NRHM-PIP Monitoring for Dakshina Kannada District, Karnataka

R Muthrayappa

P Prabhu Swamy

Population Research Centre

Institute for Social and Economic Change

Bangalore-560072

October, 2013

NRHM-PIP Monitoring for Dakshina Kannada District, Karnataka

October, 2013

  1. Executive Summary

Karnataka is located in the southern part of India. It has 9th place in terms of population size and fifth in terms of land area in the country. The decadal population growth in Karnataka is 15.6, literacy rate is 75.4 percent and urban population is about 39 percent which is above the national average. The work participation rate is 45.6 percent and female work participation rate is about 32 percent. Unmet need for planning is 15.8.

The district selected for PIP monitoring is Dakshina Kannada which comes under coastal region of Karnataka is relatively moderate in many indicators. District has 2.35 per cent of the total population of the state. In the demographic front, the district has made good progress with the growth of population during 2001-11 is 10.1 per cent which is significantly lower than the state average. The overall sex ratio of the district is 1020 and Dakshina Kannada is always female out number males. About 11 percent of the population belongs to SCs and STs. Literacy levels are much higher than the state average ie.89.6 percent for males and 78.4 percent for females.

In Dakshina Kannada district most of the demographic indicators particularly the total fertility rate estimated from 2011 census, infant mortality rate and unmet need for family planning is much below the state average. This is because health awareness and health infrastructures are good in Dakshina Kannada district. There are two Government Nursing training centres are functioning in the district in addition to five private Medical colleges and 34 private Nursing colleges.

Findings

  1. Though Dakshina Kannada district has good health infrastructure human resources at the public health facility is very less. Secondly majority of the sub-centres are in rented buildings. District hospital, CHCs, taluk hospitals and some of the PHCs are working in old buildings.
  1. In recent years in addition to female health workers, ASHA’s services have become more important in implementing health programmes at the grass root level. But the type of training they got and the amount of monthly remuneration they received is very meagre and hence many ASHA’s were dropped out. More importantly, ANM and Staff Nurses positions are vacant for long. There are instances where only 2 Nurses are working in a PHC.
  1. District Health Society is appointing health staff on contract basis and many health staff are working on contract. There is no proper co-ordination between DPMO and ARS regarding staff selection. Because staff selection is done by DPMO and appointment orders are issued by ARS. Again there will be confusion while transferring staff from one health facility to another. Therefore executive power of staff appointment and transfer should be vested with the DHO.
  1. Wenlock district hospital has RAPCC (Regional Advanced Paediatric Care Centre) consisting of 200 beds. It has PICU, NICU beds. From NRHM funds 3 staff nurses and 1 Dietician are posted to the RAPCC. The existing staff in the RAPCC cannot meet even 30 percent of the work load.
  1. Dakshina Kannada is known endemic for Malaria. Only one Malaria clinic is functioning in the district hospital. The clinic has to be run by 24x7 and the staff at the clinic cannot cater even 50 percent of the cases. There is urgent need of either transferring or recruit the expert staff for the Malaria clinics.
  1. There are 7 CHCs and 4 taluk level hospitals are functioning in the district and only 4 hospitals are given FRU facilities and status. Since Dakshina Kannada is a coastal and hilly area it is difficult to travel long distances to reach health facility during emergencies. It is suggested that at least all CHCs be given FRU facilities. So that people can reap the health benefits.
  1. Data regarding deliveries conducted in the health institutions shows that about 70-75 percent of deliveries are normal and remaining 25-30 percent are C-section deliveries. Discussions with the concerned Medical Officers during fieldwork revealed that all PHCs do not have OT facility to conduct C-section deliveries. Even such facilities are not exist in some of the CHCs also. More over all CHCs do not have Lady Gynaecologist in position to conduct C-section deliveries. It is suggested that at least all CHCs may be provided with OT facility and a Lady Gynaecologist.
  1. Logistic policy is followed for procurement of drugs and equipments. But Logistic society is not supplying drugs as per the requirement of the health institutions particularly essential and emergency drugs. However there is a provision for purchasing drugs from the user fee collected from the public. The amount of user fee collected will be very meagre. Secondly budget allotted to health facility is not sufficient to meet the hospital expenditure. Therefore corrective measures have to be taken to fill this gap.
  1. The study team observed that there is demand for generic drugs. But Medical Officers at the health facility reported that no generic drugs supplied.

