Quarterly Monitoring of Programme Implementation Plan (PIP), Washim District, Maharashtra State

(For Q1&Q2, April-September, 2013)

R.V.Deshpande

H.R.Channakki

Ragini K. Itagi

Report prepared for the MOHFW, Government of India, New Delhi

Population Research Centre

JSS Institute of Economic Research

Dharwad, Karnataka

PRC Analytical Report No.15

December, 2013

Table of Contents

1Executive Summary...... 4

2Introduction...... 8

3State Profile and district profile...... 9

4Key health and service delivery indicators...... 9

5Health Infrastructure:...... 10

6Human Resources...... 11

7. Other Health System inputs………………………………………………………………………………………….11

8Maternal health...... 12

8.1ANC and PNC...... 13

8.2Institutional deliveries...... 13

8.3JSSK...... 13

8.4JSY...... 13

9Child health...... 14

9.1SNCU...... 14

9.2NRCs...... 14

9.3Immunization...... 14

9.4RBSK...... 14

10Family planning...... 15

11ARSH...... 16

12Quality in health services...... 16

12.1Infection Control...... 16

12.2Biomedical Waste Management...... 16

12.3IEC...... 16

13Clinical Establishment Act...... 16

14Referral transport and MMUs...... 17

15Community processes...... 17

15.1ASHA...... 17

15.2Skill development...... 18

16Disease control programmes...... 18

16.1Malaria...... 18

16.2TB...... 18

16.3Other Communicable Disease...... 18

17Non Communicable Diseases...... 18

18Good Practices and Innovations...... 19

19HMIS and MCTS...... 19

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

21Annexure...... 22

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1Executive Summary

With a view to monitor the progress and performance of activities under NRHM and also to assess the adequacy of infrastructure in public health facilities to provide quality services, a field study was undertaken in Washim district of Maharashtra state during 25-28 November, 2013.During the visit, discussion was held with incharge district health officer, incharge civil surgeon, district programme officers, andmedical officers of selected CHC, PHC and ANM of SC toobtain the required information for the study.The genuineness of the reported informationwas cross checked in the field wherever possible. The findings and observations on different components are presented below.

Health Infrastructure:

  • The existing public health facilities in the district seem to be sufficient to provide quality health services. While all CHCs and SDHs are functioning in government building, one in four SCs and one in ten PHCs are functioning in private buildings. Besides this, there are 42 private nursing homes providing obstetric care services.

Human Resources:

  • For the district as a whole,in the government setup, only four specialists- one each gynaecologist, paediatrician, anaesthetist and surgeon are in position as specialists are not willing to join government services due to low salary. Due to non-availability of specialists, many deliveries are being referred; c-section and MTPs are not taking place.

Maternal health:

  • First trimester pregnancy registration is only 69 percent and information on number of pregnant women screened for hypertensive, blood sugar, urine sugar and protein tests are not available with the district health office.
  • Ninety eight percent of deliveries are institutional and no c-section deliveries are conducted.
  • Of the 12 maternal deaths reported, review has been taken place in 6 cases.Sepsis, hemorrhagic and anaemia are the key causes for maternal deaths.
  • A centralized 24*7 call centre is opened at DH but toll free number is not in place.
  • JSSK though implemented in the district, women are still spending on transportation especially to reach facility from home.Publicity on JSSK is not adequate.
  • In CHC, PHC and SC, JSY money is being paid within a week through a/c payee cheque and incentives is not being paid to home deliveries.

Child health:

  • The SNCU is very clean, well maintained and has required staff and drugs.
  • BCG is not given at birth even for the institutional deliveries but is being given later.
  • All immunisation sessions planned are conducted. However, microloans are not prepared at any facility as Medical Officers of CHC and PHC are not aware about the microplans.
  • RBSK has been functioning in the district effectively but time gap between diagnosis of disease and completion of treatment is long.

Family planning:

  • Vasectomy is unpopular in the district. Lack of supply of OC pills and EC pills is observed in DH, CHC, PHCand SC.

