place on more than 3,000 infant deaths. This has helped in sensitizing the Mitanincascade, service providers as well as the communities on this critical issue. An analysis of age of infant at the time ofdeath was done for 655 cases and it helped in bringing the focus on newborn care.8

a) Sehat ke Patte - A set of 52 flash cards in the form of playing cards which deliver essential messages on four keyareas of health and developmentb) Sehet ke Kitab - This, perhaps the most innovative part of the BCC kit, is a resource book documenting variouslocally available and highly nutritious foods in various parts of Chhattisgarh. It shows photographs, locations, localnames and nutrition values of around 60 green leafy vegetables, 40 forest based foods and around 60 localrecipes. It brings the focus back on local foods.c) Nirnay Talika (Sehat Ke Chakra) - This is a ready reckoner to be used by frontline functionaries to deliver thecorrect age specific health and nutrition messages based on the life cycle approach during counselingd) Sehet ke Kanwar - A set of 5 Flip Books onI. Newborn careii. Child malnutritioniii. Sanitation and disease controliv. Women's healthv. Food securitye) Films: A set of 3 filmsI. Aao karke dekhe: On Supportive supervisionii. Kaise ho kishori: On adolescent health and empowermentiii. Main kehta aankho dekhi: On child nutritionThe BCC kit has been provided to all Mitanin Trainers and District Resource Persons. TOT on BCC kit of 437 DRPs at statelevel and TOT of 2920 Mitanin trainer at regional level has been completed. Currently till March training of around 40,000Mitanins in 100 blocks has been completed.7. Revisiting the Mitanin Dawa-peti (Drug Kit) Design and Refilling MechanismGovernment of Chhattisgarh had introduced the Mukhya Mantri Dawa Peti Yojana in 2004 so that Mitanins could providethe first contact curative care for common ailments from a drug kit at the hamlet level. SHRC had helped in the design of thedrug kit and its contents. Prior to this year, the procurement and logistics for periodically refilling the drug kit were directlyhandled by the health department. But as gaps were being observed in timely refills reaching the Mitanins, SHRC wasentrusted with the task of handling the refilling logistics i.e. storage and transportation of the required drugs. SHRCsuccessfully replenished nearly 60,000 drug kits through three rounds of refilling (each containing drugs for four monthsrequirement).SHRC also revisited the design of drug kit in terms of the storage at Mitanin level and the quantity of drugs required as well.SHRC reviewed the earlier rationale behind the drug quantities and conducted fresh studies to find out the consumptionpattern. The drug kit and quantities were suitably redesigned based on this analysis.8. Referrals and Mitanin Help DeskThis innovation was launched in 2006 and it aims to provide support at the health facilities to the referrals being made byMitanins. It involves Mitanin Trainers volunteering to stay at the health facilities, on a rotational basis, and helping thereferrals in getting services. This concept was strengthened through the training on Supportive Supervision in 2008-09.Adequate funds were also released by the Government through the NRHM PIP in 2009-10. As per estimates based onspecific studies, Mitanins refer around 1.5 million cases annually to Government health facilities spread across the State.Currently, around 170 Mitanin help desks (mainly in CHCs and district hospitals and in some PHCs) are helping thesereferral cases though considerable challenges are still need to be overcome to make this help more effective.9

9. New Initiatives Under ProcessA number of new initiatives are in final stages of approval and almost ready to be implemented as of now. Theseinclude:Mitanin Pass Book: A new system has been designed to ensure timely and full payment of incentives to Mitanins. This waspointed out by Government of India as one of the aspects requiring urgent action. AMitanin Pass Book has been developedby SHRC as a tool to facilitate this.Mitanin Welfare Fund: Chhattisgarh State had won the national award called JRD Tata Award for progress on healthindicators. Mitanins are largely credited for this success achieved by the State. The award money has been supplementedwith grants from the Chief Minister and from NRHM to create a welfare fund for Mitanins. This innovation is now in its finalstages before implementation.2. Nutrition Security ProgrammeBackground:Nutrition Security programme was launched in 23 Mitanin blocks in 2006. This programme aims to demonstrate a methodologyto achieve reduction in child malnutrition by intensifying counseling and community mobilization around nutrition and foodsecurity issues through Community Health Workers (Mitanins). Nutrition Security interventions are built on the existing Mitaninbase and therefore are also referred to as Mitanin Plus interventions. In these blocks, a block level Nutrition Resource Person(known as Poshan Fellow) was inducted. Poshan Fellows receive regular inputs on nutrition security and communityempowerment aspects. They conduct an additional monthly meeting of MTs and conduct Large Cluster Meetings of Mitaninsand provide handholding to Mitanin Trainers (MTs). Role of MTs in providing on job support to Mitanins emphasized so thatMitanin's confidence improves and problem solving happens. Another key intervention is to promote supportive organizationsfor Mitanin at the cluster level. A baseline survey for the programme was done in 2006. It was followed up by a midline survey in2008. Both rounds of survey had a randomly selected sample size of 2300 households having children below three years of age.Activities in 2009-10Activities Planned for the YearTraining /Review of Nutrition Resource PersonsProgress on Activities12 days of review organizedAdditional 2 days of experience sharing conductedPlanning and Review Meetings with Mitanin Trainers12 days of review organized with MTs of each project blockHandholding support to Mitanins for NutritionCounseling Home Visits by Mitanin Trainers151,200 Home visits by MTsNutrition Counseling Home Visits by Mitanins187,872 Home visits by Mitanins10

Community Monitoring of Nutrition and Food SecurityProgrammesICDS - 1920 Anganwadi centres monitoredPDS - 754 fair price shops monitoredVillage Health Planning Facilitation974 Plans facilitatedFacilitation of Cluster Supportive Network of Mitanins546 clusters facilitatedBlock Level Mobilization37 Block level Events took placeHamlet level community meeting facilitated by MT25162 Meetings facilitated by MTsExposure VisitsPoshan Fellows participated in a national advocacyevent in Delhi on ICDSAchievements :The midline survey shows that the improvements in process outcomes are accompanied by desired impact on key indicators.Some of the important changes achieved as per the survey are:a) The proportion of families having access to ICDS improved from 46% to 70% over the first two years of the programme.b) Child Feeding practices also improved significantly. Proportion of children getting timely initiation of complementaryfeeding increased from 46% to 69%. Proportion of children getting pulses and green vegetables in their diets alsoincreased considerably.c) The proportion of malnourished children (Grade I, II, III, IV as per IAP standards) reduced from 66% to 62%. Thisdecrease of 2% percent points per year is more than twice the rate achieved by Chhattisgarh between the years 1998to 2005.11

3. Home Based Newborn Care Initiative (HBNC)Background:Chhattisgarh has achieved a sharp decline in the rural Infant Mortality Rate (IMR) over the first three years of starting the MitaninProgramme. However, over the last four years, the decline in rural IMR has slowed down and it still stands at 59 per 1000 livebirths (SRS - 2008). About three-fourths of these deaths are happening in the neo-natal period. Therefore, in order to make afurther dent on IMR, efforts are needed to reduce the neonatal mortality rate. Community level efforts of Mitanins on this frontalong with improvements in facility based neonatal care can help the State in reducing its neonatal mortality.Field experiments done by SEARCH, Gadhchiroli have shown the way in which Community Health Workers can make animpact on this aspect through home based action. SHRC has adapted the methodology developed by SEARCH to the context ofChhattisgarh. It has been launched in 18 blocks (one block per district) of the State in 2009. SHRC has been providingleadership to this programme right from the beginning.Objectives :In order to fulfill the overall goal of reduction in neo-natal mortality rate, the HBNC initiative in Chhattisgarh has the followingoperational objectives:1. Ensuring that Mitanin is present during all home deliveries2. Ensuring that each neonate is visited at least six times by the Mitanin in first four weeks3. Ensuring that all asphyxia cases are identified and treated by the Mitanin in case of home deliveries4. Ensuring that Mitanin provides skilled counseling for all neonates on prevention of sepsis5. Ensuring that Mitanin identifies all suspected cases of neonatal sepsis6. Ensuring that the identified sepsis cases are referred to PHCs/CHCs having admission facility7. Ensuring that the facilities (PHCs/CHCs) are able to provide treatment for neonatal sepsis round the clock and thatthe sepsis cases reaching the facility receive Gentamycin and Cotrimoxazole treatment fully8. Ensuring that the identified sepsis cases whose families are unable to go to facility, are able to reach the ANM toget Gentamycin injections; and in event of that not happening, receive full oral Cotrimoxazole dose from Mitanin9. Have clear baseline measurement of key indicators so that monitoring of impact is possible.Achievements (2009-10)1. Creating administrative will on HBNC: SHRC, with help of SEARCH organized a series of consultations with the healthstakeholders in the state to create an environment conducive to bringing in HBNC programme into state's priorities.2. Adapting HBNC methodology to the context of Chhattisgarh: The methodology developed by SEARCH neededcertain modifications in light of the situation in Chhattisgarh. The aspects which required assessment included the existingskills of Mitanins, the structure and processes of the Mitanin Programme, status of healthcare delivery through the publichealth system etc. Several discussions were carried out with Department of Health to come to a common understanding onthe design of the initiative for Chhattisgarh. There was no consensus on use of injectibles by Mitanins at the state andnational level. Therefore the key design difference from the Gadhchiroli model was in this aspect.12

3. Incorporation of HBNC in NRHM PIP: After building a state level consensus, SHRC facilitated the incorporation of HBNCin NRHM PIP 2009-10. The state has continued its commitment to the programme and it has found its place in PIP2010-11.Districts have received the funds for HBNC. Also, a list of 102 Master Trainers from the Health department has beenprepared to conduct the training of ANMs, staff nurses, MOs and health managers. Design of the HBNC kit has also beenfinalized based on the Gadhchiroli model.4. Selection of HBNC Blocks: HBNC has been launched in 18 blocks (one per each district) in December 2009. Thisinitiative covers rural population of around 1.5 million. In each district, one Block with CHC functioning as FRU has beenselected. Further, all the PHCs in the selected block are required to function as 24x7 PHCs with at least one trained serviceprovider staying on-campus.5. Assessment of Skills of Mitanins on Neonatal Care: An assessment of Skill and Knowledge of Mitanins related to neonatalsurvival was done by SHRC with support from SEARCH. The exercise covered 113 Mitanins from 6 blocks. Theassessment was done to know the gaps for further training of Mitanins on HBNC. The overall skill and knowledge level onmost dimensions like chest in-drawing, referrals etc. seems to be satisfactory. The 47% of illiterate Mitanins are also able toread thermometers. There were gaps though in 2 another specific aspects: a) determining the date of the last menstrualperiod. b) Case specific counseling to new mothers on breastfeeding related problems.Assessment of Skills of Mitanins on Neonatal Care13

6. HBNC Module Preparation : SHRC prepared the HBNC training module by learning from the modules of SEARCH as wellas the national neonatal and child survival programme (Navjat Shishu Suraksha Karyakram). It consulted the state chapterof IAP. The existing skills of Mitanins as per the IMNCI based training received by them and their current literacy status alsowere important factors in the design of the Chhattisgarh module. A seven day module was prepared and field tested withboth literate as well as illiterate Mitanins. The skills and knowledge achieved was tested in presence of state coordinator ofIAP.7. HBNC TOT : A 10 member strong State Training Team was created out of professionals with medical qualifications likeBachelor in Physiotherapy and Practitioners in Modern and Holistic Medicine (PMHM). They were trained for 10 days. Theygained further confidence in field testing. Then a seven day ToT of 90 Block Training Team members, 18 DistrictCoordinators of Mitanin programme and 36 District Resource Persons has been completed.8. Training Evaluation : Each individual participant was evaluated after each individual session. Then on the last day, a finalround of evaluation was carried out.Percentage of 144 participants achieving Grade A (90%+) on different components infinal evaluation of HBNC Training:9. Baseline Survey : SHRC has designed the methodology for the baseline survey. It is being done in two phases. The firstphase data collection by Mitanin Trainers has been completed.10. Plan preparation for 2010-11 : SHRC has prepared the plan for 2010-11 which includes completion of 2 rounds of Mitanintraining (two modules of 7 days each), training of traditional midwives (dais) and around 2000 health personnel from thedepartment. Another key challenge will be to get the HBNC kit procurement done through the health department.14

