NRHM-PIP Monitoring for Chittoor District, Andhra Pradesh
T.S. Syamala
Lekha Subaiya
Population Research Centre
Institute for Social and Economic Change
Bangalore-560072
February 2014
NRHM-PIP Monitoring for Chittoor District, Andhra Pradesh
February 2014
Executive Summary
Chittoor is the second largest district in Andhra Pradesh accounting fornearly 5 percent of the total population of the state.Chittoor is predominantly a rural and backward district with a total population of 41.1 million as per the 2011 Census Survey, and 30 percent of the population living in urban areas. The density of the population in the district is lower than in the state at 275persons per sq.The decadalpopulation growth rate of the district was about 11 per cent between 2001 and 2011. The child sex ratio was 931 females to 1000 males, and male literacy level was 79.83 percent and the female literacy level was 63.28 percent in 2011. The work participation rate in the district is 58 percent and 38 percent respectively for males and female which is almost similar to the state pattern. Around 19 percent of the population in the district belongs to the Scheduled Casteswhile 4 percent belongs to Scheduled Tribes.Agricultural labourers constitute 39percent of the workforce in the district.
Major Findings
- The study found that the Chittoor has adequate health facilities as per the norms laid down and most of the health facilities are functioning in government buildings except in the case of sub centres where majority are functioning in rented buildings. Although there are adequate facilities, aserious shortage of manpower was observed. There are shortages for doctors especially specialists, other para medical staff and technicians. Severe staff shortages are observed in Cemonc centres and SNCU units.
- Maternal and Child Health services provided in the district through various health facilities have been found to be adequate. ANC delivery and PNC care have been provided satisfactorily. ANMs and ASHAs are found to be working in coordination to provide the required services. In some areas it was felt that ASHAs have to make concerted efforts in interacting with the community in order to improve their service delivery. The district stands fourth in the state in terms of disbursing JSY benefits. Provision of food under JSSK was found to be problematic in many places, as moneywas given to women to purchase food instead of a proper diet being provided. This may not bring the anticipated benefits of providing proper nutrition to women during delivery. Further, some out of pocket expenditure was observed, especially in the case of transport or for getting certain diagnostic tests such as scanning done from a private facility. There were complaints regarding the delay in services of 108 and the patients have to depend on private transport to reach the health facility when the 108 is being utilised for another patient. In order to improve the services at the peripheral level, most sub centres have been provided with a 2nd ANM in the district. The services of 104 was found to be effective in conducting Fixed Day Health Services at the village level.
- More than 90 percent of the deliveries in the district are institutional deliveries. Normal deliveries are mostly conducted at the PHC and CHCs, with complicated cases being referred to area hospital or District hospitals. C section deliveries are also mostly done at FRUs.
- The study found that the money spent on food, drug and diagnostics at the district hospital and area hospitals are not booked under JSSK, and subsequently the funds under JSSK are shown as unspent. The DH and Area Hospitals in Andhra Pradesh come under the administrative control of the Andhra Pradesh Vaidya Vidhana Parishad (APVVP), and as such, the health functionaries of these facilities were not well-versed with the guidelines provided by NRHM. Further, it was not well known that women of ANY parity is entitled to JSY benefits, and benefits were still being provided only to the first two deliveries.
- With regard to payment of incentives to ASHA workers, there was confusion at the FRU level regarding whether the payment should take place at the PHC level itself or at the FRU level at the time that the ASHA worker brought cases to the FRU.
- Currently, attention is also being given to the control of Non Communicable Diseases in the population, with the setting up of NCD clinics at various facilities. The services of 104 MMUs are being utilised for screening patients for diabetes, hypertension and other NCDs at the village itself.
- HMIS coverage in the district is found to be about 80% or over, however MCTS coverage is comparatively low. Earlier entries were to be done at the cluster level, but due to severe delays in entry and uploading of HMIS and MCTS data the procedure has been changed so that entry is being done at the facility level itself. However, entry at the FRU level is still being carried out at the cluster, and as such delays are being reported.
- Biomedical waste management at FRUS have been outsourced to private agencies.On the other hand, in the case of PHCs, the waste management is done at the premises itself.The waste is segregated into different colour coded bins, andblood and blood related waste are incinerated and the other ones are deposited in deep burial pits.
NRHM-PIP Monitoring for Chittoor District, Andhra Pradesh
February, 2014
1Introduction
Themonitoring of NRHM-PIP was undertaken in January 2014in the district of Chittoor,Andhra Pradesh as part of monthly monitoring activities. The institutions that were selected for the field visit were: the District Hospital (DH) of Chittoor, Area hospital (SDH) of PalemnerMandal, CHC, P.Kothakotha of Pothelapettu Mandal, PHC Gudipala of Gudipala Mandal. The fieldwork for the appraisal was conducted during the 3rd week of January. The field team consisted of Dr.T.S.Syamala and Dr. Lekha Subaiya 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 type of methodology which the study utilisesisqualitative in nature, and involvedholding discussions with district health officials, MOs and other health staff of the visited facilities, and also 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 accompanied the team during the field visit.
