Janani Shishu Suraksha Karyakram (JSSK)Dr Gagan deep kaur

HIMS

Layout

• Introduction about Maternal mortality• Evolution of Mother and Child Health Care till

JSSK• Rationale Behind JSSK• Objectives• Entitlements under the Scheme• Implementation of new initiative• Implementation Status of Uttarakhand

Maternal Mortality: A Global TragedyAnnually, 585,000 women die of pregnancy related

complications

– 99% in developing world

– 1% in developed countries

India• In India, 67000 women die every year from

pregnancy or pregnancy related causes

– 25% global burden by India (with16% of world’s

population).

– Since the 1980’s successive programmes have attempted

to address the high MMR• There have been considerable decline in India’s

MMR in the last two decades: from 398 in 1997-98 to 168 in 2015

Neonate mortality

India-Neonate mortality

• Every year 13 lakh newborns die within one year of birth.

– 2/3 of newborn deaths occur within 4 weeks

First 28 days are critical to save life of the child

MCH care programmes evolution

Family Welfare Programme in 1979

– integration of family planning services with those

of MCH .

– Effective IEC to improve awareness

– Easy and convenient access to FW services free of

cost

Child Survival and Safe Motherhood Programme; 1992

• Early registration of pregnancy

• Minimum three ANC check ups

• Universal coverage with TT immunization.

• Advise on food , nutrition and rest

• Detection of high risk pregnancies and prompt referral

• Clean deliveries

• Birth spacing

• Promotion of institutional deliveries

Child component of CSSM

• New born care

• High coverage levels under the UIP

• Oral Rehydration Therapy (ORT) Programme

• Diarrheal Disease Control Programme

• ARI Control Programme

Reproductive and Child Health Programme

• 1997,Phase-1

• CSSM+RTI/STD &AIDS

• Major interventions are-

– Essential obstetric care

– 24 hour delivery services at PHC/CHCs

– Essential newborn care

– Emergency obstetric care

– Medical termination of pregnancy

– Prevention of RTI and STD

Reproductive and Child Health Programme-II

• April,2005• Major strategies are• Essential obstetric care– Institutional delivery– Skilled attendance(SBA) at delivery

• Emergency obstetirc care– Operationalizing FRU– Operationalizing PHC and CHCs for round the clock

delivery services• Strengthening referral system

National Rural Health Mission (NRHM)

• 2005 : provide equitable , accessible and affordable health

care

– To reduce MMR to 100/100,000

– To reduce IMR to 30/1000 LB

– The Janani Suraksha Yojana ( Safe Motherhood

Scheme) was the key strategy to achieve this

reduction

Janani Suraksha Yojana

• 12 April,2005

• Centrally sponsored scheme

• Benefit of cash assistance with institutional care

• Eligibility for cash assistance

– LPS- All women delivering in government health centres

– HPS- BPL women, aged 19 years and above and the SC

and ST women.

Cash Assistance

Category Mother's package

ASHA's package

Total Package(in Rs.)

LPS 1400 600 2000HPS 700 - 700

Category Mother's package

ASHA's package

Total Package (in Rs.)

LPS 1000 200 1200HPS 600 - 600

Rural Areas

Urban Areas

Key findings from JSY evaluationPositive

The JSY has unarguably resulted in an increase in institutional

deliveries, and has enabled poor women to access public health

facilities.

The no. of institutional deliveries is-41%

No of Deliveries by TBA- 49%

Concerns of JSY

• Whether this programme was reaching the poorest and most

marginalised.

• Persistence of home deliveries –40% in most districts

• High Out of Pocket Expenses on : OPD fee, diagnostic tests,

admissions, blood, on purchase of drugs and consumables from the

market

• Spending on transport from home to facility and back

• Spending on diet which was not provided in the facilities

Janani Shishu Suraksha Karyakram –JSSK

• MoHFW: consensus to provide completely free

and cashless services

– Pregnant women (normal deliveries and caesarean

operations)

– sick new born (up to 30 days after birth)

JSSK was launched on 1st June, 2011.

Objectives

– Eliminating out-of-pocket expenses for families of

pregnant women and sick newborns in government

health facilities

– Reaching the unreached pregnant women (nearly 75

lakh a year who still deliver at home)

– Timely access to care for sick newborns

Free Entitlements for pregnant women:Free and cashless delivery

Free C-Section

Free drugs and consumables

Free diagnostics

Free diet during stay in the health institutions

Free provision of blood

Exemption from user charges

Free transport from home to health institutions

Free transport between facilities in case of referral

Free drop back from Institutions to home after 48hrs stay

Free Entitlements for Sick newbornsFree treatment

Free drugs and consumables

Free diagnostics

Free provision of blood

Exemption from user charges

Free Transport from Home to Health

Institutions

Free Transport between facilities in case of

referral

Free drop Back from Institutions to home

Newborn care facilities at different levels

Health facility All newborns at birth

Sick new borns

Primary health centrePHC/SC

Newborn care corners in labour room

Prompt referral

CHC/FRU Newborn care corners in labour room and in operation theatre

Newborn stabilization unit(NBSU)

District Hospital Newborn care corners in labour room and in operation theatre

Special newborn care units(SNCU)

Ensure drugs and consumables:

• Essential drug list to be notified .

• Ensure regular procurement, Uninterrupted supply

and availability of drugs.

• Ensure quality and shelf life of drugs supplied

• The drug availability of the drugs should be displayed at the health

facility

• Empower the head of the district to procure drugs to prevent stock

outs.

Cont...• Ensure a proper inventory of drugs and consumables at each

health facility.

• In charge pharmacist of the facility to ensure availability of

drugs at dispensing points.

• Ensure that first expiry drugs and consumables are used first.

• Ensure proper storage of drugs and consumables by keeping

drug stores clean and tidy with adequate ventilation and

cooling.

Strengthen diagnostics

• Ensure lab and diagnostic services.

• Ensure availability of routine investigations.

• Ensure postings of Lab technicians.

• Make emergency investigations available round the

clock.

Cont....

• Ensure uninterrupted supply of reagents, consumables

required for lab investigations

• Empower the head of District to procure reagents,

consumables and other essentials to prevent their shortage.

• Free investigations through PPP/Outsourcing.

Ensure provision of diet

• Ensure provision of diet at all delivery points.

• If proper Kitchen and adequate manpower is not available,

then this service can be outsourced.

• Local seasonal foods, vegetables, fruits , milk and eggs can

be given to her for a proper nutritious diet.

• MO in charge should monitor the quality of food

Cont....

• Diet to be provided :

– 3 days for normal delivery

– 7 days for caesarean action.

• Funds in advance for ensuring provision of free diet.

Ensure availability of blood in case of need• Prepare time bound action plan for operationalising Blood banks.

• Maintain adequate stocks for each blood group

• Availability of reagents for blood grouping and blood transfusion

• Mandatory screening of blood before storage.

• Adequate funds to blood banks for electric backup.

• MO in charge of the blood bank to periodically visit blood storage

units for monitoring and supervision.

Referral Transport

• Transport from home to health facility

• Referral to the higher centre in case of need

• Drop back from facility to home.

Cont..

• Ensure universal reach of the referral transport.

• State is free to use any suitable model of transportation.

• Establish call centres with single toll free model.

• Vehicles with GPS, for effective tracking and management.

• Establish linkages for the inaccessible areas.

Dissemination of the entitlements

• Widely publicise these entitlements through print and

electronic media.

• Display them prominently on adequate size hoardings and

boards which is clearly visible from Governments health

facilities.

• IEC budget sanctioned in the PIP plan under RCH/NRHM

Cont..• Widely publicise the free and assured referral

transport.• Monitor and Supervise services at all levels

Exemption from all kinds of user charges

• Issue Government order for exemption from any user charges for pregnant women and sick newborns up to 30 days, at public health facilities.

State level

• Government order on free entitlements.

• State Nodal Officer

• grievance redressal mechanism

• Availability of drugs and consumables in entire state

• Functional lab facilities and diagnostic services at PHI.

• Operationalise blood banks at district levels and Storage

centers at identified FRU’s

Cont...

• District wise assured referral linkage.

• Financially empower the district and facility in

charge.

• Regular monitoring and report in designated formats

at specified periodicity

District level

• District Nodal officer.

• Circulate the G.O on free entitlements to all facility in-charge.

• Widely Publicise free entitlements in public domain.

• Grievance redressal mechanism.

• Regularly review the stocks of drugs and consumables for

ensuring availability.

• Ensure Lab facilities and diagnostic services are functional

Cont...

• Time bound action plan for operationalising blood banks.

• Review referral linkages and their utilisation by beneficiaries.

• Regularly monitor and report on designated formats at

specified periodicity.

• Review the implementation status during Block Mos/Mos

meetings

Grievance Redressal• Prominently display the names , addresses, e mails, telephones,

mobiles and fax numbers of grievance redressal authorities.

• Set up help desks and suggestion/complaint boxes at

government health facilities.

• Keep fixed hours on any two working days per week.

• Take action on the grievances within a suitable timeframe, and

communicate to the complaints.

• Maintain proper records of action taken.

Monitoring and Follow up

•NHSRC•MOHFW

National level

•State Nodal officer•District Nodal officer

State level/District level

•National•State/District levelCheck list

JSSK Uttarakhand: Implementation Status

JSSK Uttarakhand: Strengths in Implementation

• Govenment order on free entitlements is issued

• Seperate weblink for JSSK in NRHM state website.

• Programme management unit is fully staffed at state,

district and block level.

• Blood banks are available at district level

Source : PIP uttarakhand 2012-2013 M& E report

Cont..

• Special newborn care units (SNCU) established for care of the

sick and newborn in District Hospitals.

• Grievance redressal mechanism for beneficiaries.

• Transport and drop back for pregnant and newborn was found

very effective.

• 75% of beneficiaries were provided free drugs.

Source : PIP uttarakhand 2012-2013 M& E report

Weakness in implementation

• Out of 18 District Hospitals only 11 DH have C‐ section

• From a total 55 CHCs only 6 provide C‐Section and 1st

trimester abortion facility.

• Lack of coordination between the contractual staff and

permanent staff.

• Pregnancy related diagnostics such as ultra sound and other

blood tests is referred to private diagnostic centres and the

beneficiaries have to pay for it.

Cont...

• ASHAs and ANMs are not aware about JSSK though

they were aware about some of the JSSK

entitlements.

• Only 30% of women had institutional delivery and

32.2% had more then 3 ANC checkups

Beneficiaries Response on JSSK Entitlements

JSSK components PercentageFree transport 44.8Free Diet 37.9Free Drugs 82.8Free Diagnostics 24.1Free Blood 27.6

IEC material provided in PIP

•Thank you