| A. Health system strengthening |
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| Infrastructure |
Availability of the well equipped health facilities in rural areas in the last 4 to 5 years have improved the access to MCH services in rural areas that might have bridged the geographical inequalities in urban and rural areas |
| Drugs and Logistics |
Free availability of medicines in health centers in rural areas has improved the affordability of MCH services, which might have reduced the socioeconomic inequality between rich and poor. However, perceived lack of faith in the quality of these medicines reported by the mothers that prevented their access especially in district Mewat. |
| Patient Transport Service |
Free availability of ambulance service was linked to increase in access to MCH services especially for institutional delivery, which might have contributed in reducing the geographical MCH inequality in urban and rural areas. However there were issues with its maintenance, and better services with in the ambulance were needed at par with private. Other problems like inadequate number of vehicles, ambulance contact numbers could not be reached possibly due to frequent callers or late arrivals to the homes especially in district Mewat were reported to have resulted in home deliveries. |
| Human resource |
Acute shortage of manpower was reported especially specialist in both the districts. This problem was reported more in district Mewat, because of higher attrition rate of staff and non-uniform distribution of specialists with in the state. NRHM contractual staff was available but quality of contractual staff was an issue. Shortage of human resources prevented good quality of, availability of and access to MCH services especially in district Mewat. |
| Untied funds |
These funds were reported to be very helpful for upgrading the infrastructure in the health facilities or buying drugs as per the need or utilizing these funds for arranging refreshments for mothers during mother’s meetings. These funds reported to have empowered the service providers to meet their needs at the local level. |
| Mobile Medical Units |
Since functional status of mobile medical units was reported to be an issue mainly due to non-availability of doctors and limited awareness of mobile medical units in the villages in district Mewat, its basic purpose of increasing the access in the hard to reach areas did not seem to have met. |
| B. Communitization |
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| Accredited Social Health Activists |
All the stakeholders appreciated this scheme. It was believed that she was a community mobilizer and played an important role in immunization of children and pregnant women, improving institutional delivery, generating awareness about NRHM schemes & importance of institutional delivery in the villages. Because she was well known in the villages, had good rapport with the women especially decision makers (mother in laws), she called free ambulance and accompanied the families to the hospital for institutional delivery. She acted as a bridge between community and health facilities and improved the access to MCH services in the rural areas and contributed in reducing the geographical MCH inequalities. However, minimum educational qualification has a bearing on recruitment of accredited social health activists especially in district Mewat. |
| Village Health and Nutrition Day |
These were known popularly as village health ‘mela’. Immunization sessions and mother meetings were held on village health and nutrition days. These were not held regularly and did not contribute much in increasing the availability or accessibility of MCH services. |
| Village Health Nutrition & Sanitation Committee |
Members of this committee were not involved in need based village health planning. Village head would ask for bribe for utilizing the funds; and involvement of anganwadi worker in funds handling led to underutilization of funds. |
| C. Maternal Health Care Strategy |
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Janani Suraksha Yojna (Financial incentive for institutional delivery) |
This financial incentive scheme was reported to have increased the institutional delivery rate and improved the affordability for utilizing MCH services. However, there was delay in payment to the pregnant women due to administrative reasons. Linking the disbursements of financial incentives with opening of bank accounts in the name of pregnant women had resulted in underutilization of funds under this scheme, due to lack of proofs with the pregnant women that were required to get the bank account opened. |
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Janani Shishu Suraksha Yojna (Free medicine, treatment and institutional delivery) |
Availability free diet during hospital stay and cash less delivery in the health facilities was linked with increased institutional delivery. This scheme was also reported to have increased the affordability of MCH services and might have contributed in reducing the socioeconomic inequality between rich and poor. However, implementation of this scheme was reported to be partial due to lack of adequate manpower. |
| D. Child health care strategies |
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| Immunization |
Lack of sufficient auxiliary nurse midwives had led to the partial implementation of immunization sessions. Cultural barriers like fear of injections were reported for immunization of children especially in district Mewat. Accredited social health activists were reported to be the catalyst in improving the immunization coverage by mobilizing the mothers and family members. |
| Facility based newborn care |
Newborns were reported to be referred for treatment to government hospitals from private health facilities, as government new born facilities were better. This might have contributed in reduction in infant mortality rate. |
| Integrated management of neonatal and childhood illnesses |
Staff was trained in integrated management of neonatal and childhood illnesses implementation. However, caregivers lacked trust on government facilities for treatment of sick children so they did not visit subcenters in villages for treatment (less demand at subcenter level). Also due to lack of supervision of trained staff there was poor implementation of this scheme. Hence the focus of implementation was shifted from integrated management of neonatal and childhood illnesses scheme to home based postnatal care scheme. |
| Effectiveness of MCH plans in improving inequalities |
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| Geographical Inequality between urban and rural areas |
It was perceived that due to increase in utilization of MCH services in the villages in rural areas in the form of increase in antenatal registrations, institutional deliveries, reduction in maternal and infant deaths the gap between rural and urban areas regarding MCH services was bridged to some extent due to implementation of NRHM health plans. However it was reported that facilities were still more in cities. |
| Socioeconomic Inequality between rich and poor |
Socioeconomic inequalities were perceived to have decreased to some extent because of availability of free ambulances, medicines, and diet during hospital stay for the poor. However, it was reported that food security in general would reduce this. |
| Gender Inequality between girls and boys |
It was believed that NRHM had no scheme for targeting gender inequality. Small size of the families and increased educational status reported to have led to the changes in gender inequality; Gender inequality was less seen in Mewat district |
