NRHM-PIP Monitoring for Koppal District, Karnataka
C M Lakshmana
C Yogananda
Population Research Centre
Institute for Social and Economic Change
Bangalore-560072
January, 2014
NRHM-PIP Monitoring for Koppal District, Karnataka
January, 2014
Executive Summary
This report is a part of PIP monitoring work (NRHM), assigned by the Ministry of Health and Family Welfare to Population Research Centre, ISEC, Bangalore. As per the guidelines and instruction given by the Ministry of Health and Family Welfare, Government of India, the field work has been conducted in Koppal District of Karnataka during first week of January 2014. The specified check lists and questionnaires have been used to gather information. The information provided by the designated health staffs like DHO, DPMO, District Surgeon as well as the respective Medical Officers of Gangavathi Taluk Hospital, CHC of Sriramanagar (Gangavathi Taluk), PHC of Hitnal and the SC of Hulgi (Koppal Taluk), the major findings and observations have been made on the various components of NRHM on PIP. Conclusions and recommendations have been drawn at the end.
Findings and Observations
By and large the existing physical infrastructure in terms of buildings and equipments in Koppal District is adequate, but the available human resource is moderate. About 162 staff nurses are working under contractual appointment. However, about 16.21 per cent and 22.22 per cent of regular SNs and Pharmacistposts are vacant in the district. All SDHs, CHCs and PHCs are functioning in government building. And about 45 SCs (33 %) out of 175 in the district are functioning in rented building.
Electricity with power back up, running 24*7 water supply, separate Toilets for Male/Female etc., are available in the selected health institutions.SNCU is available in the district hospital of Koppal, but, it is not been functioning due to non-availability of required health staff. On the other hand NBSU is not Functioning in CHC/PHC. Staff quarters are available in DH/SDH and PHC.But, this facility is not available for any health staff including medical officer (MO) at the CHC of Sriramanagar. It is found that there has been a lack of maternity wards and health specialists like Anaesthetist, OBG, and Surgeons in DH of Koppal.Further, there is about 8 per cent (162/154) of excess SNs under contractual appointment for 24*7 PHCs in the district.
Training status among the health staff in various health skills is reasonable good. Almost 90 per cent of the health staffs in the district havetrained in one or the other health skills. However, when it comes to a particular training such as BeMOC, EmOC, LSAS and NSV is totally weak in the district. More or less, most of the health equipments including O.T. are available in the selected health institutions. But due to shortage of man power some of which are not in use.
Essential drugs and it supply in the district is absolutely no problem. However, there is shortage of drugs for hypertension, Diabetes and common ailments in district hospital. IFA tablets (blue) are not supplying to any health institutions in the district. Similarly, there is no adequate supply of IFA Syrup, Zink and ORS packets to the various health institutions. Supplies of essential consumables like Gloves Pads and gauze are sufficient in the selected health institutions.
Except LFT, Endoscopy the other general lab services are available in the district hospital. However, except Serum Billirubin test and RPR the remaining lab services are available in CHC of Sriramnagara. The CBC, Serum Billirubin test and RPR are not available in PHC of Hitnal. Apart from this the Blood Bank/Blood Storage Units are functioning in the district hospital. But the available blood bags are insufficient in the district hospital.
Service utilization in OPD and IPD in the selected health institutions in the last two quarter has witnessed for decreasing trend in the district. Over a period of time there has been significant increase of institutional deliveries in the district. It is almost 94 per cent. In which about 71.81 per cent of deliveries were conducted at public facilities and 20.41 per cent at private health facility.
District health administration has tie up with Thayi Bhagya scheme with private hospitals with regard to institutional deliveries. Proportion of C-section deliveries is about 2 per cent of the total institutions deliveries in the district. It is important to note here that due to non availability of Anaesthetist and surgeons in Koppal District even at private facilitiessome of the C-section deliveries have been referring to either District Hospital of Raichur or Bellary.
All essential skill set under quality parameters of the facility are available in the district hospital. High risk pregnancies and Sick neonates have been referring to district hospital from CHC and PHC due to non availability of health specialists.
Maintenance of registers like OPD, IPD, ANC, PNC, Drug stock and referral etc., were found available in the selected health institutions and up-to date service information has been recorded. The expenditure like AMC, untied funds and RKS is higher (almost 90 per cent) at PHC and SC level as compared to DH and SDH (80 per cent).
