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

(For quarter I and II, 2013-14)

Shriprasad H.

Ms. Manjula G Hadagalimath

Mr. Mallikarjun Kampli

PRC Analytical Report Number-13

Population Research Centre

JSS Institute of Economic Research

Dharwad, Karnataka.

November 2013

Table of Contents

1Executive Summary...... 4

2Introduction...... 10

3State Profile and district profile...... 11

4Key health and service delivery indicators...... 11

5Health Infrastructure:...... 12

6Human Resources...... 12

7Other health System inputs...... 13

8Maternal health...... 13

8.1ANC and PNC...... 13

8.2Institutional deliveries...... 14

8.3Maternal death Review...... 14

8.4JSSK...... 15

8.5JSY...... 14

9Child health...... 15

9.1SNCU...... 15

9.2NRCs...... 15

9.3Immunization...... 15

9.4RBSK...... 16

10Family planning...... 16

11ARSH...... 16

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

12.1Infection Control...... 16

12.2Biomedical Waste Management...... 16

12.3IEC...... 17

13Clinical Establishment Act...... 17

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

15Community processes...... 17

15.1ASHA...... 17

15.2Skill development...... 17

15.3Functionality of the ASHAs...... 18

16Disease control programmes...... 18

16.1Malaria...... 18

16.2TB...... 18

16.3Other Communicable Disease...... 19

17Non Communicable Diseases...... 19

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

19HMIS and MCTS...... 19

20Key Conclusions and Recommendations...... 19

21Annexure...... 22

  1. Executive Summary

The National Rural Health Mission (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 October 23rdto 26th 2013 in the Bidar district. During the visit, discussion was held with RCHO, district programme officers of the concerned programme, heads and staff of District hospital, (BRIMS), PHCs and SC

Health Infrastructure

  • Bidar District has a District hospital attached with Medical College. FRUs are 5 (One at District level and 4 at taluka level) CHCs are 7, (all in govt building) PHCs are 51, out of which 86 per cent are in government building. All PHCs are working as 24x7 PHC.SC are 270 in which85 per cent are in government buildings.
  • The road towards the district hospital is poor. There are separate toilet facilities for male and female, but not maintained properly both in the district hospital and the PHCs .The condition of the labour room is poor. There is no attached toilet in the labour room in the district hospital.

Human Resource

  • At district level there is a shortage of staff nurse. Of the sanctioned post only 47 per cent of the positions are filled. In the visited district hospital all categories of positions viz A,B, C, and D are shortage.
  • In the visited Anadoor PHC all positions are filled, but there is a shortage of staff nurse and ANM. In the Kamatana PHC, C and D group staffs are deputed to District hospital and taluka health office. In the PHC Ambulance is provided but there is no driver post not yet sanctioned.

User fees

  • Since district hospital is attached to the medical college, as a autonomous body, nominal fees are being charged for the investigation and other services. In the District hospital it was found that there is no high OOPS

ANC and PNC.

  • From April to September 19345 ANC cases are registered. 63% was within first trimester. No line listing of severely anemic pregnant women. In the district hospital PNC ward was over crowded. As a whole the ward was poorly maintained. Related documents were verified but not maintained well. MCTS entry of pregnant women are updated in both the PHCs

Institutional delivery

  • In the district 15034 deliveries occurred during January to August 2013, in that 98 per cent are the institutional deliveries. In the district hospital during the first quarter 1033 and in the second quarter 1273 normal deliveries had been conducted. Out of them 35% are C section deliveries. Assisted deliveries were very less.
  • In both the visited PHC, only normal deliveries are being conducted. Due to the shortage of staff, MOs are not very much confident to conduct C section deliveries.

Maternal death Review:

  • In last two quarters 13 maternal deaths were occurred in the district level and in that 5 at district hospital. 10 cases are reviewed 3 cases are pending. State task force has been formed to review the maternal death. No publication related to the MDR at state level. In the District hospital 5Maternal death had occurred during the last 2 quarter.
  • In the both the visited PHCs there was no maternal death reported for the both quarter. MDR related audit reports are available and register is found but not updated.
  • At all the visited facilities JSSK is implemented, however, there is only inter-facility transport service is available, but no drop-back facility.
  • In all the visited facilities JSY benefits are available. Recently JSY benefits have been extended to any number of children. Registers are checked and found up dated

SNCU:

  • The space in SNCU is very congested. Because of over admissions, in some of the beds two newborns were treated. There is a shortage of staff nurse. Medical officer expressed the view that there is a need to upgrade the SNCU from Level -2 to Level3.

NRC:

  • NRC is functional in District hospital with good Infrastructure. All are treated as per the NRC protocol. No deaths have reported during the reference period. Registers were well maintained.