4. Swasth Panchayat Yojana and Capacity Building of Village Health and SanitationCommitteesBackground:The Mukhya Mantri Swasth Panchayat Yojana has been initiated by the Department of Health and Family Welfare,Chhattisgarh, with the assistance of State Health Resource Centre in 2006. The programme aims to place health on the agendaof Panchayats and to increase their participation in action on the health issues.Developing a set of indicators to measure the health status of the Panchayats was the first step to implement the SwasthPanchayat Yojana. The indicators are based on the aspects of health status of the Panchayat, e.g. access to health careservices, health related community behavior, nutrition, education, water, sanitation and gender. These indicators include thoseaspects which are critical as per the Millennium Development Goals (MDG) and thus allow monitoring of MDG goals for eachPanchayat in the state. The data collection exercise for the Swasth Panchayat Yojana has been a large exercise covering mostof the rural households of the State.Data on 10 indicators (earlier on 32 indicators) has been collected and fed into a computerized database on the indicators.Health and Human Development Index (HDI) of all the Panchayats has been computed and ranking of Panchayats for awardsand financial support has already been done for three rounds. The Swasth Panchayat Yojana has always been visualized as atool for facilitating local health planning at Panchayat level.Village Health and Sanitation Committees (VHSCs) have emerged as a significant communitisation intervention under NRHMfrom 2007-08 onwards. Mitanin Programme has played a very critical facilitation role in formation of VHSCs, facilitating theirstart-up and their capacity building. VHSCs are now utilizing the Swasth Panchayat survey findings in preparing their own villagehealth plans.A. Swasth Panchayat Survey 2009The third Swasth Panchayat survey was conducted in August-September 2009 using 10 Indicators. The number of indicatorswas reduced from 32 to 10 this year so as to make the data collection exercise more manageable for volunteers. As expected,the accuracy of information collected improved considerably this year due to the less data points and also due to the experiencegained by volunteers over the three rounds.First, the formats for data collection at household and hamlet level were developed. The data collection was done through acombination of hamlet level meetings and door to door survey. A large number of ward Panchs were involved in the datacollection. It was a collaborative effort with the involvement of Panchayat representatives, service providers like ANM andAnganwadi workers along with community members. The collected hamlet level data was filled in a Panchayat score card. ThePanchayat score card was validated by the Sarpanch and Ward Panchs in each Panchayat. For data entry, report-generationand analysis; a new software was developed by SHRC. The whole data entry work was also streamlined based on learning fromearlier experience and the total cost was reduced considerably. The ranking of the Panchayats as per HDI was done. So in 143Blocks (out of the total 146 blocks in the state), results of the survey have been shared and the awards to the deserving GramthPanchayats have been given on the 26 Jan 2010.15

Dissemination of Results based on analysis :Categorization of Panchayats : All the Panchayats in the state have been categorized into four categories. Thecategorization is based on statistical measures of mean and standard deviation of score value of all the Panchayats. Theyhave been color coded for easy communication. The entire purpose of categorizing the Panchayats into performance wisegroups is to sensitise the Panchayat leadership on the health situation of their areas.Communication with Panchayats : The Swasth Panchayat Survey report 2007 on 32 indicators for all blocks has beenprinted for distribution to all Panchayat leaders, Block and District level officers..Bringing it in Public Domain : The result of Swasth Panchayat Survey 2007and 2009 are uploaded in Department ofHealth and Family Welfare, Chhattisgarh's web site www.cghealth.nic.in. It was utilised during the preparation of State PIP– Chhattisgarh, District Health Planning and Village Health Planning.16

B. Linkage with the Village Health Sanitation Committee:Between 2007 and 2009, 18596 Village Health Sanitation Committees (VHSCs) have been formed to involve local communitiesin addressing the health related problems at the village level, thus covering 92% of villages in the state. The function of the villagehealth sanitation committee is to identify the health related village level issues and to make a plan to address it. VHSC is a subcommitteeof the Gram Panchayat's standing committee on Education, Health and Social Welfare. VHSC instead of beinganother parallel committee, brings together the existing community institutions in the village like PRI representatives,community health workers, SHGs, Youth Clubs, Forest Protection Committees and the local service providers like ANM,Anganwadi worker, School teacher, Panchayat Secretary, NREGA assistant, Water supply mechanic etc. Mitanin being theconvener of the VHSC, acts as an efficient agent to put forward the health agenda in VHSC. One major change in VHSCleadership this year has been the bringing to forefront of women Panchs as leaders of VHSCs. Mitanin Programme again isplaying a key role in facilitating this change on the ground. This year, the existing Convener Mitanins are also making way forother Mitanins in the spirit of rotating formal leadership in VHSCs.Village Health Planning:VHSCs are being facilitated through Mitanin programme to prepare and execute Village Health Plans. It has proven to be atough task. But with 3,600 such plans getting prepared in 2009, the difficult start-up phase seems to be over. Someexamples of problem solving are given below:Aspect: Institutional deliveryGaps: Inadequate Communication, unavailability of medical staff, lack of infrastructure, low level of awareness, expensive,negative impression about govt services, trust on traditional Dais etc.Interventions made by VHSC through Village Health Plan: Arranging the local transport which is available at villagelevel during the time of emergency, Spreading awareness during VHSC meeting on JSY and the benefits of Institutionaldelivery, Negotiating with health department for local arrangement of residence facility for ANM in village and for release theamount of JSY on time etc.Aspect:Safe Drinking WaterGaps: Unavailability of hand pumps, non-functional hand pumps, pit near hand pumps which contaminate the water,unpotable water of hand pumps due to heavy iron content, non-secure source of water used by people.Interventions made by VHSC through Village Health Plan: Ensuring soak pit and drainage, demand hand pump inevery hamlet and to repair the non functional ones, spread awareness on safe drinking water etc.17

A Sample Village Health PlanWeak AspectSpecificallyWeak HabitationRoot CauseAction plannedto resolveproblemPersons whovolunteer toundertake theplanned actionTime Framefor completingactionAccess toAnganwadi servicesPateratolaIt does nothave anAnganwadi centreLink the childrento neighboringcentre as a stopgap arrangementMitanin,neighboringAnganwadiCentre Worker30 daysInstitutionaldeliveryPateratola,HarijantolaReferraltransportnot availableIdentify potentialvehicles for hire anduse untied fundsANM, VHSCPresident10 daysSafe DrinkingWaterNavatolaPateratolaHand pumpis lying brokenMechanic to be informed,use Untied Fund of VHSC(for up to Rs. 500 repair,if needed)Elected Wardrepresentative(Panch)7 daysC. Swasth Panchayat Fellowship ProgrammeWith an objective to strengthen the capacity of PRIs and VHSCs to prepare and execute Village Health Plans, the SwasthPanchayat fellowship programme has been initiated from January 2010. Out of the 25 blocks planned, the programme hasalready started in 20 blocks. These blocks cover some of the Adivasi and Dalit areas from 7 districts - Jashpur, Sarguja, Kanker,Dhamtari, Bastar, Dantewada and Janjgir Champa. The panchayat fellows have been selected from amongst the MitaninTrainers.Objectives:Activation of VHSCsPromoting involvement of PRIs in making Village Health PlansFacilitating Execution of plans and its Review by VHSCsCapacity building of Mitanin Trainers in facilitating VHSCsLocal/block level advocacy on Health, Nutrition and Women's empowermentProgress in first four months of Swasth Panchayat Fellowship InitiativeNo. of VHSCMeetingsFacilitated byPanchayatFellowsper monthNo. of VillageHealth PlansInitiated so farNo. of planswith strongparticipationof PanchayatsNo. ofProblemsIdentifiedin PlansNo. of problemsidentified earlierfor which effortmade towardsSolutionNo. ofProblemssolvedNo. of MTstrained infacilitationprocess42335521332402339129514018

5. Jeevan Deep Samittee: History of Improving Quality of Care in Public HospitalsRogi Kalyan Samittee (Patient Welfare Society) is an innovative project for the management of Public Hospitals throughcommunity participation. All these efforts were started early in the state of Madhya Pradesh, India. The project began in 1994 inMaharaja Yashwantrao Hospital, Indore with a provision of charging nominal user fees as alternative finance to support healthinstitute, of course this was a major advantage for hospital management to collect significant sum of untied funds for localimprovement.Since the Rogi Kalyan Samittee was started to enhance quaility of service, even after putting lots of emphasis to improve publicfacilites, high degree of resistance came from the community. The main criticism was, Rogi Kalyan Samittee were so focussedon collecting user fees that the poorest sections did not get exemption and, as a whole, considerable section of the poor wereexcluded from care.Another major criticism was; the funds generated by user fees, were often not used at all, or not used for hospital improvement.The idea of using the fund in a pro-equity direction for providing subsidies to the poor was never even considered. A thirdproblem was that Rogi kalyan Samittees in backward areas did not collect adequate fund hence, where it was most needed, theydid not take off at all.Looking at all these issues, there was a felt need to re-structure and re-orient the Rogi Kalyan Samittees, which lead to reformsin reconstituting the Jeevan Deep Samittees in Chhattisgarh.Transforming Rogi Kalyan Samittees to Jeevandeep Samittees: The Chhattisgarh contextGauging the experiences from other states, Chhattisgarh took a step forward to transform Rogi Kalyan Samittees intovibrant forums for public participation and decentralized management. The key area amendments were like:a) Nomenclature and New regulations for Public Participation:The Samittees were re-named as Jeevandeep Samittees – A name with a far more positive connotation and newregulations were framed for this society to make it more prone to poor people and local development. Considering theneeds, Jeevan Deep Samittees extended to Primary Health Centres, which were not in the RKS.b) Devolution of Powers:The Samittees were given new powers that enabled them to make substantial improvements in any aspect. Theseincluded the management of the land, developing new income sources, local purchase of machines and medicines andappointments of doctors and other staff members where human resource was critical. The Samittees were also given therights to recommend disciplinary actions against the doctors or the staff members for poor or negligent performance andabsenteeism.19

c) The Hospital Development Plan:Jeevandeep Samittees are being oriented to undertake the responsibility for guiding the hospitals to reach Indian PublicHealth Standards (IPHS) and an improved quality of service delivery. This specially includes Assessment of institution forMaintenance and Utilisation of equipments, appointment of Medical and Non-Medical Human Resources as per therequirements.d) Availability of Medicines:The Samittees are empowered enough to ensure availability of the medicines on the basis of the Essential Drug Listspecified by the State Government, and make arrangements for their free distributions to poor patientse) Catering Service:Except the District Hospitals, no other health facilities provide nutritious food for the admitted patients and for outdoorpatients and their family members. Provisions were made to provide food in the 'Dal Bhaat Kendra' at nominal charges.f) Accommodation for Escorts:In every district level hospital's premises, a 'Dharamshala' was planned to provide boarding for patients' family members.Developments:To facilitate a transition from theory to practice, detail rules incorporating the objectives, membership, eligibility ofmembers, functions and powers of the General Body and Executive Committee etc. were drawn up and published by theState Govenment and disseminated to the community and major stakeholders.1. Performance Rating -- Jeevandeep StarsOne of the core innovations of theJeevandeep programme is performancerating for public health facilities to makevisible and improve the quality of serviceprovision. Every hospitals were assessedtwice annually by an external agencyalong with key officials from theDepartment of Health and Family Welfareand State Health Resource Center,Chhattisgarh. The overall score wasmeasured with a set of parametersconcern with the auxiliary and ancillaryservices in the facility.1. Performance evaluation at District Hospital Korba20

2. Score chart of evaluationType of ServicesTotal ScoreCurative Services 65Ancillary Services 35Auxiliary Services 200Total score 300 -Since the overall objective of this exercise was to sensitize the staff and stakeholders in the hospital, colour coding withappropriate action point were used to simplify hospital issues and concerns even to the layman and make them toparticipate in the development of hospital.3. Colour coding based on the score achieved: based on the parameters:1. 0 to 30 % --------- Red2. 31 to 60 % --------- Yellow3. 61 to 100 % ------- GreenS. No. Score Category Code Colour Action to be Taken1 0 -30% Poor Red Set Priority and Immediate Action2 31-60% Average Yellow Periodic Surveillance3 61-100% Good Green Monitoring and evaluation4. Outcome of performance evaluationStarGolden Star - 95-100%Silver Star - 75-95%Bronze Star - 61-74%No Star - < 60%DistrictNoneKorba, Surguja, DurgRajnandgoan, BilaspurMahasamund, Raigarh, Kanker, Koriya, Raipur, Kawardha, Dantewada, Dhamtari,Janjgir, Jashpur21

With all these efforts of evaluation of health facilities, all the 16 district hospitals were evaluated. On the basis of this, noneof the district hospitals qualify for gold medal, but Korba, Sarguja, and Durg could score up to silver medal category,Rajnandgaon and Bilaspur qualified for bronze medal and rest districts failed to qualify for any category. In the entireprocess of evaluation, SHRC continually supported in making annual plan and implementation of the same and in buildingcapacities too where gaps were found. In the Post evaluation process, the Jeevan Deep Samittee meetings gotregularised: the GB met once to approve the action plan and regular bi-monthly Executive Committee meetings are beingheld, chaired by collector. In-house meetings conducted with technical support from SHRC and strategies developed toaddress the gaps. A detail district hospital improvement plan was prepared besides evaluation of CHCs in the districtscompleted by the DPMU and planning process being geared up.5. ISO Certification:Taking the Jeevan Deep evaluation ahead, Indira Gandhi District Hospital, Korba ( awarded as silver medal in JeevanDeep evaluation), was selected for ISO certification and historically got registered as the first ISO Certifide PublicHealth Facilty in the country. In this entire certification process, SOPs for each department were prepared with properreporting and documentation at every level. More emphasis was given to organizing stores and calibration of equipment,and renovation of Infrastructure. Since the human resource is still a critical issue, many of the support services wereoutsourced leading to positive outcome in the performance of hospitals.Image of Korba District Hospital before and after ISO certification.6. Lessons Learnt from Jeevan Deep Samitee1. Customers are willing to pay for quality medical services in Government Health Institutions.2. Working environment in the Hospitals have improved.3. There is a sense of ownership amongst people vis-à-vis government health institutions.4. Security and sanitation services have been outsourced successfully.5. Peoples' participation through JDS has enhanced the credibility of the government health institutions.22