NRHM-PIP Monitoring for Dakshina Kannada District, Karnataka

October, 2013

2. Introduction

For the present study on monitoring of PIP Dakshina Kannada district of Karnataka state was selected. Mangalore is the district head quarter for Dakshina Kannada district. The research team visited and collected relevantinformation from the District Programme Managing Officer (DPMO), District Health Officer (DHO)and district hospital at the district level. There are two district hospitals in the Dakshina Kannada viz. Wenlock district hospital and Lady Goschen Hospital located in Mangalore.Wenlock hospital is a general hospital catering health services to all whereas Lady Goschen hospital providing maternal and child health services. In addition to thesefacilities, research team collected information from two CHCs viz. Buntwal and Mudubidire. Buntwal is a taluk hospital and Mudubidire comes under Mangalore taluk. Information was also collected from one PHC (Shirthadi, 24x7) comes under Mudubidire CHC and one sub-centre (Valpady) comes under Shirthadi PHC. Data was collected in September 2013.

3. State Profile and district profile

3.1 State profile

Karnataka has made significant stride in demographic and health indicators during the last one decade. The decadal population growth rate is 15.6 per cent which is nearly two percentage point less than the all India level. Around 39 per cent of the population live in urban area which is considerably above the national average. The sex ratio (number of females per 1000 males) is 973 and has recorded a marginal increase as compared to the previous decade. But, the child sex ratio has recorded a marginal increase from 946 in 2001 to 948 in 2011. About 17 per cent of the population belong to Scheduled Caste and the proportion of Scheduled Tribe is around 7percent. Literacy rate has increased significantly over the last decade and the male literacy rate is 82.5 per cent while the female literacy level is nearly 15 percentage point less than male literacy in 2011. Around 32 per cent of the total females participate in labour force. Of the total labour force nearly 18 per cent are agricultural labourers.

Key indicators for Karnataka State and India

Karnataka / India
No. Districts / 30 / 640
No. of Taluks / 176 / 5576*
No. of Villages / 29, 406 / 6,38,588
Population (in lakh) / 610.95 / 12105.70
Decadal Growth Rate / 15.6 / 17.7
Rural Population / 61.3 / 68.8
Urban Population / 38.7 / 31.2
Per cent of SC / 17.15 / 16.6
Per cent of ST / 6.95 / 8.6
Sex Ratio (Females/1000 Male Population) / 973 / 943
Child Sex Ratio (Female Children/1000 Male Children / 948 / 919
Literacy Total / 75.4 / 73.0
Male / 82.5 / 80.9
Female / 68.1 / 64.6
Work participation / 45.6 / 39.8
Female Work Participation / 31.9 / 25.5

*Source:

3.1District Profile

Dakshina Kannada district which comes under coastal region of Karnataka is relatively moderate in many indicators. Dakshina Kannada has 2.35 per cent of the total population of the state. In the demographic front, the district has made good progress with the growth of population during 2001-11 is 10.1 per cent which is significantly lower than the state average. The overall sex ratio of the district is 1020 and Dakshina Kannada is always female out number males. The child sex ratio is 947; is slightly lower than state average. Around 7 per cent of the population of the district belongs to Scheduled Caste and 3.9 per cent belongs to Scheduled Tribe. The total literacy rate is 84.1 percent; with male literacy rate 89.6 per cent and female literacy rate 78.4 per cent which is much higher than state average. The female work participation rate is 25 per cent which is lower than the state average. Agricultural labourers constitute 32 per cent of the total workers significantly higher than the state average. The percent literate and percent agricultural labourers provide some indication that the district is below the state average in terms of development.

Key Demographic Indicators for Dakshina Kannada district

Indicators / 2011 / 2001
No. of Blocks / 5 / 5
No. of Villages / 421* / 360
Population / 20,89,649 / 18,97,730
District Share / 2.35 / 3.6
Decadal Growth Rate (2001-11) / 10.1 / -
Rural Population / 52.3 / 61.6
Urban Population / 47.7 / 38.4
Per cent of SC / 7.1 / 6.9
Per cent of ST / 3.9 / 3.3
Sex Ratio (2011) / 1020 / 1022
Child Sex Ratio / 947 / 952
Literacy Total / 84.1 / 83.4
Male / 89.6 / 89.7
Female / 78.4 / 77.2
Work Participation Rate / 42.3 / 49.9
Female Work Participation / 25.0 / 41.7

* Source: RHS, 2012

4. Key health and service delivery indicators

The total fertility rate has come down below replacement level in the state and stands at 1.9 children per women in 2011. Thus, at the demographic front, Karnataka is much above the national average. The total fertility rate in Dakshina Kannada district estimated from the census 2011 is 1.4 children per women slightly lower than state average. The infant mortality rate (IMR) in the state according to the Sample Registration System is 35 in 2011 and maternal mortality ratio is 178 per 1, 000,00live births in 2007-09. Both these rates are much lower than the national average 44 and 212 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 infant mortality and maternal mortality ratesare still relatively higherwhen compared to the neighbouring states like Kerala and Tamil Nadu. Most of the infant deaths in the state are concentrated in the neonatal stages. The neonatal mortality rate in Karnataka is around 25 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. The infant and maternal mortality information is available for the district from the data gathered by the health system. However, it appears to be an underestimate by comparing with the state average.Percentage of antenatal care waslittle more than 81per cent; post-natal care within two weeks after deliverywas about 70 percent. The skilled birth attendant was 71.5 per cent in Karnataka. Child immunisation is much above the national average and unmet need for family planning is 15.8 percent.

India / Karnataka
IMR / 44 / 35
Neonatal Mortality Rate / 33 / 25
MMR-2007-09 / 212 / 178
OPD, HMIS-2012-13 / 912476678 / 54185030
IPD, HMIS- 2012-13 / 912476890 / 54185208
ANC 3 or More / 49.8 / 81.3
Skilled Birth Attendant / 52.7 / 71.5
PNC (within two weeks of Delivery) / 49.7 / 69.2
Full Immunization (12-23 M) / 54.0 / 76.7
Total Unmet need for FP / 21.3 / 15.8

Source:SRS, 2012, DLHS 3 and HMIS.

5. Health Infrastructure

The study team found good health infrastructure in Dakshina Kannada district. Data regarding health infrastructure gathered from Dakshina Kannada DHO Office are provided in Table-. It shows that 430 sub-centres, 63 primary health centres, 7 community health centres and 4 taluk level hospitals are providing health care services to the people.In addition, two district hospitals are catering health services. While all PHCs, CHCs and taluk hospitals are in separate Government buildings majority of the sub-centres are located in rented buildings. Out of 430 sub-centres 195 sub-centres are in rented buildings. Four FRUsare functioning and located in Belthngady, Puttur, Sullia and in Mangalore (Government Lady Goshen hospital). Under NRHM Wenlock District Hospital has provided RAPCC (Regional Advanced Paediatric Care Centre) consisting of 200 beds. It has beds for PICU, NICU. Besides, three staff nurses and a Dietician are recruited under NRHM to provide child health care services in the district.

Details of health infrastructure available in DakshinaKannada district

Total No. of Facilities / Located in Govt. Buildings / Located in Rented Buildings
SCs
Mangalore / 129 / 69 / 60
Bantwal / 93 / 49 / 44
Puttur / 75 / 45 / 30
Belthangady / 75 / 48 / 27
Sulya / 58 / 24 / 34
PHCs
Mangalore / 21 / 21 / -
Bantwal / 16 / 16 / -
Puttur / 9 / 9 / -
Belthangady / 11 / 11 / -
Sullia / 6 / 6 / -
CHCs
Mangalore / 2 / 2 / -
Bantwal / 2 / 2 / -
Puttur / 2 / 2 / -
Belthangady / 1 / 1 / -
Sullia / 0 / 0 / -
Taluk/General Hospital
Mangalore / 0 / 0 / -
Bantwal / 1 / 1 / -
Puttur / 1 / 1 / -
Belthangady / 1 / 1 / -
Sullia / 1 / 1 / -

As per information provided by the DHO Office number of beds available is more than the requirement. For instance 854 beds are required to meet the patient’s need but actual beds available from all the facilities in the district is 1632.