Referral transport by 108 vehicles has been available and utilized properly in the district.As per the protocol most of the IEC Display materials have found available at the district hospital as well as at CHC/PHC. But the majority of the IEC displays were not seen at the selected SC of Hulgi of Koppal Taluk.
Additional support services such as Regular Fogging, Washing service, Grievance Redressal mechanisms etc., are being regularly done in the district hospital. Washing service and grievance redressal mechanisms have not seen at CHC of Sriramanagar. However all additional support services were found in PHC of Hitnal. Supervisory visits were reported time to time in the selected health institutions in Koppal District by the various officials such as ASHA state consultant, DHO, DTO and THOs in the district.
A noticeable fact is that as per the observation and information gathered from the visited health facilities in the district we did not found any malpractice and irregularities in the visited health institutions of the district which includes the district hospital.
NRHM-PIP Monitoring for Koppal District, Karnataka
1. Introduction
Koppal District is one among the northern districts of Karnataka which has identified as high focused district in terms health indicators. Hence, in order to monitoring the NRHM/PIP in Koppal District information on physical infrastructure, human resource as well as the various service delivery parameters such as maternal health, child health, Family planning, community services, JSSK, JSY and quality health care etc., have been collected from the selected health institutions by the designated health staff like District Health Officer (DHO), District Programme Managing Officer (DPMO) and District Surgeon of Koppal. Apart from this we also gathered information from the selected health institutions of SDH of Gangavathi, CHC of Sriramanagar(Gangavathi Taluk), PHC of Hitnal (Koppal Taluk) and the SC of Hulgi in Koppal Taluk. Based on the field work observations the findings and recommendations have been drawn for the study. Please refer Table 1, for general information on selected health institutions of the district.
2. State Profile and District Profile
Karnataka State is located in the southern part of India. Geographically it has four natural regions such as northern maidan, southern maidan, west and coastal regions. The total geographical area of the state is 1,91,791 sq.kms. As per 2011 census the state has 30 administrative Districts and 177 sub divisional Taluks with a total population of 61.13 million (Table 2). The total literacy rate of Karnataka is 75.36 per cent; density and sex ratio are 319 and 943 respectively. The Koppal District is one among the backward districts of Karnataka located in the northern part of the state is also known as Hyderabad-Karnataka region (Fig 1). It has 7189 sq.kms of geographical area comprising of 4 sub divisional administrative blocks with a total villages of 596. As per 2011 census the district has a total population of 13, 91,292 comprising of 16.81 per cent of urban and 83.19 per cent of rural population in the total population. The man-land ratio of the district is 250 per sq.kms. There are 983 females per every 1000 males. The child sex ratio of the district is 957. It is above the state average of 948. The District has 3.74 per cent area and 2.28 per cent of population of the State.
As per 2011, the total literacy rate of Koppal District is 67.8 per cent and the female literacy rate is below the male literacy at 25 percentage points. The proportion of male/female is almost equal in the total population. Although, the percentage of SCs and STs in the total population is 31 per cent, and similarly the percentage of children population (below 6 years) in total population is almost 15 per cent. There is about 55.65 per cent of agricultural
Table 1: General Information on Selected Health Institutions of Koppal District.
Sl. No / Name of the Health Institution / Name of Block / Catchment Population / Total Villages / Distance from head quarter KM) / Date of last Supervisory visit1 / District Hospital / - / 13,92,000 / 596 / - / 6.01.2014
2 / Sub-District Hospital (Gangavathi) / Gangavathi / 406334 / 148 / 60 / 7.01.2014
3 / CHC (Sriramanagar) / Gangavathi / 23,843 / 11 / 65 / 7.01.2014
4 / PHC (Hitnal) / Koppal / 39,000 / 11 / 20 / 8.01.2014
5 / SC (Hulgi) / Koppal / 7,354 / 1 / 4* / 8.01.2014
*Distance from PHC
Fig 1: Location Map of Koppal District in Karnataka-India
labourers in the total main workers in the district. The total numbers of public and private health institutions in Koppal District are 288 and 62 respectively. The available beds and doctors ratio per lakh population is 87. The share of private hospitals in terms of health institutions of the district was almost 21 per cent (62 in numbers).