Quality in health services:

  • Wards and different sections of facilitiesare clean and well maintained.
  • Awareness and practice of biomedical waste management is very poor in all the facilities.

IEC

  • The IEC displays at DH and CHC are limited but enough displays were found at PHC and SC on all important programmes of NRHM.
  • However, EDL, partograph, and clinical protocols are not displayed in any of the visited facility.

Clinical Establishment Act:

Clinical Establishment Act has not been effectively implemented.

Referral transport and MMUs:

  • Free referral transport facility for all pregnant women and sick neonates is available. A centralized 24*7 call centre is opened at DH but toll free number is not in operation.
  • One Mobile Medical Unit is functioning in the district. A team consisting of medical and paramedical staff is appointed and it caters the services for 36inaccessible villages.

Community processes:

  • Drug kit is given to each ASHA and drugs are being replenished regularly. Payment is being made monthly through cheque. On average, ASHA is getting Rs.1500 per month.

Disease control programmes:

  • Key posts such as DMO/ADMO, many laboratory technician posts and health worker posts are vacant.
  • The data on malaria situation in the district shows a decreasing trend since January, 2008.

Non Communicable Diseases:

Non communicable disease programme is functioning in the district since last year. In all, 8 NCD clinics spread over six talukas with the required staff and drugs are in place and providing services on screening and treating for hypertension, diabetes and cardiovascular diseases and managing strokes through physiotherapy. Since start of the programme, about 18000 persons of age 30 years and above were screened for sugar and diabetes and required service were provided.

HMIS and MCTS:

  • HMIS and MCTS data is being entered at taluka level by the respective ANM due to poor internet connectivity at the periphery.
  • To maintain quality of data, validation errors are generated and errors are corrected.
  • To ensure quality of data, validation error committees are formed at different levels and each level committee check the data for errors and refer for correction.
  • Under MCTS, only registration of pregnant woman is being taken place and tracking of woman for services is not being followed up through MCTS as software has a problem.

Conclusions and Recommendations

  • Though DH and CHC have good infrastructure, equipments and drugs, due to lack of specialists these facilities are underutilised. Hence, recruiting specialists should be given top priority for optimum utilisation of these facilities.
  • ANC care in respect of first trimester registration, provision of IFA, TT, screening for hypertension, blood/urine sugar and line listing of severely anaemic women are poor. Hence ANC care needs to be improved.
  • Though JSSK assures free pick up and drop back facility for women, many women are still spending on transportation especially to reach facility. Hence, adequate publicity needs to be provided especially on free transportation and toll free number has to be provided which helps to reduce out of pocket spending on delivery.
  • BCG which is expected to be given at birth is being given at the time of first dose of polio even for the institutional births. For improving routine immunisation programme, BCG has to be given at birth.
  • All the health functionaries need to be oriented on importance of microplan and ensure that it is maintained and updated regularly.
  • Though RBSK is functioning well in the district, time gap between diagnosis of disease and completion of treatment is long.Hence, proper support and effective follow-up is required both from health and education departments to ensure earliest completion of treatment.
  • Awareness and practice of BMW management is very poor. All staff at DH, CHC, PHC and SC is to be oriented on BMW and colour coded bags should be provided to all the facilities.
  • More publicity is required at facilities on availability of services and treatment for non communicable diseases through standard IEC displays.

2Introduction

The National Rural Health Mission,a flagship programme of Government of India, launched in 2005 with an objective to improve availability and accessibility of quality health care to the rural population particularly the poor, women and children. To achieve the objectives, many architectural corrections namely ensuring availability required infrastructure, critical health man power, equipments and drugs in public health facilities, flexible financing, decentralized planning and community involvement are proposed and implemented under mission. Further, under decentralized planning, health needs of the people is being planned at village level and is aggregated at block level and then at district level. Hence, district will play a vital role in planning and implementation of the programmes under NRHM. With a view to monitor the progress and performance of activities under NRHM and overall functioning of public health facilities towards providing quality health services,periodic surveys in the identified high focus districts in the country are planned once a quarter by the Ministry of Health and Family Welfare, Government of India and Population Research Centres (PRCs) located in different parts of the country are involved in monitoring the progress of activities. The Population Research Centre, Dharwad has undertaken the task of monitoring progress and performance of NRHM activities in public health facilities in Washimdistrict of Maharashtra State.