7. Appointment of Consultants – Hospital AdministratorQuality in health care delivery services is the prime concern of State Health Resource Center. Therefore a number ofeffective steps were taken by the department to provide and improve the quality in human resource where SHRC hadplayed a crucial role. Taking lead in this regard, for the first time in Chhattisgarh, Consultants for Hospital Administrationwere appointed In 14 District Hospitals, for which recruitment was done by SHRC. Since quality improvement is acontinuous process, SHRC has taken the task to mentor these Consultants: Hospital Administrators to streamline the issuein their respective hospitals. They were given two orientation sessions in collaboration with experts from NHSRC, NewDelhi.8. Hospital development plan:-Initiation of development plan for hospitals was one of the aim behind placing consultant hospital administrator in the districthospitals. As such all the 14 district hospitals where administrators are placed, having their hospitals annual developmentplan in hand for future course of development and action for which the financial allocation is available in the NRHMbudgetary allocation. The IPHS survey of all the District Hospitals was conducted prior to developing these annual plans.The cruxes of these activities are, in many hospitals the issues are being solved at ground level with the involvement of localadministration which was even not highlighted previously. Simultaneously performance indicators developed under CRMCis also helping them to set up their Goal and Vision making their hospitals more target based and patient friendly.6. Strengthening FRUs – Enhancing Quality in Primary CareMulti-skilling of the Medical Officers for Emergency Obstetric Care at CHCs ::Availability of specialist in both obstetrics and in anesthesia was the critical gap in making emergency obstetric care in CHCs .Most of the CHCs were without a single specialist and it was unattainable to provide specialists in all the blocks within a limitedtime frame. Therefore, proposal for short term course in Anesthesia and Emergency Obstetrics Care for medical officers was putforward called the 'Multiskilling Programme'. The trainings were conducted in the following three institutes:Pt J.N.M. Medical College, RaipurChhattisgarh Institute of Medical Sciences, BilaspurSector 9 Hospital, BhilaiThe Multiskilling training successfully completed two batches wherein 48 Medical Officers in Emergency Obstetrics and 46Medical Officers in Emergency Anesthesia were trained and reposted to their respective CHCsMonitoring of the ImplementationRigorous monitoring of the programme was done with various officials from different departments. Dr. B. P. Malani wasappointed as Nodal Officer and Dr. T. Sundararaman, the then Director of SHRC and Dr. P.D.Singh were involved inprogramme designing, coordination and monitoring.23

Current Status of the Programme:Rationalization of Human Resource :The issue of transparent and rational posting of doctors is pending since long time. Lack of a fair and non-discriminatorytransfer and promotion policy has resulted in the lack of motivation of doctors who have already completed dedicatedservice in the periphery. Considering all this aspects, policy for rationalisation of human resource was formulated andimplemented in the state. SHRC contributed significantly to this reform process.Process of rationalisationThe listing of excess Specialist doctors or Medical Officers on the basis of “Last in First out” principle was prepared andinstitution in which the total posted Medical Officer is more than the total sanctioned posts were considered as the excessposts for rationalization. In the whole process of the rationalization of human resource, high priority was given to Specialistdoctors and Posting of PGMO against the regular post of specialist was done in case the post remain vacant. Nominationswere invited from the newly selected eligible specialists from the Public Service Commission to fill the vacancies. The newamendment was passed; wherein no specialist doctor or PG Medical Officer will be posted at the PHC level and all thespecialist doctors or PGMOs posted in PHCs will be compulsorily posted in the District Hospitals or Community HealthCenters as per the vacancies. After an intensive exercise, finally, a total of 35 specialists were relocated and posted in twoTable No. 2 Total specialists relocated during the process.stS.No. Cadre 1 Round 2 nd Round Total Number1 GMO Surgery 4 2 62 PGMO Gynecologist 3 3 63 CHILD Specialist 1 1 24 PGMO Pediatrician 6 3 95 PGMO Anesthesia 3 0 36 EmOC Trained 2 4 67 LSAS trained 1 2 3TOTAL 20 15 35State level meeting for Maternal Health Training:­thState level meeting on 11 August, 2009, at the State Training Center Building was organized by Department of Health andFamily Welfare for formal assignment of nodal office for Maternal Health for which SHRC was pushing since long time. Thecore inputs and value additions agenda pushed forward by SHRC viz. Establishment of a “Monitoring Cell” for monitoringand evaluation of training programme vis-a-vis the establishment of a “Quality Assurance Cell” got materialized and cameinto action very recently.24

Orientation meeting for LSAS / EmOC Master Trainer: - 05/02/10Chhattisgarh is considered the pioneer in starting Multiskilling training in state, but it got wedged after two successfulbatches of EmOC and LSAS trainings. Since the training duration of Chhattisgarh was not matching with the GoIguidelines, state was facing difficulties to institutionalize the new batch for LSAS since long time. Finally, after longnegotiation and fulfilling desired criteria for training, GoI has granted permission to start a new batch this year. In this regard,orientation meeting was organized by Department of Health and Family Welfare and NRHM and a new guideline withprotocol was disseminated to the master trainers. Similarly, planning for revised FRUs was discussed with the experts fromGovernment of Gujarat and UNICEF, Delhi Office. Since SHRC is supporting for setting up blood storage unit in the FRUs,detail planning for blood storage unit and future action plan was discussed with experts from UNICEF. Also manyrecommendations put forward by SHRC was agreed and finalized in this workshop. This includes formation of 'QualityMonitoring Cell' for training, revised selection criteria for selection and counseling.EmOC / LSAS selection for batch 2010-11Very recently, selection andcounseling for a new batch wasconducted for the year 2010­11. For this the entire selectionprocess was conducted bySHRC in coordination withNational Rural Health Mission.It came to light that thepreviously trained doctorswere not performing as desireddue to lack of motivation. Toovercome this situation, for thefirst time, a protocol for trainingmotivation test was followed inthe selection process. Basedon this selection criterion, therecommendation list of thoseselected candidates has beenforwarded to the Departmentfor further course of action.25

7. Mainstreaming AYUSHAs the resurgence of AYUSH was increasing in Chhattisgarh, the need for technical expertise for the system was identified bythe State Health Resource Centre. The inclusion ofAYUSH systems into the public health system and mainstreaming activitiesof AYUSH in the state was poor. The need for technical activities not alone in service provision but also in the educational areas.Being first of its kind, the AYUSH Cell in SHRC was started in May 2008 with two technical consultants (AYUSH Specialists) as apart of the team. The major aim for establishment of the Cell was strengthening the AYUSH sector with the technical backbonefor all the initiatives undertaken in the state, to give focused attention to the development and optimal utilization of this branch ofmedicine and to ensure that AYUSH practitioners are brought under the regular health system, exploring the new dimensions ofAYUSH health care and provision of QualityAYUSH services in the state has been the priority.Objectives:Technical Support to Department of AYUSH in all the areas from AYUSH Education to Health System strengthening.Standardization of AYUSH Health Care servicesStrengthening AYUSH Education to increase technical workforce in AYUSHImproving the Quality of AYUSH medicines by strengthening drug testing and researchCapacity building initiatives and improving the technical skills of doctors. Initiatives for development of innovative projects for enhancing the popularity of the system. Additional pooling of resources from donor agencies for improving the AYUSH health care delivery systemConduct research and studies on the inclusion of AYUSH in public health systems.Activities implemented:1. Innovative Programmes and SchemesA. Mobilizing and Strengthening AYUSH Deep Samiti:Enhancing the AYUSH infrastructure and development of AYUSH Health Care institutions dispensaries and hospitals ascentres of excellence has identified the need for development of Institution based committees functioning for thebetterment of health care services. Strengthening AYUSH Deep Samiti at facility level had two major initiatives- orientationtraining for 408AYUSH medical officers and 816 functionaries ofAYUSH Deep Samiti in March 2009.AYUSH Cell SHRC Inputs:Resource Persons for the training of AYUSH Deep SamitiCoordination for the training with the department of AYUSHOutput:Formation of 17 AYUSH Deep Samiti and 698 UpsamitiIncreasing the coordination among the members of AYUSH Deep SamitiPercolation of the concept of AYUSH Deep to grassroot level.26

B. AYUSH Health Melas:The health care in AYUSH is limited to specific IPD and OPD services and the underserved areas in AYUSH were deficientof these services at the periphery and difficult areas. To increase the outreach of services in the rural pockets a plan forconduction of District level and Block level melas were devised. An operational module on health melas is developed byAYUSH Cell for health melas.AYUSH Cell Inputs:Planning for resource pooling for the Health MelasOperationalization ,implementation of District and Block level Health MelasFor uniformity in conduction of block level and district level health melas, development of Module named as AYUSHSwasthya Mela Nirdeshika was conceptualized, designed and developed by the AYUSH Cell.Development of Annual plan for districts for conduction of health melas throughout the yearOutput of the programme:Conducted a total of 584 health camps at block level and 36 District levelTwo lakh and 50 thousand beneficiaries.C. Ayurvedgram Scheme:The Scheme for propagation of Ayurveda to the common masses and addressing the use of herbal heritage available inChhattisgarh and initiation of behavioural change communication for adoption of Ayurveda based lifestyle. Twoorientation workshops were conducted by the technical support of SHRC. The first Orientation workshop was conducted on19 May 2009 at Circuit house and 150 doctors were oriented and the second workshop was conducted on 25 September2009 at circuit house where 200 participants( doctors functional committee) were oriented on Operationalization ofAyurvedgram. One Week Yoga Training Programme in Ayurvedgram for general public was organized from 8-14February,2010 in coordination with Patanjali yog peetha where SHRC has supported for assessment of curriculum andconduction of training, where the total beneficiaries were 41,000.The propagation of AYUSH system of medicines to thegrassroot level requires creation of awareness of AYUSH to the general public by different modes of communication andusage was the reason for generation of AYUSH Bhav Kaladal- the AYUSH Folklore. The Kaladal was conceptualized andtrained for propagation and popularization of AYUSH based principles and remedies with technical support of MitaninProgramme members. The performance of kaladal in 121 Ayurvedgram was conducted from February to March 2010.Total camps conducted in the Ayurvedgrams were 674 and the beneficiaries were approximately-1.20 lakh.2. Capacity Building Initiative:A. TOT on Essential Maternal and Child Health :The AYUSH Cell had planned for comprehensive training programme targeted to increase numbers of skilled birthattendants, to improve institutional deliveries in the state. The training was conducted in June 2009 and total 36participants were trained at SHIFW, Medical College and District Hospitals.27

AYUSH Cell Inputs: Development of AYUSH Component of the training material in coordination with the Government Ayurveda College.Identification of resource persons from Ambedkar medical college and 36 participants- Medical Officers(Pediatricianand Gynecologist) from Districts Hospitals and two AYUSH Medical Officers from each districtCoordination of 12 day TOT training on Essential Maternal and Child HealthOutput of the programme:TOT training completed for 36 participantsB. AYUSH Pharmacists training on medicine preparation, storage and dispensing:AYUSH pharmacists being integral part of AYUSH health care delivery system and the need for up gradation of the skills ofthese manpower was essential. The AYUSH pharmacists handles medicines and the training on preparation of simplemedicines and utility of herbal medicines was essential to increase their output. The training was conducted in GovernmentAyurveda College, Raipur from 10January- 10 March 2010.AYUSH Cell Inputs:Inclusion of the training in the PIP plan for resource allocationDevelopment of the module for training of AYUSH paramedics in coordination withthe Government Ayurveda College.Output:Completed the training for 400 AYUSH pharmacists; the first of its kind in the Country.C. Training of Anganwadi Workers on Herbal home remedies for the Mother and Child Health CareAnganwadis are the centres directly connected with the nutrition and overall development of mother and child. Thisdepartment needs to be directly linked with health for better outputs from the Anganwadi Kendra. The TOT for theAnganwadi Workers which was conducted in Patidhar Bhavan in 23-29 April, 2010 is directly linked with mother and childhealth by health principles of AYUSH and total 200 trainees were trained; of these 130 Block trainers of Mitanin Programmeand 70 Programme Officers of ICDS who will later train the field level 35,000 Anganwadi Workers.AYUSH Cell SHRC Inputs:Development of module for Mother and Child Care and Ayurveda and conduction of TOT trainingOutput:Module developed and TOT training of Anganwadi workers on herbal home remedies completed.Creation of interest in the Ayurvedgram Scheme by the Villagers.28

