Quarterly Monitoring of Programme Implementation Plan (PIP) in Dharwad District, Karnataka

(April-September, 2013)

Jyoti S. Hallad

S. R. Vatavati

Population Research Centre

JSS Institute of Economic Research, Dharwad

Karnataka

PRC Analytical Report No:16

December, 2013

Table of Contents

1Executive Summary

2Introduction

3State Profile and district profile

4Key health and service delivery indicators

5Health Infrastructure

6Human Resources

7Other health System inputs

8Maternal health

8.1ANC and PNC

8.2Institutional deliveries

8.3Maternal death Review

8.4JSSK

8.5JSY

9Child health

9.1SNCU

9.2NRCs

9.3Immunization

9.4RBSK

10Family planning

11ARSH

12Quality in health services

12.1Infection Control

12.2Biomedical Waste Management

12.3IEC

13Clinical Establishment Act

14Referral transport and MMUs

15Community processes

15.1ASHA

15.2Skill development

15.3Functionality of the ASHAs

16Disease control programmes

16.1Malaria

16.2TB

16.3Other Communicable Disease

17Non Communicable Diseases

18Good Practices and Innovations

19HMIS and MCTS

20Key Conclusions and Recommendations

21Annexure

1Executive Summary

As per the instructions of MOHFW, quarterly monitoring of PIP has been conducted in Dharwad district of Karnataka by the Population Research Centre, Dharwad. For this, District Hospital (DH), Urban Maternity Hospital (UMH), Two PHCs (Alnavar and Amminabhavi - both 24*7) and one HSC (of Amminabhavi PHC) were included for the field verification as there is no CHC in Dharwad taluka. The information was collected from all the concerned District Health officials, District hospitals’ staff, MOs of PHCs, ANMs of HSC and verification of registers was done along with HMIS data analysis for the quarter I and II of 2013-14.

Health and service indicators based on secondary sources

  • The district carries relatively better performance health indicators. ANC indicators like first trimester registration, TT and IFA supplementation are quite better but underreporting takes place with regard to home deliveries.
  • PNC check-up and early initiation of breast feeding is not satisfactory in the district but performance on child immunisation is quite better.

Health Infrastructure

  • The availablehealth facilities including public and private are sufficientin the district and also there are sufficient number of beds for in-patients.
  • The major observed problem relating to infrastructure is the shortage of staff quarters for all the cadre. Even if available, they are not in good condition
  • At PHC level, though sufficient infrastructure is available it is not maintained properly.

Human Resources

  • Quite a large number of posts are vacant in the district especially the Specialists, ANMs and Group D workers.
  • Facilities at periphery level also are facing the problem of vacant posts especially that of Lady Medical Officers and ANMs.
  • It is observed that training activity in the district is not satisfactory.
  • Refresher training to MOs and SNs is necessaryon a regular basis

Other health System inputs

  • DH, UMH and Medical college Hospital cater to the majority of the needs related to MCH services. UMH conducts normal deliveries and refer complicated cases to DH.
  • Available laboratory equipments are to be made use of at UMH
  • There is a separate building for AYUSH section at DH.
  • Though sufficient equipments and infrastructure are available at PHCs, optimum utilization of them is not being done.

Maternal health

ANC and PNC

  • Lot of variation takes place between HMIS reporting and actual performance on number of women registered, first trimester registration, TT2 and IFA supplementation
  • As per HMIS records, most of ANC indicators are more than 100 percent.
  • Systematic line listing of SAM and risk pregnancies and their follow up is not being taking place. No proper records on IFA supplementation
  • Half of the women found to get discharged within 48 hours in one of the PHCs visited
  • ANC and PNC registers are not properly maintained in few facilities especially at PHC
  • Hence, systematic documentation and follow up of high risk pregnancies is very much required in the district and it should strengthen its PNC unit along with correct reporting on PP care issues.

Institutional deliveries

  • Significant underreporting of home deliveries takes place in the district
  • Contribution of public facilities in conducting deliveries is around 62 percent
  • Percent of C-section deliveries is 39 percent among private sector and 17 percent at public facilities
  • DH has EMOC facilities whereas UMH and PHCs are well equipped to conduct normal deliveries.