3. Key Health and Service Delivery Indicators
According to SRS the TFR of Karnataka was 2 and CBR, CDR, IMR, NMR and MMR of Karnataka were slightly below the national average of 21.8, 7.1, 44, 31 212 respectively. During the decade 2001-2011 the CBR was declining from 22.2 in 2001 to 18.8 in 2011. Similarly the CDR has declined to 6.9 in 2011 from 7.6 in 2001. There is a gradual decline of IMR with 35 per 1000 live births in the year 2011 as compared to 58 in 2001. Even MMR also declined from 228 in 2001 to 178 in 2011. However, the reported TFR and CBR of Koppal District have shown above the state average of 2 and 18.8 respectively in the year 2011. On the other hand the reported CDR and IMR were below the state average of 6.9 and 35 respectively. The skilled birth attended (SBC) in the district was 17.2 per cent, it is below the state average of 20 per cent. However, the immunization and un-met need for family planning was shown in the district with 73.3 and 22.6 per cent respectively as against to the state average of 41.7 and 17 per cent respectively (Please refer Table 3).
A comparative service delivery indicator for selected health institutions for the period of first quarter (April-June) and second quarter (July-Sep) for the year 2013-2014 has been presented in annexure 3.1. There is a gradual increase of OPD patients with 9 per cent and 2 per cent respectively for SDH and PHC.But this trend has seen decreasing with minus 11.81, minus 72.45, minus 19 and minus 7.7 percentage points respectively for DH, SDH, CHC and PHC. There was an increased trend for ANC 1 registration in DH, SDH and CHC, but it has decreased at PHC level between the two quarter periods. Total deliveries conducted at DH were 279 in the first quarter which decreased to 213 in the next quarter. The total deliveries conducted in SDH of Gangavathi were higher than the DH of Koppal (591 in the first quarter and 603 in the next quarter). Similarly C section deliveries conducted at SDH were also higher than the DH. Further details please refer annexure 3.1 to 3.4.
4. Health Infrastructure
According to the field observation and information provided by the visited health centres of Koppal District has shown that by and large the overall physical infrastructure in terms of buildings is quite good. Except few SCs almost all health institutions are running under government buildings. No complaints have been received in this regard. The available place for health service at the selected health centres in the districtis adequate. However, as per the available information the staff quarters are not available to the health staff in CHC of Sriramnagar. And further, more or less electricity with power back up and 24*7 water supplies is available in all the visited health institutions. Similarly clean toilets separate for males and females are available in all the visited health centres. SNCU and NRC are not been functioning in District Hospital. Functioning of NBCC and NBSU are available at CHC and PHC. But available facility is inadequate. Functioning of clean labour room, clean wards, availability of mechanisms for biomedical waste management etc., have been managed well in the district hospital. There is no separate room for ARSH clinic in the respective health centres.
Table 2: Key Population and Socio-economic Indicators of Karnataka and Koppal
District.
Source: DLHS -II 2004 and DLHS- III (2008) Fact sheet.SRS Bulletin 2001 and 2011 and EPW, Fertility at the dist level in India, Guilmoto, S Irudaya Rajan, June 8, 2013
HMIS, 2012-2013.
5. Human Resource
The existing health staffs in Koppal District as a whole is quite moderate. However, there are some vacant positions in regular SNs, Lab. Technicians and Pharmacist. This could be seen in Annexure 1.The short fall of regular SNs in the district as whole is 16.22 per cent, MPH supervisors Male and Female is both at 25 percent. Pharmacist is about 22 per cent and Lab Technicians is 8.47 per cent and Multi Purpose Health Worker Female is 17.71 per cent. However there are also vacant positions of Surgeons, OBGs and Paediatricians. In general their number is marginal but, in percentage it has shown huge shortage. A similar shortage of various health staff has been observed in the selected health institutions of Koppal District. And, generally it has shown that there is no much shortage of health staff at SDH, CHC as well as in PHC except SNs, Lab Technicians and Pharmacistin the total sanctioned post. (Annexure 2). Further, it has found that in all the visited health institutions there are no separate staffhas been employed for HMIS work. Similarly, there are no separate staffs for NBCC/NBSU at SDH/CHC. It should be note that in the selected SDH and CHC the available health staffs are handling more than one responsibility due to shortage of hands. Further it is important to note here that according to MO of Ganagavathi all SDH in Koppal had upgraded as FRU. But in reality the concept of FRU i.e. full pledged RCH services are not available in the respective health institution. Due to non availability of Anaesthetists and OBG in SDH and CHC the majority of the cases have been referring either to District hospital of Bellary or Raichur.