3. Medicine Procurement Process:To regularize the medicine supply and to strengthen the procurement system in AYUSH, the Essential Drug list was theneed of the day. The Essential Medicines which are to be procured for the supply to AYUSH dispensaries and Hospitals areto be listed.AYUSH Cell SHRC Inputs:Careful assessment of the demands from the Hospitals and dispensaries as well as identification of medicine need asper the demand. The Ayurveda Medicines, Unani medicines and Homeopathy medicines were assessed andEssential Drug List for AYUSH was prepared and the book was designed by SHRC.Output:Provision of AYUSH Medicines which are essential for the AYUSH Dispensaries and Hospitals.4. Workshops and Related activities:A. Advocacy Meeting for Mainstreaming AYUSH with Department of AYUSH and WHO Country office:Mainstreaming of AYUSH is the major concern of the Department of AYUSH in the state and the activities for the same arewelcome by the state. The WHO country office and department of AYUSH jointly have identified the gaps in the system anddeveloped the means and ways to fill the weak loop holes in AYUSH for creation of vision document of AYUSH.AYUSH Cell SHRC Inputs:Conduction and coordination of the workshop and identification of the participants for the meetingIdentification of gaps in the AYUSH sector for the mainstreaming activities of AYUSH.Developed a report on mainstreaming of AYUSH in Chhattisgarh and submitted to WHO consultant, Mrs. Anita Das.Outcome:Identification of the gaps in the system and strategies to be adopted were discussed in the meeting.B. Homeopathy campaign for Mother and Child Health Care:Keeping in the view of the impact of loss of precious life of mother and children with avoidable causes on individuals,communities and societies, Department of AYUSH, GOI affirmed to reduce the Maternal Mortality and Infant Mortality Rateby Nation Wide Homeopathy Campaign due to its safety and effectivness. The state level campaign in Chhattisgarh waslaunched on 13-14 February 2010 at Hotel Babylon Inn, Raipur and 184 participants were sensitized on efficacy ofHomeopathy for mother and child health with the technical support of AYUSH Cell.29

AYUSH Cell InputsIdentification of resource personsPlanning technical sessions and conduction and coordination of two days orientation workshop.Technical inputs in policy maker's session for Homeopathy in Mother and Child Health Care. Development of IECmaterial for the workshop- 4 Posters and 12 brochuresOutput of the programmeConduction of two days workshop on mother and child health careFormulation of report on the two days workshop of Homeopathy.D. Arogya Mela:In AYUSH Stall in Arogya Melas, the IEC material printed for sensitization of the stakeholders were technicallydesigned by AYUSH Cell.5. Planning and Resource Allocation:AYUSH Cell SHRC inputs: Formulation of AYUSH Component and budget plan for NRHM PIP 2010-11.Formulation of plans for fund allocation under Europeon Union State Partnership programmeDevelopment of proposals of Essential Medicine, Upgradation of AYUSH Hospitals, Development of AYUSHinfrastructure and other capacity building and Exposure visit programmes for the funding from Department ofAYUSH, GOIDevelopment of Vision plan for AYUSH in Chhattisgarh:As the roadmap of AYUSH was required by the State Yojana Mandal, careful assessment of the current gaps in theAYUSH Sector was identified and vision document for AYUSH was developed which can be an answer for thecurrent deficit in AYUSHDrafted a report on mainstreaming of AYUSH in Chhattisgarh for WHO Country office for simultaneousdevelopment of vision paper of AYUSH.Challenges Faced:Disparities within the AYUSH systems of medicine in service delivery.Prevalent gaps in the supply side as a lacunae in Service delivery.Technical competence at district levels are poor for execution of the activity.Reporting of the activities of all the programmes and schemes are not uniform from the districts which directlycreate difficulty in monitoring and evaluation of activities.30

Future Dimension:Sensitization of other stakeholders of Health with the Strengths of AYUSH Systems:To enhance the Convergence of AYUSH Systems and health care system, orientation and sensitization workshopsare to be designed for the development of Health Care system in the state.Improving the AYUSH Health Care facilities to attain ISO Certification:Assessment of current gaps in supply as well as demand side; a study is planned to create a solution by planning andvaried management .Standardization of the health care facilities for accreditation and ISO certification.Development of roadmap of mainstreaming activities of AYUSH in the State.Mainstreaming of AYUSH in the state needs creation of roadmap of AYUSH in the state, which shall be a guide forImprovement of activities in the state.Improving AYUSH HMIS:Exploring the AYUSH health Information is essential. How to enhance the data from the field level ,what to be collectedform field level and validation of the data and development of the schemes as per the AYUSH Health Care needs is tobe developed.Standardization of AYUSH Educational Institutions:Standardizing the AYUSH Educational institutions is a must for the disbursement of AYUSH health care organization inthe state. The world class educational institutions of AYUSH need to be developed in the state. This will be a mode toattract students from other States and Countries to reach to the state and avail quality education. The AyurvedaCollege in the state needs to be developed for the standardization of health care in the state.Increasing the Research and Development activities of AYUSH in the State:Development of Ayurveda College as State of Art Institute for the development of Clinical Research Centre in thepremises. Introducing the research methodologies in the syllabus of AYUSH systems of medicine and introducingconstant activities for improvement of the research and technical skills in Govt. Educational Institutions.Capacity building of AYUSH physicians and paramedics :To improve the Clinical competency and new skills to be acquired, the AYUSH Health care providers need to beconstantly subjected to the programmes, workshops and CME. This shall help the AYUSH physicians to compete withthe modern systems of medicine and further improving the quality of care and core competence.8. Chhattisgarh Health Equipment Management SystemBackground:To deliver good quality healthcare services, a large number of medical equipments, both diagnostic and curative, arerequired. Consequently, the medical equipments, often very sophisticated and costly, require proper management, rightfrom planning to purchase and from use to condemnation.A World Bank study shows that in India, while 2-5% of district/town hospital budget is earmarked for “machinery andequipment,” while maintenance budget is merely 0.02-0.06% and rural health institutions have no maintenance budget atall, [World Development Report, 1994].31

The findings of a study in this regard, conducted by the Directorate of Health Services in Chhattisgarh, are quite revealing.A large number of costly equipment is idle in many of the Health care institutions, Reasons:1. Unaware about the existence of equipment.2. Lack of Technical personnel who can handle the equipments.3. Lack of annual maintenance contract (AMC).4. Improper breakdown maintenance services due to lack of bio-medical engineers or other competent persons.5. Transfer of in charge persons without completing formal handing over and taking over formalities.6. Improper stock recording and no annual physical verification exercise in place.7. There is no proper system for tracking of instruments from the place of purchase and distribution to the place ofinstallation.8. Payment is released on basis of inappropriate knowledge or inadequate reports and it is being certified bynon-technical authority.To solve these problems, “Chhattisgarh Health Equipment Management System (CGHEMS)” was established in the last quarterof 2008-09 with the initiation of State Health Resource Centre. Infrastructure for the state office is also established with essentialprerequisite. There are subsequently some specific outcomes in 2009-10. During this period it was supported by EUSPPprogramme, and the training component was budgeted in NRHM, which was initiated, but will be completed in the year 2010-11.Objectives:1. To facilitate functioning of a state level technical 7. Develop a web based online inventory managementcommittee for procuring drugs and equipments insystem for real time information on available stocks anda transparent manner.regular consumption of spares and consumables2. To ensure continuity of operations and services of 8. Capacity building of personnel at different level for day toinstitutions by maintaining a smooth functioningday management and operations of equipmentsof the equipments and appliances.9. To ensure and supervise regular calibration of the3. To assist in need-based purchase of equipment equipmentsat different levels.10. To ensure proper and timely disposal of scraps and4. To facilitate proper selection of vendors and condemned equipments.procurement of equipments10. To develop a system for optimal utilization of equipments5. To help in developing terms of reference for including plan for relocation, mobilizations etc.annual maintenance contract for bigger and12. To initiate Documentation – To inform authorities aboutcostlier equipments while arranging repairs forthe list of equipments and appliances present in differentsmaller ones at local levelinstitutions so that they can make appropriate use of6. To develop inventory management system for them and do not raise requisition for additionalequipment & sparesequipments.The funds available with Rogi Kalyan Samiti (JDS) under NRHM are inadequate to meet the investments and expenses that runin crores.32

Strategies/Plan of Action1. Set-up of a Central Equipment Maintenance Cell at the state level serving as a technical body to the Government ofChhattisgarh.2. Set-up of District cells to cater to the needs of Districts.3. To establish a technical cell at state implementing annual maintenance contract to take care of periodical review ofthe performance of the vendors against their services.4. Select and empanel a number of reliable, expert local vendors/contractors for repair works of equipments on callbasis5. Develop Standard Procedures for purchase, tenders, installations, maintenance etc.6. Develop inventory control system for drugs, equipments and spares7. Clean-up campaign for disposal of the condemned and obsolete equipments and appliances8. Develop district level cadre for preventive maintenance.9. Prepare a cadre of Technicians in hospitals equipment repairs from facilities by arranging practical training atChhattisgarh Health Equipment Management System10. Fix a set of minimum performance parameter for technicians based on their qualifications and level of postings.This will help to evaluate their performance for providing incentives or disincentives.Expected Outcomes1. Service delivery : Greater patient satisfaction from improved service quality and reduced out of pocketexpenditure to patients for diagnostic and curative services, which they incur due to non-functioning machinery.2. Financial : Increase fund utilization from optimized machinery life and reduced operating capital and expense3. Documentation : For evidence-based planning and prevention of duplicate or inaccurate purchase.Achievements so far:State has developed the Chhattisgarh Health Equipment Management System (CGHEMS) in 2009-2010 and thefollowing tasks were accomplished.1. 2 days training programme on X-Ray machines, Imaging equipment and safety measures, of 95 Radiographertechnicians have been completed.2. State level TOT has been completed with 45 Staff nurses on the essential equipment management, operation andutilization technique at periphery level.3. 648 equipments have been repaired in the state with its own capacity upon request of hospitals.4. System has located and identified the unused 30,000 equipments lying scattered in the state and recommended forrelocation. Strategy for relocation is under process and would be undertaken.5. Developed terms of reference for annual maintenance contract of equipment.Modifications in 2010-11:Every district will have CGHEMS unit with 2 technical assistants one for the district hospital and one for the peripherycentres, at the same time at state level there will be 3 engineers having expertise in biomedical, mechanical engineering ormedical instrumentation.33

CGHEMS has now been completely handed over to the Directorate of Health Services and the whole role andresponsibility of overall monitoring and evaluation of the same will be that of the Directorate.The formal handing over of the equipments and assets provided by SHRC to CGHEMS for official use is yet to be done.After repeated reminder and request for retrieval of these assets there is no response from the CGHEMS Cell.9. Rural Medical Assistant (RMA): Viable solution for Primary Health Care.To provide health care services to rural population has been a herculean task and the greatest challenge to overcome sincethe concepts of Primary Health emerged. There after many experiments and interventions have been tried to fillip the gapof Rural Health Care services, but still the ultimate solution is yet to be explored. Since this is a universal area of concern,many states like Maharashtra, West Bengal and Karnataka tried different alternatives and initiatives to provide specialcadres to work in remote and rural areas especially for the marginalized population. In a similar view, in 2001, Governmentof Chhattisgarh introduced the three years course called 'Practitioners in Modern and Holistic Medicine'. Students whohave completed the course have been posted as 'Rural Medical Assistant (RMA)' in all the PHCs and some even at theCHCs, especially the lady RMAs. As such there is no ultimate solution to fill the dearth of health professionals in the ruralareas, but Chhattisgarh, currently, is putting its best effort to overcome this challenge by introducing these RMAs andvisibly the improvement and positive results are being witnessed through these Cadre.From the very initiation of the RMA program, SHRC has played crucial role in conceptualization and policy formulation ofthe three years course. Also with critical analysis and advices for the experts, strong recommendation was given to postRMAs in the identified and needy areas. Later it was included in the National Rural Heath Mission Project Implementationplan which was appreciated and approved by the Government of India. Since this three year course is a unique feature inthe health care delivery system, developing job profile for this cadre was bit critical. SHRC was given the task to draft the jobprofile in relevance to Chhattisgarh context. Still there are many issues which need to be taken care of for which SHRC isproviding continuous technical support. Very recently MCI organized national level meeting for policy analysis anddevelopment of a three year course. Members from SHRC represented Chhattisgarh with key officials from stategovernment.No matter what alternative solution could be or the ultimate solution is; RMAs are not an alternative to the actual HealthCare Providers at the Primary Health Centers.Chhattisgarh has got a new ray of hope for Primary Health Care delivery system through these RMAs10. Establishment of Chhattisgarh Medical Services Corporation (CGMSC)Improper/irrational handling, storage and use of medicines have been a grave issue of concern in the State.Inappropriately dispensed medicine leads to wastage of scarce resources and wide spread health hazards, which leadsto misuse of the precious commodity indispensible for saving life. Quality and safety of medicine is less in the low incomecountries which includes India. Easy access to the medicine as per the aroused demand which are not predictable in casesof disease out breaks and adverse calamities, shall depend on effective storage and distribution System ,which needs tobe developed at the level of primary health services.34

