Monitoring of Programme Implementation Plan of Bundi District of Rajasthan

Executive summary

  • Infant mortality, neo natal mortality and unmet need of Family planning methods were higher in Bundi district in comparison to state as a whole.
  • The existing CHCs and PHCs are less than the requirement. The district does not have sub district hospital.
  • The district hospital is functioning as FRU. Therefore referral services are become centralized at district hospital.
  • There are 213 sub centers but only ten sub centers have delivery conduction facility..
  • Overall cleanness and sanitation of the wards and OPD are not up to mark and Round the clock electricity is a major problem .
  • . District is facing the shortage of man power at all the levels of health facilities.
  • The post of pharmacist is vacant at all PHCs ; compounder or staff nurse is working as a pharmacist so work of the staff nurse suffer badly at PHCs.
  • The five CHC’s have well equipped OT but lack of surgeon and anesthetist CHCs functioning as non FRU..
  • Nine maternal deaths reported in current financial year, MDR conducted every maternal death. The key cause of death was Eclampsia, severe anemia, obstruct labor etc.
  • There are 113 neonatal expired in distinct, key cause of death of neo natal is LBW, premature and infections.
  • The line listing of high risk pregnant mothers are available at all the facility.
  • Nutrition rehabilitation centres are located at three places in the district. So far only 49 children treated at these centers .
  • Sterilization facility is available at district hospital. The training of PPIUCD is going on at zonal level.
  • ARSH services are provided through VHND sessions
  • All pregnant women are entitled to JSY payments. JSY payments are generally paid at the time of discharge after delivery through bearer Cheque
  • Free and Zero expenses facility are providing to pregnant women and new born till 30 days after birth at all the delivery points of the district.
  • EDL are available at all the health facilities. The List of available drugs is displayed at health facility.
  • Call center is situated at CH& HO Office. Average 18 calls responded every day.
  • Facility for birth doze of immunization is available at DH ,CHCs and PHCs.
  • Surprise raids are conducted to check the misuse of PNDT Act and awards are given to persons who provide information regarding the violators of Act.
  • The District has a common Grievance Redressal Committee. Each of heath institution has put in place a complaint and suggestion box.
  • HMIS data are using for review of performance of RCH indicators.
  • Untied funds have been provided to all the VHSCs uniformly and health institutions located in government buildings are also given AMG funds.
  1. Introduction

The government of India had launched National Rural Health Mission. The goals of Programme are to reduce infant and maternal morbidity and mortality as well as total fertility rate. These goals can be achieved through improvements in service delivery in public health institutions. The monitoring of district hospital CHC, PHC and sub centerlevel institutions are essential to know the qualities and quantities of services provided by the facilities and assess the gapes in sevices provided by the facilities.States were implementing the approved PIPs since the launch of NRHM, but there was hardly any mechanism in place to know how far these PIPs are implemented. NowMinistry hasdecided to continuously monitor the implementation of various components ofPIP inhigh priority districts in the stateand roped in Population Research Centers to undertake this mentoring exercise. In this connection, MOHFW organized a workshop of the PRCs to discuss the modalities of this mentoring exercise. It was decided that all the PRCs will undertake qualitative monitoring of PIP in the states. This monitoring will be a continuous exercise and in every montha team of two persons ofthePRC will cover a district. The number of teams will bedepending on the staff strength of each PRC.

2.Study covered

For monitoring purpose ministry hasallotted three high priority districts to PRC Udaipurviz– Karauli , Bundi and Udaipur districts. The Present study coverBundidistrict of Rajasthan. In Bundi districtwe haveselected District Hospital (DH)Bundi, oneCommunity Health Centres (CHC)Talera , one PHC(24X7)Dablana, and aBhawanipura sub center. District has not sub district Hospital (SDH) .A team of two person of PRC visited the Bundi district during 16th September to 20th september2013.There are three Indentified FRUs in the district but none of them is functioningas FRU due to essential man power.

