National Rural Health Mission

Haryana

Programme Implementation Plan 2013–14

A Report on

Quality Monitoring of Mewat District

By

Population Research Centre

Panjab university

Chandigarh

January, 2014

Contents

1 / Executive Summary / 2
2 / Introduction / 5
3 / State Profile and District Profile / 5
4 / Key Health and Service Delivery indicators / 6
5 / Health Infrastructure / 6
6 / Human Resources / 8
7 / Other Health System Inputs / 9
8 / Maternal Health / 10
8.1 / ANC and PNC / 10
8.2 / Institutional Deliveries / 11
8.3 / Maternal Death Review / 11
8.4 / JSSK / 11
8.5 / JSY / 12
9 / Child Health / 12
9.1 / SNCU / 12
9.2 / NRCs / 13
9.3 / Immunization / 13
9.4 / RBSK / 14
10 / Family Planning / 14
11 / ASRH / 15
12 / Quality in Health Services / 15
12.1 / Infection Control / 15
12.2 / Biomedical waste management / 15
12. / IEC / 16
13 / Clinical Establishment Act / 16
14 / Referral transport and MMUs / 16
15 / Community processes / 17
15.1 / ASHA / 17
15.2 / Skill Development / 18
15.3 / Functionality of ASHA / 18
16 / Disease Control Programme / 18
16.1 / Malaria / 18
16.2 / TB / 19
17 / Non communicable Diseases / 19
18 / Good Practices and Innovations / 19
19 / HMIS and MCTS / 19
20 / Untied Funds and AMG / 20
21 / Supervisory Visits / 20
22 / Household Visits / 21
23 / Key Conclusions and Recommendations / 21

1Executive Summary

As part of the monitoring exercise of NRHM of Haryana 2013-14, this is a condensed report of the monitoring in district Mewat. District Mewat was visited towards the end of 2013. In the District hospital Mandikhera, CHC Punhana, PHC Nagina and Sub centre Indana were visited.

Health Infrastructure

  • District hospital is a 100 bedded hospital and provides services in Obstetrics andGynaecology, Paediatrics, Medical specialist, Ophthalmology and General Surgery.
  • Facility for ultrasound,X-ray and a wide range of laboratory services are available.
  • Provision for treatment of cancer patients and a special chemotherapy room exists.
  • Staff quarters are available for some Medical Officers. Staff quarters for Staff nurses and for other categories of staff are available within the premises of the hospital.
  • CHC Punhana and PHC Nagina are functioning in a government building and having all the basic amenities. Both are 24x7 delivery points.
  • SC is functioning in a rented one room building.

Human Resource

  • Severe crunch of regular medical officers and staff nurses in GH, CHC and PHC. Most of staff nurses working in these facilities are on contract.
  • Shortage of other para medical staff like Lab technicians, Pharmacists and MPW (M).
  • No standardized mechanism to monitor the performance of the contractual workers except the routine work assigned to them and the daily attendance at the facility. The contract of all the contractual staff is renewed annually.
  • Medical and para medical staff have attended a number of training programmes at district and state level to strength and upgrade their skills.

Maternal Health

ANC and PNC

  • Proportion of women registered for ANC within the first trimester is low-26 percent.
  • Among the important components of ANC (except for TT) Hb, BP and abdominal check up are not carried out.
  • Reverse tracking of severe aneamia not initiated.
  • PNC is a neglected area. Stay in the hospital is for 3-4 hours only. Very few stay beyond 48 hours.

Institutional Delivery

  • Proportion of institutional deliveries during the first two quarters was 37 percent and home deliverieswere 63 percent.
  • Proportion of public institutional deliveries is more 82 percent as against private institutional deliveries which is 18 percent.
  • Mostly normal deliveries have been conducted and only 5 caesarean deliveries were done from April to September even though a regular gynecologist is posted there .
  • Complicated deliveries are referred to Syed Hasan Mewati Medical College which is 26 kms from GH Mandikera.

