Submit Final Report HLTF

High Level Task Force Report
1
Haryana State Health Resource Centre

HIGH LEVEL TASK FORCE
REPORT
ON
HEALTH DEPARTMENT,
HARYANA

MDG GOAL 4: REDUCE CHILD MORTALITY
Target 4.A: Reduce by two thirds, between 1990 and 2015, the under-five mortality rate
MDG GOAL 5: IMPROVE MATERNAL HEALTH
Target 5.A: Reduce by three quarters the maternal mortality ratio
Target 5.B: Achieve universal access to reproductive health

MAY 2013

2

Content
Chapters
1. BACKGROUND:
2. PROFILE OF HARYANA
2.1 Health Indicators

3. MATERNAL AND CHILD HEALTH
3.1 Maternal Health:
3.1.1 Situational Analysis:
3.1.2. Strategies for Maternal Health for the Last 5 Years
3.1.2.1 Ante Natal Care
3.1.2.1.1 For improvement in number of ANC registration
and Early registration
3.1.2.1.2 For improvement in Quality of Ante Natal
Checkups
3.1.2.2 Institutional Deliveries
3.1.2.2.1 Promotion of Safe Institutional Deliveries
3.1.2.2.2 Quality improvement in Institutional deliveries
3.1.2.3 Post Natal Care (PNC)
3.1.2.4 Safe MTP services
3.1.2.5 Maternal Death Review & Audit
3.1.2.6 Supportive Supervision for Monitoring & Evaluation
3.1.2.7 Referral Transport
3.1.2.8 Operationalization of Health Facilities FRUs and 24x7
PHCs

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3.1.3 Progress So Far
3.2 Child Health
3.2.1 Situational Analysis
3.2.1.1 Major factors responsible for high neo-natal mortality
3.2.2 Strategies for Child Health for the Last 5 Years
3.2.2.1 Mother and Child Protection (MCP) Card
3.2.2.2 Provision for Essential New Born Care
3.2.2.3 Expansion of services for care of sick newborn and free
referral transport
3.2.2.4 Home Based Post-Natal Care (HBPNC)
3.2.2.5 Facility Based New-Born Care
3.2.2.6 Immunization
3.2.2.7 Infant and Young Child Feeding Practices
3.2.2.8 Micronutrient supplementation
3.2.2.9 Management of children with malnutrition
3.2.2.10 Management of Diarrhoeal Diseases & Acute Respiratory
Infections
3.2.2.11 Integrated Management of Neonatal and Childhood
Illnesses (IMNCI)
3.2.2.12 Facility Based IMNCI
3.2.2.13 YASHODA
3.2.2.14 Improving Immunization Coverage & Eliminating
Measles related deaths
3.2.2.15 Infant Death Review (IDR)


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3.3 Recommendations of the Maternal and Child health sub group
3.3.1 Improvement of Quality of Services
3.3.1.1 Antenatal Period
3.3.1.2 Intranatal Period
3.3.1.3 Postpartum care
3.3.2 Referral Transport
3.3.3 Maternal Morbidity
3.3.4 Safe abortion services
3.3.5 Continuum of care
3.3.6 Acute Respiratory Infection and Acute Diarrheal diseases
3.3.7 Infant Death Review (IDR)
3.3.8 Planning of Manpower and Infrastructure
3.3.8.1 Planning
3.3.8.2 Up gradation of Health Facilities
3.3.8.3 Capacity Building
3.3.8.4 Availability of O positive packed cells
3.3.8.5 Monitoring of JSSK Programme
3.3.9 BCC/IEC
3.3.9.1 Family empowerment to enhance their participation and
early care seeking
3.3.9.2 Pre-pregnancy Period
3.3.10 Social Issues
3.3.11 Monitoring & Evaluation:
3.3.12 Separate Cadre for MCH services


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4. ANEMIA AND MALNUTRITION
4.1 Anemia
4.1.2 Steps Taken for Management of Anemia
4.1.2.1 Iron Folic Acid
4.1.2.2 Albendazole tablets
4.1.2.3 General therapeutic measures for treatment of moderate
& severe anemia
4.2 Recommendations of Anaemia
4.1.1 Clinical screening of anaemia
4.1.2 Testing of cases for Hb status
4.1.2.1 Cases to be tested
4.1.2.2 Method of testing
4.3 Iron Supplementation to all screened case
4.3.1 Therapeutic approach to treat anaemia cases
4.3.2 Enhancing compliance to treatment
4.3.3 Education about Disease
4.3.4 Education about diets
4.3.5 Education about side effects of Iron medicines
4.4 Malnutrition
4.4.2 Strategies
4.4.2.1 Best Mother Award
4.4.2.2 Nutritional Strategy (For Eradication of Malnutrition
among Children)

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4.4.2.3 Community participation in Growth Monitoring
4.4.2.4 Nutrition Award
4.4.2.5 Formation of VLCs
4.5 Recommendations of Malnutrition
5. GENDER EQUITY AND FAMILY WELFARE
5.1 Gender Ratio
5.1.2 Strategies
5.1.2.1New initiatives
5.1.2.2 Advocacy
5.1.2.3 Efforts of Haryana Government for Women Empowerment
5.2 Family Welfare
5.2.2 Strategies
5.2.2.1 Spacing Methods (IUD)
5.2.2.2 Permanent Methods (Vasectomy & Tubectomy)
5.2.2.3 Community Participation & Capacity Building
5.2.2.4 General
5.3 Recommendations of Gender Ratio
5.3.1 Defining Gender Issues in Health
5.3.2 Strengthening Institutional Capacities
5.3.2.1 Appointment of Gender Nodal Officer
5.3.2.2 Development of curricula and faculty for Gender
Mainstream
5.3.2.3 Gender Sensitive HR Policy

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5.3.3 Strengthening of Adolescent Health Services
5.3.3.1 Recommendations on Adolescent Health
5.3.4 Sex selection
5.3.5 Violence against women
5.3.6 Community participation
5.3.7 Improved access and information
5.3.8 Access to contraceptive services


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1. Background:
Alma Ata Declaration of 1978 declared that the main social target of
governments was attainment of a level of health that would lead to a socially and
economically productive life.
The Millennium Summit of the UN in 2000 adopted the Eight Millennium
Development Goals (MDG). Among them Goal 3, 4 and 5 were focused on Gender Equality,
Child Mortality Rates and improving Maternal Health.
Although Haryana is one of the leading states of the country in economic
terms, it is grappling with social and health indicators. These indicators are not comparable
with other states with similar economic status. Therefore Government of Haryana
constituted of a High Level Task Force to address the adverse social indicators in the Health
Sector during the discussion held in the Planning Commission.
Financial Commissioner and Principal Secretary to Government Haryana,
Finance and Planning Department, Chandigarh, Vide his D.O. letter number 807/PS
Finance/2012 dated 23-07-2012 had accordingly asked the Dept. of Health to constitute a
High Level Task Force to address the adverse social and health indicators and send a report
to Honble Chief Minister, Haryana. This issue was approved in the meeting of State Health
Mission held on 17-07-2012 under the Chairpersonship of Honble Chief Minister, as this
issue had to be reviewed in annual meeting of planning commission.
Government of Haryana constituted a High Level Task Force with the composition and
terms of reference as attached as Annexure-I.
The High Level Task Force was to:
1. Review the trends of health indicators of Haryana like Maternal Mortality Rate,
Under 5 Mortality Rate (U5MR), Child Mortality Rate, Infant Mortality Rate (IMR),
Neonatal Mortality Rate (NMR), Total Fertility Rate (TFR), Couple Protection Rate
(CPR), Gender Ratio, Malnutrition and Anemia.
2. Deliberate on the strategies which have been in place for the last five years.
3. Make recommendations on the strategic interventions to be made in the next five
years (Plan period).
4. Assess the trends of malnutrition and anaemia in the State and make
recommendations to improve the nutritional status.
5. Recommend specific actions required to be taken by various departments and
measures for improvement of inter sectoral coordination.
6. Take into account both rural and urban scenarios, the regional, the socio economic
and cultural factors within the State while making recommendations.


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The first meeting of High Level Task Force was held on 23-10-2012 at Haryana Niwas, Sec-
3, Chandigarh under the chairpersonship of Mrs. Navraj Sandhu, Principal Secretary to
Govt. of Haryana, Health & Medical Education Department. In this meeting after a general
discussion about the adverse social indicators, the group was divided into three sub-groups
i.e. Group A (Maternal Health + Child Health), Group B (Anemia + Malnutrition) and Group
C (Gender Equity + Family Welfare). Details of members is given in Annexure 1.
The second and third meetings of High Level Task Force were held on 4
th
- 5
th
of December
2012 and 16
th
- 17
th
of January, 2013 respectively.
Minutes of all three meetings are attached as annexure-II, III and IV.


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2. PROFILE OF HARYANA
Haryana is located in north of the country, covering 44212 sq km area, representing 1.4%
of total area of the country. Total population of the state is 253.53 lacs (2011 Census),
which represents 2% of countrys population, out of this, 165.31 lacs (65.29%) is rural
Haryana has about 0.40 crore (15.78%) Schedule Caste population, while the state has no
tribal population.
The sex ratio of Haryana is 877 females as against 1000 males (2011 Census). State has an
overall literacy rate of 76.64%, while that for males is 85.38% and for females is 66.77%,
respectively.
Administratively, Haryana is divided into 4 divisions, 21 districts, 54 subdivisions, 119
developmental blocks and 6955 villages.
Table 2.1 Distribution of Health Facilities of Haryana

Number of Districts (RHS 2010) 21

Number of Sub Division/ Talukas 54

Number of Blocks 119

Number of Villages (RHS 2010) 6955

Number of District Hospitals 21

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

Number of Community Health Centres (RHS 2010) 107

Number of Primary Health Centres (RHS 2010) 441

Number of Sub Centres (RHS 2010) 2484

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

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national figures of 212 and 50. The Sex Ratio in the State is 877, as compared to 940
for the country. Comparative figures of major health and demographic indicators of
Haryana vizaviz India are as follows
Table 2.2 Comparison of Indicators of Haryana and India

Indicator Haryana India

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

Infant Mortality Rate (SRS 2011) 44 44

Maternal Mortality Ratio (SRS 2007-09) 153 212

Total Fertility Rate (SRS 2009) 2.5 2.6

Decadal Growth (Census 2011) (%) 19.9 17.64

Crude Birth Rate (SRS 2009) 22.7 22.5

Crude Death Rate (SRS 2009) 6.6 7.3

Natural growth rate (SRS 2009) 16.0 15.2

Sex Ratio (Census 2011) 877 940

Child Sex Ratio (Census 2011) 830 914

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

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

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


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2.1 Health Indicators - Haryana

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

SRS 2005 SRS 2009

Indicators HARYANA HARYANA

Infant Mortality Rate 60 44 (2011)

Natural growth Rate 17.6 16.1

Crude Birth Rate 24.3 22.7

Crude Death Rate 6.7 6.6

Maternal Mortality Ratio 186 153


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3. Maternal and Child Health
3.1 Maternal Health
Maternal Mortality Ratio of Haryana is better than Indian figure of MMR, however Haryana
is quite far from the MDG goal of 100 MMR while some states have already achieved the
MDG target. The major causes of maternal deaths are excessive bleeding during child birth,
obstructed and prolonged labour, infection, unsafe abortion, disorder related to high blood
pressure and anemia.
Table 3.1.1.1 Maternal Mortality Ratio (MMR)-Haryana
MMR (Maternal Mortality Ratio) SRS (maternal deaths per 1 Lac births per year)
Year Haryana India
1999-01 176 327
2001-03 162 301
2004-06 186 254
2007-09 153 212
Goal by 2015 100 100
Haryana ranks 7
th
in MMR amongst all states and UTs.
Comment : Haryana has been improving over the years in this regard but not up to the
expected levels. From 1999 to 2009 while National MMR has come down by 115 points the
MMR of Haryana has come down by 23 points only during this period. The difference of all
India average and Haryana average was 151 in 1999 but in 2009 the difference is 69. The
progress in other states has been much rapid, but not so rapid in Haryana. One reason
could be that after a certain level it becomes difficult to continue to reduce the ratios at the
same rapid rate. It is expected that economic development should translate into better
access to health care and matching improvement in the health indicators. Reasons of
maternal mortality are directly related to availability of facility for institutional delivery,
better quality of available services and desire of a patient to access the facility. Therefore,
the whole emphasis is on maximizing safe institutional deliveries.
The state has expanded the availability of facilities substantially under NRHM. With
this objective in mind the state started the concept of delivery huts and now has 993
delivery points in Government sector. It has dramatically improved its institutional
deliveries from 49% in 2006 to 84% in 2013.

