NRHM-PIP Monitoring for Bellary District, Karnataka
T N Bhat
K S James
Population Research Centre
Institute for Social and Economic Change
Bangalore-560072
November, 2013
NRHM-PIP Monitoring for Bellary District, Karnataka
November, 2013
Executive Summary
The PIP monitoring was undertaken in Bellary district in Karnataka in November, 2013. The district hospital of Bellary, sub-district hospitals (SDH), Sandur, Taranagar PHC and Taranagar SC of Sandur taluk were visited as part of the field work. In addition, discussions were held with DHO, District Programme Officials and other officials at the district head quarters. The major findings are emanated from the study are as follows.
Bellary district constituting nearly 4 percent of the total population of Karnataka has recorded higher population growth rate than the state average. Both in terms of demographic achievement and progress in social indicators, the districts fall below the state average. The male literacy level is 77 per cent and the female literacy level is 58 percent in 2011. The female labour force participation rate, however, is above the state average. However, this may be an indication of poverty induced work participation than the progress. The percentage of workers in agricultural sector is also relatively higher than the state average. Agricultural labourers constitute 42 percent of the workforce as against the state average of 26 percent for Karnataka. The fertility and infant mortality in Bellary were marginally higher than the state average indicating that the district is less developed in terms of demographic indicators as compared to Karnataka as a whole. The total fertility rate in the Bellary district is 2.4 as against the state average of 1.9 children per women in 2011. The mortality information available from earlier census (2001) also shows Bellary below the state average in terms of infant and child mortality rate. Comparable data for the recent times are not available.
The district appears to be less developed in terms of creation of health infrastructure as well. The average population served by the PHCs is better than the prescribed population norms. At the same time,population served by SCs and FRUs and bed population ratio in Bellaryare below the suggested normThe DH has a newly constructed building with capacity of 100 inpatient beds. But, at present, it is non-functioning FRU due to lack of blood storage and SNCU facilities. No c-section and complicated deliveries are conducted here.The Medical College of the district is established on the outskirts of Bellary city in a different campus with a separate hospital complex.Whiel facilities are better in lower level facilities, the FRUs including DH are yet to be fully operational. Staff quarters are not available in all the facilities and required medical kits and essential drugs are not adequately supplied to the ANM. It is common scene to see stinking toilet, piling up of dusts in the medical wards and altogether the cleanliness has been rather poor in most visited facilities.
The major problem noticed in the field work was lack of sufficient human resources, particularly the doctors. The visited primary level FRUs, i.e., SDH and CHC are found to be practically non-functional FRUSs as there are no specialist doctors in these facilities. . Severe scarcity of doctors is reported with the vacant posts of about 60 percent for specialist doctors and about 55 percent for general doctors (MOs). This excludes the positions in DH which under the management of Medical College.Vacant posts are particularly very high among Gynecologists, Pediatricians and Anesthetists.
Even in the case of ANC services the performance of district is moderate. HMIS data indicate that around 85 per cent of the women receive full ANC in the district. However, the ANC services are reported to be satisfactorily provided at facilities as well as through outreach services with help of ASHA and Anganwadi workers. On an average daily about 30-40 percent of the OPD cases in the visited study facilities are said to be for receiving for ANC services including follow-up check-ups, despite weekly fixed ANC day in the facilities. Management of high risk pregnancy needs more attention in the district. With PHCs and CHCs do not have necessary clinical facilities and specialist doctors for scanning pregnancy complications and delivery risks,the load is on FRUsor local private facilities for pregnancy scanning. But, scanning costs incurred in private facilities are not reimbursed to womenbecause of objections of approval, accounting and audit problems. It is mentioned that the risk pregnancies including high risk cases in Bellary district is around 25 percent.
According to the available data 73.4 per cent of deliveries take place in public health facilities 24.1 % among private facilities and 2.5 % at home.The CHCs and PHCs attend to normal delivery cases. The maternal deaths reported in the district during the last two quarters are quite high. There were 34 maternal deaths from May to October, 2013. Review of the deaths were conducted and discussed.
The number of JSSK beneficiaries for the 7 months period April-August 2013 has been low indicating that the coverage of the scheme is still complete. There has been substantial delay in fund transfer to the District this year resulting in shortage of money. Food is provided satisfactorily in most facilities. Free referral transport is provided for pickup from home and from facility to facility, and not for dropping back home or to the facility back. However, most beneficiaries interviewed during the field visit did not avail the transport facility. JSY incentives Bellary district is below satisfactory in the 6 months period during May-October 21013. Out of the total 21,053 deliveries in the district during the period 4755 women or about 22.60 percent have been paid JSY incentives. Considering the poverty and large proportion of SC/ST in the district, this appears to be far below the expected coverage. JSY amount is not paid to mother with more than 2 children still
SNCU is functional only in Bellary Medical College Hospital.The NRC program is yet to be implemented in Bellary district. Over all, child immunization is satisfactorily implemented in the district.The family planning programme and the IEC activities relating to that are implemented appropriately. The adolescent health clinics are also regularly conducted. The ASHA has been rendering their service effectively although the monitoring part of ASHA work needs more strengthening.