  1. State andDistrict Profile

The Bundi District is situated in South Eastern part of Rajasthanstate. The town of Bundi is the district headquarter.The district is bounded to north by Tonk District, to west by Bhilwara District, to East by Kota District and to southwest by Chittorgarh District of State.The district hascovered an area of 5,550km with population density of 193 people per square kilometer. According to the 2011 censusthe district has population of 1113725. The decadal growth rate of population was 15.70. It is lower than the State (21.44.). Sex ratio and child sex ratio of the district was 922 and 886 respectively. The overall literacy rate of the district was 62.31 percent and female literacy rate was (47 %) it is lower than the female literacy rate of the state (47 %). The district has five blocks and 839 villages.

Table -1

DemographicProfile

Indicators / Rajasthan / Bundi
No. Districts / 33 / 1
No. Blocks / 244 / 5
No. Villages / 44672 / 839 (habited)
Population (2011)
Male
Female / 68621012
35620086
33000926 / 1113725
579385
534340
Decadal Growth rate / 21.44 / 15.7
Sex ratio / 926 / 922
Child Sex ratio / 883 / 886
Literacy rate
Total
Male
Female / 67.06
80.51
52.66 / 62.31
76.52
47.00
Density of population / 201 / 193

  1. Key health and service delivery indicators

Infant mortality,neo natal mortality and Unmet need of Family planning methods was higher in Bundi district in comparison to state as a whole.

Table -2

Key health and service delivery indicators

Key health and service indicators / Rajasthan(Source) / Bundi (Source)
Infant mortality Rate(IMR) / 57 (AHS 2011-12) / 63(AHS 2011-12)
Neo-natalmortality Rate (NMR) / 38(AHS 2011-12) / 44(AHS 2011-12)
Maternal mortality rate (MMR) / 388(census 2011) / -
OPD / 63467115 (HMIS2012-13) / 1265158(HMIS2012-13)
IPD / 2811655(HMIS2012-13) / 84899(HMIS2012-13)
Ante NatalCare (ANC) / 1866803 (HMIS2012-13) / 25365(HMIS2012-13)
Safe Birth Attended (SBA) / 44221(HMIS2012-13) / 50(HMIS2012-13)
Post Natal Care (PNC) / 991434(HMIS2012-13) / 20130 (HMIS2012-13)
Immunization / 1297581(HMIS2012-13) / 20856 (HMIS2012-13)
Unmet need for FP / 17.9(spacing +limiting method)
(Source-DLHS2007-08) / 22.42(spacing +limiting method)(RCHO office)
  1. Health Infrastructure

The Bundi district has a district hospital, 9 CHCs,26PHCs and 213 sub centers. All the CHCs and PHCs are 24 X 7.Twelve sub centershave not ANMs,but at ten subcentres, GNMs are working against the post of ANM.Fifty three sub centers have posted two ANMs. Ten sub centreshave delivery point.The existing CHCsand PHCs are less than the requirement. The district has not sub district hospital. The district hospital is functioning as FRU in the district because of district hospital has emergency obstructs care including surgical interventions like caesarean, new born care and blood storage facility on 24 hours basis. Beside this five private hospitalsalsoprovidingtheFRUservices.Therefore the referral services are becamecentralized at district hospital. Overall 766 beds available at all the public facilities

( 466 beds under the control of CH&HO and 300 bed under the control of PMO) in the district. It is more than the requirement as per norms of population of the district.

Table -3

Health Infrastructure

Health InfrastructureParticular / Rajasthan / Bundi
Available * / Required** / Available # / Required**
District Hospital / 34 / 34 / 1 / 1
Sub District Hospital / 16 / 0 / 0
CHC / 382 / 465 / 9 / 9
PHC / 1526 / 1862 / 26 / 33
Sub Center / 11487 / 11459 / 213 / 207
Beds (as per norms of 500 beds per ten lack population) / 34274 / 766 / 555

