Thrissur - PIP Report

POPULATION RESEARCH CENTRE

KERALA

1Executive Summary

As part of the monitoring of NRHM PIP of Kerala 2013-14, Government of India identified eight districts in Kerala. This is a concise report of the first monthly monitoring in the district of Thrissur, Kerala. The health facilities selected as per the guidelines from Government of India are District Hospital Thrissur, Ollur CHC, Vallachira PHC, and ArattupuzhaSC. The field work was done during the first week of October 2013.

District Hospital Thrissur provides the services surgery, medicine, cardiology, gynecology, pediatric, emergency care, trauma care, ophthalmology, ENT, dermatology, family planning services, ancillary services of blood bank, radiology with pathology, palliative care and clinic for NCD. It is a 240 bedded hospital covering a population of one lakh. Human resource is reported to be insufficient in specialtycadre. This facility faces shortage of Staff Nurses, lab technicians and Radiologist. The shortage of cleaning staff is the most important problem and needs to be addressed with higher priority.

All free entitlements under JSSK are given from the hospital, the referral transport is restricted to payment of Rs. 500/-. Non payment of JSSY entitlements and JSSK traveling allowance to those women discharged on holidays, out pocket expenditure during ANC especially for Scanning and lack of knowledge of beneficiaries about the free entitlements are the main draw back observed from the beneficiary interview.

The Hospital Management Committee in the hospitals, the Medical Officers in the CHCs and the PHCs and also the SCs under it, ensures delivery of various services as per guidelines in all the facilities visited.The new programmes like Palliative care projects and the setting up of NCD clinics at the CHC and PHC level benefits the old age population and the adult population. Participation of population in these clinic is high. Availability of drugs is problematic in almost all the facilities visited and the authorities need to solve this problem.

Mainstreaming of AYUSH, which is conditionality mentioned in the NRHM PIP needs to be prioritized as no facility selected has integrate AYUSH. Biomedical waste management at the CHC and PHC level should be as per guidelines. IEC Display on various services such as Timing of health facility, Citizens charter, phone numbers and list of services, Essential drug list and Protocol posters and Immunization schedule is not at all present or not at satisfactory level in all of the facility. IEC on JSSK, JSY RBSK, NCD services need to be improved in DH, CHC, PHC, SC and at the community level. Establishing Nutrition Rehabilitation Centres at least in DH, where sufficiently large children seek treatment for SAM is another aspect need immediate attention. The aspects that need to stressed or properly implemented at the facility level are line-listing of severe anemia cases, which are not being practiced in any of the health facilities, and setting up of computerized inventory management in the health facilities. A concerted effort from all the departments in providing good quality service in the district should help in witnessing increase in the use of public sector facilities.

2Introduction

With the implementation of various programmes under NRHM in Kerala for the past five years, the state has been able to improve the quality of service delivery especially along with the KASH (Kerala Accreditation Standards of Hospital) initiative. The new initiatives like JSSK, Arogyakiranam (RBSK) are undoubtedly makinghealth care affordable, equitable and of good quality to the rural population especially. As part of the monitoring of NRHM activities in the state, Population Research Centres were made nodal agencies in their respective states to review the activities under NRHM. The present report is based on monthly monitoring activities initiated by Ministry of Health and Family Welfare, Government of India. Thrissur district forms the area of present study. The health facilities selected in Thrissur district are District Hospital Thrissur, Ollur CHC, Vallachira PHC, and Arattupuzha SC. The field work was done during the first week of October 2013.

3State Profile and district profile

Kerala is divided in 14 districts. There are 152 blocks and 1018 villages in the state. The population of the state as per Census of India 2011 is 33406061 out of which 16027412 are males and 17378649 are females. The sex ratio of 1084 females to 1000 males gives Kerala the distinction of having the only state with sex ratio favourable to females in the country. Kerala is also the most literate state with 93.91 percent of its population literate. The density of population is 860 persons per sq.km.

Kerala / Thrissur District
No. Districts / 14
No. of Blocks / 152 / 17
No. of Villages / 1018 / 254
Population (2011) / 33406061 / 2975440
Literacy / 93.91 / 92.56
Sex Ratio / 1084 / 1092
Density of Population / 860 / 981

Source: Census of India 2011

Thrissur District is situated on the central west coast of Kerala. Thrissur is the abbreviated anglicized form of the Malayalam word "THRISSIVAPERUR" which means the town of the "SACRED SIVA". The town is built on an elevated ground, at the apex of which is the famous "VADAKKUMNATHAN" Temple. This district occupies an area of 3032 sq.km. The district isdivided into 5 Taluks. There are 17Blocks,254 Villages, 92 Panchayats, 1Corporation and 6 Municipalities. The health service delivery in the public sector is rendered through 1 District Hospital, 8 TalukHospitals, 24 CHCs, 11 24X7 PHCs, 64 PHCs,470 SCs, 1Leprosy Centres and 1 MHC.

4Key health and service delivery indicators

The decentralized health care delivery system in the state has helped to achieve low levels of fertility and mortality. The CBR in the state is 15.2, and the TFR is 18 as per the latest report of SRS (2011). Child Mortality rate (3) , U5MR (13), IMR (12), NMR (7), Peri-natal MR (10), Still BR (6) are the lowest for any state in the country. The sex ratio at birth in the district is 1109 females per thousand males. The HMIS data shows that ANC first trimester registration is about 75 to 80 percent. The private hospitals have a greater share of deliveries (around 88 percent) and the average Caesarean section deliveries in public and private hospitals is around 45 percent.

5Health Infrastructure:

DistrictHospitalThrissur–It is a 240 bedded hospital covering a population of one lakh. It is functioning in Government buildings. It is located in the heart of the town and easily accessible to public. It is identified as a delivery point, 14 wards, ICU, CCU, Labour room etc, is working in 24x7 basis. It provides following services: surgery, medicine, cardiology, gynecology, pediatric, emergency care, trauma care, ophthalmology, ENT, dermatology, NSV(family planning) services, ancillary services of blood bank, radiology with pathology, Palliative care and clinic for NCD. Electricity, water and functional Blood bank on 24X7 basis, separate wards for male and female are available. Most of the buildings are in good condition and the building facility is sufficient for all department except for OP departments. This drawback will be rectify when the new block will inaugurated by December 2013. Functional and clean toilet facility wards are available separately for male and female. It has almost all the essential functional equipments such as functional Neonatal, Paediatric and Adult Resuscitation kit,Needle Cutter, Radiant Warmer, Suction apparatus, Foetal Doppler/CTG, Autoclave, EVA Equipment etc. Functional OT equipments such as Anesthesia machines, Ventilators, Pulse-oximeters, Multi-para monitors, Laparoscopes and Autoclaves etc are available in the facility. Almost all laboratory equipment are available. A dialysis unit also started recently. The major gaps found in DH are lack of functional quarters for MOs, SNs and other staff. Urgent essential requirement as per the medical supernatant is a functional RMO quarter

Ollur CHC is situated in Thrissur Taluk of Thrissur district. The catchment population is 228938 and situated in the periphery of Thrissur corporation. This is about 10 km from the district head quarters. The health facility is easily accessible from nearest road and it functioning in a government building with adequate facilities. Six quarters are available in this facility, one each for Doctor, staff nurse, pharmacist, HS, LHS and JPHN. Among these quarters, doctor is not residing in the allotted quarter. Water supply is available in 24 X 7 basis and electric supplyavailable without back up facility. One male ward and two female wards are functioning in the facility, total bed capacity is 18, wards are kept clean. Separate toilets are available for both males and females. The facility is not functioning as a delivery point. For the waste management a pit is constructed. A complaint box is instituted recently, but it is not in working condition.

Vallachira PHC is situated in the Cherpu block. The PHC covering a population of 23890 and situated about 14 km from district head quarters. The health facility is easily accessible from nearest road and it functioning in a government building having adequate facilities. No Staff quarters are available. Adequate water and electric supply is ensured in the facility. Separate and clean toilets are available for both males and females. The centre is not functioning as a delivery point. Waste disposal is done using pits.

ArattupuzhaSC - This sub centre is under Vallachira PHC. Catchment population of the area is 7202. It is 5 km away from PHC and is 14km away from the district head quarters. It is functioning in government building. The condition of the building is good, the quarters for JPHN is attached with the centre. The JPHN is residing in the quarters and the condition of quarters is good. The facility have adequate water and electricity facility. The centre is located near main road and in main habitation. The general cleanliness of the sub centre and surrounding is excellent. The approach road have sign boardsshowing directions. No complaint /suggestion box is available. A pit is taken for biomedical waste management.

6Human Resources:

DistrictHospitalThrissurOffers6 Gynaecologists, 2 Anesthetist, 3 pediatricians, 2 general surgery, 3 physicians .one specialist doctors each in ophthalmology, radio therapy, pathology, ENT, Dental, and Dermatology.There is inadequacy of specialist doctors, staff nurses and Lab technicians. Lack of one each specialist doctors in Medicine, Anesthesia, Pediatrics and General Surgery against IPH standard, only 8 medical officers against IPH standard of 15, only 79 staff nurses working against IPH standard of 135 and 3 laboratory technicians against the IPH standard of 12. The absence of a Radiologist is a major problem raised by medical superintendent. The sanctioned post radiographer/ radiologist, since the post of radiographer is filled no chance to fill the post of radiologist. The gap of technical staff in various category filled regularly against the sanctioned post under RSBY/HMC which in turn help the function of the DH smoothly. Another major problem expressed by Medical Superintendent is the gap of cleaning staff. There is only 37 cleaning staff, which is very much insufficient for making the general cleanliness of 14 wards and other department in 24x7 manner. According to the Medical superintendent 50 more cleaning staff are required for the cleanliness of the hospital. The newly constructed SNCU is not functional only because of lack of cleaning staff. The strategy adopted for retention of NRHM contract staff is based on their performance appraisal. Appointment or retention of NRHM staff is not affected by the functioning of facility.

At Ollur CHC a total of 3 doctors and 4 staff nurses are working in the hospital. Seven JPHNs, 6 JHIs are in the facility. One pharmacist, 2 radiographer, and one ophthalmology assistant are working in the facility.. The supervisory posts of one HS, one LHS, one LHI are also working in the CHC. The post of one doctor for NCD under NRHM is vacant now.The staffs are not getting adequate training. None of them are trained to conduct NSV and IUCD. One doctor received training on RTI/STI. Seven members in the facility got training in immunization and cold chain mechanism.. In the first quarter of the financial year 18907 out patients utilized the facility and 20819 in the second quarter. 203 in-patients were there in the first quarter and 333 in the second quarter. The expected pregnancies in the catchments area of the facility is 259and 90 percent registered women are tracked for MCTS.

Vallachira PHC - The staff pattern is 3 MO. 1 SN, 3 ANMs, 1 Pharmacist and 1 LHI. One medical officer received training on MTP. The SN received training on NSSK and RTI/STI One JPHN and LHI received training on IUCD insertion. The recently appointed MO has not received the basic trainings. There are six trained staff to handle cold chain. The OPD attendance is in one quarter is about 6400. There is no IP service in the PHC. The percentage of women registered in the first trimester are 74 % and 80 % respectively in first and second quarter. The level of MCTs entry is poor in this PHC. The percentage of MCTs entry is only 70% and 55 % respectively in first and second quarter.

ArattupuzhaSC–One JHI work along with the JPHN for the needs of the population in the sub centre area. On the day of visit JPHN, JHI and ASHA workers were present in the SC. The percentage of women registered in the first trimester is 84 % and 82 % in the first and second quarter.