Table 3: Key Demographic Health and Delivery indicators of India by States and District 2001 and 2011.
Sl.No / Indicators / Karnataka / Koppal2001 / 2011 / 2001 / 2011
1 / TFR / 2.4 / 2.0 / 2.80 / 2.9
2 / CBR / 22.2 / 18.8 / 23.2 / 22.8
3 / CDR / 7.6 / 6.9 / 6.0 / 5.95
4 / IMR / 58 / 35 / 88.7 / 20.5
5 / NMR / 24
6 / MMR / 228 / 178 / 89.94
7 / OPD / 46836197 / 1113030
8 / IPD / 2416945 / 81697
9 / ANC / 29.6 / 1463352 / 24.4 / -
10 / SBA / 20.7 / 14719 / 20.1 / 17.2
11 / PNC / 680316 / - / 44.6
12 / Immunization / 71.3 / 1180438 / 41.7 / 73.3
13 / Un-met need for FP / 15.1 / 15.8 / 17.1 / 22.6
Source: DLHS -II 2004 and DLHS- III (2008) Fact sheet.SRS Bulletin 2001 and 2011 and EPW, Fertility at the dist level in India, Guilmoto, S Irudaya Rajan, June 8, 2013
Note: SL No. 7 to 12, HMIS.
6. Other Health System Inputs
Basically, the Koppal city in particular and District in general does not have any super speciality hospital or women hospital in providing specially care services including Surgery, Medicines & Gynaecology, cardiology, emergency Trauma care. However, there are about 10 private nursing homes are running in Gangavathi Taluk. There is no exclusive maternal and child health hospital in the district. Blood Bank and Blood storage facility is available at DH, but there is a shortage of Blood bags. Interestingly it is important to note here that due to shortage of medical officers (MBBS doctors) about 65 per cent of PHCs are run by AYUSH doctors. Re. 2 and Re.10 has been collecting respectively for OPD in DH as user fees. Similarly user fees of Re. 5 and Re. 40 has been collecting for OPD and IPDin SDH of Gangavathi. However, the user fees is not been collecting at the visited CHC/PHC.
7. Maternal Health
7.1 ANC and PNC
The district target of ANC registration for the year 2013-2014 was 35195 and the reported registrations were 25134. The achievement is 71 per cent in the target. Similarly the achievement of ANC registration within 12 weeks was 84.35 per cent (25134) in the total. The target of ANC registration at DH was 1794 and the achieved progress was 838 (47 per cent). Similarly the registered ANC in District Hospital within 12 weeks was 86 per cent in the target. MCTS entry at CHC level was 100 per cent. The trend of OPD and IPD in the district hospital between the last two quarter has seen decreasing trend at minus 6.31per cent and 11.81 per cent respectively. But, this trend has seen increased at 9 per cent and 38 per cent respectively in Taluk Hospital for OPD and IPDin SDH of Gangavathi.The ANC coverage in all the selected health institutions has been increased over time. Similarly pregnant women given IFA tablets havealso been increased both at SC, PHC and CHC in the district. See further details in annexure 3.1 to 3.4.
7.2. Institutional Deliveries
The expected deliveries in the district hospital during the first quarter of April toJune 2013 were 42 which increased to 58 in the next quarter of July-Aug 2013. A similar trend was witnessed in CHC/PHC and SC level also. The trend in total deliveries conducted in the selected health institutions in Koppal District has shown the decreasing trend at DH with minus 23.66 per cent in the last two quarter. On the other hand the trend has increased at SDH of Gangavathi and some extent in CHC. However, total deliveries conducted at PHClevel was also decreasing. Coming to the particular aspect of institutional deliveries as per the record available at DH& FWO of Koppal in the year 2012-2013 around 94 per cent of deliveries in the total deliveries were institutional deliveries. In which about 80 per cent of deliveries conducted at government institutions and 20 per cent held at private health institutions. Increased deliveries at SDH of Gangavathi were more than double as compared to DH. A similar increase has seen in CHC of Sriramnagar (Annexure 3.1). And as per the information provided by DPMO of Koppal there is about 30 per cent of C section deliveries out of total institutions deliveries were reported in the district.