Source:-* Rural health statistics of India 2012 # CM&HO office Bundi

** Calculated on basis of population norms of the facility

  1. Physical Infrastructure

The physical infrastructure of visited facility reveals that district hospital, CHC and Sub centreare easily accessible from nearestroad head. All the selected facilities are functioning in govt. buildings.The districthospital is situated in the centre of Bundi town and has four separate buildingsin apremise viz- Emergency, Janana, Trauma and general. In the visited facilities, the overall sanitation and cleanliness was not up to mark. The visited CHC (Talera) has acute shortage of space. The building is old and some portion of buildingshas developed cracks .Overall sanitation of the wards and OPD is not up to mark. Round the clock electricity is a major problem in all the health institutions visited by us.The condition of building of visited PHC( Dabalana) is not good. The space is alsolimited to serve the available facility like wards, store of medicine, Laboratory, Seating room of doctor etc. Power cut off is general problem of the district but appropriate alternate of power back up facility isavailable at district hospital and CHC. The district hospital has separate toilets for male and female but toilets, wards and premises of the facilities are not so clean. Districthospital is providing special care servicesincluding surgery, medicine, trauma care, obstetricsand gynaecology,ophthalmology, ENT, family planning and ancillary services of blood bank with pathology etc. The CT screen is available at district hospital but it is not in operation.CHCs and PHCs (24X7) are providing RCH services but None of CHCs and PHCs are conducting C-section delivery. They are providing facility of free medicines and diagnostics (Table-4 in Annexure).

  1. Human Resources

District is facing the challenge of shortage of man power at all the levels of the health facilities.At the district hospital a post of senior specialist (orthopedic), senior specialist( pediatric) , senior specialist ( medicine), senior specialist (anesthetic), senior specialist (ENT), senior specialist (Giyani), senior specialist (Pathology) and senior specialist (Radiology), five post of junior specialist and six post of medical officers are lying vacant. At the CHC andPHC levelfive posts of junior specialist( Medicine), nine posts of junior specialist (surgery), three post of junior ( Giyani ) , three post of pediatrician , four post of senior medical officer, nine post of medical officer and five posts of rural medical officer are lying vacant in the District.The vacant post of paramedical and technicians are concern, five post of nurse gradeI, forty nine post of nurse grade II, four post PHN, nine post of pharmacist, one post of radiographer, five post of assistant radiographer, five post of lab technicians and fifty three post of ANM’s are lying vacant in the district.

The five CHC’s have well equipped OTbut lack of surgeon and anesthetist resulted FRU become non functional. Therefore it is suggested that fillup the post ofanesthetists and surgeon as per requirement for functional FRU.Itwill fill up the gape of conduction of C-section delivery.

At the selected CHC post of anesthetist is exists but post of general surgeon is vacant. A general surgeon can be posted at CHC to fill up the gap of conduction of C-section delivery. None of the OBG is available at CHC and PHC. Two post of medical officer are at PHC, one of them is medical officer of AYUSH. At the PHC level no post of pharmacist therefore nurse grade II involved in distributing the free medicine at the facility.(Table-5 in Annexure)

8. AYUSH

Though the state has established AYUSH clinics at PHCs only but due to the shortage of doctors in other health facilities, some AYUSH medical officers have also been attached with DHs and CHCs. The district ISM units which function under the administrative control of Director ISM are co-located with DH.All the facilities where an AYUSH doctor is posted havenot an AYUSH Pharmacist in place. AYUSH doctors are involved in the implementation of National Health Programmesbesides their routine work.

  1. Training of Human Resources

Trainingcomponent is importantaspects of medical and paramedical staff. At the district level three obstruct and gynecologist (OBG) are posted so they are able to handle the complicated deliveries. There are eight paramedical staff is trained in SBA at district hospital. Six each medical personals are trained inF-IMNCI at district hospital and CHC respectively. There are five medical officersare also trained in minilap sterilization, three in laparoscopysterilization and one in blood storageat the district hospital (Table-6 in Annexure).