People of Chhattisgarh have been subjected to poor access to medicine as the resources are scarce and the drugprocurement and storage system is haphazard. Strategies and methods is in process to devise and create a strongmedicine procurement and storage system to improve the medicine flow to the health care institutions.To achieve the objective of a rational drug management system, abiding to the applicable laws of the state with regulatoryrequirements pertaining to the drugs and medicines a quality policy is adopted in the state. The Protocol / Policy aimed toproviding a systematic and uniform approach in the decision-making process relating to the procurement of essentialdrugs and supplies. In other words availability of quality drugs in the specified quantity at appropriate time and place at themost competitive price is aimed at.Proposed CGMSC-The policy also seeking to put in place an efficient economic system based on the guidelines of the Central VigilanceCommission for the procurement of goods/ services in a transparent manner. For all above, one systemic reform isproposed to work for the procurement and logistic / inventory management. The past experience of Tamil-Nadu state,where one corporation known as TNMSC (Tamil-Nadu Medical Services Corporation) is established for all, is one of thebest practices to reduce the above mentioned gaps. Chhattisgarh State likely to establish CGMSC based on TNMSCmodel. It is proposed to develop the head office for procurement and handling of distribution of medicine, and 6 districtsWare House will be developed initially in strategic regional locations in identified place for storage and distribution ofmedicine to health facilities. Mr. R. Poornalingam (IAS), Rtd. Chairman, Task force, Procurement & Logistic Management,MOHFW, Govt. of India had visited the state for preparatory works of establishment of Chhattisgarh Medical ServicesCorporation (CGMSC) and highly recommended the feasibility & need of CGMSC.Activities ­The requirement for establishment of the CGMSC in the State and Districts are to specify dosage size, primary andsecondary packaging standards, design and develop organogram for state/district Drug Ware House and Procurement,creating adequate storage facility, designing the layout for State and develop districts and CHC Drug Ware House, whichSHRC had undertaken.Monitoring and Evaluation ­The Computerized System will evolve the scientific statements for the effective planning and execution for Systematizedprocurement and supply system. The monitoring of the drug distribution system needs to be initiated from the fore castingof the requirement processing of tender notice to the management information system which handlesProcurement/Logistics functions of health commodities.Role of SHRC in the establishment of CGMSC­SHRC was involved in the conceptualization and formation of CGMSC from the very initial stage. Two days exposure visitth thto TNMSC, Tamilnadu State and Karnataka state was undertaken from 12 -13 may 2009, the state team comprised of fivemembers. On the basis of this, the design and infrastructure layout for Drug Warehouse for State, Districts and Blocks wasprepared. Further on the basis of this visit, a state level meeting was conducted on 03-08-09 and 28-10-09 with Secretary,Health, Director Health Services, Mr. R. Poornalingam (IAS) Rtd. Chairman, Task force, Procurement & LogisticManagement, MoHFW, Govt.of India and other stake holders. The concept and proposal for the establishment of CGMSChas been approved and is under process.35

11. Leprosy Cell: 'Accelerating the NLEP programme'Even when India has reached nearer to elimination of Leprosy but Chhattisgarh is still struggling to tackle the highprevalence rate in the state. The statistics have shown that Chhattisgarh is a highly endemic state in India and the sixknown districts are contributing more in this regard. Since Leprosy elimination is high priority in state, the government hastaken up many steps to boost up the DPMR services in the state. By virtue of this, SHRC also took the opportunity and theinitiative to support Disability Prevention and Medical Rehabilitation (DPMR) activity implementation at primary healthlevel and secondary level besides tertiary level.With this vision SHRC has appointed Dr. S. L. Gupta (Retired Senior District Leprosy Officer) as consultant to facilitate andaccelerate the ongoing Leprosy Elimination Programme by providing technical support and capacity building which is oneof the most important activity under the “Disability Prevention and Medical Rehabilitation”. Also Capacity building of all staffincluding medical officers, Recognition of complications including reactions , neuritis and its management , recordmaintenance of DPMR, Community Mobilization through cost effective IEC by involving block, district and state levelfunctionaries.With this vision, Dr. Gupta participated and became a master trainer in National Level Workshop on strategicDetection/Survey of leprosy cases in identified Districts. Recently intensive field visit with interventional strategy done inhigh focus districts- Manhasamund, Raiagarh, Janjgir Champa, Bastar and Dantewada and provided capacity to improvethe effectiveness of the programme to the officials of Districts and Blocks. Based on the field review and current situation aseven points recommendations is being developed to involve the Government to improve the programme. Besides these,SHRC started a sensitizing drive of all the district Collectors about this programme for special attention and had recentlycompleted mahasamund district on this aspect.36

Chapter 3 : Policies, Strategies & Proposals Contribution under Health Sector ReformsSHRC has been playing, since its inception, a pivotal role in supporting and contributing to the Health Sector Reforms innumerous ways viz. Conceptualisation, review and formulation of Policies, Acts and Project Proposals besides, healthprogrammes initiatives, implementation and monitoring of reforms process in the Health Sector of Chhattisgarh State, alwayswith utmost care, sensitivity and inclination toward pro-poor perspective. Few major contributions in this context are asmentioned below:1. Policy/Drafts formulation:a. Chhattisgarh Health and Population Policyb. Closing Gaps in Medical Officers for Rural Areasc. Health Insurance Programme for the Poor for the State Governmentd. Chhattisgarh Nursing Homes and Medical Establishment Acte. PPP in Health Sector with Monitoring Mechanism2. Review and inputs:a. Organ Transplant Policyb. Non Communicable Diseases Policyc. Human Resource Council3. Project Proposal Formulation:a. EU-SPP Programme Design:The State Government of Chhattisgarh sought funding support from the European Union under EU State PartnershipProgramme for improving the status of various development sectors- particularly health & education. The partnershipprogramme took off by the end of 2006. SHRC has played a key role in preparing the background paper for healthsector partnership as well as in preparing the plan and in initiating the process towards Medium Term ExpenditureFramework for health. SHRC has been providing technical assistance for planning of European Union StatePartnership Programme since 2006.b. NRHM-RCH PIP FormulationSHRC has made significant contribution towards health planning efforts under NRHM. It has facilitated the DistrictProgramme Managers in preparation of District Health Plans through situation analytical approaches withconsultations of the district concerns. It is part of the State Task Force for formulation of the state PIP for NRHM. Withreference to preparation of NRHM state PIPs, SHRC has been the principal technical agency. For the first initial yearswhen NRHM was introduced in Chhattisgarh, it was SHRC which conceptualised, drafted and compiled the NRHMPIPs for the State.38

c. Establishment of Chhattisgarh State Medical Service CorporationSHRC has been providing technical support for setting up a logistics and drug procurement system for the stateincluding the creation of a new Corporation for the purpose. The proposals and policies for setting up the CGMSC wasdeveloped by SHRC with consultation from the Directorate of Health Services.ththd. Drafted the health sector proposals under 11 and 13 Finance Commissione. Policy and Strategy formulation for Chhattisgarh Rural Medical Corps (CRMC):The initial concept note for Chhattisgarh Rural Medical Corp was prepared by SHRC and proposed in the NRHM StatePIP and EUSPP in 2008-09. Further a task force was made with the NRHM Unit where the SHRC had the pivotal role indeveloping the strategy.f. Technical Support and institutional strengthening to Directorate of Health Servicesand Health SocietyOperationalisation of SIHFWOperationalisation of CGHEMSOperationalisation of PHRNSupporting the Health Department in preparing the National and State reviews as well asDistrict Health Planning.g. Design and Development of Rare and Critical Disease Schemes1. Chief Minister’s Child Heart Protection Scheme:SHRC actively played a pivotal role in conceptualizing and initiating the policy and implementation of the 'Child HeartProtection Scheme', popularly known as the 'Mukhya Mantri Bal Hruday Suraksha Yojana' in the state of Chhattisgarh.The scheme had been launched and successfully being implemented since the last 3 years. SHRC till date providescontinuous technical support and advice as and when required. Dr. K.R. Antony, Director, and Dr. Kamlesh Jain,Technical Advisor, Public Health, SHRC are actively involved in the scheme as Advisory Committee members of theScheme.2. Chief Minister’s Cochlear Implant Scheme to restore the congenital hearing loss:SHRC in consultation with faculty of Medical Colleges had undergone a consultative process to analyse the emergingproblem of hearing loss in young children. Following this the need to develop a scheme was felt as the poor andmarginalised section of the population were not in a position to afford the high cost of the operation. Taking the situationat hand SHRC took the initiative of designing and developing the scheme. Dr. K.R. Antony and Dr. Kamlesh Jain fromSHRC are members of the Advisory Committee of the scheme.39

Chapter 4 : Research and Studies...SHRC has over the years conducted a number of Research and Studies independently as well as in collaboration with otherinstitutions and organisations. To mention a few...1. A Study on Issues of Workforce Management, Rationalization of Services and Human ResourceDevelopment in the Public Health Systems of Chhattisgarh State2. The Unaccounted Newborn - Issues of Birth Registration in Chhattisgarh (Supported by UNICEF)3. Patterns of illness and Cost of Health Care (Supported by Action Aid, India)4. Nutrition Programme for Adolescent Girls (NPAG) - SARGUJA (C.G.) (Supported by NFI, India)5. National Rural Health Mission – Hopes and Fears6. Prescription AnalysisStudies conducted in the year 2009-10:1. A study on the nursing and midwifery service organization and performance inChhattisgarh and compare with Orissa, Bihar and Rajasthan.Introduction:A study was conducted in Chhattisgarh by National Health Systems Resource Center (NHSRC) and the Academy ofNursing Studies (Hyderabad) with the collaboration of SHRC to study the nursing and midwifery service organizationand performance in Chhattisgarh and compare with Orissa, Bihar and Rajasthan.Objectives of the study:To review the organization of nursing and midwifery service in the state public health systemTo assess the geographical distribution of nursing and midwifery human resource and the influencing factors in theinequalities with the state and across the state.To review the workforce management policies for nursing and midwifery service of state health system includingcareer progression, working condition in public and private sector and the reason for not pursuing professionalcareer.The relative workforce performance, working conditions, and the extent of skills in nursing and ANMTo compare the service polices for contractual and regular staff as well as divergent features and utility of serviceTo examine the current admission capacity (public and private) in GNM and ANM schools. more specially in tribalblocks and underserved areas41

Role of SHRC:SHRC coordinated with the Department of Health and Family Welfare and NRHM unit to provide support and required datafrom various departments and institutions. Similarly provided orientation to research team and held discussion on existingnursing and human resource policy and its application in the State.2. Assessment of the impact of Janani Suraksha Yojana (JSY) on Promotion ofInstitutional DeliveryA study on Janani Suraksha Yojna (JSY) was conducted by SHRC to assess the impact of it on promotion of institutionaldelivery.The Objective of this study was:1. To measure the change in rate of institutional delivery since implementation of the scheme2. To measure the time gap in disbursal of fund from date of delivery.Major Findings1. 52.4 % families of home delivery and 15.5 % institutional deliveries received incentive2. 8.9 % of home deliveries had received amount less than the stipulated amount.3. About 5 % home deliveries and 14 % of institutional deliveries received money within a week, 8 % families after6 months for institutional deliveries and 11.1 % for home deliveries.4. 37.6 % beneficiaries did not receive any transportation cost.:3. A study on Multi skilling: Evaluation of Life Saving Anesthetic Skills Training for MBBSDoctors in Chhattisgarh.This Study was conducted to evaluate the Life Saving Anesthesia Skills Program in Chhattisgarh, which is beingimplemented since the year 2004. The evaluation was conducted by the National Health System Resource Center(NHSRC) and IIM Ahmadabad with the support of State Health Resource Center. The aim of the study was to evaluate theLife Saving Anesthetic Skills Training for MBBS Doctors in Chhattisgarh.Objective of study:1. To obtain the current posting and performance status of all medical officers trained in anesthetic skills since 2004.2. To analyze the trends present within groups of performing and non-performing trainees and highlight factors thosewere common amongst the trainees.Role of SHRC:SHRC coordinated with the state official to conduct and to support this study, similarly all the possible support wereprovided for literature review, background information, current situation of program and sampling accordingly. AlsoCoordinate with Master Trainers and head of training institute to participate and to provide adequate support for the study.42

4. A study on the design of the Recording Formats for ANMs in ChhattisgarhA study was conducted in Chhattisgarh in collaboration with T. A. Pai Management Institute, Manipal, for designing theRecording Formats for ANMs. The project was to analyse the current ANM register, data recording and exporting.Objective of the studyTo design a more efficient data recording format for the ANMs (Auxiliary Nurse Midwives).Role of SHRCSHRC guided and provided technical support in coordinating with the Department of Health and Family Welfare, NationalRural Health Mission and at field level to provide support and required data for this study.Major Recommendations –Consolidate the registers to decrease the physical load on ANMsStandardize the recording formats across the state to avoid any data loss and to ensure all required datais capturedJudiciously allocate the number of pages to minimize wastage.5. A Study on Village Health and Sanitation CommitteeSHRC conducted a sample assessment of 53 VHSCs spread across 8 districts and 22 blocks of the state specifically onFormation, Functioning and Utilization pattern of Untied Grants received. Besides a separate sample survey of more than1000 VHSCs was carried out to assess the Utilization of Funds.Major findings and recommendations:It was found that there was adequate representation from the Women Self Help Groups, Mitanins and Panchs and PRImembers is 90%, more than 94% accounts were opened, 75% received trainings, but the utilization of funds was very poorat 30% at the time of the assessment. Though the utilization pattern covered a myriad of sectors as desired viz. Health andSanitation, Social, Institutional strengthening, motivation (incentives to TBAs and Mitanins). Based on these findings aspeedy action on providing orientation and training of all districts and block level officials was recommended as well as onutilization of the grants.6. Study on Hospital Management of Durg District7. Study on Mitanin Drug Use8. Study on Assessment of Child Heart Protection Scheme for further Programme Correction.43