Maternal death Review

  • Total 48 Maternal deaths have been reported in the district and conduct the MDR
  • No death have been reported at the facilities visited during the reference period

JSSK

  • Usually women use public transport while reaching hospital and no drop back facility is available.
  • Minimum charges for registration and free diet is given
  • All the diagnostics and medicine are available at free of cost

JSY

  • JSY has been implemented in the district in all the facilities.
  • Among home deliveries, negligible percent of women found to get JSY benefit.
  • At DH money transfer is being made through CPSMS mode and at other facilities it is through account payee cheque or through account transfer. All the facilities have kept proper records also.
  • Payment is not being made before discharge.

Child health

SNCU

  • SNCU exists at DH and has been maintained very well. It has sufficient infrastructure like incubators, warmers and phototherapy units.
  • Ventilators are not there in NICU
  • The UMH and PHCs have a functional NBCC

NRCs

  • NRC is very well maintained at DH.

Immunization

  • All the antigens are being provided and Hepatitis B0, Zero polio and BCG are given within 24 hours of birth for almost all the new-borns at DH and UMH. At PHC level BCG is given on weekly basis.
  • Immunization registers are maintained in all the facilities and are found to be up to date.
  • Role of UMH is found to be very high in providing immunization services especially for second and third doses of OPV and DPT and Measles, as it is 300-400 percent compared to number of deliveries conducted at the facility
  • There was adequate vaccine stock in all the facilities.

RBSK

  • RBSK is not yet implemented in the district

Family Planning

  • All permanent methods of FP are not available in any of the public facilities.
  • DH performs only Tubectomy
  • Though all spacing methods are available, acceptors of spacing methods are very much negligible and also proper documentation is not done on distribution of spacing methods.
  • IEC materials on different FP methods, including NSV are well displayed in all the facilities.

ARSH –

  • ARSH clinics are being conducted at all the facilities on every Thursday
  • Doctors at DH face problems like privacy, time and also there is problem of sufficient number of specialists
  • MOs at PHCs are not very serious about these clinic sand there was no proper records on adolescents attended or treated

Quality in health services

Infection Control

  • Due to high number of in patients and shortage of Group D workers difficult to maintain cleanliness.
  • Regular fumigation/sterilization is being done, at DH but not in UMH and PHCs.
  • DH has functional autoclaves and own laundry facility. Appropriate drug storage facility is available in both the hospitals.

Biomedical Waste Management: Bio Medical Waste Management is outsourced in both the hospitals and pit is available in both the PHCs

IEC : IEC materials have been displayed at DH on most of the MCH issues whereas UMH and PHCs had not displayed on few issues like services available, JSSK, updated essential drug list. On the other hand HSC had not displayed most of the IEC materials

Clinical Establishment Act- The district follows KPEA act under which so far 60-70 private doctors have been registered

Referral transport and MMUs

  • The existing ambulances are sufficient in the district.
  • 2 MMUs working in the district and one MMU has conducted 160 camps during the period April-September 2013

Community processes - ASHA

  • Sufficient number of ASHAs have been appointed and have got trained
  • Drug kit replenishment (mainly paracetamol) is being done regularly at PHCs or HSCs.
  • Regular payment is being made to ASHAs to their bank account at district head quarter.

Disease control programmes

Malaria

Around 114 cases are found to be positive among total blood sample collected and proportion of positive cases for Malaria is 0.07 percent during previous 2 quarters in the district.

TB

Information could not be collected

Other Communicable Disease

On an average 17 cases found to be positive for Leprosy. During the reference period, 115 cases detected and 102 got cured. The success rate is 95%.

Staff have not received any training

Non Communicable Diseases –Information on Non Communicable diseases could not be collected during our visit.