Maternal Deaths

  • Number of maternal deaths recorded in two quarters was 29 and review of these is yet to be undertaken

JSSK

  • JSSK entitlements are provided to the beneficiaries in the delivery points.
  • Free pick up and drop back transport facility, free and cashless delivery, free C-section, free drugs and consumables, free diagnostics, free diet during stay at the facility and free provision of blood are provided.
  • At CHC and PHC milk, eggs and bread are made available to the patients in the post natal ward. Since the stay at the facility is less,very few avail free diet and the drop back transport facility.

Child Health

SNCU

  • The district hospital has an eight bedded SNCU manned by a paediatrician, 2 MOs and 9 SNs.
  • Most of the sick new born are out born. Twenty one newborns in each quarter were referred to higher facility.
  • Forty percent of the newborns are low weight babies, i.e. less than 2500 gms at the time of admission.

Immunization

  • Proportion of fully immunized children is low- 33 percent for two quarters
  • Dropout rate is rather high – 45 percent from BCG to DPT for both the quarters
  • Micro plan have been prepared and it is being followed.
  • VHND is not being organized in some of the visited facilities.

Family Planning

  • Acceptance of permanent method is low.
  • IUD is the most widely accepted.
  • Acceptance of PPIUD is low.
  • With the availability of regular gynaecologist in the district, camps are being held at different facilities.

ARSH

  • ARSH has been implemented in the district hospital.
  • Outreach programmes are being conducted.
  • WIFS is distributed to the adolescents girls.

.

  • RBSK
  • RBSK have started from Dec 2012. A team visits government school and screen approximately 100 students everyday.
  • Dental caries is found to be the most common problems among school going children.
  • One of the problem faced by the teams is non-availability of transport facility for visiting schools in their area.

Referral Transport

  • The district has 16 ambulances, one ALS and 2 MMUs.
  • Due to connectivity problem of 102 an alternate toll free number has been given which has been widely publicized.

Community Processes

  • The required number of ASHA is 1050 and 917 are in place. Shortfall of ASHAs varies from 16 percent to 50 percent in the visited facilities.
  • All the ASHAs have received training up to Module 5.
  • Some of the ASHAs have undergone second round of HBPNC training and they have received the drug kits.
  • Monthly earnings of the ASHAs range between Rs 2000-2500.

Non Communicable diseases

  • NCD cell is functioning in this district,
  • Most common problems identified are hypertension and diabetes.

2Introduction

As part of the monitoring of NRHM activities in the state, Population Research Centres were entrusted monitoring of PIP in their respective states to review the activities in the selected districts by Ministry of Health and Family Welfare, Government of India. The districts have been allocated by the Ministry in consultation with NHSRC, The present study has been conducted in Mewat district. The health facilities selected in Mewat district are District Hospital MandiKhera, Punhana CHC, Nagina PHC and Indana SC. The field work was done during the third week of December2013. Apart from this, 10 JSSK beneficiaries were interviewed and for household level interviews, 10 households each with pregnant women and 0-6 years age group children were interviewed from the study area.

3State Profile and district profile

In state of Haryana there are 21 districts, 119 blocks, 154 towns and 6841villages. The totalpopulation of Haryana is 25,351,462 (2011 census) of which male population is13,494,734 and females are 11,856,728. The sex ratio in Haryana is 879 which is below national average of 940 and is the lowest in the country. Literacy rate in Haryana has seen upward trend and is 75.55 percent. Density of Haryana is 573 per sq km.

Haryana / Mewat district
No. Districts / 21
No. of Blocks / 119 / 5
No. of Villages / 6841 / 431
Population (2011) / 2,53,51,482 / 10,89,406
Literacy / 75.55 / 56.1
Sex Ratio / 879 / 906
Density of Population / 573 / 561

Source: Census of India 2011

Mewat district is located at southern edge of Haryana. It came into existence in 2005 prior to which it was under the administration of Gurgaon. The district is bordered by the districts of Gurgaon, Rewari, Faridabad and Palwal. The main centre of administration is the city of Nuh. The district of Mewat is also known as the ‘Land of the Meos’ which are found in huge numbers in the region.At present Mewat district consists of four tehsils and one Sub-tehsil. As mentioned in the above table, there are 5 Blocks and 431Villages