2State Profile and district profile
Andhra Pradesh is the fourth largest state in the country with a geographical area of of 275.04 lakh ha accounting for 8.4 percent of the country’s area. With a population of 84,580,777,as per the 2011 Census, the state accounts for 7.1 percent of the country’s population making it the 5th most populous state. The state has 23 districts, with 9 districts in the coastal area, 10 districts in the Telangana area, and 4 districts in the Rayalseema region.
The decadal population growth rate of the state during 2001-11 was about 10.9 percent which is nearly seven percentage points lower that of the national average. The density of population in the state is 310 per sq. km which is well below the national average of 382 per sq km.Aboutone third of thepopulation in the state lives in urban areas. The total sex ratio and child sex ratio of Andhra Pradesh higher than the national average and the state also fares better in comparison with most other states of India. The overall sex ratio (females per 1000 males) in the state is 993which is well above the national average of 943. The child sex ratio in the state is 939 which is also higher compared to the national average of 919. However, the literacy level in the state (67 percent) is below the national average (73 percent). Further, the female literacy level is nearly 15 percentage points lower than the literacy level among males in 2011. About 16 per cent of the state’s population is comprised of Scheduled Castes and about 7 percent of Scheduled Tribes. The labour force participation for both males and females in the state is higher than the national average with 47 percent of males and 36 percent of females participating in the labour force as against 40 percent males and 26 percent females in the county.
Key Population and Socio-economic Indicators of Andhra Pradesh and India.
Key indicators / Andhra Pradesh / IndiaNo. Districts / 23 / 640
No. of Mandals / 1128 / 5576
No. of Villages / 27800 / 638588
Population (in lakh) / 845.81 / 12105.70
Decadal Growth Rate (2001-2011) / 10.98 / 17.7
Rural Population / 66.64 / 68.8
Urban Population / 33.36 / 31.2
Per cent of SC / 16.41 / 16.6
Per cent of ST / 7.0 / 8.6
Sex Ratio (Females/1000 Male Population) / 993 / 943
Child Sex Ratio (Female Children/1000 Male Children) / 939 / 919
Literacy Total / 67.02 / 73.0
Male / 74.88 / 80.9
Female / 59.15 / 64.6
Work Participation Rate / 46.61 / 39.8
Female Work Participation Rate / 36.16 / 25.5
Chittoor is the second largest district in the state and is located in the region of Rayalaseema. The District is surrounded by kadapa and Anantapur districts in the North, Karnataka State in the West, Nellore in the East and Tamilnadu State in the South. The Chittoor District comprises of 3 revenue divisions namely Chittoor, Tirupathi and Madanapalli and 66 Revenue Mandals for administrative convenience. Chittoor is predominantly a rural and backward district with total population of 41.1 million as per Population of 2011 census with 20 percent of population living in urban areas. It has nearly 5 percent of the total population of Andhra Pradesh. The district has a population growth rate of 11.43 percent during 2001-11, which is slightly higher than the state average. The overall sex ratio of the district is 997which is also marginally higher than the state average, and the child sex ratio of 931 which is slightly lower than the state average. The literacy level in the district is 71.53 which is higher than the state average. The male literacy level is 79.83percent and the female literacy level is 63.28 percent in 2011.Around 19 percent of the population in the district belongs to the Scheduled Casteswhile 4 percent to the Scheduled Tribes.Density of population in the district is lower than in the state at 275persons per sq. km against the state average of 308 per sq. km. The level of urbanization in the district is below the state level as proportion of population living in urban areas of the district is about 29.5 percent against 33 percent the state average according 2011 Census. The work participation rate in the district is 58 percent and 38 percent respectively for males and female which is almost similar to the state pattern.. Agricultural labourers constitute 39percent of the workforce in the district.
Key Health and Service Delivery Indicators
The total fertility rate has come down below replacement level in the state and stands at 1.8 children per women in 2011. Thus, the fertility levels in Andhra Pradesh is far below the national average. The total fertility rate in Chittoor district estimated from the census 2011 is also 1.8 children per women similar to state average. The infant mortality rate (IMR) in the state according to the Sample Registration System is 41 in 2012 and maternal mortality ratio is 110 per 100,000 births in 2010-12. Both these rates are much lower than the national average of 48 and 212 respective for IMR and MMR. However, the level of infant mortality rate and maternal mortality rate is still relatively high compared to the neighboring states like Kerala and Tamil Nadu. The mortality information for the district provided by the district health official show that the IMR for the district is 20 and MMR is 112.The unmet need for family planning in the district is 10 .7.
Key Demographic Indicators of Andhra Pradeshand Chittoor District.
Indicator / Andhra Pradesh / Chittoor DistrictEstimated TFR / 1.8 (SRS (2012) / 1.8 (Census 2011)
Estimated Birth Rate / 17.5 (SRS 2012) / 16.0 (Census 2011)
Estimated Death Rate / 7.4 (SRS 2012) / -
Estimated IMR / 41 (SRS 2012) / 20.3 (DM & HO Office)
MMR / 110 (SRS 2012) / 112.1(DM & HO Office)
3Health Infrastructure:
The primary healthcare services in Chittoor are presently rendered through 93 PHCs, 644 SCs , 8 CHCS, 12 FRUs, 9 SDHs, one district hospital, one medical college and 95 AYUSH clinic in the public sector. In addition, the district also has 123 private hospitals, 209 private clinics and one private medical college. Except in case of sub centers, all other health facilities are located in the government building. In case of sub centre, out of the total 644 sub centres, majority (391) of the sub centres are functioning in the private rented building. In terms of population served by the facilities, on an average there is a PHC and a SC established for every 31000 and 4500 rural population respectively and a FRU for every 1,47,000 population in the district. The average population served by the PHCs, SCs and FRUs in Chittoor are as per the prescribed norms suggesting the existence of adequate health facilities in the district..
Number of Health Facilities available in Chittoor district
Facilities / NumbersSCs / 644
PHCs / 93
CHCs / 8
FRUs / 12
SDH / 9
District Hospital / 1
AYUSH (Public) / 95
AYUSH (Pvt) / NA
Pvt Clinics / 209
Pvt. Hospital / 123
Medical Colleges, Public / 1
Medical Colleges, Private / 1
Status of Buildings
Health FacilitiesPublic / Private
SCs / 253 / 391
PHCs / 94 / -
CHCs / 9 / -
FRUs / 20 / -
SDH / 9 / -
District Hospital / 1 / -
Total / 386 / 391
Although, the infrastructural facilities are is adequately created in the district, there are shortage of manpower. In several visited facilities there were shortage of doctors, specialists, para medical staffs and technicians. In the visited CHC Kothakotha of Pothalapettu mandal, the field team observed that in the CHC radiographer is in place but X ray unit was not in place. In the visited PHC Gudipala., quarters for the health staff were not available and they were commuting from the nearby town. When the field team visited the Palemner area hospital, and also the CHC, the medical superintend informed that they are unable to conduct C sections because of not havingboylers apparatus and anesthetist in the hospital. Overall, certain short comings are observed in terms of not having adequate facilities in the visited centre or not having enough staff to carry out the required tasks. Therefore there is an urgent need to plug these gaps for the smooth provision service delivery.
Regarding creation of physical infrastructures and facilities 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 suggest that infrastructures and supplies in the facilities appear to be developed satisfactorily. However, the record keeping and in the district hospital and other visited SDHs are not very systematic and therefore retrieval of data becomes very slow in these facilities. The medical superintend and MOs of the visited facilities opined that physical and medical infrastructures of the heath faculties 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 programs and activities. Further, they also felt that the in general cleanliness and the general ambiance of the facilities are also improved by making use of the funds supplied by NRHM under various heads.
4Human Resources
The analysis of the human resource available to deliver the health care services indicates that there are several vacancies in the district. Position of general doctors and specialist doctorswere vacant and the vacancy was more among the specialized doctors. Out of the 184 sanctioned civil assistant surgeon posts, 34 posts are filled in contractappointment.. The vacancy among paramedical staff is even higher. The vacancy among MPHEO, MPHS, male and female, MHPA male and female varied between 35 percent to 72 percent. Vacancy was also quite high among 24X7 staff nurse and CEMONAC staff nurse. The contractual appointments are quite high when it comes to lab technician and pharmacist. The second ANMS to the sub centres are on contract appointment and even with that there are vacancies in the district. In the state of Andhra Pradesh, the secondary level institutions such as District Hospital, Area Hospitals and CHCs are under Andhra Pradesh Vaidya Vidhan Parishath andPHCs and SCs are under the control of DM&HO. The recruitment also takes place at the levels of APVVP and state health department. The discussions with the DM&HO and other district level health officials brought out several issues of coordination between these two administrative set ups. The referral institutions are under the control of District coordinator of Hospital services (DCHS)and the PHCs and sub centres are under the control of DM & HOs. Often there are communication gaps and coordination problems between these two set ups (Annexure 1).
The data on the health personnel recruited under NRHM also indicate shortage of staff. There are shortages among doctors and staff nurse forCemonc centres and staff nurse for SNCU unit. .Large vacancy is also seen for AYUSH doctors. The total post under NRHM recruitment is 1154 and out of these 191 posts that is around 17 percent are vacant. (Annexure 2)