Studies completed early this year...1. A study of PHCs in Chhattisgarh in collaboration with PHFI and NHSRC New DelhiA. Chhattisgarh Experience with 3 year course for Rural Health Care Practitioners: A Case StudyThe study explored the origin, initiation and the various processes and changes undergone in terms of policies andpolitical interests in operationalising the programme. It also studied the challenges and hurdles which the cadrethemselves had to face in the course of pursuing their study and ultimately the various challenges being met at theirworking place (PHCs/CHCs), especially, system adjustments and acceptance in the whole hierarchy of the publichealth system. Finally, the discussions and suggestions, vis-à-vis the pros and cons of introducing this unique cadre inthe public health system/structure.B. Which Doctor for Rural India? : An assessment of Primary Health Care CliniciansThis study provides a comparative assessment of the performance of different types of primary health care clinicians –Medical Officers, non-physician clinicians with short training duration i.e. RMAs, AYUSH physicians and paramedicalstaff (nurses and pharmacists) – in their capacity as the main providers of clinical services at PHCs. The performanceof these clinicians is examined on several dimensions. First, their competence ('how much they know') to manageconditions like malaria, diarrhea, pneumonia, TB, preeclampsia and diabetes. Second, how patients and thecommunities they work in view them in terms of satisfaction with services and perceptions about the quality of carereceived. Third, how much the PHCs they work in are used by ill community members. Finally, it examines theirattitudes towards rural service and levels of job satisfaction. Assessing the performance of these different types ofclinicians on a variety of dimensions enables a comprehensive understanding of their suitability as primary health careproviders. The study was conducted in the state of Chhattisgarh in 2009.C. Factors influencing decisions of Doctors to serve in Rural and Remote areas of ChhattisgarhState : A Qualitative Research StudyIn this qualitative research study the objective was to explore the converse – the reasons why some qualified healthworkers remain and continue to serve in otherwise underserved rural and remote areas. Thirty-seven in-depthinterviews were conducted with medical practitioners serving in rural healthcare facilities in seven districts ofChhattisgarh, in July and August 2009. Data were thematically analyzed using the “framework” approach for appliedqualitative research.Ongoing Research...1. Menopausal Study in Chhattisgarh: Pattern of Menopause in Chhattisgarh: In process (Conceptual andMethodology finalised)2. HBNC Baseline3. Better Medicine for Children Project in Chhattisgarh: A survey of the availability and price of Children'sMedicine4. Facility assessment and standardisation of AYUSH services44

Chapter 5 : SHRC PublicationsSHRC has a number of Publications for strengthening Public Health and for influencing the Health Sector Reforms and policiescoupled with training modules for community health volunteers. Similar publications produced in 2009-10 and further on theanvil are as follows…Nanhemaan Ke Poshan Aur ParamarshA Training Module for Mitanins onInfant Young Child and FeedingSehat Ke KetabA Training Module for Mitanins onBehaviour Change and CommunicationNanheman Ke SehatA training Module for AWWS on IMNCI46

Sugghar Swasth Hamar AspaasA Training Module for AWWson AYUSHLalna Ke JatanA Training Module for Mitaninson Home Based Neonatal CareMitanin PatiA News Letteron Women Empowerment and MitaninsAyurved Gram Yojna NirdeshikaA Guideline for Ayurved Scheme47

Ayush Deep Samiti SandarshikaAvum NiyamawaliA Guideline for Ayushdeep SamitiDast Ke IlajA training module on Zinc and ORSfor Diarrhoe managementFurther modules under production...Chale Chalo Mitanin Sangh AA Training Module for Mitaninson Malaria and LeprosyChale Chalo Mitanin Sangh BA Training Module for Mitaninson HIV/AIDS and TB48

Chapter 6 : Audio – Visual LibrarySHRC has produced a number of films, radio programmes and songs based on various health issues and programmes in localdialects for extensive dissemination and coverage as a medium for IEC/BCC at all levels, especially at the local and communitylevel. Few major productions of these are as follows:1. Documentary films on:a. Swasthya Panchayat:Documentary on the concept, process, implementation and impact of the Swasth Panchayat Yojna has been developed (aUNDP supported Film).b. Real Life Heroes:SHRC has proposed and initiated the preparation of a film on real life heroes (Doctors) in terms of provision of health care inremote areas. It has identified a number of such exceptional doctors who have spent many years providing good qualityservices in extremely remote rural areas. The work is under process.2. Training films on:a. VHSC1. Jurmil Banabo Swasth Gaon : A documentary film on VHSCs' role and responsibility, for use in training, blockmeetings, district meetings.b. Training Visual CDs on BCC: A set of 3 CDs titled1. Aao karke dekhe: On Supportive supervision2. Kaise ho kishori: On adolescent health and empowerment3. Main kehta aankho dekh: On child nutrition3. Radio programmes in local dialects:a. "Kahat He Mitanin"- A social mobilisation as well as training tool under Mitanin Programme. It comprises of 16episodes. This programme received tremendous response from the civil society. This serial was later adopted in otherregional dialects as well. These episodes were produced as part-1 and Part-2 in 2003-04 and 2006. In continuum aththird part is under process. Five scripts are ready for radio programmes. This is proposed to be launched on 15 August2010.4. Audio/Visual Documentary:a. Two Audio CDs on AYUSH (AYUSH Geet Mala and AYUSH Geet Natya) for general orientation on mainstreaming ofAYUSH.50

. A video documentation on AYUSH Bhav Kala Dal (social mobilization): The shot of the video is completed; final editingin the process.A clipshot of the documentary…c. Anthology of songs, CDs/Audio Cassettes on Kalajatha etcA number of songs in local dialects (Chhattisgarhi), based on various health themes, concepts and issues have beencomposed/ improvised and recorded for the purpose of dissemination and use for the community and at the local level.Themes on basic health issues like Nutrition, Reproductive Health, diseases like Malaria, Diarrhoea, Pneumonia etc.51

Chapter 7 : Workshops and SeminarsSHRC has been an advocate of Public Health policies and programmes coupled with a deep rooted commitment for CommunityHealth and participation initiatives. To supplement in meeting these commitment and achieving the goal it has been playing apivotal role in organizing workshops and seminars, at national and state level, for dissemination of public health policies andprogrammes, exchange of best practices and ideas across districts and states of India. To mention a few, some of these majorevents, conducted and participated for the benefit and interest of public health, are as follows:1. Workshop on Capacity Building for RMAs (Three Year Medical Course - a Chhattisgarh experience/best practices):SHRC took the initiative of organizing a workshop for pre training capacity building of the RMAs (three year medicalcourse) recently introduced into the public health system for providing health care at the PHCs and CHCs. RMArepresentatives and other technical experts from the state participated. The purpose of the workshop was basically todiscuss and decide on the training modules and strategies.2. Workshop on Establishment of Chhattisgarh Medical Services Corporation (CGMSC)A one day workshop was conducted by SHRC for the preliminary discussion on the establishment of CGMSC with allconcern departmental heads from the directorate and health ministry of CG on 28-10-09. The main resource person forthis workshop was Mr. R. Purnalingam, from Tamil Nadu, Rtd. IAS officer, Chairman, Task force, procurement andlogistics management and MOHFW GoI. Leading to which the establishment of CGMSC is in the process.3. Workshop on Review of Essential Drug List 2007 and Better Medicine for ChildrenththAtwo days workshop (17 and 18 May 2010) on review of the Essential Drug List and better medicine for children washeld with the initiative of SHRC. This workshop was conducted in collaborationwith representatives from WHO, India, and Health Department CG. The mainemphasis was on the review of the Essential Drug List of CG 2007 specificallyon availability and better medicine for Children. Delegates and subcommitteemembers from Health Department, SHRC, Medical colleges of Raipur,Bilaspur and Jagdalpur, the State Medical Council of India, the StatePharmacy Council of India and the Civil Surgeons from the districts participated in this workshop. The recommendedlist of Essential Drug has been forwarded to Director, Health Services, for finalization.Outcome of the workshop1. Recommendation put forward to establish drug testing laboratory in the state for regular quality monitoring of drugs.2. Revised Essential Medical List 2007.3. Strategies planned for conducting mass study for “Better Medicine for Children in Chhattisgarh” in collaboration withWHO India and Government of Chhattisgarh.53

th4. Workshop on “Ensuring Quality of ANM Course based on Standard Protocol” - 15 March' 2010One day workshop was organized in collaboration with Department of Health and Family Welfare, Government ofChhattisgarh, Nursing Council, Chhattisgarh. The aim of thisworkshop was Official negotiation of course fee for sponsoredcandidates , Maintaining standards of ANM training centers,Admission protocol / procedure, Training protocol for training.Representatives from the Health Department, NRHM, State NursingCouncil, Public and Private Nursing Schools participated in thisworkshop. Around 70 participants took part in this workshop.Outcome –1. State level technical committee established comprising the government officials, members from private / nonprofitorganizations for revise and fixed the course fees.2. Established quality monitoring cell for and inspection and monitoring.3. Consensus taken for uniform time line for admission for government and private nursing training schools4. Developed new eligibility criteria for selection of Mitanin/ AWW/ ANM for state ANM/ GNM sponsorship programme545. “Workshop on “Building Partnerships and Quality improvement in Blindness Control” –thth28 April 2010 to 29 April 2010Two days workshop was organized by State Health ResourceCenter in collaboration with Department of Health and FamilyWelfare, Government of Chhattisgarh and Sight SaversInternational. The aim of the workshop was to buildpartnership with private / Non Governmental Organization forblindness control in Chhattisgarh State. Around 50 Stakeholders and representatives from Private Sectors and NonGovernmental Organizations participated in this workshop.Outcome :1. Facility wise performance indicators developed.2. Policy level recommendations given for delinking PGMOfrom emergency duties in hospital to make them full timeavailable for program.3. State level Quality Monitoring Cell established for supportivesupervision and monitoring.4. Existing norms for reimbursement revised with consensus of5.participant.On the basis of need analysis, it is recommended to haveskill up gradation programme for PGMO / OphthalmicAssistant.

6. AYURVED Gram Workshop:thA one day workshop on sensitization of Ayurved Gram Scheme was conducted twice in the month of may (19 ) andthSept. (25 ) 2009. In all 121 Ayurved Gram Dispensaries Physicians, District Ayurveda Officials, Ayurved Gram GroupMembers attended the workshop. In the first workshop there were 150 particpants and in the second workshop 180participants participated. This workshop was conducted in collaboration with the Department of AYUSH at Raipur.7. Homeopathy Workshop:Atwo days State level workshop on homeopathy was organized on 'Healthy Mother and Child through Homeopathy' onthth13 and 14 Feb. 2010. There were in all 200 participants from the state. Homeopaths, District Ayurved Officials, SeniorAyurveda Consultants, State Administration and Homeopathy colleges' representatives and students.. Resourcepersons from Kolkotta, Delhi, Mumbai, Rajkot (Gujarat) and other states participated in the workshop. This wasorganized in collaboration with Department of AYUSH and CCRH (Central Council and Research in Homeopathy,Delhi) and NIH (National Institute of Homeopathy, Kolkata).55

8. Workshop on Mainstreaming of AYUSH:thA workshop on 'Mainstreaming of AYUSH' was conducted on 7 Oct. 2009 at Raipur. 30 participants from all overthe state viz. state officials and faculties from all departments participated in the workshop. The workshop wasconducted with collaboration of WHO and AYUSH.9. Envisioning Workshop on Mitanin Programme:A major workshop was organized on the envisioning of Mitanin Programme by SHRC. In this the Governing BoardMembers of SHRC along with the Programme Persons and Field Coordinators were involved. The main agenda wason the future prospects, strategies and sustenance of the Mitanin Programme.56Workshops and Conferences attended and participated ...Besides conducting workshops and seminars, SHRC also have been actively involved in attending and participating insuch events at the State, National and International level. Also, SHRC has been diligently designated and assigned forbeing a part and parcel of the State and National level mentoring and evaluation team in all public health related issues.These are as follows.1. MCI Workshop, New Delhi:Delegates from Chhattisgarh State had been invited to be a part of the workshop conducted by the Medical Council ofIndia at New Delhi for discussion and policy decision on the findings and presentation of the Task Force on MedicalEducation for the National Rural Health Mission, a three years medical course 'Alternative Model for UndergraduateMedical Education' termed as BRMS. The SHRC representatives along with the state officials attended the meeting.th thThis was held on 4 and 5 of Feb'10.

