NRHM-PIP Monitoring for Bijapur District, Karnataka
T N Bhat
K S James
Population Research Centre
Institute for Social and Economic Change
Bangalore-560072
January, 2014
NRHM-PIP Monitoring for Bijapur District, Karnataka
January, 2014
Executive Summary
The PIP monitoring was undertaken in Bijpur district in Karnataka in January, 2013. The district hospital of Bijapury, Sub-District hospital (SDH) of Basavanabagewadi, CHC Talikote of Muddebihal taluk, PHC Tikota and Tikota B-SC of Bijapur taluk were visited as part of the field work. In addition, discussions were held with DHO, District Program Officials and other officials at the district head quarters. The major findings are emanated from the study are as follows.
Bijapur district constituting 3.6 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 about 57 percent in 2011. The female labour force participation rate (38 percent) is above the state average (31 percent). 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 38 percent of the workforce as against the state average of 26 percent for Karnataka. The fertility and infant mortality in Bijapur 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 Bijapur district is 2.51 as against the state average of 1.9 children per women in 2011. The mortality information available from earlier census (2001) also shows that Bijapur is 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 populations served by the CHCs (or FRUs), PHCs and SC and population-bed ratios are higher than the prescribed population norms. The DH complex is under renovation at a cost of 8.75 crores. The visited SDH, CHC and PHC have been renovated in recently. There are 2 private medical colleges established in Bijapur on the outskirts of the city with hospitals. In higher level facilities, i.e., SDH and DH many services are fully operational, while service delivery is better at lower levels, viz., in CHC and PHC. Essential drugs and required medical kits are satisfactorily to the ANM. Toilets, medical wards, laboratories and X-ray rooms in the facilities are poorly maintained and need to be better housekeeping.
The major problem for service delivery is shortage of sufficient human resources, particularly the doctors. The visited Basavanabeagewadi SDH is non-functional FRU.as there is no Anesthetist doctor in the facility. While the visited CHC Talikote is functional as the MO and LMO in the facility have undergone shot term training course in Gynecology and Anesthesia to handle FRU service, mainly the c-section deliveries. Severe scarcity of doctors is reported with the vacant posts of about 72 percent for specialist doctors and about 18 percent for general doctors (MOs). The posts are particularly in demand for Gynecologists, Pediatricians and Anesthetists.
The ANC services the performance of district is moderate. HMIS data indicate that 60.03, 93.83, 117.56, 113.74, 117.50 percent pregnant women respectively have registered during first trimester of pregnancy, received 3or more ANC checkups, TT1, TT2 and 100 IFA tablets. 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 not having necessary clinical facilities and specialist doctors for scanning pregnancy complications and delivery risks, the load is on FRUs or local private facilities for pregnancy scanning. But, scanning costs incurred in private facilities are not reimbursed to women because of objections of approval, accounting and audit problems. It is mentioned that the risk pregnancies including high risk cases in Bijapur district is around 25-35 percent.
The HMIS data for 2013 April-December 9 months period show that 94.2 percent of the deliveries are institutional deliveries. This progress in is commendable in a span of 5-6 years perhaps due to strong NRHM interventions. The CHCs and PHCs attend to normal delivery cases. The level of maternal deaths in the district is quite as quite high in the district as 22 maternal deaths have been reported during last 9 months from April to December, 2013. SNCU is functional only in Bijapur DH and Basavanbagewadi SDH. The NRC program is operational only in the DH since April 2103 and yet to pick up momentum. Over all, child immunization is satisfactorily implemented in the district.
The number of JSSK beneficiaries reported in the last 9 months for three quarters (April-December 2013) is low indicating that the benefits extended under the scheme is less than satisfactory. There has been substantial delay in fund release to the district in current 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 of the beneficiaries interviewed during the field visit did not avail free referral transport facility. Disbursement of JSY incentives is also below satisfactory in the district during last 3 quarters (April-December 21013). Out of the total 30, 826 deliveries in the district during the period only 6,452 or about 20.93 percent women have been paid JSY incentives. Considering the poverty and large proportion of SC and OBCs in the district, the achievement appears to be far below the expected performance. JSY amount is not paid to mother with more than 2 children still in many facilities, particularly higher level facilities.