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Table 3.1.1.2 Progress on Maternal Health Indicators
Indicators (in %)
DLHS-III
(2007-08)
CES
(2009)
HMIS
(2010-11)
HMIS
(2011-12)
Three plus ANC 52.4% 68.9% 77.03% 81.77%
Registration within 12 weeks 55.1% 57.4% 46.89% 51.15%
TT1 & TT2 Booster - - 100% 100%
Mothers who consumed 100 IFA
tablets
29.0% 49.1% 88.4% 79.15%

ANC has improved substantially from 52.4% in 2007 to 81.77% in 2012. The improvement
in the figures of ANC indicated that the state is making efforts to improve ANC services in
the last few years.
Table 3.1.1.3 Institutional Deliveries as per CRS Data
Year Govt. Inst. Pvt. Inst. Total Inst. Non Inst. Total
2006
83133 166464 249597 259373
508970
16.30% 32.70% 49% 51%
2007
96948 178273 275221 236752
511973
18.90% 34.80% 53.70% 46.20%
2008
120042 198053 318095 219224
537319
22.34% 36.85% 59.19% 40.79%
2009
164388 196864 361252 177658
538910
30.50% 36.53% 67% 33%
2010
205086 197282 402368 142252
544620
37.65% 36.22% 73.88% 26.11%
2011
237067 198607 435674 127882
563556
42.07% 35.24% 77.31% 22.69%
2012
247153 202143 449296 11437
563733
43.84 35.86 79.70% 20.30%
Comment : From the above table, it is seen that total institutional deliveries have almost
doubled from around 49% to 80%. Furthermore, the institutional deliveries in the private
institution have almost remained constant but in the government institution have
increased three folds. The number of institutional deliveries in the Govt. institutions have

15
increases from 83133 to 247153. The staff of Govt facility has not however increased in
that proportion. The proportion of home deliveries has declined dramatically during the
last 5 years.
Table 3.1.1.4 Institutional and Non
Institutional Deliveries Year 2012
District
Govt.
institution
%
Gov
t
Pvt.
Instituti
on
%
pvt
Total
institution
%
institutio
nal Home
%
Ho
me Total
Ambala 10642 51 9400 45 20042 97 685 3 20727
Bhiwani 11011 37 13862 46 24873 83 4999 17 29872
Faridabad 16842 38 20096 45 36938 83 7385 17 44323
Fatehabad 9755 43 7706 34 17461 76 5468 24 22929
Gurgaon 15057 41 18868 51 33925 91 3206 9 37131
Hisar 13941 35 18089 46 32030 81 7725 19 39755
Jhajjar 8114 51 4566 29 12680 80 3161 20 15841
Jind 13370 52 8329 32 21699 84 4202 16 25901
Kaithal 10568 45 8466 36 19034 81 4328 19 23362
Karnal 15474 48 11435 35 26909 83 5441 17 32350
Kurukshetra 7742 37 10392 50 18134 87 2774 13 20908
Mewat 15047 38 2095 5 17142 44 22196 56 39338
Mohindergar
h 10634 63 4237 25 14871 88 2003 12 16874
Palwal 8556 29 7477 25 16033 54 13398 46 29431
Panchkula 10207 76 2908 22 13115 98 294 2 13409
Panipat 9487 35 11211 41 20698 76 6456 24 27154
Rewari 8681 46 9437 50 18118 95 906 5 19024
Rohtak 16726 63 6535 24 23261 87 3461 13 26722
Sirsa 13736 53 8042 31 21778 84 4288 16 26066
Sonepat 11615 40 10063 35 21678 75 7361 25 29039

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Yamunanaga
r 10278 43 9026 37 19304 80 4820 20 24124
247483 44 202240 36 449723 80 114557 20 564280

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

FIGURE 3.1.1.5: Maternal Death Review Data

Comment : If we further group the causes based on period of their occurrence into
1. Ante-natal : Hypertensive disorders and Anaemia manifest during this period and
aggressive follow-up during the III trimester can easily help in detection and
intervention on these cases.
2. Intra-natal : Obstructed labour, sepsis and Eclampsia (Hypertensive) relate to this
period.
3. Post-natal: Though sepsis is caused because of interventions during the natal period
but its fatal implications get manifested along with hemorrhage mostly during this
period.
31%
9%
7% 15%
4%
1%
21%
12%
Chart Title
HEAMORRHAGE
SEPSIS
ABORTION
OBSTRUCTED LABOUR
HYPERTENSIVE DISORDERS IN
PREGNANCY
ANAEMIA

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4. Related to Unsafe Abortion: Have an implication on the provision of safe and easily
accessible MTP services in the state. It is estimated that globally close to 70,000
maternal deaths annually (13 per cent) are due to unsafe abortions UNFPA-SRH
framework).
The most common causes of maternal deaths beckon us to improve maternal services
during all the three phases of pregnancy. Keeping the above stated generally known
causes of maternal death, the state has adopted a comprehensive strategy and series of
intervention addressing all the issues/gaps under NRHM. Some of them are highlighted
as given below:-

3.1.2 Strategies For Maternal Health For The Last 5 Years
Table 3.1.2.1 Strategies and programs of last five years to decrease MMR:
S.No.
2008-09 2009-10 2010-11 2011-12 2012-13
1
Early Registration
of Pregnancy
Continued Continued Continued Continued
2
Three ANC Continued Continued Continued Continued
3
Institutional
Deliveries
4
Postnatal Care Continued Continued Continued Continued
5
Ensuring
Emergency
Obstetric care
6
Operationalization
of FRUs
7
Referral Transport Continued Continued Continued Continued
8
JSY Continued Continued Continued Continued
9 Delivery Hut
Scheme
10 RCH outreach
Camps
11 Social Mobilization
through ASHA
12 Training of EmOC
& LSAS doctors

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13 SBA Training of
Staff nurse
14

Capacity
Building
of ASHA
Continued Continued Continued
S.No.
2008-09 2009-10 2010-11 2011-12 2012-13
15

Blood
Storage
Centres
16

Provision for
extending maternity
wards by increasing
no. of beds
Continued Continued
17

Provision of 4 staff
nurse
Continued Continued
18

Provision of
specialists for FRUs
Continued Continued
19

Provision of LT at
DH
Continued Continued
20
Equipment & Drugs Continued Continued
21
Infrastructure Continued Continued
22

Operationalization
of 24*7 PHCs
Continued Continued
23

Recruitment of staff
nurses, LTs, ANMs,
Pharmacists
Continued Continued
24

Recruitment of
sanitary workers
Continued Continued
25

Monitoring of
Health services
Continued Continued
26

Provision of
Disposable Delivery
kits in PHCs & SCs
Continued Continued
27

Provision of MTP
services at CHC,
SDH, DH., Training
for MTP of MOs
Continued Continued
28

Scheme of social
marketing of
Continued Continued

19
sanitary napkins for
Rural women (since
2009)
29

Maternal Death
tracking
Continued Continued
S.No.
2008-09 2009-10 2010-11 2011-12 2012-13
30

Scheme Janani
Suraksha Yojna
Continued Continued
31

Jachcha bachcha
scheme
Continued Continued
32
Incentives to DAIs Continued Continued
33
Urban RCH Continued Continued
34

Appointment
of 3
rd
ANM at
sub-centres
Continued
35

Prevention
of RITs/STIs
Continued
36

Surakshit
Maa Award
in four Dist.
37

Reverse
Tracking of
Anaemia
38

Tracking of
High Risk
Pregnancies

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

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

3.1.2.1.2 Reverse tracking of anemic patients
Reverse tracking of anemic patients, arriving in the labor room for delivery, to the
concerned service provider/ANM has been started from December, 2011. Online Anemia
Tracking System is in process. Doctor in the labor room is required to maintain a list of
severe anemic patients and report by email to the State HQ. A return email is then sent by
the HQ to the concerned MO-Incharge of the PHC/CHC or PP Centres to take corrective
steps to fill the gaps in the service delivery.
Number having Hb less than11 gm
Year Survey Number Percentage
2010-11 HMIS 259974 42.71%
2011-12 HMIS 298334 49.56%
2012-13 HMIS 356999 67.41%

No. having severe anaemia Hb<7 gms treated at Institution:
Year Survey Number Percentage of severe anaemic women
to women with Hb level <7gms
2010-11 HMIS 40365 15.52%
2011-12 HMIS 39589 13.27%
2012-13 HMIS 26571 5.01%

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

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

3.1.2.2 Institutional Deliveries

3.1.2.2.1 Operationalization of Health Facilities FRUs and 24x7 PHCs

List of 24x7 Delivery Points
Year DH SDH CHC PHCs SCs
Medical
Colleges
ESI
Hospitals
Military
Hospitals
Urban
FRUs
Total
2009-10 21 10 53 110 460 3 2 3 2 664

21
2010-11 21 11 54 114 468 3 2 3 2 678
2011-12 21 12 56 121 469 5 2 3 2 691
2012-13 21 19 97 315 469 5 2 3 2 933

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

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

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

Analysis of delivery points show that they are not evenly spread out and the deliveries at
such points are not as per the benchmark at all places. State needs to have a [policy about
the provision of delivery point for normal deliveries within a reach of 10-15 km , 24 by 7.
Services should be evenly spread out.
3.1.2.2.2 Increasing no. of functioning FRUs:
Year DH as FRUs SDH as FRUs CHC as FRUs
Urban
FRUs
Total
2009-10
18 (Except
Jhajjar,
Mewat &
Palwal)
5 (Nilokheri, Jagadhari, Tohana,
Bahadurgarh & Naraingarh)
3 (Meham,
Dabwali & Kalka)
2 28
2010-11
19 (Except
Mewat &
Palwal)
6 (Narwana, Nilokheri, Jagadhari,
Tohana, Bahadurgarh & Naraingarh)
3 (Meham,
Dabwali & Kalka)
2 30
2011-12
20 (Except
Mewat)
8 (Ambala Cantt. Nilokheri,
Jagadhari, Tohana, Ballabhgarh,
4 (Meham,
Dabwali,
2 34

22
Year DH as FRUs SDH as FRUs CHC as FRUs
Urban
FRUs
Total
Narwana, Bahadurgarh &
Naraingarh)
Shahabad &
Kalka)
2012-13
till Dec.
20 (Except
Mewat)
8 (Ambala Cantt. Nilokheri,
Jagadhari, Tohana, Ballabhgarh,
Narwana, Bahadurgarh, &
Naraingarh)
5 (Meham,
Dabwali,
Shahabad, Kalka
& Safidon)
2 35

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

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

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

Janani Shishu Suraksha Karyakram (JSSK) (Implemented on 01.06.2011)
Sr.
No.
Free Entitlements
Date of
Implementation
Entitlements for Pregnant Mothers
1 Free delivery 01.01.2009

23
Janani Shishu Suraksha Karyakram (JSSK) (Implemented on 01.06.2011)
Sr.
No.
Free Entitlements
Date of
Implementation
Entitlements for Pregnant Mothers
2 Free caesarian section 01.01.2009
3 Free drugs and consumables 01.01.2009
4 Free diagnostics (Blood, Urine tests and Ultrasonography etc.) 01.01.2009
5
Free diet during stay (up to 3 days for normal delivery and 7
days for caesarian section)
07.12.2011
6 Free provision of blood 01.01.2009
7
Free transport from home to health institution, between health
institutions in case of referrals and drop back home
14.11.2009
8 Exemption from all kinds of user charges 01.01.2009
Entitlements for sick new born
1 Free and zero expenses treatment 01.09.2011
2 Free drugs and consumables 01.09.2011
3 Free diagnostics 01.09.2011
4 Free provision of blood 01.09.2011
5
Free transport form home to health institution, between health
institutions in case of referrals and drop back home
01.09.2011
6 Exemption from all kinds of user charges 01.09.2011

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

3.1.2.2.2 Quality improvement in Institutional deliveries
Ensuring good quality Emergency and Obstetric Care. Up-gradation of labor rooms as
separate Aseptic Labor Room, separate Septic Labor Room, separate Procedure Room,
separate Eclampsia Room and expansion of Post-natal Wards with sufficient number of
beds for 48 hours stay of the patient after deliveryCapacity building of the doctors for
EmOC, LSA and their posting at FRUs is being done.
Training of service providers for SBA (Skilled Birth Attendant) is being conducted. New
incentives and reward schemes to encourage the EmOC and LSA trained doctors.
Comment: All these are good initiatives and need to be followed up aggressively.
3.1.2.3 Post Natal Care (PNC)

24
ANMs/ASHAs are being utilized for Post Natal Checkups and detection of any post natal
complication and their referral to FRUs. Motivation for family planning methods is also
being done.

3.1.2.4 Safe MTP services
MTP Services (HMIS Survey)
2010-11 2011-12 2012-13
up to 12 weeks of pregnancy 10489 11063 10253
More than 12 weeks of pregnancy 191 265 569
Total no. in Govt. Facilities 10680 11328 10822
Total no. in Pvt. Facilities 16363 16469 11346
Total MTPs 27043 27797 22168
Total number of Govt. Facilities reporting MTPs
Total number of Pvt. Facilities reporting MTPs 631 631 631
Total number of doctors providing MTP services 256 283 283

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

3.1.2.5 Maternal Death Review & Audit
Maternal Death Review (HMIS Survey)
2009-10 2010-11 2011-12 2012-13
Maternal Deaths 280 172 260 366

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

Comment : The initiative is innovative but state needs to improve its reporting.
3.1.2.6 Supportive Supervision for Monitoring & Evaluation
Supportive supervision inviting teams from PGIMS Rohtak, PGI Chandigarh, PRC
(Population Research Centre) and State Head Quarter is being done. Supervision of labor

25
rooms for their up-gradation by the State Head Quarter Officers is being done. Data is
analyzed and presented in the Civil Surgeons Conference.