4Key health and service delivery indicators

The CBR in the state is 21.6 (SRS, 2013) and the TFR is 2.5and the Infant Mortality rate is 42 and child mortality 13.2 (FW Year book, 2011). According to the latest estimates given by Guilmoto and Rajan (2013 (Fertility at the District level in India Lessons from the 2011 Census EPW Vol. XLVIII No 23 June, 2013) the district CBR is 38 an the TFR ( 2011) is 4.9 which are the highest in the state.According to the HMIS data (April – September, 2013) the sex ratio at birth in the district is about 913 females per thousand males. The HMIS data (April-September2013) of the district shows that ANC first trimester registration is very low, i.e.26 percent and nearly 12 percent of all ANC registrations are JSY beneficiaries. In the district 37 percent deliveries are institutional and 63 percent are home deliveries. The share of institutional deliveries is more in public hospitals than private institutions. The number of caesarean section deliveriesare very less. Only 5 caesaran section deliveries were done during first and the second quarter.

5Health Infrastructure

The health service delivery in the public sector is rendered through one District Hospital,three CHCs,13 PHCs, 84 Subcentres to cater the population of the district.Most of the health facilitiescover a large population much more than the norms. On an average, CHC caters to a population of 3.5 lakhs, PHCs cover population of one lakh and the sub centre’s covers more than 10,000 population. Thus the district requires more facilities for adequate coverage of population. During the visit to Mewat in July 2012 it was found that 46 sub centres are being constructed and till December, 2013 none of the sub centres have been made operational.

District Hospital Mandikera – TheAl- AlfiaDistrict Hospital is located in Mandikhera which is about 20 kms away from district headquarter Nuh. The hospital is situated on the Gurgaon – Alwar highway and is easily accessible. The hospital is 100 bedded and the building is in good condition. Basic amenities like electricity and 24x7 water supplyis available. However the power back up is not reliable and it was observed that there were frequent power cuts and the hospital is in complete darkness and subsequently the water supply is also affected. There is provision for separate toilet for males and females. Staff quarters are available for some Medical Officers. Staff quarters for Staff Nurses and for other categories of staff are available within the premises of the hospital. The hospital has septic and aseptic labour rooms. This hospital provides cancer treatment and there is facility of chemotherapy in the hospital. This DH provides services in surgery, Obstetrics and Gynaecology,emergency care, ophthalmology, medicine,limited family planning services, radiology and pathology. There is a blood bank unit in the hospital. There is an ARSH clinic and a functional 8 bedded SNCU. AYUSH services are also available.

PunhanaCHC is situated in Punhana block of Mewat district. The catchment population is 3,57,601 and it covers 123 villages of the district. The health facility is easily accessible and it functioning in a government building with adequate facilities. Staff quarters are available for the Medical Officers, staff nurses and other categories of staff within the premises of the hospital. Adequate water and electric supply is ensured in the facility. The facility of power back up is not available, although the process has started. In the CHC there are only 18 beds. Separate toilets are available for both males and females. Cleanliness of the facility is good. The CHC is functioning as 24x7 delivery point. Wards are kept clean for both males and females. The citizen charter has not been displayed at the CHC. The complaint box is available in the facility. For the waste management system, the facility has constructed a pit. The facility has a functional New Born Care Corner.

Nagina PHC is situated at a distance of 2 kms from the GH and about 23 kms from the CHC Ferozpur Jhirka. The catchment population of this PHC is78, 209 and it covers 41 villages. The health facility is easily accessible from nearest road and is functioning in a government building. Staff quarters for MOs are available but due to shortage of staff quarters the staff nurses are staying in them. Adequate water and electric supply with power back upis available in the facility. Common toilets are available for both males and females. The centre is functioning as a 24x7delivery point and also has a new born care corner. Waste disposal is done using pits.