th rd2. International exposure visit to Europe Health systems (9 to 23 Sept. 2009):A State team representing the State Government of Chhattisgarh was invited by the HR division of WHO, GenevaOffice to Copenhagen (Denmark), Oslo University and Geneva (WHO) for exposure and exchange of ideas on HRmanagement and implementation of Public Health Systems wherein Dr. Kamlesh Jain, as Technical Advisor, fromSHRC also was a member. The team was exposed to various Health Systems Structure, HMIS and Public HealthCourses being run in Europe. The team also had the opportunity for presenting Chhattisgarh specific Best Practices inthe Health Systems and rationalization of Human Resources, Case specific implementation of the Rural MedicalAssistants (RMAs) and Community Health Volunteers coupled with local health planning and management system(Swasth Panchayat Yojna) at local/village level at Geneva and Oslo University.3.4.5.6.7.ASHA Evaluation:SHRC delegates were a part of the Central ASHA Evaluation Team to the states of Bihar, Jharkhand and the NorthEast.CRM Team:Dr. K.R. Antony, Director of SHRC, was a team member of the Central CRM team for review of the State NRHM ProjectImplementation Plan for Madhya Pradesh.IAPSM National Conference (Ranchi) 22-23 Feb '10:SHRC representatives attended the National Conference of the IAPSM at Ranchi on February 2010 as delegates andalso as resource person for a presentation on “Rationalisation of Human Resource: AChhattisgarh Experience”.Visit to Tamil Nadu and Karnataka:SHRC delegates made an exposure visit to Tamil Nadu and Karnataka with reference to establishment of the druglogistic for establishment and design of Drug Warehouse and Inventory System in Chhattisgarh (CGMSC) to adapt theTamil Nadu Medical Services Corporation (TNMSC) Model.Exposure Visit of Maternal and Child Survival Intervention – Guna ModelGuna Model, MP, is considered tobe one of the best practices in thefield of reduction of maternal andchild mortality. Taking forward suchinnovations and replication inChhattisgarh suitable to localconditions, two days exposure visitof 74 Health Officials / Staffs fromthe Department and NRHM wasorganized57

th thbetween 7 to 16 May, 2009. Inthis visit whole management andcoordination was taken care ofby State Health ResourceCenter in collaboration withNational Rural Health Mission,Chhattisgarh and UNICEF.Financial support for thisexposure was provided byUNICEF, Chhattisgarh.8. Exposure Visit to Gujarat State:SHRC delegates along with the state health officials of C.G. made a visit to Gujarat State along with Officials from theState Government of CG. The purpose of the visit was on the overall exposure and exchange of ideas on the HealthSystems Structure and Management.9. Visit to Andhra Pradesh:A State level team from Chhattisgarh made an exposure visit to Andhra Pradesh to study the EMRI Model wherein Dr.Kamlesh Jain from SHRC was a member of the team.58

Chapter 8 : Training and Capacity BuildingOne of the core activities of SHRC lies in its training capacity and Institutional strengthening. In this context SHRC has beencontinuously involved intensely in conducting and providing training to various level of health cadres from various departments.To mention a few they are as follows:1. Training on HMIS:A 3 days training on HMIS was organized in collaboration with the NRHM, CG and NHSRC, Delhi. In this all the dataoperators from the block, district and state level were trained. The main resource persons were from the NHSRC, Delhiand NRHM CG. This was the first ever major training programme organized for the data operators in the state.2. Training on health equipment operations and management:a. A 2 days training programme on X-Ray machines, Imaging equipment and safety measures of 95 radiographertechnicians was conducted at SHRC training centre.b. State level TOT was conducted for 45 Staff Nurses on the Essential Equipment Management, operation andutilization technique at periphery levelth th3. Training on Equipment Calibration and Maintenance for Neonatal Care - 7 to 12 August, 2009:Three days residential training on “Equipment Calibration and Maintenance for Neonatal Care” was organized incollaboration with Department of Health and Family Welfare and State Institute of Health and Family Welfare,Chhattisgarh. The training was organized specially for tutor nurses. It was conducted in two batches, each comprisingof 55 and 54 participants.4. Capacity building on District Health Planning and Management for AYUSH personnel:The first ever training for the AYUSH health personnel on “District Health Planning and Management” for seven dayswas conducted in collaboration with AYUSH and PHRN wherein 52 participants from all the districts and state officialsattended.60

5. Swasth Panchayat Fellow Training:A new troupe of community health cadres were appointed specifically for swasth panchayat scheme wherein thedevelopment of village health plans based on Swasth Panchayat Scheme and VHSC will be their priority. Withreference to this an intensive 3 days in-house and on field training was conducted for the Swasth Panchayat Fellows.6. Hands on Accounting Training for all District Accounts Manager (DAM)and Block Accountant & Data Assistant (BADA):A two days state level hands on training (batch wise) was held for all districts and blocks accounts personnel as well asthe DPMs on Tally ERP 9 at Raipur. This was the first ever training conducted for all Accounts personnel at the Statelevel in collaboration with NRHM CG. Altogether 110 participants from the districts and blocks participated in thetraining.7. Training of RMAs:An intensive training programme for the Rural Medical Assistants (RMAs) for 15 days has been proposed andscheduled to be trained this year. The proposal has been approved and the training modules are under preparation. Aseven days training will be on Public Health and other basic Preventive and Promotive clinical subjects. The secondphase of the training will be on EMoC and BeMoC for all lady RMAs and others posted at the CHCs and FRUs.8. Capacity building of ICDS staff:A statewide level training of Anganwadi Supervisors have been conducted on IMNCI. State ToT and District leveltrainings have been completed. Another proposal has also been processed for training these same cadres on AYUSH.This will be conducted in this financial year 2010--1161

Chapter 9 : Centre for Training and Exposure; exchange of ideas...SHRC - The 'Focal Point' for Public Health Training and ExposureSHRC has been labeled a Public Health Laboratory and a Training ground for aspiring Public Health professionals and a field forexposure for those Health professionals, Administrators, Managers and Community Health Workers desiring to learn throughfirsthand experience at the grass root level from the field. This has been so due to the fact that it has the highest potential toprovide exposure in bringing about Health Sector Reforms and policy formulation to implementation of Health Programmes andCommunity initiativesl. With its unique stature, as additional technical assistance to the Department of Health and FamilyWelfare, CG, and by virtue of being an autonomous body/organization coupled with a myriad of best practices, success stories,information and resources, SHRC is considered the epicenter for training and exposure in the field of Health Sector Reforms andPolicy formulation coupled with implementation of Community Health Programmes at the grass root level.In the last couple of years SHRC has been accommodating Public Health professionals from various states, organizations,institutions and even international/overseas interns.Interns from : Institutions/deemed universities like TISS, Mumbai, IIHMR, Jaipur, JNU, Delhi, IISWBM, Kolkatta, SCTIMST, Kerala,T.A. Pai Management Institute (TAPMI), Manipal, and other local institutions like GGU, CG etcForeign nationals like Germany, Socio-medical Sciences and Global Health, Mailman School of Public Health,Columbia University, Oxford University etc…Exposure visit teams from :States like the NE states, Rajasthan, Bihar, Ranchi, Orissa, Maharashtra, West Bengal, Chennai, Tamil Nadu,Delhi, Jharkhand, Bangalore etcOrganisations like NHSRC, Delhi, ICICI, Mumbai, ICCHN, Pune, RRC, North-East, SEARCH, Gadchiroli,local NGOs etc…Foreign nationals from UK, USA, South Africa etc.63

Chapter 10 : Impact of SHRC on the Health Sector Reforms – A critical appraisalState Health Resource Centre (SHRC) is an innovative institutional capacity that was set up in 2002 by State Health Departmentof Chhattisgarh, under Sector Investment Programme (SIP). Worked as the backbone of the community based health sectorreforms in Chhattisgarh, the centre has been able to give shape for a number of successful models of community participation inhealth like the "Mitanin Programme" and "Swasth panchayat.” For improving the supply-side interventions on health care, it hasdeveloped "Equip approach" through a set of studies and research. In order to improve the facility development andmanagement, it was able to suggest a comprehensive facility development package around the existing Rogi Kalyan Samitisetups, in the form of "Jeevan deep Scheme.” Once the SIP was over, the SHRC was absorbed for providing technicalassistance in planning and imparting of NRHM. All the community-based components under NRHM are being implementedalso, by SHRC, for the state Government. The NRHM has requested other states, to setup similar institutes.The SHRC has been working as a technical assistance agency to the department. It is supporting on a four-year term under arenewable MOU between the State Health Society and the SHRC (2008-09 to 2011-12). The technical support provided bySHRC has been as envisaged in the MOU and as approved in the NRHM PIP. This has enabled continuation of SHRC's supportfunction- both for community programmes and for capacity building. Basically, SHRC plays the role of Community hand ofNRHM in Chhattisgarh. It is also providing technical assistance to programme and policy design and for support toimplementation of innovative process intensive new programmes. It plays a critical role in capacity building for district healthplanning. It gives timely inputs to the government wherever it is necessary, in the areas of private sector regulation, insurance,and many other initiatives.In addition to the areas where SHRC is already working, SHRC’s technical support have been incorporated in the field of AYUSHmainstreaming and Medical education this year. In the community level intervention, SHRC is looking at operationalising theVillage Health & Sanitation Committees. SHRC is supporting the capacity building of officials in district health planning initiativesof the Public Health Resource Network, which have been actively conducting the trainings as planned.Summary of outputs achieved by SHRC in 2009-10Outputs:• Supporting the Mitanin (ASHA) Programme: SHRC provided overall design, capacity building and monitoringth th thsupport for this flagship community based programme. SHRC designed training materials for 12 , 13 and 14Rounds of training of Mitanins in consultation with other stakeholders and resource groups. SHRC coordinated onjoband field based support to the Mitanins in terms of providing critical handholding and problem solving support byarranging visits of trained facilitators to locations where Mitanins work. SHRC trained, monitored and supported thefacilitation cascade of Mitanin Programme through its District Coordinators. SHRC conducted specific micro-studiesto observe efficacy of the training inputs being provided to Mitanins. SHRC helped in collection of MIS information onMitanins' activities from field locations, its analysis and sharing with key stakeholders. SHRC is currently formulatingththe 15 Round of Mitanin Training. It has also facilitated logistics of ensuring that drug kits reach all Mitanins in time. Ithas also strengthened the Nutrition Security Community Interventions through the Mitanin programme.65

• Strengthening Village Health and Sanitation Committees (VHSCs): SHRC played a key facilitation role information and in account opening of VHSCs across the state. SHRC facilitated the coordination between the healthdepartment, Panchayat department and PRIs at the block/grassroots level for establishing VHSCs. For this purpose,SHRC also mobilised the Mitanins and their supporting cascade of Mitanin Trainers, District Resource Persons andDistrict Coordinators to actively facilitate formation of VHSCs, opening of their bank accounts and transfer of untiedgrant amounts into the bank accounts. SHRC facilitated problem solving wherever gaps existed in understanding ofblock level officials and PRI representatives. To give a kick-start to this important community based initiative ofVHSCs, SHRC coordinated a social mobilisation campaign called 'Gram Swasth Niyojan Abhiyan' across the stateand provided trained human resource support to facilitate conduction of special Gram Sabhas on issue of VillageHealth Planning. Through this process, more than 18,000 VHSCs were initiated and activated. Mitanins being theConvenors of VHSCs in Chhattisgarh, Mitanins and their trainers are playing a critical role in organising meetings ofVHSCs and facilitating village health planning in them. So far around 3,000 VHSCs have been able to initiate villagehealth plans and their implementation. SHRC gave a big push to the capacity building for this programme byorganising a well designed Training of VHSC members, including Panchayat representatives, Anganwadi workers,ANMs, SHGs along with Mitanins. These capacity building efforts have also helped many VHSCs in making goodutilisation of the untied grants. SHRC is currently involved in strengthening the capacity of VHSCs further to emergeas the key community institution having PRI participation and active in health planning and its execution.• Formulating Home Based Newborn Care (HBNC) initiative: In order to give a boost to IMR reduction strategy ofChhattisgarh, HBNC has emerged as an important intervention. SHRC facilitated formulation of a HBNC operationalstrategy which is based on collaboration between community health workers (Mitanins) and the Primary HealthcareSystem. SHRC developed the guidelines for the programme implementation, selected blocks in consultation withstate NRHM unit, designed training modules by combining the strength of SEARCH HBNC modules with existingneonatal survival programme of Chhattisgarh. SHRC is currently involved in rolling out the ToT and other trainings forthis initiative. It is also providing overall support for baseline survey design and execution, coordination andmonitoring of programme activities spread across 18 districts of the state.• Strengthening the Role of PRIs in Health: SHRC has been at the forefront of conceptualising the 'SwasthPanchayat Yojana' initiative of Chhattisgarh. SHRC has helped in design of Panchayat level indicators and Healthand Human Development Index (HDI), design of appropriate questionnaires for Swasth Panchayat survey, training ofCommunity volunteers (mainly Mitanins, Panchs and Mitanin Trainers) in data collection, validation of collected dataand its compilation, designing a special software for analysis, dissemination of survey findings and facilitating PRIs inmaking use of the analysed information.• Technical support to AYUSH and Social Mobilisation for AYUSH: SHRC has set up an AYUSH cell to act asadditional technical capacity to AYUSH directorate and programme unit. It has supported the AYUSHGRAM initiative,designed and executed large scale social mobilisation campaign around AYUSH through AYUSH kalajathas andtrained Mitanins on AYUSH remedies.66