3.1.2.7 Referral Transport

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

Referral Transport Scheme under JSSK
Year
Total
User
Pregnant
Women
Drop
Back
Pregnant
Women
Referral
of
Pregnant
Women
Sick
New
Born
Drop
Back
Sick New
Born
Referral
of Sick
New
Born
2009-10 36156 25891 N.A. 10265 N.A. N.A. N.A.
2010-11 150439 99075 N.A 51364 N.A. N.A. N.A.
2011-12 320836 149246 117904 47014 1776 1118 3778
2012-13 310704 141730 111189 45764 2974 2590 6457

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

3.1.3 Progress So Far:
MMR has decreased to 153 per lac live births (SRS 2007-09). Millennium Development Goal
to be achieved is 100 per lac live births by 2015. There is increase in Institutional Delivery
from 49% (2006) to 77.3% (2011). Operationalization of FRUs at 36 Health Facilities and
establishing 24x7 delivery points at 421 facilities is being done. Free delivery/caesarean
with free referral transport is provided under JSSK Scheme. All Maternal Deaths are
reported and audited. Severely anemic patients in district hospital are tracked back to the
Service Provider/ANM. JSY payments to BPL and SC are done regularly. Further matter is
being taken up with GOI to relax the BPL requirements.

Comment on maternal Health Interventions:

26
Since 2006, state has drastically improved its maternal Health services. A large number of
initiatives have been taken to provide safe institutional delivery at the doorstep by opening
of large number of institutions at subcentres and PHCs, improvement in quality of services
and providing services for handling complicated deliveries. The number of delivery points
have increased from 664 to 933, which has increased the number of deliveries to 3 times
even while private sector deliveries have remained stagnant. The number of PHCs
providing 24X7 deliveries have increased from 110 to 315 and number of centres
providing services to handle complicated deliveries from 28 to 35. The referral transport
system has also drastically improved its services and data of mothers transported is very
encoutaging. In order to monitor the causes of maternal mortality state analyses 1/3 of all
maternal deaths but it needs to use the analysis for identifying and improving gaps in its
services.
The state needs to focus on critical issues like handling of severe anaemia in pregnancy,
Hypertension / Eclampsia, post-partum hemorrhage, infection free services and improving
access to safe MTP services.
3.2 Child Health:
According to SRS 2011, IMR of Haryana is 44 as compared to 66 in 2001.
Figure 3.2.1.1 Infant Mortality Rate-and Neonatal Haryana Mortality Rate
IMR
Year India Haryana
2004 58
2005 58 60
2006 57 57
2007 55 55
2008 53 54
2009 50 51
2010 47 48
2011 44 44
NMR 2011
Indicator India Haryana
NMR Total 31 28

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

27
is among the developed states of the country the fall should be faster than all India
decrease.

Figure 3.2.1.2 Comparative Status of IMR
Status of IMR across states
59
57 57
55
52 52
48
44 44 44
43
41 41
39
38
36
35 35
34
32 32
30
29
28
26
25
24
23
22 22
21
20
19
12
11 11
0
10
20
30
40
50
60
70
I
M
R

p
e
r

1
0
0
0

l
i
v
e

b
i
r
t
h
s
State wise IMR, SRS 2011
four large states (Punjab, Kerala, Tamilnadu & Maharashtra ) and 11 others have achieved MDG 4 target (IMR< 30).

Regional Difference
HARYANA IMR
EASTERN 44
WESTERN 54
TOTAL 48

28

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

Figure 3.2.1.2 Causes of Under five deaths in India
Malnutrition
>33%
Causes of Under-five deaths in India:2010

More than half of the U5 deaths are in the neonatal age-group. If these are further analyzed
further it is seen that Preterm delivery is an important cause of neonatal mortality and this
would improve if ANC coverage and quality improves. Asphyxia and infection relate to
better labour room infrastructure and practices. The other causes like diarrhea and
pneumonia account for more than 10% of U5 deaths. Malnutrition is an underlying cause in
a large proportion of U5 deaths.

29
3.2.1.1 Major factors responsible for high neo-natal mortality:
Poor nutrition and anaemia among adolescent girls and women
Low coverage and quality of ante-natal, intra-natal & postnatal care
High proportion of unsupervised home deliveries and poor quality of institutional
deliveries
High proportion of low birth weight of newborns
Delayed initiation of breastfeeding
Not maintaining adequate warmth of newborns
Delay in seeking health care for sick newborns
3.2.2. Strategies for Child Health for the Last 5 Years
Table 3.2.2.1 Strategies for Child Health for last 5 Years
S.No. 2008-09 2009-10 2010-11 2011-12 2012-13
1 Nutrition
supplementatio
n of Pregnant
mother &
children (0-6
years) through
ICDS
2
Immunisation Continued Continued Continued Continued
3
IMNCI Continued Continued Continued Continued
4 Essential New
Born care
5 Vit. A
supplementatio
n (6 month
3years)
6 IFA to Primary
School children
7 Mid day meal
scheme
8 De-worming of Continued Continued Continued Continued

30
school going
children
9
IMNCI Continued Continued Continued
10

School Health
Scheme
11

Health
promoting
school
approach
12 IYCF Continued Continued
S.No.
2008-09 2009-10 2010-11 2011-12 2012-13
13

Management of
ARI
Continued Continued
14

Management of
Diarrhoea
Continued Continued
15

Establishment of
SNCU at DH,
Newborn & Child
stabilisation
units at FRUs,
Newborn care
corner at 24x7
PHC, Nutritional
Rehab. Centres
Continued Continued
16

Monitoring
under IMNCI
Continued Continued
17
IEC/BCC Continued Continued
18
NSSK Continued Continued
19

Implementation
of F-IMNCI
Continued Continued
20

Facility Based
Newborn care
(FBNC)
Continued Continued
21

Newborn
Corners at PHC
Continued Continued

31
22

Implementation
of community
based neonatal
care
Continued Continued
23

Implementation
of Facility based
infant & child
care
Continued Continued
24

Infant Death
Audit
Continued Continued
S.No. 2008-09 2009-10 2010-11 2011-12 2012-13
25

Child referral
unit
Continued Continued
26
IBSY Continued Continued
27

Home based
Post Natal
newborn
care
(HBPNC)
Continued
28

Measles
campaign
Continued
29

Child SNCU
helpline
established
30

Yashoda
introduced
31

Mother &
Child
Protection
cards

3.2.2.2 Provision for Essential New Born Care
Provision for Essential New Born Care is of top most priority. Establishment of New born
Care Corners at every delivery point is the planned target of the state. The persons
handling delivery are trained in Newborn Sishu Suraksha under the NSSK programme
which provides Essential New Born Care training. New Born Care Corners are established
in 81 CHCs/ PHCs / Delivery Huts on the basis of their no. of delivery.

32
The entire focus is on safe delivery at a specified delivery point. Those newborn who are
high risk and need special new born care are referred to higher centres. For the care of sick
newborns SNCUs at MCH Level III facilities and NBSUs at MCH Level II facilities have been
established. Along with this, arrangement for free referral transport for sick newborns to
health facilities has been made improving newborn survival.
Those newborn who are not at risk are sent home along with mother, however to follow up
in the newborn period, Home Based Post New born Care (HBPNC) has been started.

3.2.2.4 Home Based Post-Natal Care (HBPNC)
HBPNC contains a range of interventions providing opportunity to identify the danger sign
and referral by ASHA. Training of HBPNC for ASHAs for five days has been completed after
earlier 2 days training (around 13,000 ASHAs trained) in all the districts in the month of
May 2012. 10,000 Salter Weighing Scales digital thermometers & drug kits have been
provided to ASHAs.
3.2.2.11 Integrated Management of Neonatal and Childhood Illnesses (IMNCI),
Facility Based IMNCI
As per presentation made, IMNCI trainings, booklets and formats have been provided to
IMNCI trained workers. During 2012-13, till Sep, 103300 new born babies were visited
within 24 hours out of which 13332 were assessed, 11297 were treated & 2561 were
referred. Reorientation of MOs using the Multimedia package has been initiated. 9200
health workers & anganwadi workers trained till Sept. 2012.
Comment: The state needstake up the programme district wise and make in fully
functional in few districts before moving to the next. It should do a third party evaluation
to check the effectiveness of this programme.
3.2.2.12 Facility Based IMNCI is an important training program to bridge the gap in the
facility based intervention in child health care. Facility based IMNCI is to empower the
Medical Officer and Staff Nurses in managing sick children referred through IMNCI trained
workers. F-IMNCI also covers the neonatal care including the resuscitation and
management of low birth weight child in the facilities. 2177 health personal trained in
facility based IMNCI (F-IMNCI).
3.2.2.5 Specialised Facility Based New-Born Care
State is focusing on improving the child health services to reduce the Infant & Child
Mortality. Thirteen SNCUs (Sick Newborn Care Units) have been established and in rest of
the district Hospitals they are under process of establishment. Till Sep 2012, A total of 5441

33
(3304 Inborn & 2137 Outborn) babies were admitted in the SNCUs, out of which 815 were
referred to higher centres and 268 died.
New born Stabilizing units are established at 19 CHCs and 11 SDH while in some districts,
SUs are under process of establishment. Training of SNCU staff is being done in
collaboration with NNF.
3.2.2.3 Free Referral Transport for sick newborn.
ENBC, HBPNC, and IMNCI programmes have lead to identification of sick newborn at their
households and improved referral of sick newborns to health facilities. Bringing these two
together has resulted in an increased number of sick newborns presenting in referral
hospitals. In this situation, Facility-based newborn care has a significant potential to bring
favourable impact in newborn survival.
3.2.2.7 Infant and Young Child Feeding Practices
Another important Child Health Intervention strategy adopted to address malnutrition is
measures to improve IYCF practices. The IYCF practices reduce malnutrition in infants and
young children through:-
Timely initiation of breastfeeding, Exclusive breastfeeding during the first six months of
life, & timely introduction of complementary foods, at six months, while breastfeeding
continued until 24 months and beyond.Age appropriate complementary feeding, adequate
in terms of quality, quantity and frequency for children 6-24 months, with increased
quantity, density and frequency as the child grows.
Data from CES 2009 shows that IYCF practices vary widely across the states. Initiation of
breastfeeding within half an hour of birth has an all India average of just 33.5% while
percentage of children exclusively breastfed for 6 months (among 6-9 months children) is
only 37%. In Uttarakhand, Uttar Pradesh and Delhi percentage of exclusively breastfed
children is less than 20%, while Himachal Pradesh, Sikkim, Tripura nearing 60% and
Jammu Kashmir close to 80%. The percentage of children 6-9 months on complementary
feeding and breast milk is an average of 57% for India and ranges from 40-90% in various
states. However this age is a critical period when children are likely to falter in growth if
the quantity and quality of complementary food is inadequate.
Renewed focus on BCC during home visits, VHND and ANC is required. Mothers should be
counselled and supported for breastfeeding during postnatal visits. Most states have
dedicated budget for IEC on Child health, which can be used more effectively for creating
awareness on breastfeeding practices.
3.2.2.13 YASHODA

34
In the state, Yashoda worker was introduced to ensure good IYCF practices, provision of
birth doses to the newly born in the facilities and to act as birth companion. The Yashoda
facilitates registration of mother at the facility. Ensure Care of new born, recording of birth
weight and support to mother, ensures early initiation of breastfeeding, counseling for
exclusive breast feeding and watching for post natal risks to mother and new born.
Provides counseling. Ensures Zero dose Polio & BCG to the new born before discharge. So
far, 128 Yashodas have been recruited out of 148 sanctioned in various districts.

3.2.2.8 Iron supplementation
The NFHS-3 survey highlights widespread anaemia, with prevalence of 69.5 per cent in
children between 6 59 months. Anaemia remains widely prevalent in all states. Except for
a few states, more than half to two thirds of children are anaemic. Despite paediatric IFA
tablets / syrup and deworming tablets being supplied as part of Kit A to all sub-centres,
twice a year, the coverage of children with IFA remains very low.
3.2.2.9 Management of children with malnutrition
42.5% children under age of five years are underweight (low weight for age). 48% children
are stunted (low height for age). In numbers it means that more than 47 million children
under 5 are chronically malnourished. 19.8% children are wasted (low weight for height),
over 6% of children under five years of age suffer from Severe Acute Malnutrition (SAM). In
numbers it translates into 25 million children with wasting and 8 million with severe
wasting or SAM. 22% babies are born with low birth weight. SAM significantly increases
the risk of death in children under five years of age. It can be a direct or indirect cause of
child death by increasing the case fatality rate in children suffering from such common
illnesses as diarrhea and pneumonia. Children who are severely wasted or underweight are
9 times more likely to die than well-nourished children.
3.2.2.10 Management of Diarrhoeal Diseases & Acute Respiratory Infections
Intervention is done through the IMNCI programme.
Comment: Currently the state does not have a database on the incidence of ADD and ARI.
3.2.2.15 Infant Death Review (IDR)
IDR is tool to analyze the causes of Infant Death and taking corrective actions. All infant
deaths to be reported (surveillance started). State and District level review committees
analyze the causes of deaths and fulfill gaps in health system. Total infant deaths reported
till Sept 12 were 3533, still births were 2437. Till Sept 12, total no. of Infant deaths
reviewed were 948 and no of still births reviewed were 307.