Indana SC - This sub centre is under Singar PHC. Catchment population of the area is 9863. It is about 5 kms away from PHC and is 15 kms away from CHC and about 36 kms from District Hospital. It is functioning in a rented building. Only one room is available for the SC and it has electricity and water supply. Approach road have no sign boards showing directions of the SC. Neither residential quarter is available for ANM nor is ANM residing at the SC. No complaint /suggestion box is available. No pit is made. Waste is disposed in PHC.

6Human Resources

District Hospital Mandi Khera - There is an inadequacy of medical officers in the district hospital. Out of the 42 sanctioned posts of MOs, only 30 are in position. Out of 30 MOs, 7 MOs have been deputed to various PHCs/CHCs and two MOs are absent from duty. There are Obstretics and Gynecologist, Anaesthetist, Pediatrician, medical specialist, General Surgeons, and other specialist in the hospital. There are two dental surgeons,two Pharmacists and one radiographer. One post of Pharmacist and one of Radiographer is vacant. There is an acute shortage of nursing staff in the District hospital. Out of 24 sanctioned posts of regular staff nurses, only two SNs are in position and the remaining 22 posts of SNs are vacant. Six contractual staff nurses have been hired. There are 5 posts of nursing sister for the GH and only two posts of nursing sister are filled. All the five posts of regular lab technicians are vacant. Lab technician are either working on contract or DC rate. There is no standardized mechanism to monitor the performance of the contractual workers except the routine workassigned to them and the daily attendance at the facility. The contract of all the contractual staff is renewed annually.

Under NRHM, several training programmes are organized for medical and para medical staff at district and state level from time to time to strength and upgrade the skills of number of medicaland other para medical staff. Information regarding the training status of the human resource reveals that four and two doctors have received EmoC and BemoC training respectively. Other trainings received by doctorsare F-IMNCI, NSSK, SBA, IUD and PPIUCD.One doctor has received Mini lap training.

AtPunhanaCHC a total of two doctors (one LMO and another MO) and 4contractual staff nurses are working in the CHC. The post of Dental Surgeon is lying vacant. There isone AYUSH MO appointed on contractual basis. Apart from this, 2 AYUSH MOs have been appointed for RBSY. Regular post of pharmacists and Laboratory techniciansare vacant and the posts of 2 Lab technicians and one Pharmacist have been outsourced and are working in the CHC. The post of one LHV, one HI and one radiographer are filled. Two posts of sweepers are and one Class IV is filled. LMO has attended EmoC andPPIUCD training. All the staff nurses posted in CHC are SBA trained, one F-IMNCI and three are NSSK trained. One staff members in the facility got training in handling immunization and cold chain mechanism. In the first quarter of the financial year 4917 out patients utilized the facility and 9241 in the second quarter. There were 232 in-patients in the first quarter and 460 in the second quarter. During the first quarter 652 pregnant women were registered,403 women were given IFA tablets.In the second quarter 403 women were registered and 141 were given women IFA tablets.

Nagina PHC –In the facility 2 posts of MOs are sanctioned but one MO is deputed to CHC Ferozpur Jhirkra and one MO isposted in the PHC itself. There is one Dental Surgeon 3 contractual SN,one Pharmacist, one LT, one LHV and one HI. Among the para medical staff there are 6 regular and 8 contractual ANMs. Regarding the training status of the staff, some of SNs are SBA and NSSK trained. The Health Inspector is trained to handle cold chain. The OPD attendance for the first quarter was 4312 and for the second quarter it was 7108.

Indana SC–There is no regular ANM in this centre. One RCH ANM and one ANM on DC ratesare working to cater to the need of the sub centre area. ASHA workers are also appointed in the villages and one ASHA was present in the SC on the day of the visit.

7Other health System inputs

District Hospital Hisar- This is a 100 bedded hospital. There were 53661 patients in OPD and 3264 patients in the IPD in the last two quarters. OPD are functioning on the ground floor of the hospital main building. All the essential drugs and consumables are available in the pharmacy. All the essential equipments in the OT and laboratory are available except a ventilator and one OT lightwere not functional. There is no functional CT scanner in the hospital.