• Design of Behavioural Change Communication initiatives: SHRC has designed a full-fledged BCC kit for use ofASHA and Anganwadi Workers. It has also created a consensus on the developed tools through consultation withvarious agencies. It is currently involved in taking these BCC tools to the grassroots level through training of humanresources.• HR Recruitment Support to NRHM: SHRC has helped the state NRHM unit in recruitment of more than a thousandhuman resources including District and Block Programme managers, data operators etc. It has also extended thissupport to Malaria Control programme, Leprosy Elimination Programme and EUSPP.• Operational Research for Policy formulation and Programme Evaluation: SHRC provided research support tothe Health department in critical areas of human resources in health. It has conducted a large scale study on 'HealthService Providers in PHCs' including Rural Medical Assistants in collaboration with national institutions like PHFI andNHSRC.• SHRC has conducted a study to assess the ground level situation of Janani Suraksha Yojana.• Capacity Building of RMAs: This important human resource has been recently inducted into the primary healthcaresystem and requires capacity building support. SHRC is providing support in formulation and execution of trainingprogrammes for this specific group of healthcare providers.• SHRC has initiated preparation of a film on real life heroes in terms of provision of health care in remote areas. Ithas identified a number of such exceptional doctors who have spent many years providing good quality services inextremely remote rural areas.• SHRC has started implementation of a training programme for 35,000 Anganwadi Workers across the state onIMNCI in collaboration with the Women & Child Development department.• SHRC has made significant contribution towards health planning efforts under NRHM. It has facilitated the DistrictProgramme Managers in preparation of District Health Plans. It is part of the State Task Force for formulation of thestate PIP for NRHM.• Establishment of the CGHEMS: SHRC has initiated the concept and process of setting up and operationalising theCGHEMS. The set up has been fully operationalised and has further been handed over to the Directorate of HealthServices Chhattisgarh.• SHRC has been providing technical support for setting up a logistics and drug procurement system for the stateincluding for the creation of a new corporation (Chhattisgarh Medical Services Corporation) for the purpose.67

• SHRC has provided technical advice in certain policy areas like the Nursing Homes and Medical EstablishmentsRegulation Act (draft), organ transplant policy, non-communicable diseases policy etc.• Promoting career pathways of Mitanins: SHRC has provided conceptualisation and handholding support foradmission and sponsorship of Mitanin volunteers into BSc (Nursing), ANM and GNM courses.• Provided technical assistance: For planning of European Union State Partnership Programme.• Financial Support and Grant : In addition to the above contributions, SHRC as a registered institution has alsobeen providing financial support and grant to its staff for their career growth and higher education. Besidesprovision of medicare, health insurance and staff welfare.Focus Areas of SHRC for 2010-11SHRC will continue its role as additional technical capacity in policy and programme areas of NRHM as well as Departmentof Health and Family Welfare. In addition to the existing areas of work, the following will be the new initiatives to focus uponin 2010-11 Operationalisation and handholding support for a 'PIP Cell' at the state level. This cell will track the progress madeby various districts in achieving PIP milestones and also help in compilation and appraisal of the Block and Districtlevel health plans for the coming year.Operations Research in areas like Human Resources in Health, Disease Control Programmes, Non-Communicablediseases, Home Based Neonatal Care Baseline study, Janani Suraksha Yojana, Untied Grant Utilisation pattern atvarious levels, Jeevan deep (RKS) Samitis etc.Technical support for Health Sector Reforms especially in the area of Human Resource policies including reformin rules and regulations in health services, promotion of public health cadre, medical education.Capacity building of various health cadres to improve the quality of Public Health SystemsEnhancing quality of Public Health facilities.Strengthening Human Resources in Health Sector:Inadequate workforce was one of the major hindrances in programme implementation at all levels. Regular appointmentswere delayed for various posts under NRHM and Directorate of Health Services, Chhattisgarh. So, SHRC was entrustedwith the task of Recruitment and Recommendations for Contractual Appointments. Recruitment process was conducted in2009-10 and recommended lists were sent by SHRC to the concerned Departments for following vacancies:-68

st1 PhaseSl Department Posts No. of recruitment TotalNo1. CGSACS Counsellor 55 120Lab Technician 53Divisional Assistant 122. NRHM Block Programme Manager 54Block Accounts and Data Assistant 52 216Hospital Administrator 15Computer Programmer 3Consultant and others 3Malaria Technical Supervisor 66Lab Technician 33Total 336Recruitment process Conducted and Recommendations sent by SHRC, appointments done for all the above posts2 nd phaseSl. No Department Posts No. of Recruitment Total1 NRHM State Level Posts: 8 8 596District Level Posts: 124 124Block Level Posts: 464 4642 NVBDCP GIS Entry Operator 1Accountant 1Secretarial Assistant 1Insect Collector 2Financial and logistic Asstt. 11Data Entry Operator 113 Leprosy Control Programme Data Entry Operator 6 64 European Union State Partnership Programme (In process) 9Total 638Recruitment process Conducted and Recommendations sent by SHRC for the above posts Still many approved positions under NRHM andDirectorate of Health Services are lying vacant which are to be filled on a priority basis.69

Governing Board...Sl. NoNameDesignationOrganisation1Mr. Harsh Manda (Chairperson)Member-National Advisory Council andSpecial Commissioner to Supreme Court2 Dr. Sundararaman (Member) Executive DirectorNHSRC, Delhi3Dr. Alok Shukla (Member)Dy. Election CommissionerElection Commission of India4 Mr. Biraj Patnaik (Member) Principal Advisor to Commissioners Supreme Court, Delhi5V.R. Raman (Member)Consultant, Public HealthICCHN, Mumbai6 Dr. Vandana Prasad (Member) National Convenor PHRN, Delhi7Ms. Sulakshana Nandi (Member)State ConvenorPHRN, CG8 Dr. D.N. Sharma (Member) President Sandhan, Durg9Dr. Yogesh Jain (Member)SecretaryJan Swasthya Sahyog,Bilaspur10 Sister Georgina (Member) RAHA, Ambikapur11 Dr. K.R. Antony (Member Secretary)DirectorSHRC12 Ms. Ritu Priya (Member) Advisor NHSRC, New Delhi13 Dr. S. JenaHeadShaheed Hospital,Dalli Rajhara14 Dr. P. Padmanabhan Advisor NHSRC15 Rajani VedAdvisorNHSRC1617Secretary, Health &Family Walfare, Govt. C.G.Director, Health Services,Govt. of CG71

Executive Committee...Sl. NoNameDesignation1 Dr. K.R. Antony2 Dr. Kamlesh jain3 Mr. Samir Garg4 Mr. Avinash Loomba5 Mr. Puni Kokho6 Ms. Rachna TiwariDirectorTechnical Advisor (Public Health)/Senior Programme CoordinatorConsultantSenior Programme CoordinatorProgramme CoordinatorProgramme Coordinator7 Mr. Komal Dewangan8 Late Dr. P.D. SinghFinance OfficerSenior Programme CoordinatorSHRC Team...Sl. NoName Designation Section/Department1. Dr. K.R. Antony Director Overall in Charge2.3.Dr. Kamlesh JainPuni KokhoTechnical Advisor (Public Health)/Senior Programme CoordinatorProgramme CoordinatorHealth Sector Reformsand Policies4.Mahendra GawareProgramme Coordinator5.Premshankar VermaProgramme Associate (Consultant)6.7.Avinash LoombaSamir GargSenior Programme CoordinatorConsultantCommunity Health Planningand Initiatives8.Rachana TiwariProgramme Coordinator9.Mukesh DewanganProgramme Associate10.Prabodh NandaProgramme Associate (Consultant)72

Sl. NoNameDesignationSection/Department11.Dr. Nilesh JainProgramme CoordinatorAyush Cell12.Dr. Sumi JainProgramme Coordinator13.Suhas DasAccountant & Finance Coordinator14.Manoj NayarSteno Typist15.Dr. S.L.GuptaProgramme Officer (consultant)Leprosy16.Rafique MohmadProgramme AssociateCommunity Mobilization,Media and Kalajatha17.Hemant VaishnavProgramme Associate18.Anju KhewarTraining CoordinatorTraining19.Mr. Komal DewanganFinance OfficerFinance and Accounts20.Amit KalyaniAccounts Officer21.Toofan NashaAccountant22.Preeti DaveProgramme AssociateAdmin & HR23. Virendra Kumar Programme Associate (Consultant)Inventory Managementand Drug Procurement24.Shibu KumarExecutive AssistantSupport Team25.Sunita SonkarOffice Assistant26.Surbhi BeheraReceptionist27.Rajesh Puri GoswamiOffice Assistant28.Hemant Kumar GendreOffice Assistant29. Amar Das Sonwani Driver73

The Field Team...Sl. NoName Designation District1. Omprakash Burman Programme Associate Bastar Region2.Ramjag Gond Programme Associate Bastar3. Satya Prakash Sahu Programme Associate Bilaspur4.Rakesh Singh Programme Associate Koriya5. Mohd. Tazuddin Programme Associate Sarguja6.Jageshwar Ram District Coordinator Sarguja7. Mrs. Roshan Jahan Ansari District Coordinator Sarguja8.Ms. Lalita Xalxo District Coordinator Sarguja9. Kushal Ram Ghosle Programme Associate Kanker10.Ms. Shakuntala Lahare District Coordinator Raipur11. Pooran Singh District Coordinator Raipur12.Ms. Poonam Vaishnav District Coordinator Raipur13. Rohit Kumar Yadav District Coordinator Raipur14.Roshani Singh District Coordinator Koriya74

Sl. NoName Designation District15. Mrs. Manisha Awasthi District Coordinator Korba/Janjgir16.Mrs. Alka Dubey District Coordinator Kawardha17. Ashish Ranganath District Coordinator Dantewada18.Sanjay Namdev District Coordinator Dhamtari19. Aaju Ram Verma District Coordinator Bastar20.Ms. Punita Banjare District Coordinator Bastar21. Ms. Anjani Sahu District Coordinator Rajnandgaon22.Mrs. Ashu Sahu District Coordinator Mahasamund23. Ms. Lalita Meravi District Coordinator Bilaspur24.Mrs. Sudha Deshmukh District Coordinator Durg25. Ms. Vandana Gupta District Coordinator Jashpur26.Ms. Vrinda Chouhan District Coordinator Jashpur27. Ashish Parwat District Coordinator Janjgir28.Santosh Son District Coordinator Raigarh75

Partner Agencies/Department for Collaboration1. Directorate of Health and Family Welfare Department, CG2. NRHM CG3. ICCHN, Mumbai, for Food Security Project (Food Security and Nutrition)4. CGSACS5. PHRN/IGNOU6. NHSRC, New Delhi7. EUSPP8. WHO9. PHFI, New Delhi10. UNICEF11. CINI/MI12. Population Foundation of India13. NIN14. Jan Swasthya Abhiyan15. CARE16. BPNI17. IAP18. NNF19. SEARCH20. Women and Child Development21. Vigyan Prasar, New delhi22. Govt of India, State Govt. of Chhattisgarh, Jharkhand, MP, AP, WB, Orissa, Bihar, Maharashtra23. AYUSH Department24. Department of Medical Education25. Field NGOs76

Abbreviations…1.2.3.4.5.6.7.8.9.10.11.12.13.14.15.16.17.18.19.20.21.22.23.24.25.ANMASHAAWCAWWAYUSHCBOCHCCDPOCMPCRMCRMCCGHEMSCGMSCDRPEDLFRUGPHBNCIMNCIIMRLHVMMRMDGMTNPAGAuxiliary Nurse Midwife (Same as female MPW)Accredited Social Health ActivistAnganwadi CentreAnganwadi WorkerAyurveda, Yoga & Naturopathy, Unani, Siddha and HomoeopathyCommunity Based OrganisationCommunity Health CenterChild Development Project OfficerCommon Minimum ProgrammeCommon Review MissionChhattisgarh Rural Medical CorpsChhattisgarh Health Equipment Management SystemChhattisgarh State Medical Service CorporationDistrict Resource PersonEssential Drug ListFirst Referral UnitGram PanchayatHome Based Neonatal CareIntegrated Management of Newborn and Childhood IllnessInfant Mortality RateLady Health Visitor (Same as Sector Superior Female)Maternal Mortality RateMillenium Development GoalMaster TrainerNutritional Programme for Adolescent Girls77

26.27.28.29.30.31.32.33.34.35.36.37.38.39.40.41.42.43.NFINRHMPHCPHRNPPPRCHPRIRTIRMASDFSHRCSIHFWSoPSTGSTIToTVHSCVHNDNutrition Foundation of IndiaNational Rural Health MissionPrimary Health CenterPublic Health Resource NetworkPublic Private PartnershipReproductive and Child HealthPanchayati Raj InstitutionReproductive Tract InfectionRural Medical AssistantState Drug FormularyState Health Resource CentreState Institute of Health and Family WelfareStandard Operating ProceduresStandard Treatment GuidelinesSexually Transmitted InfectionTrainer of TrainersVillage Health and Sanitation CommitteeVillage Health and Nutrition Day78

SHRC Family ...