Immunization:

  • From April to September 9016 immunization sessions were planned, in that 8546 sessions were held.
  • Alternative vaccine distributors are identified at district level, who is distributing the same to concerned sub-centers. Visited PHCs are having enough vaccines for immunization. Micro plans are prepared by the ANMs and will be submitted to the DH office.
  • From April to August antigen coverage is BCG 47 per cent, DPT Polio 37 per cent, Measles 39 per cent, Hepatitis B 29 per cent is being covered.

RBSK

  • Under RBSK Total 3 teams were constituted and working since 2013 consisting of 2 MOs (Ayush), 2 staff nurse, however not yet reported.

Family Planning

  • Spacing method and limiting methods are followed in the district for family planning. In the visited district hospital staff is trained in Laparoscopy sterilization, however, due to lack of equipment the laparoscopy services are not being done. Therefore students are not getting the exposure of the same.
  • In the visited PHCs even though OT room is available, sterilization is not being conducted due to lack manpower and equipment.

ARSH Services

  • There is no ARSH Clinic at District hospital, generally there is no awareness. At PHC, ARSH clinic is working on every Thursday. At sub-center level ANMs are giving ARSH services.

Infection control and Biomedical waste Management

  • General cleanliness in the District hospital unsatisfactory. Staff is having the awareness of color coded bin. Protocols are maintained by the staff. District hospital is having CSSD, all equipment are sterilized and supplied from the (CSSD).Bio medical wastes are managed by outsourcing the task.

IEC:

  • In the district hospital except family planning related IEC, rest of the IEC materials related to JSSK, JSY and MCH are displayed. Clinical protocols were maintained. In the visited PHCs and sub center all IEC related to programmes were displayed.

Clinical Establishment Act:

  • Karnataka Private Medical Act implemented in 2007. However registration under the Act started in 2011. There are stillmanyun-official private practitioners.

Referral transport and MMUs:

  • In the district hospital there are three Ambulances, one brought from JSSK, for which fuel cost is maintained under JSSK. The other two ambulances of the district hospital provide drop back facility on minimum charges.
  • In Kamatana PHC there is a ambulance, however there is no driver since four months. In the visited Sub center 108service is used to refer the cases to the higher facility.
  • Bidar District has 5 Medical Mobile Units. As per the prior plan unit will visit the villages, if the complicated cases found, patients are referred to the District hospital.

Functionality of ASHA:

  • Kits are replaced at the concerned PHCs. ASHAs are keeping demand on drugs in the monthly meeting. The Payment to ASHAs earlier was through cash, but now it is through A/C payee. A payment of ASHA is pending due to the non-availability of funds. ASHAs are referring most of the maternal cases.

Malaria:

  • In the district the Malaria cases shows the decreasing trend over the years. The disease is more prevalence in Hunnabadtaluka. There are no major issues regarding the staff position.

TB:

  • In the district total 16 DMC are working. In the district defaulter rate is high
  • All the health staff is made responsible for follow-up of each positive patient to reduce the incidents. ASHAs are made as DOTS providers.
  • The existing digital X-Ray machine is not functioning properly in the District hospital. Besides, to diagnose the spinal TB, there is a requirement of MRI scan machine
  • The private practitioners are not referring the positive cases to the DTC. No major issues regarding staff positions.

NLEP:

  • From 2008-09 to 2010-11 there was a decreasing trend in Leprosy. However, from 2010-11 onwards, there is a slight increasing trend has been recorded. Except the clerical post all the posts are working for NLEP

Non communicable Diseases:

  • PIP for Non communicable Disease has not yet submitted 2013-14.

HMIS and MCTS:

  • At visited PHCs and sub center HMIS entry is done by SDA and ANMs.
  • At district hospital there is no separate computer for HMIS/MCTS entry. PHC ANMs are used the MCTS generated report to track mother and child.
  • As expressed by the DPMO all ANMs have received the training on HMIS/MCTS, still they are unable to perform the task efficiently due to multi reasons. One of the key reasons is the age factor of some of the ANMs, unable to cope up with the computers.

Key Conclusion and Recommendations

In the visited district hospital all categories of positions Viz A, B, C, and D are shortage. General cleanliness in the District hospital unsatisfactory. In last two quarters 13 maternal deaths were occurred in the district in that 10 cases are reviewed 3 cases are pending. In the district hospital PNC ward was over crowded. As a whole the ward was poorly maintained. The space in SNCU is very congested. Staffs are trained in Laparoscopy sterilization, however, due to lack of equipment the laparoscopy services are not being done. The existing digital X-Ray machine is not functioning properly in the District hospital. Besides, to diagnose the spinal TB there is a requirement of MRI scan machine. Also it was reported that the private practitioners are not referring the positive cases to the DTC. As expressed by the DPMO all ANMs have received the training on HMIS/MCTS, still they are unable to perform the task efficiently due to the age factor.