35
3.2.2.6 Immunization
Table 3.2.1.1 Immunization rates in Haryana
Indicators DLHS-3 (2007-08) DLHS-2 (2002-04)
Child Immunization Total Rural Urban Total
1
Rural Urban
Number of children age 12-23 months 2,111 1,580 531 2,214 1,638 577
Children 12-23 months fully immunized (%) 59.6 55.9 70.8 59.1 56.7 66.3
Children 12-23 months not received any vaccination (%) 1.9 1.9 1.9 11.8 12.4 10.3
Children 12-23 months who have received BCG vaccine (%) 86.5 85 91 83.5 82.5 86.1
Children 12-23 months who have received 3 doses of DPT
vaccine (%) 69.1 66.3 77.6 73.6 71.6 78.6
Children 12-23 months who have received 3 doses of polio
vaccine (%) 67.9 65.1 76.2 72.9 70.8 77.9
Children 12-23 months who have received measles vaccine (%) 69 66.4 77.2 65.4 63.5 70
Children (age 9 months and above) received at least one dose of
vitamin A
supplement) (%) 46.3 43.8 53.9 42.2 39.3 49.2

Free Immunization services to all pregnant women & Children to prevent against 7 Vaccine
Preventable Diseases. Fully Immunized children are 71.7% (CES 2009), from 59.6% DLHS
(2007-08). No Polio Case in state in last two years i.e. Jan 2010. Haryana is the first state in
India to complete Measles Catch up campaign in which 48.50 lac children (9M to 10Y) were
vaccinated. Unique urban vaccination strategy by providing additional ANM for
Immunization at Urban RCH Centre has been started. Hep. B vaccination launched from
14
th
Nov 2011 in all districts. One of the best equipped cold chain in country with four
regional vaccine stores & cold chain technician in every district. State launched Pentavalent
vaccine in Nov, 2012 and state level workshop conducted for Pentavalent vaccine. It has a
special programme to prevent Adverse Events Following Immunization (AEFI).
RAPID i.e. Supportive Supervision for Immunization conducted in 3 districts of Haryana
(Palwal, Panipat & Mewat). 52 Immunization Field Volunteers (IFVs) have been recruited
for monitoring of Immunization activities in collaboration with NPSP-WHO.
Provision of prophylactic IFA syrup and ORS+ Zinc to all children with Diarrhoea has been
made. Ensuring a total of 9 doses of Vitamin A to all children below five years of age.
1,00,000 IU dose of Vit A is being given at 9months and 2,00,000 IU after 9months at 6
monthly intervals upto 5 years of age.
3.2.2.1 Mother and Child Protection (MCP) Card
MCP card has been recently adopted as a tool for monitoring growth of children, assessing
key milestones during early years of development and empowering families to make

36
decisions for improved health and nutritional status of children under 3 years. These cards
are a joint initiative of the Ministries of Health & Family Welfare and Woman & Child and
bring about convergence on the issue of child nutrition.

3.3 Recommendations of the Maternal and Child health sub group

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

3.3.1.1 Defining Services, Gap analysis and closure.

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

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

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

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

37
d. Reallocation of resources and Upgradation/ Reclassification of facilities On the basis
of gap analysis, the state must upgrade its facilities appropriate to the level of care. The
health resources including manpower and equipment should be reallocated depending
upon the gap analysis of health facilities. Trainings should also be deferentially targeted
based on identified gaps. Budget allocation, construction of buildings and postings of
personnel should be made accordingly. In case of non availability of adequate manpower,
infrastructure or budget, the facilicity should be reclassified on the basis of available
resources. Resources can be reallocated according to the need of each district. Some
performance based indicators and total population covered can be used as parameters for
decising needs of each district. Primary care should be designed in such a way to decrease
the load of tertiary care.

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

3.3.2.1 Antenatal Period

a. Quality of Antenatal Checkup (ANC):

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

ii) Indicators to check the quality of services being provided at every step must be
developed. Indicators should be structural, process and outcome indicators (eg
availability of examination table, Number of pregnant women referred with
major risk factors after ANC; Number of severe anaemia/ high BP identified). It
would be difficult to monitor quality amongst the large number of indicators,
therefore selected few key indicators as a starting point. These key indicators
should be evidence based, nationally and internationally recognized. The clinical
practices related to these key indicators should be modified so as to contribute
to the reductions in mortality and adverse outcomes. Reverse tracking of
maternal deaths should be done as a tool to identify gaps in ANC.


38
iii) State should device a system of annual accreditation of ANMs skills. It should
regularly identify gaps in their knowledge, skills and practices specially those
that would enable them to identify high-risk pregnancies and conduct specific
trainings to fill these gaps. ANMs can be certified on the basis of these training.
State must define and document the high risk obstetric cases and this
information should be available with all care providers.

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

v) Sub centres should be equipped with BP apparatus, Hb testing equipment, digital
thermometer, weighing machine and examination table. Weighing machines, BP
apparatus etc should be regularly checked and calibrated. ANC should be done in
clean environment offering privacy to the women.
c. Mobile Teams for ANC: State should provide Mobile Teams providing ANC services for
underserved areas. It could comprises of a team of nurses, SBA trained ANC health
workers, lab technicians etc equipped with BP Appratus, weighing scales and lab facility
can visit the underserved areas/villages following a fixed schedules and provide basic
antenatal services and identify high risk cases and complications. They could also schedule
and conduct check-ups at the health centres/hospitals in remote areas or where the
coverage is unsatisfactory due to paucity of staff.

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

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

3.3.2.2 Intranatal Period:

a. Setting standards and Infrastructure improvement: State must improve the quality,
safety and privacy of its labour rooms, caesarian OTs and delivery services at all levels of

39
care. Guidelines for Antenatal care and Skilled Attendance at Birth and MNH guidelines of
MOHFW, Govt. of India, April 2010 should be adopted formally as standards for providing
intra-partum care. Every labour room and caesarian OT should be provided with facility to
handle essential new born care. Safe practices should include standard infection control
and Biomedical Waste disposal practices. Best practices could be less number of PV
examinations; not giving Inj. Oxytocin before delivery; maintaining Partographs to monitor
progress of labour. These can be painted on the wall of Labor Room.

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

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

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

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

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


40
b. 48 hour stay and Discharge: State should ensure a mandatory stay of 48 hours in
institutional deliveries. High risk mothers & neonates should be kept for a longer period.
An exercise of calculating the number of PN beds should be done for every delivery point
based on the delivery and population load. If there are inadequate number of beds in the
PN wards then the number of beds should be increased to meet the objective of 48 hour
stay on priority basis. Food, clean water and toilet facilities should be ensured in the PN
wards.

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

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

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

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

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

3.3.3 Referral Transport:

a. State must ensure that adequate number of ambulances are available to transport
serious cases (mother/children) at appropriate level in timely and safe manner. State
can consider augmenting its existing fleet of ambulances. It should integrate its

41
ambulance services with other state agencies/NHAI/private players. It could consider
having a single call number in case of emergencies for police/NHAI and health dept.
ambulances.

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

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

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

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

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

RECOMMENDATION 4 :

42
3.3.4 Improvement of Trainings: Quality of training needs to be improved and monitored

a. Appropriate Training: State must provide training appropriate to the need. It may
conduct a gap analysis of training need, make an annual plan and budget based on gaps
identified and follow the plan. The training need should be linked to the need of the
programmes.
b. Improving Quality: State must improve the quality of trainings provided to all cadre
involved in MCH services. Before and after each training a written and oral test must be
conducted and certificate issued.
c. Practical Experience: The medical as well as paramedical staff of peripheral health
facilities like Medical Officer, ANM, Staff Nurse and ASHA should be deputed for 3-4
days in a month at respective District Hospital. This would help them learn and practice
the key skills through observation and practice. It will provide helping hands in busy
hospitals and also facilitate in rapport building which will then help in cases of referred
patients. Support and hand holding is needed for SBA trained personnel. Doctors under
going EmOC/LSA training should be posted at DH and their follow up indicators after
completion of training should be developed.
d. Monitoring: It should develop indicators to monitor the quality of trainings. The
indicators must be analysed and acted upon. Training could be monitored by means of a
third party monitor.
e. Posting of trained staff: All trained staff must be posted in a rational manner keeping
in view the gaps and level of facility, so that the skills that they acquire are properly
utilized and not lost.
f. Retraining: Each category of MCH staff must undergo retraining after every 3 years to
upgrade their skills.

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

3.3.3 Maternal Mortality and Morbidity:

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


43
b. Medical complications: Complications like hypertension, anaemia, TB during
pregnancy are also important cause of maternal deaths. Strategies to address these
medical problems should be devised. Horizontal integration of maternal health with
existing programmes for RNTCP, NVBDCP, Anaemia Control Programme etc. should be
done.

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

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

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

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

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


44
a. MTP Services: Illegal abortions are one of the leading causes of maternal deaths.
Provision of safe and quality MTP services are as important as providing good
institutional delivery services. The state must ensure that better access to MTP
services is provided through the public health system at primary and secondary health
care level. There is a need to conduct mapping of the available MTP services in the
State (Private and Government) and close the geographical gaps in the services to
provide better access.
b. Better access of MTP services: MTP services should not be limited to pregnancies in
married adults. Teenage and unmarried girls should also be provided abortion services
to prevent mortality and morbidity. Care should be taken to be ensure confidentiality
of personal identity in such cases. Provision should be made for counselling of such
cases in order to reduce mental trauma. Abortion services should be provided free of
cost at Govt. health facilities without too many formalities and in a user friendly
manner.

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

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

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

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

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


45
g. Right to safe abortion: Womens awareness about abortion services has to be
enhanced. Access to Safe abortion should be recognized as a right of every pregnant
women irrespective of age, caste, or marital status.

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

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

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

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

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

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

RECOMMENDATION 8 :

46
3.3.8 Special Newborn care (SNBC): Since certain percentage of newborn like low birth
weight, premature newborn, need to be provided intensive care environment for survival
State should also focus on Special New Born Care.

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

b. Protocols : State must formally adopt or develop and implement standard clinical
protocols for SNBC services. The protocols should specifically focus on quality and
safety.
c. Training Facility: State may develop some of its SNCUs as training facilities for its
staff providing SNBC by contracting trainers from agencies like NNF/PGI/AIIMS and
training infrastructure. State may consider starting special courses of neonatal care
for doctors and nursing staff in its medical and nursing colleges and provide them
with special incentive in service rules.

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

a. In the first 48 hours state must properly identify at risk newborn and retain
them after delivery.
b. After 48 hours the programme should address Post natal visits at homes of
newborn and at-risk new-borns must be promptly identified and referred
appropriately to prevent mortality in the newborn period.

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

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


47
a. In the post-neonatal period Pneumonia, diarrhoea and under nutrition are the top
causes of deaths. The deaths due to these illnesses are preventable. State should
adopt standard protocols for early detection, treatment and referral of these cases.
The health workers have to be trained in IMNCI. The field level health workers must
be able to recognize early signs of dehydration in diarrhea, respiratory distress in
pneumonia and growth retardation. \
b. IMNCI (Integrated Management of New-born Care and Child Illness) : State should
strengthen its IMNCI programme. This can be done by making a few districts fully
functional in IMNCI and gradually extending to all districts. There is a need for focus
rather than spreading it across the state.
c. IMNCI v/s HBPNC :State should resolve duplication in IMNCI programme
component for infants between 0 to 2 months of age and the HBPNC programme
which is also for newborn between 0 to I months of age. Both the programmes are
being run concurrently.

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

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

RECOMMENDATION 11:
3.3.10 Infant Death, still birth and Child death Reveiw(IDR):- The process of Infant
Death and still birth Review needs to be strengthened along with community involvement and
morbidity review. The state could consider introducing under 5 mortality review

3.3.7.1
a. Infant Death Review (IDR): The process of Infant death and still birth audit needs to
be strengthened. The review should not be a fault finding but a fact finding exercise and
result in corrective and preventive systemic actions without assigning blame to any
individual. The systemic action could be structural or process related. Reverse tracking
of deaths and severe cases of diarrhea and pneumonia should be carried out.
b. Community Involvement: The community/civil society involvement in IDR to look at
the social determinants of infant deaths and still birth including gender related causes
is recommended.

48
c. Near Miss Audit: Along with death audits state may consider conducting Near Miss
Audits in cases of newborn as per the UNFPA guidelines. These audits at times can be
useful in learning about gaps in care.
d. Morbidity Audit : Many of the conditions of disability including Mental Retardation,
spasticity and developmental delays in children have their origin in the antenatal and
inter-natal period. State may consider conducting audits of such cases to arrive at
process gaps in the ante-natal and delivery services.
e. Under 5 Audit : State may like to audit some number of its U5 deaths to identify gaps in
the services for the under five age gp.