Number of Inpatient Beds available and required

Taluks / No. of Bed Available / No. of Beds Required
Mangalore / 129 / 39
Govt. Lady Goschen Hospital, Mangalore / 260 / 240
District Wenlock Hospital, Mangalore / 701 / 200
Bantwal / 186 / 70
Puttur / 166 / 210
Belthangady / 105 / 90
Sullia / 85 / 5
Total / 1632 / 854

6. Human Resources

Availability of trained human resources is important to deliver the health services in a better manner. In the district, health personal have been recruited under NRHM as well as from regular health department. These recruitments have been taking place under plan and non-plan grants in different schemes. During fieldwork,Study team noticed that though the positions were sanctioned under different heads many of the positions were vacant. For instance 42 medical specialists’posts were sanctioned but, only 20 specialists are working. Similarly,85 general duty Doctors positions were sanctioned but actual working is 53 persons and 13 members were working under contract. Data regarding working and vacant staff positions under different heads are provided in annexure-. Since Medical and Para-medical staff positions are vacant delivery of health services has effected in the district. For example in Shirthadi PHC there are 4 sub-centres 2 ANMs and 2 staff Nurses are working. Since this PHC is a 24x7, 2 staff nurses are insufficient to cater health services as they have to attend regular MCH cases as well as other medical services. Secondly 2 ANMS have to look after 4 sub-centres. In view of this,many patients go to private health facility where they have to pay hefty money to avail health services. Similar is the situation with respect to CHC of Mudabidire, Buntwal taluk hospital and district hospital. Lady Goschen Hospital is 260 bedded and staff strength is not even sufficient to provide health services to 50 percent of the patients. During discussion with the District Surgeon in the Wenlock Hospital mentioned thatDoctors,Staff Nurses and other Paramedical staffs are deputed to other health centres in the district. In view of this,there is a severe shortage of staff in the district hospital.Hence, there is an urgent need to recruit Doctors and Para-medical staff in the districtto deliver health care services more effectively.

Dakshina Kannada district has two training centres at Mangalore as well as in Surathkal where they impart training in how to handle Cold Chain, RTI/STI, ASHA 6th and 7th Module, NLEP, NPCB and IDSP training to different category of health staff. The number of trainings conducted in the last two-three years has been reduced due to shortage of staff in the training centres.

7. Other health System inputs

As stated earlier, there are two district hospitals in Dakshina Kannada district viz. Wenlock district Hospital and Lady Goschen Hospital. Wenlock district Hospital was established in 1848 and sanctioned bed strength being 705. Bed occupancy rate at any given time is more than 80 percent and annual outpatient count is more than 2 lakhs. The hospital is providing all the Super Specialty Services with highest performance in each of the faculty including Oncosurgery, Plastic surgery, Urosurgery, Neurosurgery, CT surgery, Paediatric surgery, Laser surgery and Nephrology with latest and advanced facilities. There is a well-equipped Regional Super Specialty annexure attached to the presenthospital block.

Government Lady Goschen Hospital is 260 bedded hospital providing maternal and child health services. This hospital is attached to Kasthuraba Medical College as Public Private Partnership Project (PPP) and Indian Red Cross Society is maintaining Blood Bank in the premises as PPP Project.

  • In both the district hospitals C-section deliveries are being conducted
  • State Logistic Policy is followed in procuring the drugs.
  • Required equipmentsare procured by the state budget released by DME. Smaller portion of the equipments are supplied by DME directly. On enquiry, the study team found that budget released by DME is not sufficient to the need of both the hospitals. Besides, necessary equipments are also procured by the ARS.
  • The drugs essentially needed to the hospitals are not supplied by the drugs logistic society. It is also reported that lives saving drugs and Factor-VIII injections are not supplied regularly.
  • There is no proper drug storage facility in the district hospital. Therefore, drugs are getting spoiled because of rodents.
  • There is demand for Psychiatric drugs but supply is less.
  • No generic medicine supplied to these hospitals.

Wenlock district hospital has AYUSH services and this department consisting of Unani and Panchakarma speciality. One Unani Doctor and one MPW are working. Ayush service is also available in Mudubidire CHC. But, these services are poorly used by the people of the district.

User fee is charged in all the health facilities including PHCs, CHCs, TLHs and district hospitals. The exemption is given to pregnant cases and neonatal cases and they need not pay any user fee.