  1. Maternal Health

One of the priority areas of the State is to improve maternalhealth facility at District hospitals, CHCs and PHCs. In Bundi district some of the PHCs have been upgraded and strengthened to provide facilities for conducting deliveries. Under the JSY, institutional delivery reported 10625 and 6785 women availed free transport facility from home to institution and come back to home. In the district 13863 and 14134 pregnant women received free medicine and free lab test respectively.All the CHCs and PHCs refer the complicated cases of delivery to District hospital. Only normal deliveries are conducted at CHCs and PHCs. Management of RTI/STI services are available at all the CHCs and PHCs. All SCs provide ANC services and they refer complicated cases and severe anemia cases to higher facilities. Only ten sub centers are functioning as delivery points but performance of deliveries of thesecenters is very meager.

In Bundi district severely anemic mothers was 10.73 percent in 2012-13, it became 2.8 percent from March 2013–Sept 2013. Less than two percent of mothers indentified ascases of < 7 gm Hb and hypertensive and about 54 percent of mothers conducted blood sugar test.More than half of mother given TT2 and about 83 percent of the mothers received IFA tablets.,141 C-sectiondeliveries conductedfrom March 2013- Sept 2013 at district hospital. Emoc and Bemoc facilities are available at district hospital and selected CHC respectively.

  1. Maternal Death Review

Maternal and Infant Deaths Review has conducted in the district. Death reviews are done under the chairmanship of Districtcollector. ASHAs are given incentives to report maternal and infant deaths.Nine maternal deaths reported in current financial year,MDR conductedevery maternal death. he key cause of maternal deathwas Eclampsia, severe anaemia, obstruct labor etc.There are 113 neonatal expired in distinct, key cause of death of neo natal was LBW, premature and infections There were 154 infant death reported in distinct.

The line listing of high risk pregnant mothers are available at all the facility. They refer such cases to higher facility and every month they also monitor the weight, BP, HB and conduct urine test. They also inform to familymember and public leader of the village for timelytreatment of highrisk pregnant mothers. All the ANMs have registration booklet of high risk pregnant mothers. In the booklet they mentioned the parameters of high risk pregnant mothers of their area. Time to time monitor the parameters of high risk pregnant mothers

  1. JSSK

There are 30 exist interview conducted at different facility.About 93 percent mothers were aware on breast feeding initiation within an hour of birth and90 percent mothers adherence to Initiating breast feeding within an hour of birth,80 percent of mother adherence to exclusive breast feeding for Six months and continuedtill 2 years and they adherence on initiating complementary food from 6 months onwards. About two third of mothers were awareness about ORS+ Zinc. About half of the mothers were aware about danger signs and 40 percent of mothers were aware about whom to approach on recognizing the danger signs.

There are 23 exist interview conductedto pregnant womenand high risk pregnant women .About 87 percent of women told us that MCP card being regularly filledup, more than half ofpregnant womenaware about birth preparedness. None of pregnant woman has received Safe motherhood booklet, about 57 percent of pregnant woman have the telephone number of call centre for referral transport/ other available referral transport but 61 percent of pregnant woman have telephone numbers of ASHA/ ANM. All the high risk pregnant women werereferred to district hospitals. JSY implemented according to normslike ANC registration, four visits,free transportation and free medicine, free tests, free mealetc. In case of home delivery Rs 500is given to BPL women during the delivery. Payment of institution deliveryis provided through bearer cheque at the time of discharge from the delivery point.

  1. Child Health

Thedistrict hospital and all the CHCs and PHCs are currently functioning as delivery points. Sick New Born Care Units (SNCU) has been set up in district hospital,1009 Neonatestreated up to Sept 2013. New Born Stabilization Units (NBSU) have been established at two CHCs, 50 neonates treated in the units. Thirty four CHCs and PHCs have New Born Care Corner (NBCC). Most of NBCC located in the labour room. Essential equipments and trainedmanpower are available at all the delivery points. There are 3439 and 933new born babies (up to 30 days)given free medicine and free lab test respectively.There are 487 children provided free transportation facility at the time of their sickness.