Monitoring of Programme Implementation Plan (PIP), District Belgaum, Karnataka

(For quarter I and II)

Shriprasad H.

Ms Manjula G Hadagalimath

Mr. MallikarjunKampli

PRC Analytical Report Number-9

Population Research Centre

JSS Institute of Economic Research

Dharwad, Karnataka.

Table of Contents

1Executive Summary...... 4

2Introduction...... 11

3State Profile and district profile...... 12

4Key health and service delivery indicators...... 13

5Health Infrastructure:...... 13

6Human Resources...... 13

7Other health System inputs...... 14

8Maternal health...... 15

8.1ANC and PNC...... 15

8.2Institutional deliveries...... 16

8.3Maternal death Review...... 16

8.4JSSK...... 16

8.5JSY...... 17

9Child health...... 17

9.1SNCU...... 17

9.2NRCs...... 17

9.3Immunization...... 17

9.4RBSK...... 17

10Family planning...... 18

11ARSH...... 18

12Quality in health services...... 18

12.1Infection Control...... 18

12.2Biomedical Waste Management...... 19

12.3IEC...... 19

13Clinical Establishment Act...... 20

14Referral transport and MMUs...... 20

15Community processes...... 20

15.1ASHA...... 20

15.2Skill development...... 20

15.3Functionality of the ASHAs...... 20

16Disease control programmes...... 21

16.1Malaria...... 21

16.2TB...... 21

16.3Other Communicable Disease...... 21

17Non Communicable Diseases...... 22

18Good Practices and Innovations...... 22

19HMIS and MCTS...... 22

20Key Conclusions and Recommendations...... 23

21Annexure...... 24

1.Executive Summary:

Introduction

The National Rural Health (NRHM) of Government of India, launched in 2005 with an intention to improve accessibility of quality health service to the rural population particularly the vulnerable population, women and children. To attain this many administrative and structural corrections has been made along with pumping higher resource towards the health sector. GOI has taken many measures in order to monitor the progress and performance of the NRHM from time to time. In order to monitor the performance and status of the health facility under NRHM a field work has carried out during September 23d to 26th 2013 in the Belgaum district. During the visit, discussion was held with RCHO, districtprogramme officers and heads and staff of selected District hospital, (BIMS), CHC, PHC and SC

Health Infrastructure

  • In the Belgaum District one District hospital is functioning (Govt. Building) of around 1000 bedded. There are 9 SDH functioning in the government building. Number of CHC are 17 (all are in Govt. building) Total number of PHCs are 140 out of which 89 (63%) are 24X7.

Human resources

  • Most of the key positions in the District hospital is vacant. Only 13 per cent of the ‘A ‘Group posts are filled. RMO in the District hospital expressed that staffs are the non-available for the all key positions at the prevailing pay scale The status of B,C, and D group vacancy too are weaker. Due the lack of specialists and other category of staff most of the services are deprived on the part of patients. At PHC level MO, senior Nurse, LHV posts are vacant. In the visited Sub-center ANM and Male health worker are in position.

Availability of drugs and diagnostics, Equipment

  • Functional Foetal Doppler/CTG, Functional mobile light, Functional ILR and Deep Freezer not available in the District hospital. Partograph though available at labour room. All OT equipment’s are available and functional except functional surgical Diathermies. C.T. Scanner not available. Essential drugs available. Indeed complete safe abortion drug not available. There had not been proper supply of the glove since 2 years.
  • In the visited CHC except MVA/EVA equipment, rests of the equipment are available and functioning. All laboratory equipment are available and functional. Except IFA tablet-blue, IFA syrup with Dispenser, vitamin A syrup and Zinc tablets, all other drugs are available. The kits related to pregnancy diagnosis and family planning contraceptive pills are being supplied except OC pills. In the visited PHC except the functional Neo-natal, pediatric and adult resuscitation kit, MVA/EVA equipment rest of the equipment are available. The kits related to pregnancy diagnosis and family planning contraceptive pills are being supplied, except the OC pills.