The FP programme and IEC activities are satisfactorily carried out. The service provided under ARSH programme is quite satisfactory. The ASHAs have been rendering service satisfactorily service, although monitoring ASHA workers is somewhat weak. Transportation of biomedical waste to the central disposal unit by carrier is available in only in DH and SDHs.
NRHM-PIP Monitoring for Bijapur District, Karnataka
2. Introduction
The monitoring of NRHM-PIP was undertaken in January 2014 in the district of Bijapur, Karnataka as part of monthly monitoring. The district hospital (DH) of Bijapur, sub-district hospital (SDH) of Basavanabagewadi, Talikote CHC of Muddebihal tahasil, Tikota PHC and and Tikota B-SC of Bijapur tahasil were selected for the field visit. The fieldwork for the appraisal was conducted during 2nd week of January 2014. The field team consisted of Dr. T N Bhat, Mr. C Yogananda and Mr. Chetan Patel 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 district supervisory staff 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 decade and 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 Bijapur district.
Indicator / Karnataka / Bijapur DistrictNo. of Districts 2011 / 30
No. of Blocks (Tahasils) 2011 / 176 / 5
No. of Villages 2011 / 29340 / 660
Population 2011 / 6,10,95,297 / 21,77,331
Population Growth Rate 2001-11 / 15.67 / 20.50
Population Share to the Total / 5.05 / 3.56
Density of Population per Sq. Km 2011 / 319 / 207
Percent Urban Population 2011 / 38.67 / 23.05
Percent Child Population 0-6 (Census 2011) / 11.72 / 14.62
Sex Ratio 2011 (Females per 1000 Males) / 973 / 960
Child (0-6) Sex Ratio 2011 (Females per 1000 Males) / 948 / 931
Percent Literacy 2011: Total
: Males
: Females / 75.36
82.47
68.08 / 67.15
77.21
56.72
Percentage of SC Population 2011
Percentage of ST Population 2011 / 17.15
6.95 / 20.33
1.80
Workforce participation Percent 2011: Total
: Males
: Females / 45.62
59.00
31.87 / 49.90
61.31
38.08
Percent Workers as Agr Laborers 2011 : Total
: Males
: Females / 25.67
17.97
40.33 / 37.90
30.20
38.95
The district of Bijapur is located in the ‘Northern Mumbai Karnataka Region’. It has a share of about 3.6 percent of the total population in Karnataka. The population growth rate of the district increased by about 3 percentage points between 2001and 2011 as against decline in the state by 1.84 percentage points. The overall and child sex ratios of the district are (960 and 931) much lower than state average. The literacy levels in the district are much lower than the state with 67, 77 and 57 percents total, male and female literates, respectively. The proportion of SC population is higher, while ST population is much lower in the district than in the state. The density of population in the district is lower than in the state with 207 persons per sq. km against the state average of 329 per sq. km. The level of urbanization in the district is much below the state average. The female work participation in the district is 38 percent which is higher than the state average of 32 percent. Agricultural labourers constitute 38 percent of the workforce, significantly a higher proportion than the average of about 26 percent for Karnataka. Agricultural labourers among males and females in the district are about 30 and 39 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 Bijapur district as estimated from the census 2011 is 2.51 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 Bijpur district.
Indicator / Karnataka / Bijapur DistrictEstimated TFR / 1.9 (Census 2011) / 2.6 (Census 2013)
Estimated CBR: / 13.79 (HMIS 2010-11) / 19.30 (HMIS 2010-11)
Estimated IMR / 35 (SRS 2011) / 28.4 (District HMIS 2013)
MMR / 178 (SRS 2007-09) / 112 (District HMIS 2013)
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 are significantly lower than the SRS estimate for the state. However, the census estimate of IMR based on 2001 census was 58 for Bijapur district, which is above the state average of 54. Bijapur is, of course is considered to be one of backward district in health development and demographic change in Karnataka.