  • Since SNCU is very congested there is a need to extend the space within the SNCU to avoid the current congested status. Also SNCU required to be up graded the from level -2 to level-3 to ensure the intensive care
  • PNC ward required to be up graded in terms of actual capacity to avoid the crowd and uncleanliness. This would also make sure the focused follow-up of neo-nates and the delivered women.
  • There is no proper arrangement to sit the clients in ICTC center in the district hospital. Therefore it shall be made more clients friendly by providing good infrastructure and privacy for the beneficiaries.
  • There is a need of functioning laparoscopy, digital X-Ray and MRI scanner in the district hospital to provide the service to the needy. This would also ensure the proper utilization of trained staff in this direction within the hospital.
  • Manpower at all the level (DH, PHC and SC) required to be filled where it is lacking. Optimum utilization of existing machines and equipment of the concerned facility can be ensured through this. This would also pave the way for right functioning of each level of facility that it is supposed to be.
  • General cleanliness in the district hospital requires special attention to prevent the secondary infections.
  • There is a need for convincing the private practioners to send the Positive TB cases to the public health set up to get the treatment free of cost.
  • Effective training is required on the part of ANMs to enhance the clarity of HMIS/MCTS

2. Introduction

Context and Methodology

The National Rural Health Mission (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. 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 October 23d to 26th 2013 in the Bidar district. Bidar District hospital, two PHCs and one sub center were selected for the field analysis. During the visit, discussion was held with DHO, district programme officers and heads and staff of District hospital, selected PHCs 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, Bidar earlier known as the Civil Hospital is established in the year 1978. The hospital serves the people of the district and also the rural people of the bordering villages of the neighboring state; Maharashtra and Andhra Pradesh. The Bidar Rural Institute of Medical Science (BRIMS) of the city is attached to this hospital. The Bidar Institute of Medical Sciences, Bidar was established vide G.O. No .HFW 511 2005, dated 22/01/2005 Thus the hospital is working as an autonomous unit since 2005.The bed strength of the hospital is around 350. It has specialized services in medicine, surgery, pediatrics, maternity, gynecology, ENT, skin diseases, ophthalmology, psychiatry, blood bank and dentistry. Apart from the District hospital, two PHCs one is Andoor PHC and another one is Kamtana PHC,( both are 24X7) were visited and a related (kolar) sub-center also visited in Bidar Taluka. The information and data are gathered in the order prescribed by the NHSRC. The specific objectives of the visits are as follows. 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
  1. State profile and District profile:

Population of Karnataka state is 6.11 crores with decadal growth of 15.60 per cent. Bidar is a predominantly rural district is situated in the northern part of Karnataka with an area of about 5,448 sq. km. In 2011, Bidar had a population of 1,700,018 of which male and females were 870,850 and 829,168 respectively. The population of the district constitutes around 3 percent of the total population of Karnataka state. (Table 1) The district has 5 blocks covering 631 villages with average density of 312. Sex ratio of the district is 931.

4. Key health and service delivery indicators

IMR of Bidar district is 20, NMR is 86%, MMR is 80, OPD (all) is 4680 per day, IPD is 295 per day, ANC is 3400 per month, and Immunization is 90 per cent. Out of the total deliveries 83 per cent PNC taken in the institution from April to August. Un met need of sterilization and IUCD is 6 per cent each and oral pills is 18 per cent up to September 2013.

5. Health Infrastructure

Bidar District has a District hospital with Medical College. FRUs are 5 (One at District level and 4 at taluka level) The number of CHCs are 7 (all in govt building) PHCs are 51, out of which 44(86%) are in government building. All PHCs are 24x7 PHC.SCs are 270 in which 231(85%) are in government buildings. There are 2 Ayurvedic hospitals, Ayurvedic dispensaries are 16, Unidispensaries are 6and homeopathy dispensaries are 3.All the health facilities are constituted Arogya Raksha Samiti. There are 17 ICTC centers in the District. All the villages are having VH&SC.

The District hospital is a very old building, working as civil hospital earlier and later up graded as Bidar Rural Institute of Medical Science in 2007( BRIMS). Total numbers of beds are 400. Hospital is easily accessible from the nearest road head. However the road towards the hospital is poor. Help desk is functional. The facility has Electricity with power backup. Water supply is regular. There are separate toilet facilities for male and female, but not maintained properly. The condition of the labour room is poor. There is no attached toilet in the labour room. Functional new born care corner and functional new born stabilizer unit are existing. There are separate wards for males and females. Complaint box has kept in the entrance of the hospital. ICTC and PPTCT centers are functioning. However in ICTC it is noted that there is no proper place and chair to sit for clients. A new hospital with 350 beds are sanctioned recently

6. Human Resource

At the district level, out of 54 sanctioned posts of MOs, 52 are in position. Of the 14 sanctioned office superintendents post only 3are in position. Female health assistant, sanctioned posts are 63 and working is 54. The sanctioned post of Male health assistant is 204 and 168 is working. Out of 137 sanctioned post of Staff nurse working is 68 only.