7Other health System inputs

DistrictHospitalThrissur–It is a 240 bedded hospital and in the process of up gradation to 350 beds. The Specialty care services such as Surgery, Medicine, OBG, Cardiology, Emergency, Trauma care, Ophthalmology, ENT, Dental, Ortho, Dermatology, Psychiatry, FP services, Service of Blood bank, Pathology etc are working in the DH hospital on 24X7 basis. The Blood bank of the hospital was functioning in 24x7 manner and sufficient blood bags are available in the hospital. Almost all laboratory services are available expect for TB and HIV. This is because of TB center and ICTC functioning nearer to the hospital. Essential drugs and consumables are available in the pharmacy, but there is shortage of drugs for NCD. Functional laundry and washing services are available. All the essential equipments in the OP, OT and laboratory in the hospital are available and functional. A new dialysis unit implemented in recently. Weekly regular fogging is done.. Appropriate drug storage facility is available.. Tally has been implemented in the computer. The gaps found in DH are - AYUSH service not started so far and no initiation to start ATUSH, the EDL is not displayed in the hospital, free sanitary napkin supply not started, computerized inventory management for drugs not implemented. Tally is not implemented.

Ollur CHC– Functional BP apparatus, Stethoscope, needle cutter, suction apparatus, facility for oxygen administration, autoclave, ILR and deep freezer, emergency tray with emergency injections are available. Microscope and centrifuge are available and functional in the laboratory, Hemoglobinometer, is available but not functioning and Semi autoanalyzer is not available in the facility. The necessary registers like OPD, IPD, ANC, Family Planning, Immunization etc are available and correctly filled in the facility. Micro plans are available but no separate register not maintained for it. No separate register for referrals. Essential drugs are available and EDL displayed, the inventory management of drugs are not computerized and tally not implemented. The laundry and washing services done by a lady once in week. Dietary service jot available in the facility

Vallachira PHC -BP apparatus, Stethoscope, needle cutter, weighing machine, autoclave, ILR and deep freezer are available and functional. Supply of drugs was reported to be sufficient. Essential drug list is not displayed in the Pharmacy. Computerized inventory management not started, There is no supply of OCPs and E C Pills and sanitary napkins. Urine, albumin and sugar testing kit not supplying. No laboratory service provided. IUCD insertions conducting once in a while, number of IUCD insertions are 8 and 4 for the last two quarters. Essential consumables like gloves , pads, bandages and gauze are available.

ArattupuzhaSC - BP apparatus, Stethoscope and Haemoglobinometer are available but not functioning. Available and functional equipments at the centre are Blood sugar testing kits, weighing machine (adult and infant), Needle cutter. IFA tablets, IFA syrup with dispenser, Vitamin A syrup and ORS packets are available at the centre. Tablets for non communicable diseases are distributed through the sub centre. Pregnancy testing kits and OC pills are available but EC pills and sanitary napkins are not available in the centre.

8Maternal health

8.1ANC and PNC

District Hospital Ollur, ANC1 registration in the two quarters April-June and July to September is about 170 and 123 respectively. The ANC3 coverage is about 70 and 155. About 99 percent of the first trimester registrations have been captured in MCTS. All women have been given IFA tablets in the two quarters. The number of women referred to other facilities is 23 and 0 in the two quarters respectively. With regard to PNC services, women are compulsorily asked to stay back 48 hours after delivery and almost all women stay hospital for at least 48 hours after delivery

The lab services offered are testing of haemoglobin, Urine albumin and sugar, blood sugartest for malaria, TB, HIV, LFT, and ECG. X-ray facility is done in the District hospital which is in the same compound. All the services offered are documented.

No severely anemic pregnant women reported in during the last two quarters and no separate register maintained for line listing severe anemia cases The number of cases of hypertension related to pregnancy, B-sugar, U-sugar and protein tests are available in the lab records. Counseling for IYCF is available in DH. Immunization carried out in DH on every Monday, Wednesday and Saturday and thus zero doze BCG, Hepatitis B and OPV given at post natal clinic before discharge of women after delivery.