Good Practices and Innovations

  • There is good understanding and coordination between District Health Officer’s office and between DH, UMH and Medical College hospital

HMIS and MCTS

  • Sufficient man power in terms of Data entry operators have been appointed in all the facilities. Every month all the facilities report complete data to the HMIS, as per the time line
  • After verification of the HMIS forms it is observed that few major problems exist while filling HMIS reports mainly due to lack of understanding of issues.
  • MCTS is being done at UHC for urban areas and by ANMs for rural areas

Recommendations

  • There are sufficient number of Public health facilities along with sufficient number of beds for in-patients in the district
  • All the facilities have basic required infrastructure but Special attention is needed for the construction of staff quarters including quarters for MOs
  • Some measures and incentives are necessary to appoint specialists and to retain them. Appointment of Group D workers is very much required
  • Training component has to be strengthened especially on skill development, new schemes and communicable and non-communicable diseases
  • Systematic documentation and follow up of high risk pregnancies including SAM women is very much required in the district and all the facilities should strengthen their PNC along with documentation on ANC and PNC services.
  • JSSK is partially implemented in the district. Special attention is needed to strengthen the pickup and drop back facility. Diet, diagnostics and medicine are being provided free of cost
  • JSY has been implemented systematically
  • RBSK has to be implemented in the district
  • All permanent methods should be made available in DH and people should be motivated for spacing methods along with maintenance of proper records on distribution of spacing methods
  • Privacy is required at ARSH clinics and at PHCs such clinics should be organised more systematically
  • Training on filling up of HMIS formats is required and certain issues on HMIS and MCTS are to be clarified

2Introduction

Under National Rural Health Mission, all states submit Programme Implementation Plan (PIP), annually containing the programms, activities, interventions to be implemented with budget requirements to achieve the targeted goals. Ministry of Health and Family Welfare Government of India took initiation for monitoring of PIP activities in every state by designating Population Research Centres (PRC) since 2012-13. To make this monitoring process more systematic and regular, MoHFW and NHSRC assigned few high focus districts to each PRC, so as to monitor the activities on a quarterly basis. Total 14 districts (Karnataka (5), Maharashtra (8) and Andhra Pradesh (1))have been assigned to PRC, Dharwad and this report is of Dharwad district of Karnataka.

During this quarter, as per the instructions of MOHFW, health facilities were restricted to Dharwad Taluka only. District Hospital (DH), UrbanMaternity Hospital (UMH) (reports under the name ‘Dharwad urban unit’ for HMIS), Two PHCs (Alnavar 24*7 and Amminabhavi 24*7) and one HSC were included for the field verification as there is no CHC in Dharwad taluka. The field verification was done during 6-11November, 2013 and verification has been done for the two quarters - April to September, 2013. This report is based on the information collected from the District Health officials (DHO, DRCHO, DPMO, DPM), Heads of DH(RMO) and Urban Unit (MS), Various programme officers and MOs of the visited health facility, verification of records and HMIS desk analysis for a period Q1 (April-June) and Q2 (July-September) of 2013-14.

3State Profile and district profile

Dharwad is the cultural headquarters of North Karnataka.The administrative headquarters of the district is the town of Dharwad. Dharwad is the administrative seat of the district of the same name. The municipality (resulting from a merger with neighboring Hubli in 1961) covers 191 km2. Dharwad is located 425 km northwest of Bangalore and 421 km south of Pune, on the main highway between Bangalore and Pune. The district has 5 taluks and the total population is around 18.5 lakhs. As shown in Table 1, literacy rate of the district is 80 percent and sex ratio is 971 and both are bettercompared to that of the state average. Density of population is 434 which is higher than the state average. Around 10 percent of the district population belongs to Scheduled caste and another 5 percent belongs to the scheduled tribe.

Figure 1: Davangere district in Karnataka

Figure 2: Dharwad Taluka in Davangere district

4Key health and service delivery indicators

Important indicators related to health and service delivery based on different sources like DLHS3, SRS, KDP and HMIS indicates that the district carries relatively better performance on health (Table 2 to 4). With regard to the extent of HMIS reporting, so far the district has reported 55 percent of expected number of pregnant women, around 50 percent of estimated number of deliveries and infants during the period of 6 months of 2013-14 (April to September), which means that level of reporting in HMIS for the district is satisfactory (Table 2). Further, health and service delivery indicators of HMIS are compared with that of DLHS3 in Table 3. As per DLHS3,around 72 percent of the women go for first trimester registration of their pregnancy and the HMIS reporting is also the same. However, reporting on 3 ANC checkups and TT injections is very high in HMIS compared to that of DLHS3. Especially HMIS reports 188 percent of 3 ANC checkups which needs to be corrected immediately. Further, proportion of institutional deliveries is also very high as per HMIS compared to that of DLHS3 (100 % against 66 %).