Objectives:

  1. Tounderstand the progress and performance of activities proposed in PIP of the district
  2. To assess the availability and adequacy of infrastructure, manpower, equipments and drugs in selected public health facilities of the district.
  3. To assess the performance of key reproductive and child health indicators
  4. To assess facility level free entitlements of JSSK and to know out of pocket spending on delivery by the beneficiaries
  5. To suggest ways to improve functioning public health facilities in the district

Methodology:

Four different levels of health facilities namely district hospital, CHC-Mangrulpir, one 24X7 PHC-Kataand aSC-Kandala Jamrebelonging to PHC have been selected. In all the four facilities information on availability of infrastructure, manpower, equipments, drugs and performance indicators on key RCH aspects have been collected from the respective departments of the facility through checklists supplied by the Ministry. Discussion was also held with the DHO(I/C), Medical Superintendent,Civil Surgeon(I/C), all district programme officers and heads of the each selected health facility on performance and progress of their activities under NRHM, lacunas and suggestions to improve the quality of health care delivery services. The performance and genuineness of plan of visit of the MMU was also assessed through surprise visit to a village where MMU was planned for visit.

During the course of field visit,performance of MMU was assessed by visiting the village where MMU was doing the work. A team of three research staff headed by the Principal Investigator toured the district during 25-28November, 2013along with M and E officer and collected the required information.

State Profile and district profile

Washim district is the smallest district in the state, bifurcated from Akola district in 1997,lies in the eastern part of the state and belongs to vidarbha region. Table 1 presents state and district profile. The district has 6Tehsils with698villages. According to 2011 Census, the district has a total population of 11,96,714 accounting for 1.06 percent of the total population of the State. The decadal growth rate of the district during 2001-2011 was 17.23 percent which is higher(15.99 percent) than the decadal growth rate of the state as a whole.The density of population is 244 per sq km. The sex ratio of the population (number of females per 1,000 males) in the district according to 2011 census is 926, which is almost same as that of state (925) and child sex ratio (0-6 years) is lower (859) than that of state (883) and nearly three-fifths of the females aged 7 years and aboveare literates.

3Key health and service delivery indicators

Table 2 presents trends in key health and service delivery indicators for India,Maharashtra state and Washim district during 2007-08 (DLHS3) to 2012-13 (HMIS). It is observed that at the national level, there has been a sharp increase in many service delivery indicators since2007-08. For instance, only nearly half of the PW had received 3 ANC and 100 IFA tablets during 2007-08 increased to about 75 percent in 2012-13. However, Maharashtra state’s progress in these indicators during the period is poor compared to national level. The performance of deliveries conducted at institutions is better in Maharashtra compared to India as a whole. While 65 percent increase in institutional deliveries was observed in Maharashtra since 2007-08 but it was only 57 percent for the country as a whole. The percent children breastfed within an hour has also increased from a less than fifty percent to about 80 percent. The unmet need for family planning, which is one of the indicators to assess the effectiveness of family planning programme and demand for FP services/supplies,is about 6 percent for spacing and 8 percent for limiting.

Washim district has also recorded a marked improvement in many reproductive and child health service indicators since 2007-08. For instance, the first trimester registration which was 61 percent during 2007-08 increased to 73 percent in 2012-13 and proportion received 3 ANC recorded a high of 84 percent in 2012-13 from 69 percent during 2007-08.Visible improvements are also observed in the district with respect to institutional deliveries, children fully immunized and children breast fed within an hour which is almost cent percent.

  1. Health Infrastructure:

In all, there are 153 SCs, 25 PHCs, 7CHCs and adistrict hospital. Of them, 114SCs (75 percent) and 22 PHCs (88 percent) are functioning government building and remaining are functioning in private buildings. However, all CHCs and a DH are functioning in government building.Besides this, there are 42 private nursing homes providing obstetric care services.

