Guidance Note for Block Monitoring Visits in High Priority Districts

September 2013

Block Monitoring Visits

I. Why Block Monitoring Visits?
The RMNCH+A strategic approach for improving maternal health and child survival envisages support from Development Partners, State and District Programme Management Unit for integrated planning, implementation and monitoring of the RMNCH+A interventions across high priority districts. In order to ensure that districts get timely support to implement the most critical interventions, the Development Partners are expected to offerneedbaseddistrictlevelassistance and work alongside district and block level stakeholders to identify key bottlenecks and address themsystemically. It has been observed from the field visits that there exist interblock variations within the districts in terms of health infrastructure and service delivery. This could be due to clustering of vulnerable and marginalized populations, geographical inaccessibility, or security concerns (eg; LWE affected), on account of which these blocks remain relatively underserved. Under the District Intensification Plan, the block is envisaged as the primary unit for implementation and management of RMNCH+A interventions, the capacities for which are to be developed locally through mentoring support by the district and state management units and the development partner.

II. Purpose of Block Monitoring Visits

The purpose of Block Monitoring Visitswill be to: 1. make a quick assessment of the infrastructure, human resources, and provision of services (both at facility and community level) ; 2. assess service delivery (quality and coverage) at block level; 3. review progress of community outreach and community/home based interventions; 4. validate the data reported into HMIS; and 5. gauge the client (beneficiary) satisfaction level with RMNCH+A services.

III. Steps in Block Monitoring Visit

To achieve the above goals, constitution of appropriate mixed skills team is important. These team members should be able to provide mentoring/handholding and supportive supervision. It is proposed that District Monitors, assigned by various Development Partners, visit one block each month in each high priority district. They will be joined on these visits by government representatives from district and state, and where directed by the SPMU, experts, resource persons from mentoring institutions and NGO representatives may also be part of the team. The dates for block monitoring visits should be informed in advance to all team members. The schedule of visit for three or six months may be drawn up so that the District Monitors can schedule it in their monthly work plans and availability of all team members is ensured.
Guidance Note for Block Monitoring Visits in High Priority Districts

The team should visits delivery points including DH & FRU (if present in the block), 24 x 7 PHC, CHC, and sample of sub-centresdesignated and interact with the community. During the visit the focus should be on: 1) Bottleneck hampering quality / effective coverage of essential interventions saving newborn and mother lives, at all level community, outreach, facility level throughout continuum of care 2) Implementation of strategies overcoming the bottleneck and addressing inequity and disparity at block level (geographical, gender, social groups..) 3) Trends / progress of key indicators to follow a. Effective implementation of strategy b. reduction of bottleneck c. increase coverage of essential interventions 4) Real time feedback and report to adjust and accelerate implementation and scale up from block to district wide scale.

IV. Reporting format

Following the visit, the District Monitors, along with the team members are expected to prepare a visit report that includes: 1) Major actionable points & level at which the action is to be taken (i.e. facility, block, district or State); 2) Stakeholders (Development Partner/s, DPMU, SPMU, other experts or resource persons, NGOs) responsible for providing technical support along with timelines; and 3) Actions taken on previously identified bottlenecks and visit reports. The Reporting Formatbelow provides a broad guidance on the parameters to be assessedduring monthly visits to the blocks and to be reported thereafter. Additional components may be included by the District Monitors based on experiences from the field visits so that most relevant and critical issues are reported. It is important that not only is the progress captured but also the bottlenecks for delay are explored and recorded. The actions should focus on addressing these bottlenecks. The reports should be forwarded by the District Monitors to the concerned authorities at District and State levelwithin one week of completing the visit. The State Lead Partner Agency can compile the reports from different block visited during the month , presentthe key findings and proposed actions to the SRU/SUT before forwarding it to the National RMNCH+A Unit (NRU) in the following month. Note: Specific tools and checklists may be used to assess the various parameters included in the reporting format. These can include facility assessment tools/monitoring checklist, community / household visit tool, tools for assessment of labour rooms, newborn care facilities, hygiene and sanitation facilities, and so on. The data may be accessed from District /Block Management Unit before or during the visit and validated in the field/health facility.
4
Guidance Note for Block Monitoring Visits in High Priority Districts

Reporting Format
Name of the Block/s & District visited: Dates of Visit: Name of team leader & organization: Names of team members & organizations:

I. Block Profile
i. Demographic information Whether it has areas that are difficult to reach (due to hilly or difficult terrain) Whether block has more than 50% Tribal Population Whether the block is LWE affected Total Population Male Female Census 2011 Name of the villages that are difficult to reach Yes/No Yes/No Total Urban Rural

ii. Infrastructure Number of Sub-Health Centers Number of 24x7 Primary Health Centers Community-Health Centers FRU (facility providing C section/ EMONC) Any adolescent health clinic/s SNCU (Yes/No) Any NBSU Any NRCs Any health facility with blood bank Any facility with blood storage unit Block covered by functional MMUs (Mobile Medical Units) Yes/No Detailed Observations and comments

Sanctioned

Presently Functional

iii. Human resources BPMU staff ASHAs ASHA Supervisors 1st ANM 2nd ANM Staff nurses

Sanctioned posts

In position (contractual +regular)

Guidance Note for Block Monitoring Visits in High Priority Districts

FRU 24X7 PHCs LHVs MPWs (male) Medical Officers FRU 24X7 PHCs AYUSH MOs Specialists (at any health facility in the block) Obstetricians &Gynaecologist Anaesthetist Paediatrician Surgeons Detailed Observations and comments

iv. Health service provision

# designated as delivery point against total no. of facilities

# having SBA & NSSK trained ANM/ SNs against total no. of delivery points

# having functional NBCC against total no. of delivery points

Sub-Health Centers 24x7 Primary Health Centers Other PHCs Community-Health Center Number of facilities in the block conducting C-section Number of facilities with fixed day family planning services Number of facilities with RMNCH+A counsellors Number of functional Anganwadi centers % villages with functional VHSNC No of Villages with NO Access to any public health facility within 30 minutes walking distance Detailed Observations and comments Names of the villages CHC 247 PHCs SC

Guidance Note for Block Monitoring Visits in High Priority Districts

II. ASSESSMENT OF KEY RMNCH+A COMPONENTS AT BLOCK LEVEL

The following components shouldbe assessed during the field visits and the related quantitative and qualitative information provided in the visit report.

Health facilities
1. Delivery points: (Assess on the following aspects as pe national guidelines- availability of skilled human resources, rational deployment, infrastructure, equipment , supplies (including vaccines, contraceptives); delivery of key RMNCAH service packages, hygiene & sanitation, waste management, functioning of blood banks/ blood storage units, data management, maintenance of records) 2. Management of pregnant women with high risk pregnancies, including severe anaemia: (Assess number and type of high risk pregnancies managed , referral mechanisms) 3. Newborn care facilities: (Assess as per national guidelines the status of NBCCs, NBSU(if any) in terms of skilled HR, infrastructure, utilisation , data maintenance, adherence to protocols including asepsis, initiation of breastfeeding& exclusive breastfeeding promoted; hygiene & sanitation facilities,referral mechanisms) 4. Family Planning services: (Assess PP-IUCD programme, availability of RMNCH+A counsellors, fixed day services/sites for interval IUCD, training for IUCD insertion, status of sterilisation services) 5. Comprehensive Abortion services (Assess if services available, number of abortions performed, methods used, training/skills of providers) 6. Adolescent Health services: (Assess if services available, clinics held regularly, service utilisation)

Health Systems
7. JSSK scheme: (Assess if the scheme rolled out and number of entitlements in place, number of beneficiaries, public grievancesredressal system, citizens charter, ambulances &call centre, client feedback on satisfaction with services and out of pocket expenses, if any) 8. JSY scheme: (Assess the performance in terms of number of beneficiaries, payments, mandatory stay of 48 hours, client feedback, ASHA feedback) 9. Utilisation of RKS funds (purpose for which funds have been utilised, frequency of RKS meetings, maintenance of books of account) 10. Training of health workers (Assess functionality of training institutions, progress on key trainings EMONC, BEMOC, SBA, NSSK, IMNCI, PP-IUCD, IUCD insertion etc. and rational deployment)

Community level
11. Communitisation processes (formation of VHSNC and their functionality, if social audits being conducted, convergence with PRI & other sectors like water & sanitation, rural development, involvement of self-help groups/ womens groups in health & nutrition activities)

Guidance Note for Block Monitoring Visits in High Priority Districts

12. VHNDs (Numbers held against planned, number of services provided, presence of community workers and other stakeholders, availability of supplies, equipment, client feedback, record keeping, MCP card, IFA supplementation for adolescent girls and boys, line listing of women with severe anaemia/high risk pregnancy, convergence with women and child development department) 13. HBNC scheme (Module 6 & 7 training ,ASHA kits, home visits, referrals made, line list of LBW/ preterm babies, detection of congenital defects, MCP card, client feedback during home visits) 14. Immunisation: (Assess availability of microplans, RI sessions held, coverage, dropouts, strategies for reaching dropouts, vaccine availability at site, cold chain) 15. RBSK scheme (whether it has been launched, number of mobile health teams, progress on DEIC, number of schools covered, preparedness of AWCs) 16. Doorstep delivery of contraceptivesby ASHAs: status of implementation, supplies, trends in uptake of contraceptives, feedback from ASHAs and clients 17. Menstrual Hygiene Scheme: supplies, uptake, acceptance of the product, ASHA and client feedback 18. WIFS: Number of schools covered, supplies, monitoring mechanism, convergence with department of education, handling of complaints following administration of IFA tabs, feedback from students & teachers 19. IEC/BCC on RMNCH+A (Strategies used for IPC, BCC, mass media , local innovations, availability of IEC materials in local language etc.) 20. Maternal Death Review: whether being conducted regularly, causes of maternal deaths, key recommendations emerging from reports, regularity of reporting to state & national level 21. Any other pilots/ schemes /innovations

Guidance Note for Block Monitoring Visits in High Priority Districts

III. VALIDATION OF KEY RMNCH+A INDICATORS REPORTED IN IN HMIS AND MCTS

The team should validate the HMIS reporting of following indicators from the primary data source ( eg; registers) available at the facility/block management unit. Sample data from last two quarters can be validated.
Pregnancy Care HMIS data Specify the data source Primary Data recorded in the data source Comments (whether the HMIS data matches the data recorded in primary data source)

1st Trimester registration to ANC registration Pregnant women received 3 ANC checkups to total ANC registration Pregnant women given 100 IFA to total ANC registration Cases of pregnant women with Obstetric Complications and attended to reported deliveries Pregnant women receiving TT2 or Booster to total number of ANC registered Child Birth SBA attended home deliveries to total reported home deliveries Institutional deliveries to ANC registration C-Section to reported deliveries Post natal Mother& Child care Newborns breast fed within 1 hour to total live births Women discharged in less than 48 hours of delivery in public institutions to total no. of deliveries in public institutions Newborns weighing less than 2.5 kg to newborns weighed at birth Newborns visited within 24hrs of home delivery to total reported home deliveries Infants 0 to 11 months old who received Measles vaccine to reported live births Reproductive Age Group Post-partum sterilization to total female sterilization Male sterilization to total sterilization IUD insertions in public plus private accredited institution to all family planning methods (IUD plus permanent)

Guidance Note for Block Monitoring Visits in High Priority Districts

IV. Key Findings and Actions

5 major actionable points agreed upon for action after block monitoring visit &level at which the action is to be taken i.e. facility, block, district or State to be mentioned 1 2 3 4 5

Action taken on last visit report (Date of the last visit) 1 2 3 4 5

Date of preparation of report: Signatures of team members: 1. 2. 3. 4. 5. 6.

10 Guidance Note for Block Monitoring Visits in High Priority Districts