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

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

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

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

49

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

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

RECOMMENDATION 14 :
3.3.13 Social Issues:- Social issues like caste problems in delivery of health services should be
identified and addressed accordingly.
3.3.10 Social Issues: Group recommended that social issues like neglecting lower socio-
economic group. Group also felt the need to address caste problems like some ANMs of
upper caste dont visit the areas where people of lower caste reside and vice versa is also
true. State should map out pockets within villages and urban areas and specific groups
which are vulnerable to neglect on account of caste or religious factors and closely monitor
these areas for service delivery.

RECOMMENDATION 15 :
3.3.14 Monitoring & Evaluation:- Routine Monitoring and Evaluation as well as third party
evaluation of all programmes should be strengthened.
3.3.11 Monitoring & Evaluation: Routine Monitoring & Evaluation of all the services and
programs should be done. This can be done internally and also by third party.

50
3.3.8.5 Monitoring of JSSK Programme:- The State should put in place a regular
mechanism of third party evaluation of implementation of JSSK.

RECOMMENDATION 16 :
3.3.15 Separate Cadre for Public Health services:- A Separate Cadre like public health
cadre should be made to look after all functions of public health including MCH services.
3.3.12 Separate Cadre for Public Health services: A Separate Cadre should be made to
look after the public Health services including MCH services being provided in the state.
State needs to clearly delineate its clinical, administrative and public health functions and
assign the works to persons who are specialists in their respective areas. The health
department has the responsibility for implementation of various national and state
programmes including MCH Programme, Family Planning prog, Immunization programme,
Adolescent Health Prog, large number of Communicable and Non-communicable Disease
control programmes, School Health Programme, Disease Surveillance etc. These
programme address preventive health in large population groups. The state has also to
provide curative services in its various hospitals. Currently the public health programs are
being managed by specialists like surgeons, anaesthetists, pathologists but very few
persons with Public Health degrees. Absence of a separate public health cadre results in
wastage of specialist clinical manpower to run the public health preventive programmes
who are not trained in public health. State may consider adopting models of Tamil Nadu
and Maharashtra for a Public Health Cadre.


51
4. Anemia and Malnutrition

4.1 Anemia

4.1.1 Background & Situational Analysis
Iron deficiency Anemia (IDA) in Haryana is a serious public health problem and is a
reflection of undernourishment and poor dietary intake of iron.
World Declaration and Plan of Action for Nutrition in December 1992 pledged
to reduce substantially within this decade important micronutrient deficiencies, including
iron
but the exalted objective has eluded the policy makers despite efforts.
The WHO in its Iron Deficiency Guidelines, 2001 has made a clear distinction between iron
deficiency and iron deficiency Anaemia (IDA). Iron deficiency has been defined as a
condition where there are no iron stores in body with or without anemia. It has considered
IDA as a continuum from iron deficiency to iron deficient blood formation (erythropoiesis)
to IDA. This differentiation has an important programme implications when dose
schedules are planned.
MOHFW, GOI, National Iron + Initiative adopting this concept identifies Iron deficiency as a
consequence of decreased iron intake, Increased iron loss from the body and Increased
iron requirement by the body.
As per NFHS-III data 2005-06, gives prevalence of anemia in Haryana among selected
groups and shows that state position does not fare well vis--vis all India figures.
Table 4.1.1.1 Prevalence of anaemia in Haryana and India
Selected Group Condition Haryana India
6 months to 3 years Any Anaemia Hb < 11g/dl 82.3% 79%
6 months to 5 years Any Anaemia Hb < 11g/dl 72.3% 69.5%
6 months to 3 years Severe Anaemia Hb < 07g/dl 4.3% 03.0%
All women Any Anaemia Hb < 12g/dl 56.1% 55.3%
Ever married women Any Anaemia Hb < 12g/dl 56.6 56.0%
Pregnant women Any Anaemia Hb < 12g/dl 71.1% 58.7%
Lactating women Any Anaemia Hb < 12g/dl 63.5% 63.2%
Adolescent girls Any Anaemia Hb < 12g/dl 57.7% 55.8%
Adolescent boys Any Anaemia Hb < 12g/dl 26.0%


52
The anaemia in all groups is very quite high and has ben resisting all programme
interventions.
WHO has classified public health significance of Anaemia as Mild, Moderate and Severe.
According to its IDA report, 40 % and above prevalence of anaemia in a population has
been classified as a severe public health problem.
Table 4.1.1.2
Reports of Hb Testing Under IBSY (Fy 2012-13) till 14
th
Jan 2013
S.No
.
District Schools No of
childre
n
whose
Hb
testing
done
Mild
Anemi
a
Moderat
e
Anemia
Severe
Anemi
a
Total
no. of
anemi
c
Abendazol
e tablets
distribute
d
Schools
covere
d
1 Ambala 476 56439 25247 10787 451 36485 101700
2 Bhiwani 415 41449 15159 5814 49 21022 151210
3 Faridabad 64 14594 5175 1199 131 6505 97821
4 Fatehabad 136 27597 10857 3727 323 14907 98370
5 Gurgaon 189 24672 10949 4788 110 15847 127000
6 Hisar 10824 4720 1701 86 6507 158677
7 Jhajjar 500 64000 17000 46860 140 64000 73852
8 Jind 365 58509 32551 11194 482 44227 72819
9 Kaithal 422 80614 16388 8425 248 25061 44298
10 Karnal 530 78344 34221 17199 215 51635 222735
11 Kurukshetr
a
496 53484 17718 9788 340 27846 138691
12 Mewat 58 28189 14925 5148 47 20120 41000
13 Narnaul 498 39707 17130 6170 385 23685 57808
14 Palwal 237 26899 11849 5731 97 17677 46438
15 Panchkula 159 20979 9533 2699 114 12346 20738
16 Panipat 236 64992 32830 11947 795 45572 26998
17 Rewari 98 30058 14773 8716 148 23637 80623
18 Rohtak 298 44857 19496 17025 28 36549 80210
19 Sirsa 225 19967 10150 6232 176 16584 32975
20 Sonipat 158 27813 10169 6326 202 16605 97400
21 Y.Nagar 262 28055 16455 3568 85 20108 55365
Total 5822 842042 347295 195044 4652 54692
5
1826728


53
IBSY is a flagship program of Government of Haryana launched in 2010. It covers all the
children between 0-18 years in the Govt. schools and Anganwadis in terms of disease,
deficiency and disability including anemia. In 2012-13 out of 8.4 lac school children tested
5.5 lacs (65%) were found to be anemic.

4.1.2 STEPS TAKEN FOR MANAGEMENT OF ANEMIA:
4.1.2.1 Iron Folic Acid:
One Small IFA tablet daily for 90 days to all child given in all the Govt. schools for classes
1
st
to 5
th
by the class teachers after mid day meal under IBSY having 20mg elemental Iron
and 100 microgram folic acid. The children of classes 6
th
to 12
th
are covered under WIFS
(weekly Iron and Folic Acid supplementation) giving 100mg elemental iron (fersolate) and
500 micro gram Folic acid. It also includes creating awareness about importance of
personal hygiene and sanitation.
4.1.2.2 Albendazole tablets:
Albendazole tablets to school children by class teachers biannually for classes 1
st
to 5
th
under IBSY and 6
th
to 12
th
under ARSH.
4.1.2.3 General therapeutic measures for treatment of moderate & severe anemia:
The PBF slides for the severely anemic children is made for knowing the cause of
anemia and further treatment. Reporting of the number and name wise list of severe
anemia cases at District level and compilation at state level is being done.
List of anemic children is made and is made available to ASHAs and ANMs for
proper follow up of these cases. ASHA is incentivized at Rs 25/- on completion of IFA tab
course for 90 days for each child with moderate and severe anemia (only for govt. school
children) on prescription by the MO. Education and counseling material on dietary changes
in form of manuals has been provided to schools to create awareness among the children
by the teachers about prevention of anemia.
Comments: The IBSY initative and through it the data generated by state is commendable
and it is not far from the data of NFHS. State is able to cover around 6000 schools and test
8.4 lac children for anaemia is itself a herculean task. But state needs to move ahead in
interventions in addition to providing iron and albendazole tablets. It may like to focus to
analyse the data microscopically to look at certain schools which have more cases of
anaeimia and have severe anaemia for effective follow up as a pilot. The state also needs to
adopt a policy to treat iron deficiency in addition to anaemia cure.

54
4.2 RECOMMENDATIONS OF ANAEMIA:
RECOMMENDATION 17: State should formulate a comprehensive policy and programme for
reducing Iron, folic acid and B12 deficiency, Anaemia control and constitute appropriate
administrative structure to achieve objectives laid out in the policy.
a. As of today Anaemia programme is component of several programmes of health
Department like Maternal Health (MH), Child Health (CH) and Indira Bal Swasthya Yojna
(IBSY) and Adolescent Health Programme to take care of anaemia in mother, children and
adolescents and also Women and child department. However in order to monitor anaemia
across the programmes state should create an independent Cell for Anaemia Control at the
state level. State may consider naming its programme with a catchy name like Operation
Red so as to focus on the issue.
b. The Anaemia Cell should be provided with appropriate structural support and its function
should include devising and adopting standards and policies, intersectoral coordination and
monitoring of anaemia across programmes.
c. Programme should be expanded to cover all age groups and both genders as anaemia is
prevalent in all age groups affects both genders. So policy should address broader coverage
in a more comprehensive manner. In the Maternal Health Programme instead of focusing
only on the pregnant and lactating mothers, all women is reproductive age group should be
focused.
d. intervention should target mainly Iron deficiency anaemia but also other deficiencies like
folic acid and B-12 deficiency anaemias. State may also like to address the issues of various
other types of anaemia like haemolytic anaemias and make a comprehensive policy for all
types of anaemias.

RECOMMENDATION 18: Diagnostic protocol to detect anaemia:- A definite clinical and
laboratory protocol to diagnose type as well as extent of anaemia in individuals and
population groups should be put in place. The state should define the lab protocols for each
level of facility.

55
a. Diagnostic Protocols : State may adopt or formulate diagnostic criteria for anaemia for all
age groups and gender.
b. The state may either adopt a 2g band system for classifying anaemia starting from 4 g/dl
means that there would be 5 bands viz
Band 1 < 4
Band 2 4-6 g/dl
Band 3 6-8 g/dl
Band 4 8-10 g/dl
Band 5 10-12g/dl

c. Or the following criteria as recommended by the GOI in its Iron + initiative with addition of
very severe category recommended by WHO. State may consider adoption of these
protocols. Very severe anaemia in pregnant women is a medical emergency due to the risk of
congestive heart failure; maternal death rates are greatly increased.
Table 4.1.1 Haemoglobin levels to diagnosis anaemia (g/dl)
Age Group No
Anaemia
Mild Moderate Severe Very
Severe
Children 6-59 months of
age
>11

10-10.9 7-9.9 <7 < 4
Children 5-11 year of age >11.5 11-11.4 8-10.9 <8 < 4
Children 12-14 year of age >12 11-11.9 8-10.9 <8 < 4
Non pregnant women
(15 year of age and above)
>12 11-11.9 8-10.9 <8 < 4
Pregnant women >11 10-10.9 7-10.9 <7 < 4
Men >13 11-12.9 8-10.9 <8 < 4
d. Clinical screening of anaemia:- Before undertaking laboratory testing Clinical
screening of all children from 6 months to 5 years should be done by ASHA and
AWW. School and college teachers should screen the children and adolescents (boys
& girls both) under IBSY & ARSH. ANMs should screen all women in reproductive

56
age groups. All cases irrespective of their age and gender having any degree of
anaemia should be referred for further testing.
e. Suggested Cases to be tested:-
1. All cases of irrespective of their age and gender referred after screening having any
degree of anaemia should be tested for Hb status.
2. Following cases should be tested for their Hb status irrespective of clinical status:-
a) All pregnant women ( at least 3 times during pregnancy)
b) All postnatal cases before discharge from health institute including Hb
testing at home by ANM in case of home delivery.
c) All lactating mothers (At least 6 monthly).
d) All women of reproductive age group having IUD in place (At least 3
monthly).
e) All OPD cases of any age and both genders should be assessed clinically and
tested for Hb at all health facilities as a routine investigation.
f. Training: A training module to train the field workers on clinical assement with
pictoral chart (comparing the degrees of red colour) should be put in place for ensuring
good clinical assessment. At the end of training the health workers should be able to
atlest identify all cases of severe anaemia.
g. Method of testing:- Depending upon the expertise and facilities available the method
of testing of Hb may be as following:-
Sr. No. Facility Method of Testing
1 Sub Centre Haemoglobometer (Sahlis Method)/ Color Scale
Method and dry dot method for pregnant
women
2 PHC, CHC and
SDH
Calorimeter (Cyanmeth Hb meter)
3 DH Haematological cell counter for complete
Haemogram


57
*Note: All pregnant women should undergo their Hb testing by calorimeter method at PHC
or higher level.
Haematology counter and Anaemia Clinic should be set up in every District Hospital and
must be provided with Cell counters. All cases which come to these counters a complete
profiling of their anaemia should be done to detect type of anaemia and given complete
treatment at the Anaemia clinincs.
Category of cases :
Pregnant women : There are about 5.5 -6 lac pregnant women in the state every year.
Every pregnant women must be tested 3 times during her pregnancy with cynemet
method. At subcetntre level dry dot may be prepared and filter paper may be sent at the
PHC level for testing. All cases of severe anaemia should be immediately referred to district
hospital at the Anaemia Clinics.
Children: There are more than 40 lac children in schools being tested for anaemia. The
state may consider revising its strategy of testing every child for Hb. Rather it should
clinically screen the children and test those suspected to be anaeimic that too only for the
purpose of follow-up on the effectiveness of treatment.
Provision of Equipment and personnel : State must upgrade its anaemia testing facilities
at all levels of care as recommended in the table above.All DH must have haematology
counters, all SDH, CHCs, PHCs must have calorimetry. All facilities from PHC and above
must have atleast one LT who must do Hb testing. The aim of the state should be to provide
accurate method of testing Hb upto the level of PHC. Subcentres can continue to have
Sahlis method or any other colour comparison method.
Capacity Building of Personnel involved in testing:-
ANM as well Lab Technicians must be trained with manual publication for a small number
of tests being carried out by them. NIN lab manual may be used as reference.

RECOMMENDATION 19: Iron Supplementation and Treatment Protocol:- All cases being
screened and detected as anaemia should be treated as per standard protocols. The
protocols must define the prophylactic and therapeutic methods for treatment. It should also
define the policy of the state towards injectable iron preperations.

58

a. Iron supplementation would be the key intervention of the state for treating iron
micro-nutrient deficiency. While adopting any protocol especially of dose duration,
state should adopt a general principal of treating iron deficiency in addition to iron
deficiency anaemia. Therefore, all iron supplementation should be broadly divided
into prophylactic and therapeutic.
b. Anaemia prophylaxis should start as early as at age of 6 months as per the IMNCI
Guidelines. While in IBSY (WIFS component) Weekly iron supplementation is given
to boys and girls both but in anaemia campaign of ARSH component only adolescent
girls are tested and treated for anaemia. Boys should also be included in anaemia
campaign.
c. Therapeutic Approach : Every case of iron deficiency must be given iron
supplementation beyond 90 days to replenish the stores. Principal of test and treat
should be followed.
d. State should consider formal adoption of Govt. of Indias Guidelines for Control of
Iron Deficiency Anaemia in its Anaemia programme or develop its own protocols.
The protocols should include prophylactic and therapeutic approach included doses
and duration for all categories of anaemia, age groups and gender.
e. Vit B12 and Folic acid : State should continue to give folic acid in pregnant women
and also consider adding vit B12 and Vit C in some cases.
f. Ayush department may consider promotion of preparations based on ayurveda,
homeopathy etc in some of the PHCs on experimental basis and then arrive at a
comprehensive strategy for anaemia treatment the state based on Ayush based
treatments.
g. Enhancing compliance to treatment: - Every case should be educated accordingly
to the compliance with treatment regimen. A list of warning about expected side
effects and dietary education to enhance absorption should be made and handed
over to each and every patient. Vitamin C may be added to increase bioavailability of
Iron.

59
RECOMMENDATION 20: -Dietary Interventions:- Dieting interventions are very important
aspect in case of Iron deficiency disease. Dietary intervention should include availability and
better access to iron rich food for vulnerable population and bring about change in feeding
practices. These intervention should be listed out and public should be educated accordingly.
The govt should promote effective iron food fortification diets through an iner-departmental
approach.
a. Dietary intervention is the most cost effective and sustainable way to improve
status of deficiency diseases and Iron deficiency anaemia is one of them. ICDS and
Mid day meal at AWC and Schools should be made iron rich. They can consider
Amla Candy in their mid day meals.
b. Availability and Accessibility of Iron Rich Food : Iron rich foods should be made
available in the state by involvement of agriculture, forest and panchayat
departments. Fruit trees like amla, Jamun, drum stick, Amrood, ber and olives
should be promoted on Panchayat lands. Forest departments should make wild
fruits available to population at affordable rates. Health department must grow all
these trees in its PHCs and CHCs. Coarse cereals rich in iron like ragi should be
promoted.
c. Ayush Department may be asked to identify and popularize the iron rich foods like
jiggery, gur chana, gur ke chawal among population at large.
d. Food practices : Availabilty of food to vulnerable sections within family and
community should be exhorted. Education about selecting iron rich and iron
absorption enhancing foods, avoiding foods which inhibit iron absorption should be
spread.
WHO has listed iron enhancers as haem iron, present in meat, poultry, fish, and
seafood., ascorbic acid or vitamin C, present in fruits, juices, potatoes and some
other tubers, and other vegetables such as green leaves, cauliflower, and cabbage;
and some fermented or germinated foods.
And iron inhibitors as phytates, present in cereal bran, cereal grains,high-extraction
flour, legumes, nuts, and seeds; foodsthat contain the most potent inhibitors
resistant tothe influence of enhancers include tea, coffee,cocoa, herbal infusions in

60
general, certain spices(e.g. oregano), and some vegetables; and calcium, particularly
from milk and milk products.
Tea coffee coco and milk should be avoided for 2 hours after meals as they inhibit
iron absorption.

e. Schools and colleges syllabus should include a chapter of nutrition giving emphasis
of Iron rich balanced diet. Health Wall should be painted in school emphasizing
health and nutrition.
f. Fortification of foods with iron:- state should identify important items of food
which can be fortified with iron. Iron fortified Salt, flour other cerials should be
considered for universal coverage and methods of making powdered form of iron
rich foods be explored to be used in mid day meal.

RECOMMENDATION 21: -Public education about disease and drugs:- A precise public
education material should be made by experts including all aspects of anaemia and
treatment. Community should be involved directly in each and every public health problem as
without their participation no goal can be achieved.
4.3.3 Education about Anaemia:- As a large number of cases detected with low Hb level
are asymptomatic because development of symptom depends upon the rapidity of
development of anaemia . In chronic anaemia cases even severe anaemia will not lead to
any major symptomology. A women with chronic onset o severe anaemia would be able to
do normal activities of daily living without any complaints. Therefore, public should be
educated about this fact and sensitized about the adverse outcomes of anaemia to make
them responsive to the interventions.
4.3.4 Education about diets:- A list of traditional iron rich diets like jaggery should be
prepared and included in public education campaign. Cooking in iron utensils should also
be emphasized. Role of food items which affect absorption of Iron should be taught and list
of both enhancers and inhibitors of iron adolescent should be included in the training
modules/BCC strategy..

61
4.3.5 Education about side effects of Iron medicines:- All person given iron preparation
should be cases should be educated about actions, expected side effects to enhance
compliance with the treatment.


62

4.4 Malnutrition:
Child malnutrition is mostly the result of exposure to infection and inappropriate infant &
young child feeding and caring practices, and has its origins almost entirely in children between
0-3 years. However, the commonly held assumption is that food insecurity is the primary cause
of malnutrition which is erroneous. Consequently the existing response to malnutrition in India
has been skewed towards food based interventions and has placed little emphasis on schemes
addressing the other determinants of malnutrition and bringing about a behavioural change to
address the problem of undernutrition in children.
Table 4.4.1.1 Nutritional Status of Children as on July, 2012
NUTRITIONAL STATUS OF (0 to 6 years) CHILDREN AS ON July, 2012
Sr.
No.
Name of District Total population
of children
Total Children
weighed
Normal
Grade
Moderate Severely
Underweight
1 Ambala 86329 86329 52878 26967 6484
2 Jind 127348 127262 84960 34829 7473
3 Bhiwani 130866 124526 86323 31380 6823
4 Hissar 141932 129500 80894 40569 8037
5 Karnal 132549 109495 67857 34302 7336
6 Narnaul 85932 85932 56510 24193 5229
7 Rohtak 93240 88509 65401 23108 0
8 Gurgaon 124236 116078 79944 26176 9958
9 Faridabad 144647 141997 83241 47271 11485
10 Kurukshetra 73739 69422 47805 18516 3101
11 Sonepat 138675 138543 108383 30107 53
12 Sirsa 94858 83665 57510 24197 1958
13 Y.Nagar 97041 96575 68540 24564 3471
14 Rewari 80536 80483 51646 24148 4689
15 Panipat 119647 119647 84521 30086 5040
16 Kaithal 102955 102844 71991 24683 6170
17 Panchkula 31660 31660 23306 7921 433
18 Fatehabad 92655 84518 55654 23511 5353
19 Jhajjar 86672 79521 48951 23587 6983
20 Mewat 182021 154634 81230 64877 8527
21 Palwal 140487 126112 75549 46719 3844
Total 2308025 2177252 1433094 631711 112447


63
Comments : The data indicates wide scale malnutrition in the state which is specially so in
certain districts.
4.4.2 Strategies:
Keeping the above in view, the department of WCD has introduced several initiatives and
awards like improving infant & young child feeding practices, Nutrition Award, Best
Mother Award, Nutrition Strategy, Ladli, etc to combat malnutrition in the State.
Supplementary Nutrition Program: Under the Supplementary Nutrition Program of ICDS,
State is now providing hot cooked food to children, Adolescent Girls , pregnant and
lactating mothers through Village level women SHGs and that is being monitored by VLCs.
Most of the Rural children are being covered under ICDS. Of the 33.35 lac children in
Haryana, 23.66 lac children are being provided ICDS services. As the coverage of the urban
children is low, efforts are being made to cover all the urban slums through opening of new
Anganwadi centers in the 3
rd
Phase of expansion of ICDS so that there is complete
universalization of ICDS in Haryana. Unfortunately the scheme at present ignores the
coverage of children 0-3 years age who suffer from undernutrition and the risk of death
maximally. The attendance of children in this age group and of the undernourished
children is very low even though their needs are maximal.
Food intake is not the only determinant of childs nutritional status. The effect of the
feeding efforts can decline if environmental hygiene and domestic health management
practices are poor. In this context, Convergence with public health department regarding
total sanitation campaign and drinking water supply is being carried out to cover 100%
Anganwadis with these facilities.
New attractive and acceptable recipes have been introduced to ensure the consumption of
micronutrients and other nutrients in the Anganwadis. The food items like Aaloo Puri,
Stuffed Prantha, Dalia (sweet as well as salty), Khichri, Gulgule / Sevian etc have been
introduced by the department. These recipes have a flavor of festivity among the target
group and have evoked great response among the community. It is likely to facilitate the
increase in the number of beneficiaries in the Anganwadis.
4.4.2.1 Best Mother Award: - To encourage women for proper rearing of the children
especially girl child. The scheme of best mother award has been started from the year
2005-06. Under this scheme from each circle and each block of ICDS Scheme , 3 Mothers
having at least one Girl Child are selected for 1
st
, 2
nd
and 3
rd
Prizes of Rs. 1000/- , Rs. 750/-
and Rs. 500/- respectively at block level and Rs. 500/- , Rs 300/- and Rs 200 respectively at
the circle level.

64
4.4.2.2 Nutritional Strategy (For Eradication of Malnutrition among Children) : A
nutritional strategy has been implemented with effect from January , 2003 under which ,
each Anganwadi worker adopts 4 families/ children( on the basis of nutritional status) and
visits each family thrice a week for 3 months to provide information and knowledge about
child care , nutritional health and 100% weight measurement is being done quarterly and
Diet chart being provided to adopted children by supervisors and parents committee
meeting are being conducted fortnightly.
To involve the community in growth monitoring and to have sense of community
ownership of ICDS Programme, further the component of community participation in
growth monitoring under the nutritional strategy was added.
4.4.2.3 Community participation in Growth Monitoring: - VLCs and SMS are involved in
monitoring nutritional status of the children at the village level from September 2007.
Incentives to 3 best mothers in each village, 3 VLCs and SMS in each block are given to
motivate the community for better health of the child. Under this strategy, weighment of
the children is carried every month on weight day and weekly nutritional education day
through SMS is conducted to counsel / motivate the mother for proper care, health and
hygiene of the children.
4.4.2.4 Nutrition Award: - To motivate the people and to give recognition to the districts
who have brought improvements in the nutrition and health status of children. Nutrition
Awards have been initiated from year 2006-07 and so on which will be awarded to 3 best
districts for showing maximum improvement in the nutritional status of the children below
six years. The first prize of Rs. 2.00 lacs , 2
nd
Prize for Rs. 1.00 lac and 3
rd
prize for Rs.
50000/- will be given to the districts standing first, second and third position respectively.
4.4.2.5 Formation of VLCs:- Govt. of Haryana has set up village level committee (VLC) in
every village in the state for supervision of Anganwari Centres. These VLCs, has been
created as sub committee of panchayats, and given wide ranging administrative and
financial powers like appointment of AWW, monthly reviewing of working of anganwari
centres, maintenance of child tracking records and monitoring of child birth, survival,
health, education in the true spirit of devolution of powers to PRIs. The Steps being taken
by State Govt. under Women and Child Development (WCD) Department Haryana for the
improvement of nutrition intake in the children of 0-3 years of age are:
Improving Infant and Young Child Feeding Scheme (IYCF):- As more focus is required for
younger children ie. Under 3 years. IYCF scheme has been introduced in the State from the
year 2005-06 with the objective to impart training to Supervisors/AWW/SMS Members,
ASHA workers to equip them with skills for better communication of knowledge to
mothers and care takers encouraging mothers to adopt appropriate Child Care Practices.