  1. Human Resources

Of the 112 medical officers posts sanctioned in the district, 78 are in position.Further, there are 34 medical officers for RBSK and 13 medical officers for PHCs are appointed oncontractual basis.Severe shortage of specialists like gynecologists, pediatricians and anesthetists is observed in the district. It is shocking to note that one gynecologist, one pediatrician, one anesthetist and one surgeon are in position for the whole district in the public facilities. Of the 17 sanctioned posts of specialists in the district hospital, only 4 are in position since long time. Shortage of specialists is also observed in CHCs. However, almost all the sanctioned posts of non specialists are in position in both DH and CHCs.

To fill the posts of specialists, repeated advertisements have been made in the local papers and IMA was contacted and requested to motivate candidates to apply for the posts. Despite these efforts, they could not get specialists. Too much political interference in day to day work coupled with low salary and heavy work load are said to be the main reasons for the poor turnout of specialists. To fill the gap, specialists are being hired from private sector either on call basisand general duty medical officers are being deputed for the short term course on anesthesia. Further, 6 additional increments are being offered for the fresh appointees to ensure their retention. With respect to paramedical posts, shortage of staff nurses, health visitors and multipurpose workers are observed in CHCs and PHCs.

  1. Other health system inputs

Though District Hospital has a good infrastructure, many services are referred or outsourced because of lack of specialist doctors. Since surgeon visits the hospital for 2 days in a week, surgeries are being refered to other places. Since no gynecologist is in position, only normal deliveries are conducted, EMoc and BEMoc services are not in place, C-section and MTPs are referred, radiology and pathology services are available only two days in a week. However, services for ophthalmology and family planning operations are taking place regularly. The district hospital has a NCD clinic where patients are screened for diabetes and hypertension. The other services available at DH are dialysis, chemotherapy, blood bank, Ayush, ICTC, PPTCT, RTI/STI sickle cell anemia treatment, treatment cell for senior citizensand ARSH services.

Though selected CHC is a FRU, required man power and trained staff in EMoC, LSAS and MTP are not there. Because of lack of specialist, many expected services such as EMoC and MTP are not being conducted. However, it has almost all equipments, essential drugs and supplies except zinc tablets, misoprostol tablets, pregnancy test kit, OCPs and ECpills.

The selected PHC is a 24*7. Though it has required trained staff, equipments and drugs, only 23 deliveries have taken place during last two quarters against the expected 300 deliveries. ANC,PNC and immunization services are not being given. With respect to drugs and supplies, supply of IFA tablets, oral contraceptives and EC pills is lacking in CHC. Computerized inventory management of drugs is in placein DH and CHC but not in the PHC.

Ayush services are available at CHCs and district hospital. Of the 4 MOs of Ayush at DH, two are post graduates-one each in unani and homeopathy and other two are graduates in ayurveda and unani. Separate OPD for Ayush in DH is in place and about 400 OPDs are taking place in a month. Ayush drugs are being supplied from state Ayush department and supply is sufficient. According to District Ayush Officer, since there is more demand for Panchakarma services, proposal submitted has been sanctioned but establishing it has become problem due to no sanctioning of equipments. Of the 7 CHCs, two CHCs have each 3 Ayush medical officers and each CHCs have about 300 OPDs per month. Besides this, there are 11 Ayurvedic dispensaries spread over all talukas manned by one medical officer each with ayurvedic degree.

District hospital, CHCs and PHCs are charging Rs. 5 as a registration fee to all patients. However, DH and CHCare charging an amount ranging from Rs 5-50 for investigations other than ANC cases but all investigations are free at PHC.

8.Maternal health

8.1 ANC and PNC

In all the facilities visited, all ANC services are provided. For a district, a total of 11867 ANCs are registeredduring April-September,2013 and of them women registered within first trimester was 8218 (69 percent).However, information on other ANC services such as number of pregnant women screened for hypertensive, blood sugar, urine sugar and protein tests are not available with the district health office.The district hospital, CHC, PHC and SCare providingall ANC, PNC services and round the clock normal delivery services. The list of severelyanemic women is available and maintained by at SC.