5. Health Infrastructure
The primary healthcare services in the Bijapur district are presently rendered through 60 PHCs all of which are 24X7 facilities, 299 SCs, 8 CHCs (of which 1 is a functioning FRU), 4 Non functioning FRU SDHs (taluk level) and a DH. In Talikote CHC, the MO and LMO have been trained in short term Gynecology and Anesthesia course and are able to handle c-sectional deliveries making the facility functional. On an average there is a PHC, a SC and a CHC established for every 27,922, 8016 and 2,09,419 rural population respectively, and a FRU for 4,35,466 population in the district. Average number of beds available per 10,000 population in the PHCs and CHCs is about 2 and 1.4, while in the case of FRUs (SDH and DH) it is 24 beds per 1 lakh population with overall beds per 1 lakh population being 52 in the district. The average populations served by the PHCs, SCs and CHCs and bed population ratio in Bijapur district are higher than the suggested norms. In fact, the visited PHC, SC and the CHC are covering 52,270, 6238 and 2, 0,858 populations, i.e., above the prescribed national population norms for coverage rural health institutions. The district, thus, appears to be less developed in terms of creation of health institutions and provision of patient beds.
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 in the facilities appear to be satisfactorily developed as per information gathered in the Monitoring Check List (given in Annexure). However, the SDHs in the district are not providing even essential FRU services because of vacant positions despite satisfactory development physical and medical and infrastructures. Some of the medical facilities even in the DH are not fully functional due to shortage of specialist doctors, specifically in the departments of Pediatrics, Gynecology, Anesthesia, Radiology, General and Forensic Medicine. The District Surgeon mentioned that OT in DH is yet to developed into a fully equipped unit.
The DH building Bijapur which is more than 40 years is presently under renovation at a cost of Rs. 8.75 crores and is expected to be completed by next year. Change of floors and plumbing, i.e., sanitary and water connections, repairs of electric lines and seepage in the walls and roofs, construction of patient and elderly friendly steps, toilets and bathrooms as well as building paintings and reconstruction of OT room are some of the initiatives are being undertaken as part of renovation of the DH. The District Surgeon opined that, since the government hospitals do not have any accommodation facilities at present for providing lodging to accompanying persons or care givers of inpatients there is need to construct Dhrmashals for them. The staff quarters available at the DH is reported to be quite adequate except District Surgeons’ quarter which needs to be rebuilt. The renovation is being monitored by the KHSRDP. He has already proposed this plan in the current undergoing renovation of the DH. The renovation and repairs of the other visited facilities, viz., Basavanabagewadi SDH, Taikote CHC and Tikota PHC were taken up recently and have been completed. About cleanliness in the hospitals, it is noticed that cleanliness of toilets, medical wards, laboratories and X-ray rooms are poor in all the visited facilities and need more better maintenance. Mechanized biomedical waste disposal is done only at the FRU levels in the district, i.e., DH and SDHs, but not at the CHCs and PHCs. The MOs in the visited facilities felt that physical and medical infrastructures have been remarkably enhanced in the last 5-6 years due mainly to financial and other resource assistance received from NRHM funds under various schemes and activities.
6. Human Resources
Although, the physical and medical infrastructure is satisfactorily expanded the district, major hindrance for provision of services and quality in particular is the shortage of doctors and paramedical staff. Severe scarcity is reported for doctors with the vacant posts of about 80 percent for specialist doctors and about 18 percent for general doctors (MOs). Vacant posts are particularly very high among Gynecologists, Pediatricians and Anesthetists. The vacant positions among paramedical staff are also high specifically for the posts of Male Health Workers (MPW-Male), LHVs and ANMs at 41, 27 and 25 percents respectively. This observed to be much true in the visited facilities. Evidently, the vacant post of specialist doctors in the DH is 49 percent, while it is 55 percent in Basavanbagewadi SDH and 100 percent in Talikote CHC. The MO and LMO of Talikote CHC have undergone short term training course in Gynecology (EMOC) and Anesthesia and are handling c-section deliveries. Attempts are made to appoint specialists as well as general doctors under NRHM, but it is reported that the candidates are not coming forward to accept the posts in spite of open offers. It is reported that the health staff under NRHM, viz., the staff nurses, AYUSH doctors and physiotherapists, etc, have not received salary for the past 3-4 months since the salary funds are not released.