User fees and OOPS

  • There are user fees, ward charges, fees for X-ray and blood investigations in District hospital ranging from 40-500. Some of the core head of fees are Blood for General patients of Govt. Hospital Rs 350Blood for patients of Pvt.Hospital / special ward in BIMS Rs 700. Portable X ray Rs 200. ANC and PNC
  • Due to the non-availability of Gynecologist in the CHC and also CHC is near to the District hospital most of the surrounding people prefer District hospital for the ANC check-up. Line listing of severely anemic women has not done in the District hospital. In the visited Community health center and PHC line listing of severely anemic women has done only for high risk pregnancies. At the District hospital 31 MTPs were conducted and in CHC one MTP was conducted during the first quarter. There is no trimester wise MPT register as such in both the facilities. In the visited CHC, IFA tablets given to 178 women during the first quarter. In PHC 1800 IFA tablets are distributed during the same period through ASHA and ANM.

Laboratory services

  • Except RPR test all other tests are being conducted at District hospital. Laboratory in the District hospital found over crowded, being blood drawn in a single room for all kinds of tests. In the visited CHC, except CBC, RPR rest of the tests is being conducted. At PHC level, routine tests are conducted. However HIV test is being conducted once in a month. For the rest of the tests, patients are referred to the higher facility.

Institutional deliveries

  • For all the delivery cases registers are found and well maintained at all the level. During the first quarter, total 1977 deliveries took place in DH, out of which 25% are C section. EmoC facility is existing only in District hospital. During the first quarter 164 women were transfused the blood during the delivery. In CHC during the same period, deliveries are 175, no ‘C’ section deliveries took place. CHC and PHC are not having Emoc facility.

Maternal Death Review

  • There are 3 maternal death had occurred (Two in May and one in June) in the District hospital during the first quarter. The key causes for the maternal death a District hospital during quarter are Cardio-respiratory arrest with severe anemia SevereAnemia, Cardio pulmonary arrest, severe anemia with blood transmission reaction. All the Maternal Death had been reviewed District hospital from April to June. There is no maternal death in the CHC and PHC during the reference period.

JSSK

  • JSSK has been implemented in the District hospital and in the visited CHC and PHC. Related services like dietary, (outsourced), medicine and treatment are given free of costNone of the visited facilities have maintained the register for the referral transport cases. During the first quarter 1967 patients are treated under JSSK. Interviews had revealed that all the entitlements are free under JSSK.

JSY

  • JSY is implemented at District hospital and in all the visited facility. All the payments were found to be made in time subject to the availability of fund and other supportive documents. Modes of payments are through cheque since April 2013. No expenditure had incurred by Mothers on travel, drugs and diagnostics.

Child health

  • SNCU: The infrastructure of SNCU is good. But there is a problem of related manpower in the District hospital
  • NRC is existing at District Hospital.

Immunization

  • In District hospital there is a daily vaccination services. There is no outreach activities and micro-plan to cover inaccessible and migrant population. Under CHC once in a week (every Thursday) immunization services are being provided. In the sub center along with ASHA,ANM is conducting the Immunization sessions. All the levels of visited health system have been maintained the registers for Immunization except the sub- center.

RBSK

  • At the district hospital during the interaction it is found that they have no idea on RBSK. At taluka level a team had constituted with 2 MOs, one pharmacist and one ANM and one D group worker. However activities are not yet started.

Family Planning

  • Limiting method, laparoscopy, IUCD and injections are the major adopted method of family planning in the visited region. DMPA injection is a popular modern method adopted in the region. OC found not available at any level.

ARSH

  • There is no separate ARSH clinic and services in District hospital and Community health Centre. At PHC and sub center level all ANMs are doing ARSH programmes for adolescents on nutrition and hygiene. If they find any problematic cases, then it will be referred to the higher level..