65
4.4.2.6 Midday Meal Programme : The elementary school Department MDM
programmes are being carried out in all Govt schools to provide nutrition to all School
going children..

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

66
RECOMMENDATIONS OF MALNUTRITION:

5. RECOMMENDATION 22: State should formulate a comprehensive policy and
programme on nutrition and malnutrition and constitute an appropriate
administrative structure to achieve the objectives set out in the policy.

a. State policy should be comprehensive to cover all vulnerable groups and all forms of
undernutrition (refereed as malnutrition) including micronutrient deficiencies like
iron, Vit A, iodine etc. The policy should translate into a comprehensive programme
of implementation to address the objectives of the policy.
b. As there are mainly three departments viz the WCD, School Dept and the Health
Dept coordinating an appropriate structure in the form of an independent Nutrition
Cell for nutrition at the state level with inter-departmental coordination should be
formed.

c. The Nutrition Cell should be provided with appropriate structural support and its
function should include devising and adopting standards and policies, intersectoral
coordination and monitoring of malnutrition across all departments of the state.

d. Programme should be expanded to cover children of all ages (0- 18 years) and both
gender and pregnant women. as malnutrition is prevalent in all age groups affects
both genders.

e. It should have a focus on the backward districts and urban slum areas and other
underserved pockets.
RECOMMENDATION 23: Classification :- State must adopt criteria and method for
classification of malnutrition in different age gp and target groups.
a. State must adopt a uniform method of nutritional assessment, whether it can
be weight for age, weight-for height, Body Mass Index (BMI) etc.

67
b. State may consider addition of length/height measurement of children in its
Anganwadi Centres and Schools along with age and weight so as to record the
indicators such as weight for height as an indicator of acute malnutrition (wasting)
in children and height for age as an indicator of chronic malnutrition (stunting) and
BMI in adolescent. State may also collect data on Low birth weight newborn at birth.
c. It must also adopt a uniform criteria for classifying malnutrition among
children various age groups of children (upto 18 years) and pregnant women which
should be followed across the state and departments. The target age groups should
include newborn and under 5 children.

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

a. Lifecycle approach covering newborn children, adolescents, and women in the
reproductive age groups. Best practices in Breast feeding and providing maternal nutrition
should be adopted by the state. State can follow a stategy of community based and facility
based rehabilitation of acute under-nourished children through a special programme
which could be led by the health department. The state could adopt the MOHFW
operational guidelines for facility based management of children with Severe Acute
Malnutrition
b. Better content planning for nutrition programmes While deciding on contents of
Supplementary Nutrition Programme (SNP) (ICDS) and Mid Day Meal programme (MDM)
(SME), there should a proper representation from Health Department. To improve the
content of nutrition, recipe prepared by institutes like National Institute of Nutrition (NIN)
may be looked at for Supplementary Nutrition Programme (SNP) and Mid Day Meal
programme.
c. Improved nutrient intake with focus on micro nutrients Seasonal menu may be
prepared instead of fixed menu to make SNP and MDM for more cost effective, rich in
micronutrient and more interesting for the child. The micronutrient (iron) can be
extracted from any possible method to make it powder and may be used to sprinkle
before eating in SNP and MD.M Salt, sugar or flour fortification could also be considered.
d. Better Policy Decisions:- The syllabus may be examined for the content of nutrition,
anemia and malnutrition and revisions could be made if required.

68
Growth Chart (WHO new growth charts) should be made available for all Anganwadi
Centers and Schools. The MCP card has been approved by the government of India It should
be distributed widely and should be kept with the family to empower them and to guide
them about feeding growth and nutrition during pregnancy and child under the age of 3
years.
Group suggested to look for the possibility to give the wages without work to lactating
mothers through MNREGA scheme. The groups suggested considering lactation as a work.
Food pyramid could be put in Anganwadis. Supplementary feeding activities need to be
better targeted towards those who need it most and growth monitoring activities need to
be performed with greater regularity, with an emphasis on using this process to help
parents understand how to improve their childrens health and nutrition.

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

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

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

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

i. Use of Mother and Child Protection Card (MCPC) should be promoted and monitored at
field level. As MCPC enable the care giver and service providers to make comprehensive
nutrition and health information in pictorial and written form.
j. Capacity Building:- Efforts should be made to build the capacity of mothers/ caregivers
through counseling and support to identify the nutrition and health problems in their child.
Demonstration and practice by doing on the preparation of energy dense child foods using
locally available, culturally acceptable and affordable food items. Enough attention should
be given to improve child care behavior and on educating parents how to improve nutrition
using the family good budget. Special focus should be given on timely, adequate and
appropriate feeding for children and on improving skills of mothers and caregivers on

69
complete age appropriate caring and feeding practices. Facility based care for
malnourished should be provided and it can be done through establishing facilities like
Nutritional Rehabilitation Centers (NRC).
k. Targeting the determinants of malnutrition. ICDS activities need to be refocused on the
most important determinants of malnutrition, programmatically this means emphasizing
disease control and prevention activities, education to improve domestic child care and
feeding practices and micronutrient supplementation.
Service delivery should be more focused on the youngest children (under three), who could
potentially benefit most from ICDS interventions. Emphasis should be there on changing
facility based feeding and caring behavior. Children should be given sensory stimulation
and emotional care.
l. Strengthening of Monitor and Evaluation:- Monitoring and Evaluation activities need
strengthening through the collection of timely, relevant, accessible, high quality
information and this information need to be used to improve program functioning by
shifting the focus from input to results, informed decisions and creating accountability
for programme. Involving communities in the implementation and monitoring of ICDS
can be used to bring in additional resources into the Anganwadi centre, improve quality
of service delivery and increase accountability in the system.


70
5. GENDER EQUITY AND FAMILY WELFARE
5.1 GENDER RATIO:
The sex ratio of patriarchal States of Haryana & Punjab has been tilted heavily in the favour
of males since 110 years as compared to the matriarchal States of Kerala & Tamil Nadu.
With advent of ultra sonography for Pre-natal detection of sex, people shifted to the sex
selection and sex selective abortion in comparison to the option of female neglect and
female infanticide. Again this effect of the modern technology was evident in the child sex
ratio (0 to 6 years) in all the states including the patriarchal states as well as matriarchal
states of Kerala and Tamil Nadu.

Table 5.1.1.1: Inter temporal trends in Sex ratio in India: A State wise Decomposition
Sr.
No.
Name
of the
State
1901 1911 1921 1931 1941 1951 1961 1971 1981 1991 2001 2011
1. Haryana 867 835 844 844 869 871 868 867 870 865 861 877
2. Punjab 832 780 799 815 836 844 854 865 879 882 874 893
3. Kerala 1044 1008 1011 1022 1027 1028 1022 1016 1032 1036 1058 1084
4. Tamil
Nadu
1044 1042 1029 1027 1012 1007 992 978 977 974 986 995
India
(Av)
972 964 955 950 945 946 941 930 934 927 933 940
(Source 2011 census)

Table 5.1.1.2 STATE WISE CENSUS CHILD (0 TO 6 YRS.) SEX RATIO
Sr. No. State 1991 2001 2011
1. Haryana 879 819 830
2. Punjab 875 793 846
3. Kerala 958 963 959
4. Tamil Nadu 948 939 946


71
The enactment of the PNDT Act in 1996 and proactive subsequent enactment of
amendment to PCPNDT Act has yielded some improvement in the sex ratio as per the CRS
system of Haryana.
Table 5.1.1.4 District wise sex ratio at birth 2012 (CRS)

District
Sex Ratio excluding Delay Registration year 2012
Jan
Upto
Feb
Upto
Mar
Upto Apr
Upto
May
Upto Jun
Ambala 869 834 860 849 840 841
Bhiwani 903 877 882 880 884 884
Faridabad 897 890 898 895 891 884
Fatehabad 834 862 849 867 865 861
Gurgaon 859 846 838 840 843 830
Hissar 862 870 867 853 853 859
Jhajjar 883 861 852 845 839 826
Jind 834 819 813 837 835 840
Kaithal 823 827 824 823 818 823
Karnal 829 836 853 861 865 852
Kurukshetra 827 846 831 810 789 779
Mewat 897 945 946 951 952 937
Mohindergarh 782 773 755 765 755 747
Palwal 831 834 828 834 833 841
Panchkula 990 946 936 906 902 886
Panipat 853 863 804 829 837 830
Rewari 728 754 786 786 788 779
Rohtak 824 831 849 833 822 813
Sirsa 814 829 833 853 864 861
Sonepat 918 896 880 851 838 826
Yamunanagar 831 818 816 803 802 801
Haryana State 854 855 852 852 849 844

5.1.2 Strategies: In Haryana, till June 2012, under PC & PNDT Act, 1315 centres have been
registered, out of which 54 are in Government sector. 14576 inspections done, 194
ultrasound machines seized and sealed, 346 licenses suspended /cancelled, 74 court cases
launched, 3o persons convicted out of which, 24 are doctors. 1111 District Advisory
Committees and 28 District Task Force meetings were held.

72
5.1.2.1 New initiatives: Registration of Veterinary ultrasound machines, incentive for
informer up to Rs. 20,000/- , Mandatory Residence ID proof for ultrasound of pregnant
ladies, Registration and tracking of pregnancies between 12 to 20 weeks (ideal period of
sex selection), Constitution of District Task Force to review PNDT activities in the districts
and awards for District PNDT teams are new initiatives to curb the female foeticide and
sex determination.

5.1.2.2 Advocacy: Fortnight Pakhwara by SMS Groups from 1
st
to 15 March dedicated to
prevention of sex selection to create awareness and various forms of IEC activities like
seminars/workshops, street plays, painting competitions, Radio jingles, press
advertisements and T.V. programmes telecast on the issues of skewed sex ratio from time
to time. Health Wall is being painted in villages on prominent places displaying number of
girls out of 1000 boys during the year. Training /workshops of various stakeholders at
State and district level to create awareness about PC & PNDT Act.
Adolescent Health
Adolescents (10-19 years age ) comprise more than 30 lacs in Haryana. This is the critical
turning point and period of vary rapid transition when very large number of physical,
mental and sexual changes are taking place very rapidly; This is a period of great
opportunity as well as challenges. The seemingly good health of adolescents is deceptive
since health in this age shows up in the form of numerous reproductive and sexual health
problems, early onset of adult life style diseases like diabetes, hypertension., Obesity Heart
disease chronic obstructive lung disease related to tobacco use and cancers.
This is a period of great opportunities and challenges many adolescents practice risk
behaviour and these risk factors have a cumulative as well as clustering effect in later life.
This is also the period of pre conception.
Health sector cannot do it alone. Cooperation and collaboration with department of
education and ICDS is important At the same time behaviour change through engagement
of peers and parents is required and can have very positive results.
Haryana has already started mitrata clinics in the state and is undertaking a program for
the training and engagement of peer educators. Support will be provided through the
counsellors.
The strategy should be more be more broad based than the sole focus on Reproductive and
sexual health alone.


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5.1.2.3 Efforts of Haryana Government for Women Empowerment :
The various stakeholders like NGOs, Media, politicians, religious leaders, Panchayati Raj
Department, Women and Child Department, Education department etc. have been roped in
to given their inputs, create awareness and change the mind-set of the people towards
gender equality.
Some of the major steps taken to address the issue in Haryana are as under:-
Concession of 10 Paisa per unit is being given to women for domestic electricity
connection in the name of woman, in case the property is owned by woman.
2% rebate is being given on stamp duty in respect of purchase of immovable
property in name of women.
5% concession on education loan to girls for higher education.
33% seats are reserved for women in direct recruitment quota in teaching
category in Education Department, Haryana.
30% seats are reserved for girls in I.T.I.
33% seats are reserved for women in Panchayati Raj elections.
50% rebate is being given in bus fare for women more than 60 years age.
Ladli Scheme was launched in 2005 by Women & Child Development
Department. Under this scheme, the Government provides benefit/ financial
assistance of Rs. 5000/- on the birth of 2
nd
girl child for 5 years or till the scheme
is continuedd. This amount will be deposited in the bank and is given when the
second girl child attains the age of 18 years (approximately Rs. 86927/-
depending on the present rate of interest).
Balika Samridhi Yojna scheme has been launched by the State through Women
and Child Development Department. Under this scheme, the cash assistance for
below poverty line families has been given with Ante-natal care, institutional care
during delivery and immediate post-partum period.
Delivery huts have been set up for safe delivery in neat and clean environment,
especially in rural areas, thus reducing the Infant Mortality & Maternal Mortality.
A prize of Rs. 5.0 lac, Rs. 3.0 lac and Rs. 2.0 lac is being given to first three districts
showing improvement in the child sex ratio by Department of Woman & Child.
An exclusive University and Medical College for women has been set up for girls
at Khanpur Kalan in district Sonepat.
Haryana Govt. has announced awards in the name of females, Rs. one lac for
Indira Gandhi Mahila Shakti Award, Rs. 51000/- for Kalpna Chawla Shorya Award
and Rs. 51000/- Shanno Devi Panchayati Raj Award.
Education Department provides rewards to the girls coming first, second and
third in matriculation examination as Rs. 2000/-, 1500/- & 1000/- respectively.