NRHM-PIP Monitoring for Bellary District, Karnataka
November, 2013
2. Introduction
Themonitoring of NRHM-PIP was undertaken in November 2013 in the district of Bellary, Karnataka as part of monthly monitoring. The district hospital (DH) of Bellary, sub-district hospitals(SDH) of Sandur andTaranagar PHC and Taranagar SC of of Sandur taluk were selected for the field visit. The fieldwork for the appraisal was conducted during 2ndweek of November. The field team consisted of Prof. K S James and Dr. T N Bhat of PRC-Bangalore. The appraisal provides a review of key population and demographic indicators, health infrastructure facilities, human resources and other inputs. The appraisal also provides insights on MCH service delivery including JSSK and JSY schemes, FP and ARSH services, functioning of bio-medical management, referral transport and ASHA scheme, communicable and non-communicable service delivery, HMIS and MCTS. The study is based on qualitative approach through discussions with district health officials, MOs and other health staff of the visited facilities and through exit interviews of beneficiaries. The available quantitative data from the respective facilities are also used for the assessment. The DPMO and other district supervisory staff have accompanied the field team during the visit.
3. State Profile and District Profile
Karnataka located in the southern part of India has a population of about 61 millions in 2011 and retains the 9th rank as in terms of population size among the Indian states. The decadal population growth rate of the state during 2001-11 is about 15.6 percent which is nearly four percentage points lower than the national average. The population growth recorded a decline of 1.91 percentage point in ten years in comparison to 17.5 percent registered during 2001. However, the density of population in the state (321 per sq.km) is below national average. Around 39 percent of the state population is living in urban areas; which is considerably higher than the national average. The state has witnessed an increase of 4.68 in the proportion of urban population in the last decade. The urban population of the state steadily is increasing due to its rapid efforts towards development and progress.The sex ratio (females per 1000 males) is 973 recording a marginal increase in comparison to the previous decadeand is about 20 points higher than the national average. The child sex ratio also recorded a marginal increase from 946 in 2001 to 948 in 2011. As witnessed during the previous decades, the overall literacy (effective) level of the state has increased from 66.44 percent in 2001 to 75.36 in 2011 with male literacy rate of 82.5 percent against female literacy rate of 68.1 percent. The female literacy level is nearly 15 percentage points lower than among males in 2011. Around 17 per cent of the state’s population comprises of Scheduled Castes and about 7 percent of Scheduled Tribes. Agricultural labourers constitute about 26 percent of the total workforce in the state; about 40 percent among females workers and 18 percent among male workers.
Table 1: Key Population and Socio-economic Indicators of Karnataka and Bellary District.
Indicator / Karnataka / Bellary DistrictNo. of Districts 2011 / 30
No. of Blocks (Tahasils) 2011 / 176 / 7
No. of Villages 2011 / 29340 / 546
Population 2011 / 6,10,95,297 / 2452595
Population Growth Rate 2001-11 / 15.67 / 20.99
Population Share to the Total / 5.05 / 4.01
Density of Population per Sq. Km 2011 / 319 / 290
Percent Urban Population 2011 / 38.67 / 37.52
Sex Ratio 2011 (Females per 1000 Males) / 973 / 983
Child Sex Ratio 2011 (Females per 1000 Males) / 960
Percent Child Population 0-6 (Census 2011) / 11.72 / 14.03
Percent Literacy 2011: Total
: Males
: Females / 75.36
82.47
68.08 / 67.42
76.64
58.09
Percentage of SC Population 2011
Percentage of ST Population 2011 / 17.15
6.95 / 21.10
18.40
Workforce participation Percent 2011: Total
: Males
: Females / 45.62
59.00
31.87 / 52.97
62.26
39.50
Percent Workers as Agr Laborers 2011 : Total
: Males
: Females / 25.67
17.97
40.33 / 42.21
30.06
62.86
The district of Bellary is located in the ‘Northern Hyderabad KarnatakaRegion’. It has a share of 4.01 percent of the total population inKarnataka. The population growth rate of the district although declined by about 4 percentage points, it is still much higher than the state average. The overall and child sex ratios of the district are (983and 963) higher than the state average. The literacy levels in the district are much lower than the state with 67, 77 and 58 percents total, male and female literates, respectively. The proportions of SCs and STs population in the district are much higher than in the state. Density of population in the district is lower than in the state with t 29o persons per sq. km against the state average of 329 per sq. km.The level of urbanization in the district is slightly below the state average. The female work participation in the district is 43 percent which is higher than the state average of 32 percent. Agricultural labourers constitute 42 percent of the workforce, significantly a higher proportion than the average of 25.67 percent for Karnataka.Agricultural labourers among males and females in the district are about 30 and 63 percents. The district thus appears to be poorly developed in comparison with the state in terms of socioeconomic indicators.
4. Key Health and Service Delivery Indicators
The total fertility rate (TFR) has come down below replacement level in the state and stands at 1.9 children per women in 2011. Thus, in the demographic front Karnataka is much above the national average. The TFR in Bellary district estimated from census 2011 is 2.38 children per women,which is higher than state average. The infant mortality rate (IMR) in the state according to SRS estimates is 35 in 2011 and maternal mortality ratio (MMR) is 178 per 100,000 births in 2007-09. Both these rates are much lower than the national average of 48 and 212 for IMR and MMR, respectively.The IMR has registered significant decline in the state during the last six years of NRHM period. It has declined from 50 in 2005 to 35 in 2011. However, the level of IMR is still relatively high compared to the neighboring states like Kerala and Tamil Nadu. Most of the infant deaths in the state is concentrated in the neonatal stages. The neonatal mortality rate (NMR) in Karnataka is around 24 and early neonatal deaths are around 20 per 1000 live births. It indicates that most of the children are dying soon after the delivery which can be addressed only by providing better hospital care.
Table 2: Key Demographic Indicators of Karnataka and Bellary District.
Indicator / Karnataka / Bellary DistrictEstimated TFR / 1.9 (Census 2011) / 2.38 (Census 2011)
Estimated CBR: / 13.79 (HMIS 2010-11) / 20.9 (HMIS 2010-11)
Estimated IMR / 35 (SRS 2011) / 14.5 (District HMIS 2012)
MMR / 178 (SRS 2007-09) / 119(District HMIS 2012)
The mortality information for the district comes from HMIS data and as such is not strictly comparable with the SRS figures of the state. The IMR and the MMR of the district estimated from HMIS is significantly lower than the SRS estimate for the state. However, the census estimate of IMR based on 2001 census was 76for Bellary district against the state average of 54. The IMR in Bellary was not only highest among the districts of Karnatakabut also it was considered as one of districts with very high IMR in the country. Bellary is of course considered to be one of backward district in health development and demographic change in Karnataka and regarded as high focus district for RCH program interventions in the state.
5. Health Infrastructure
The primary healthcare services in the Bellary district are presently rendered through 55 PHCs all of which are 24X7 facilities, 293 SCs, 8 Non-FRU CHCs, 6FRU SDHs (taluk level)and a DH. On an average there is a PHC, a SC and a CHC (Non-FRU) established for every 27,861,5230and 1,91,544rural population respectively, and a FRU for 3,06,574 population in the district.Average number of beds available per 10,000 population in the PHCs and CHCs is about 2, while in the case of FRUs including SDH and DH it is about 30 beds per 1 lakh population with overall beds per 1 lakh population being 150 in the district.The average population served by the PHCs is although better than the prescribed population norms, population served by SCs and FRUs and bed population ratio in Bellaryare slightly higher than the suggested norms.In fact, the population visited PHC Taranagaris covering 30,738 population, while Taranagar SC is covering 8,000 population above the national population norms. The district, thus, appears to be less developed in terms of creation ofhealth institutionsand provision of patient bedsthan in the state.
The functioning of District Hospital at Bellary needs some attention. The DH has a newly constructed building with capacity of 100 inpatient beds. But, it is reported to be non-functioning FRU due to lack of blood storage and SNCU facilities as well as for not conducting c-section or complicated deliveries. The DH started functioning in the newly building about a year ago and it was functioning as a FRUhandling c-section and complicated deliveries. But it was discontinued in January 2013 after providing FRU services for 2-3 months in 2012. In fact, the DH is under the administrative and organization control of State run Vijayanagara Government Medical College with autonomous governing body. The Medical College has to initiate action to make the DH a functional FRU by providing necessary medical infrastructures andposting doctors as well as paramedical staff. The Medical College is established on the outskirts of Bellary city in a different campus with a separate hospital complex. At present, FRU cases coming to DH are being referred to Vijyanagara Medical College Hospital. It is to be noted here that the data compiled in HMIS for DH therefore represents mostly Vijanagara Government Medical College Hospital data rather than Bellary DH data.
Regarding creation of physical and medical infrastructures such as availability of clinical/surgical instruments, laboratory equipments, and; supply of essential drugs, contraceptives, medical kits, etc., in the visited facilities, the information gathered (given in Annexure for Monitoring Check List) suggest that facilities and supplies in the facilities appear to be developed satisfactorily. However, as already mentioned the FRU facilities in the DH are yet to be fully developed. Staff quarters are not available in the visited SC as well as required medical kits and essential drugs are not adequately supplied to the ANM. It is common scene to see stinking toilet, piling up of dusts in the medical wards, laboratories and X-ray rooms, tobacco spitting and piled up garbage within and around the facility complex, unrestricted entry of patient companions and public inSandur SDH and Taranagar PHC. The MOs of the visited facilities opined that physical and medical infrastructures of the heath facilities in the district have been remarkably enhanced in the last 5-6 years due mainly to financialand other resource assistance received from NRHM funds under various schemes and activities.