Infection Control

  • General cleanliness in the District hospital is unsatisfactory. The sewage system in the District hospital is very poorthere is no proper toilet facility in the District hospital even to collect the urine by the patients. The infrastructure and general cleanliness in the CHC, PHC and sub-Centre is satisfactory.In CHC and PHC the general cleanliness is satisfactory.

Fumigation

  • In district hospital fumigation done through automatic machine once per six cases. In CHC, a day earlier to any surgery fumigation being done and a register has found for the same. At all the level of visited facilities autoclave mechanism found in a working condition. A separate register has been maintained for the same in District Hospital and CHC. A List of instruments to be autoclaved has also been maintained.

Bio-Medical Waste Management

  • The bio-Medical waste management are being segregated according to the colour coded box protocol in all the visited facilities. At all the level of facilities staff are found to be having awareness about the same. The task of Bio-medical waste disposal has been outsourced by the District hospital and the CHC.

IEC

  • All the IEC material and the citizen chart found to be displayed in the District hospital, however except JSSK and JSY entitlements none of them are clearly visible. In the visited CHC all IEC material are displayed, clear and good. In the Primary Health center all prime IEC are displayed. Sub-center visited had no IEC materials at all.

Clinical Establishment Act

  • In Karnataka it is called as Karnataka Establishment ACT, implement in 2007. According to this at district level District Committee has been formed. This committee shall visits private hospitals and requires to check the protocol, equipment’s and infrastructure.

Referral Transport and MMUs

  • At District hospital there is one ambulance and is working. It is outsourced. At DH office one mobile medical unit is working. At CHC one ambulance is functioning, it provides only drop back facility. Patients visits the CHC either by own or by public transport. At the visited PHC there is no ambulance facility.
  • Community Processes
  • ASHA: Currently 2990 (District level) Ashas are working but actual required number is 3397.So far 407 ASHA workers are left due to multi-reasons

Skill Development

During the first quarter, to upgrade the skill of Ashas,3rd and 4th module training (April 2013) had been given at District Training Center. Each month there is a meeting for TOTs of ASHA at District level and every month on 21st , at all PHC level ASHA meeting shall be held. There are 11 ASHA resource centers in Belgaum District. One of them is at District Health Office.

Functionality of ASHAs:

Kits are replaced at the concerned PHCs .The Payment to ASHAs earlier is through cash, but now it is through A/C payee since April 2013. To get the payment, ASHAs have to enter their monthly progress in HMIS web portal .Accordingly as per their performance will get the honorarium.

Malaria

  • The prevalence rate of Malaria has come down since 2010 onwards. In the year 2013 from Jan to Sep total 42 Positive cases are found. All cases are treated no deaths had occurred during the reported. RDK and drugs under NRHM are available only for high focused district. For the remote areas, drugs are distributed through ASHAs.

TB

  • At District hospital there is a separate cell for RNTCP. In the visited CHC sputum is collected in the common laboratory. For the positive cases drugs are given in the pharmacy of the CHC. Category wise TB drug kit is given and RNTCP register has been maintained. At the PHC level suspected cases for TB will be referred to CHC for the examinations.

NLEP

  • Kanapura, Chikkod and Ramadurg are the high prevalence talukas in the district. However causes are still unknown. For positive cases treatments are being given. For deformity cases referred to HubliAnand Nagar, rehabilitation center Karnataka. For reconstructive surgery, the cases are referred to Miraj, with Rs 5000/- for incidental expenditures.

Non Communicable diseases

  • PIP for Mental health, Cardiovascular, Neurology, CVA, Psychiatry, Accidental Injuries, Snake bites, Cancers had been submitted for approval. PHC Medical Officer are trained for three days to identify and screen the cases. The problematic cases are referred to the District Hospital.

Good Practices and Innovations.

  • To control malaria at District programmehaddeveloped two species of Fish which are capable of swallowing the Malaria eggs, as a result the process would able to break the Malaria cycle. Also during the epidemic situation the programme officers established the tents in the prone areas to screen, provide the tablets and creating the awareness. Another important innovative practice is the introduction of DMPA injection in the region for family Planning. .