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To promote sports in rural females in Haryana, Government has started annual
sports competition at State and District level.
17 working women hostels have been set up by Government for working women
to provide protective stay at concessional rate.
Two years child care leave is being given to female employees in Haryana.
Pension of widows of ex-serviceman has been increased from Rs.6000/- to
11000/- by Haryana Government.
Rs. 500/- per month pension is being given to parents after the age of 45 years
having two girls under the scheme Ladli Samajik Surkhsha pension Yojna by
Women and Child Department, Haryana.
Free Bus service is being provided to girls and women on the eve of Raksha
Bandhan by Transport department, Haryana.


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

Table 5.2.1.1 Demographic trends of the state

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

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Trends of Family Planning indicators

Table 5.2.1.2 Birth Rate

Year Haryana India
1971(Census) 42.1 36.9
1981(Census) 36.5 33.9
2001(Census) 26.8 25.4
2007-SRS 23.4 23.1
2008-SRS 23.0 22.8
2009-SRS 22.7 22.5
2010-SRS 22.3 22.1

Table 5.2.1.3 Total Fertility Rate (TFR)

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

Table 5.2.1.4 Current use of family planning methods (%)

Sr. No. Indicators DLHS-II (2002-04) DLHS-III (2007-08)
1. Any method 60.3 62.0
2. Female sterilization 35.6 36.3
3. Male sterilization 1.0 1.0
4. Oral Pill 3.1 2.8
5. IUD 4.5 3.8
6. Condom 10.0 10.4
7. Any traditional method 6.0 7.4
8. Emergency contraceptive pills NA 0.5


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

Year
Percentage of sterilization
acceptors after No. of the
children
Percentage of IUD Acceptors after
No. of the children
0-2 3 and more 0-2 3 and more
2005-06 40.28 59.72 63.89 36.11
2006-07 41.12 58.88 68.04 31.96
2007-08 42.43 57.57 67.47 32.53
2008-09 41.81 58.19 69.32 30.68
2009-10 41.68 58.32 71.66 28.34
2010-11 47.69 52.31 69.43 30.57
2011-12
(up to Dec.11)
49.68 50.32 70.36 29.64

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

Ster. Tubectomy Laparoscopic Vasectomy NSV
Total % of Ster. Total % of Ster. Total % of Ster. Total % of Vas.
2011-12
(up to
Dec.11)
56623 51639 91.2 13293 25.7 4984 8.80 4984 100.0

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

Sr. No. Component Current Status Target
1. Contraceptive Prevalence Rate 2005-06(NFHS-3) 2012- 13(%)
Over all 61.0 NFHS-3 Change all
SC/ST NA 70
2. Contraceptive Prevalence Rate(limiting
methods)

Male Sterilization 1.0 - NHFS-3 15

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Sr. No. Component Current Status Target
Female Sterilization 38 NHFS-3 64
3. Contraceptive Prevalence Rate (spacing
method)

Oral Pills 3% - NFHS-3 4.5
IUDs 5% - NFHS-3 9.5
Condoms 12% - NFHS-3 7.0
4. Unmet need for spacing methods among
Eligible Couples
3.2 - NFHS-III 1.5
5. Unmet need for terminal methods among
Eligible Couples
5.1 - NFHS-III 2.0
Total Unmet need- 8.3 - NFHS-III 3.5

5.2.2 Strategies
5.2.2.1 Spacing Methods (IUD)
Extra emphasis on spacing methods is being under taken for which service delivery
point are being increased, personnel are being trained and supply line is being
maintained.
IUD insertion services are being provided at all sub centres on all working days.
PPIUCD is being promoted aggressively and special trainings are being held for the
officials/Officers at DH, SDH & CHC level.
PPIUCD is required for mother and childs optimum health growth of the child
survival of the child and also to maximize the potential for child development lack of
child spacing is a major factor in the birth of low birth weight babies (about a
quarter of babies are born low birth weight) For the success of PPIUCD the pregnant
women have to be convinced their concurrence for adoption of IUCD obtained and
the insertion of IUD should be done while the child is still in the hospital the
credibility of IUD and its acceptance has to be improved in order to make it more
acceptable This is potentially a powerful intervention in the programme and should
be prioritized in the strategy.
5.2.2.2 Permanent Methods (Vasectomy & Tubectomy):
More stress on couples with 2 children to adopt Permanent Methods.
Younger age couples (less than 35 years) are being motivated to adopt Permanent
Methods.

79
Organise special camps for Vasectomy & Tubectomy in addition to fixed day static
services.
Additional Mobility Support to Surgeons team (if required) has been provided for in
PIP 2012-13
5.2.2.3 Community Participation & Capacity Building:
Capacity building by training of personnel and providing needed equipments is
being under taken at all level.
IEC activities are being under taken to bring behavioural changes and demand
generation among community by creating awareness about availability of services.

5.2.2.4 General:
Regular monitoring on monthly basis at all levels.
Monitoring and supervisory visits by State, district and sub district level officers are
being under taken.
Dedicated FW counsellors are being appointed in each district to address unmet
need of the society.
For providing Terminal/Limiting Methods Fixed Day Static (FDS) approach in
sterilisation Services i.e. providing on fixed day, throughout the year on a regular
and routine manner is being implemented.
A scheme of Home delivery contraceptive by ASHAs is being implemented in
district Mewat as a pilot project which would be extended to other districts also in
near future.
An action plan for providing/strengthening Postpartum sterilisation services
including PPIUCD services at Health facility in district has been formulated and
being implemented.
A rational human resource development and deployment plan for Minilap, NSV and
IUD services is being formulated and implemented
Intra and Inter departmental co-ordination is being promoted and ensured at all
level to achieve the common goal of population stabilization.


80

5.3 RECOMMENDATIONS OF GENDER RATIO:
RECOMMENDATION 25:
5.3.1 Defining Gender Issues in Health :- Gender issues in health go beyond the issue of
adverse sex ratio and implementation of the PNDT Act. For mainstreaming of gender, issues
like violence against women, teenage pregnancies, early marriage, reproductive and sexual
evaluation etc should also be focused upon through intersectoral coordination.
For intersectoral coordination there would be a State level and district level committees
which would meet every month/quarter. The members of the committee would be from
the WCD Department, Education Department and Health Department. Health Department
should appoint a Nodal Officer to coordinate these meetings, draw up agendas and minutes.
The proceedings of these meetings should be monitored by the Principal Secretary, Health.
The group was of the opinion that gender issues in health should not be restricted to
adverse sex ratio. This is a narrow lens and it could rather broaden the issues to bring
about mainstreaming of gender in the state, not merely looking it as implementation of
PNDT Act. The group suggested that other gender issues like violence against women,
teenage pregnancies, early marriage, reproductive and sexual education etc should also be
focused upon. The group further felt that issues go beyond the domain of the health
department and should be addressed in a comprehensive manner through several
departments.
The sub group identified the following broad objectives, which should become part of
entire discourse:
1. Sex selection
2. Neglected daughters.
3. Adolescent health targeting both girls and boys.
4. Women and nutrition.
5. Unmet needs of contraception.
6. Addressing women health needs beyond reproductive life stage.
7. Women and HIV.
8. Crime/Violence against women as a health issue.
9. Dowry related deaths.
10. Community mobilization for changing mindsets towards gender equality.
The group felt that these issues have only been identified as issues concerning gender
mainstreaming. However, instead of discussing all these issues, the group decided to discuss
issues relevant to the scope of sub group of the task force.

81
RECOMMENDATION 26:
5.3.2 Strengthening Institutional Capacities:- For mainstreaming of gender institutional
capacity of Health Department has to be strengthened.
5.3.2.1 Appointment of Gender Nodal Officer
The Health Department should appoint a Nodal Officer at State level to ensure the
implementation of Gender mainstreaming. His/Her role would be to integrate a gender
perspective in key programmes like Declining Sex Ratio, Adolescent Health, Family
Welfare/Contraceptive Services, planning for other Gender and Health issues like Violence
against Women as a Health Issue.
5.3.2.2 Development of curricula and faculty for Gender Mainstream
SIHFW/HSHRC should develop a gender mainstreamed training curricula and faculty.
5.3.2.3 Gender Sensitive HR Policy
State should develop an Annual Plan for Gender Mainstreaming and gender sensitive
Human Resource Policy at state level. Senior Nursing professionals (Nursing Directors/
Principals of Nursing Colleges etc) should be included at all levels of Health planning.
District level gender mainstreaming through orientation of district health officers and a
district health plan which is gender sensitive. The role and job descriptions of MPW Male in
RCH and Adolescent Health services for male involvement should be reworked. State
should consider studies on issues and concerns of women health workers- ANMs, Staff
Nurses (e.g. Safety, career opportunities etc) and corrective measures implemented.

RECOMMENDATION 27:
5.3.3 Strengthening of Adolescent Health Services:- The State should promote a well
designed Adolescent Friendly Health Services. The Adolescent Reproductive and Sexual Health
(ARSH) Programme should be broad based and renamed as Adolescent Health Programme
(AHP)to address overall issues of the Adolescents.
5.3.3.1 Adolescent Health:
a. It was recommended to rename it as - Adolescent Health Programme to address overall
health issues of the adolescents.
It should include the following:
Reduction of tobacco use and substance use.

82
Prevention of injury and violence including gender based violence (especially
violence against women)
Prevention of early onset of adult onset ;life style diseases through healthy eating
and regular physical activity.
Mental and emotional well being.

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

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

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

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

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

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

RECOMMENDATION 28:
5.3.4:- Appropriate measures to prevent sex selection by any means should be taken.
5.3.4 Sex selection:
A suggestion was made that central data base of all ultrasound machines in Haryana should
be compiled by collecting information from companies that manufacture and sell
ultrasound machine including vetenary ultrasound machines. There should be strict
implementation of PC & PNDT Act. in the State. As regard the PNDT Act, an observation was
made by the state team that registered clinics were not so much a problem but problem lies
in unregistered machines, which operate from houses, mobile vans, go-downs etc. The
people who carry out the illegal sex determination, work through various types of
middlemen. The Health Department needs to use decoys to catch them. A suggestion was

83
made that all second trimester abortions should be tracked to generate evidence on
reasons and profile of women requiring second trimester abortion. However, some
members opposed that all second trimester abortion should be tracked. Rather, they felt
that it would divert the women to illegal and unsafe abortion providers. Instead of tracking
the second trimester abortion, data of all second trimester abortion should be collected,
compiled and analyzed to fund out the reasons for abortions.
RECOMMENDATION 29: -
5.3.5:- Violence against women should be viewed as a health issue to be addressed by the
Health Department by means of specific strategies in place.

RECOMMENDATION 30: -
5.3.6:- Community awareness has to be created by means of effective BCC/IEC strategies to
make community aware about gender equity.
5.3.6 Community participation:
There is a need to make community aware about gender equality. There is a need for better
IEC/BCC strategy. Promote community awareness about value of girl child through
awareness campaigns i.e.
Wall paintings in the villages depicting health and nutrition indicators & sex ratio
(health wall).
Folk media to give the required information about equal value of girls and boys,
men and women.
Posters, Flip Charts, T.V., Radio, Documentaries, Advertisements in Newspaper to
deliver health messages in an understandable manner.
However the contents and quality of all the communication material is to be scrutinized
before use to prevent repercussions on access to safe abortions under MTP Act.
There should be amendments in the Panchayat Act, enhancing the role of Panchayat in
reporting maternal, child death and birth, nutrition status of children, sex ratio of the
villages to involve them in health related activities.


84
RECOMMENDATION 31: 5.3.7 Improved access and information:- There is a need to
provide better information and access to the family planning services.
Access, information and adoption of appropriate family planning methods should not be
viewed only as a method of population control but also as an essential instrument for gender
empowerment and promoting maternal and child health.
Quality of Family Planning services needs to be improved.

5.3.8 Access to contraceptive services:
Family planning services are essential to enable women to delay, space and limit
pregnancies, potentially reducing maternal deaths by 20 to 35 per cent (UNFPA).
Access to comprehensive modern contraception, emergency obstetrical care and skilled
birth attendance can prevent abortion, and complications of unsafe abortion, including
mortality and morbidity (UNFPA SRH framework).
a. Poor access to and quality of family planning services are two important issues in
catering to the unmet demand.

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

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

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

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


85
f. There should be effective contraception campaign to change the attitude in society
to avoid teenage pregnancy by delaying first pregnancy.

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

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

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

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

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

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

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

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

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