Among institutional deliveries,62 percent of the deliveries take place at public facilities (HMIS) which indicates a major workload on the public health sector including tertiary health facilities. PNC checkup and early initiation of breast feeding is not satisfactory (only two-third of the deliveries) in the district but performance on child immunisation is quite better (78%). Around 57 percent of the couple use Family planning method, mainly the female sterilization (52%) like any other state in Karnataka and unmet need for family planning is 17percent.

The above discussion based on available secondary sources indicates that maternal and child health indicators are comparatively better in the district.

5Health Infrastructure

The district has one DH, one urban maternity hospital (UMH)at district head quarter and 3 Sub Divisional Hospitals (SDH). There are no CHCs in the whole district of Dharwad. 30 PHCs and 183 HSCs cater to the health need of rural population (around 8 lakhs) (Table 5). All the PHCs are having at least6 beds. Karnataka Institute of Medical Sciences (KIMS-Government) and Shri Dharamasthala Manjunatheswara (SDM) Institute of Medical Sciences(Private) – Both attached to medical collegeswork at the tertiary level at the District.The district has 12 UHCs, 2 Training centres and 1 ANM training centre.

DH, all 3 SDHs, 30 PHCs and 86 out of 183 SHCs have Government buildings (Table 6) and are in good condition. The DH has electricity back up and 24*7 water supply however Maternity hospital do not have sufficient power back up. All the district level officials felt that that they have sufficient number of beds in the district for the in-patients. DH has 250 beds, 3 SDH hospitals have 100, 30 and 30 beds respectively. The major observed problem relating to infrastructure is regarding the staff quarters for all the cadre. Either the quarters are not availableor even if available they are not in sufficient number or not in good condition. It is observed that usually MOs do not stay at the quarters allotted to them and thus they are being used by SNs or LHV. This tendency is observed at all the facilities visited by us like DH, UMH, both the PHCs and HSC. All the MOs travel from District Head quarter. There are no separate wards and toilets for male and female in-patients at both the PHCs. Water problem exists at DH.

6Human Resources

Table 7, 8 and 9 provide details on number of staff positions sanctioned and vacant in the district, DH and PHCs respectively. As indicated in Table 7, quite a large number of posts are vacant in the district both under NRHM and regular recruitments. Under regular positions the major problem is that of large vacancy of Specialists, ANMs, MPHWs and Group D workers. Under NRHM recruitment also many positions are vacant in the district mainly that of SNs. If the staff position is checked specifically for the DH, (Table 8), as high as 5 specialists and 2 MOs’ posts are vacant and there is a shortage of 13 technicians and 44 Group D workers. Even at the Maternity Hospital only one MO is managing as 3 MOs’ posts are vacant. Further, PHC Alnavar has only one MO of the total 3 sanctioned positions. This is creating work pressure on existing specialists and almost impossible to maintain cleanliness in the hospital premises because of non-availability of Group D workers. Though quite a good number of personnel have been provided under NRHM, the problem of specialists and doctors continues as the salary and other benefits provided to them is very low compared to that earned by private consultancy. All the district officials mentioned the problem of getting Gynecologists, Anesthetist and Pediatrician and felt that these posts are to be filled- in on an emergency basis.

With regard to the training received by the staff, it is observed that training activity is negligible, though 2 Training centres existin the district. During first and second quarters of the year 2013-14, training program has been organized on 5 issues. However, the total number of persons got trained is very less. Table 10 gives total number of health personnelwho have received training during this year in the district. Further table 11 presents facilitywise number of staff ever trained on different issues and as indicated, very few MOs found to get in service training on EmoC, LSAS, MTP/MVA, NSV, Mini Lap and Laparoscopic sterilizations. However, quite a good number of SNs and ANMs found to be trained on SBA, IMNCI, NSSK and IUCD. Hence it is suggested to organize refresher training to MOs and SNs on a regular basis as there is sufficient training infrastructure in the district.