HMIS-MCTS

  • HMIS-MCTS are managed by a contractual and a permanent staff, who had received the training. All the entries at the District level found be maintained timeliness and completeness. HMIS line items were collected on each day and complied on each month. However it is found that MCTS format had not been generated. MCP cards are filled by ANM at SC and PHC level. At CHC pharmacist is managing the entry of HMIS and MCTS.

Recommendations:

  • Though infrastructure is reasonably good, due to the lack of right personnel to handle the same, infrastructure is being underutilized. Accordingly patients are deprived of the necessary services. Therefore to ensure the necessary services and for effective utilization of infrastructure there is a need to attract qualified personnel by offering attractive package. This may be result in achieving the health goals and reduction in both social and economic cost of the state in course of time.
  • Recruiting the key personnel in the CHC and PHC is necessary for the optimum utilization of existing good infrastructure in both the facility. This may also bring-down the pressure of District hospital
  • The urgent need of the time is to upgrade the general cleanliness of the District hospital so that infection can be controlled. The sewage system and toilet facility requires immediate attention.
  • The laboratory investigation system needs to be improved to avoid the crowd especially for ANC in District Hospital.
  • OC pills shall be made available at all the levels at the earliest to meet the un met need of the Family Planning.
  • Supply chain of Gloves to the laboratory requires to be strengthened at all the levels to ensure timely availability so as to avoid possible dual-sided fatal infections
  • IEC materials at District hospital required to be made visible with clarity,(other than JSSY/JSSK). Sub-center required to be display the related IEC materials.
  • ASHAS required quality training on HMIS/MCTS
  • Leprossyprogamme needs to be special attention in the region to sustain the attained target.

2. Introduction

Context and Methodology

The National Rural Health (NRHM) of Government of India launched in 2005 with an intention to improve accessibility of quality health service to the rural population particularly the vulnerable population, women and children. To attain thismany administrative and structural corrections has been made along with pumping higher resource towards the health sector. GOI has taken many measures in order to monitor the progress and performance of the NRHM from time to time. Accordingly, to support this task, PRCs national-wide were assigned the work through NHSRC. PRC Dharwad had been assigned to monitor the progress in the States of Karnataka, Andhra Pradesh and Maharashtra. In order to monitor the performance and status of the health facility under NRHM a field work has carried out during September 23d to 26th 2013 in the Belgaum district. Belgaum District hospital, one CHC, one PHC and related one sub center were selected for the field analysis. During the visit, discussion was held with DHO, districtprogramme officers and heads and staff of selected District hospital, CHC, PHC and SC to gather the required information for the proposed study. The findings on differ components/issues are shown with descriptive and tabular approach

The District Hospital, Belgaum earlier known as the Civil Hospital is the earliest hospital in the district and dates back to 1859. This serves the people of the district and also the rural people of the bordering villages of the neighboring state. The Jawaharlal Nehru Medical College of the city is attached to this hospital. Thus the hospital is working as a autonomous unit since 2006, as Belgaum Institute of Medical college (BIMS).The bed strength of the hospital is around 1000. It has specialized services in medicine, surgery, pediatrics, maternity, gynecology, ENT, skin diseases, ophthalmology, psychiatry, blood bank and dentistry. Apart from the District hospital, one CHC Bagewadi, one PHC attached to this, (designated as 24X7) i.e.Bendigeri PHC and a related sub-center also visited in Belgaum Taluka. The information and data are gathered in the order prescribed by the NHSRC. The specific objectives of the visits are as follows

  1. To evaluate the availability and competence of infrastructure, equipment and manpower in selected public health facilities of the district.
  2. To assess the performance of Maternal health and child health indicators
  3. To review the quality of health services in the concerned health setup
  4. To recommend the measures to enhance the quality of functioning public health set-up in the district

3. State Profile and District Profile: