Monitoring Of Programme Implementation Plan

(PIP), District Prakasham, Andra Pradesh (For Quarter I, II and III, 2013-2014)

Dr. Shriprasad H.

Mrs. Manjula G Hadagalimath

Mr. Mallikarjun S Kampli

PRC Analytical Report Number: 18

Population Research Centre

JSS Institute of Economic Research

Dharwad, Karnataka.

January-2014

Acknowledgements

We are grateful and thank to the ministry of Health and Family welfare (Stat), Government of India, New Delhi, for giving us an opportunity to work on PIP and providing us financial support to carry out this study.

We express our sincere gratitude District Medical and Health Officer District training centre officer, District StatisticalOfficer, DPSHN of Prakasam Distrinct of Andra Pradesh, as well as for all District Progrmme Officers and team for their collaboration and support in complete the task. We are greatly thankful to DPO,all the Medical Officers and their staff members of Prakasam district for providing essential information and evidences in the course of our study.

We are greatly thankful to the Director and staffs, PRC Dharwad for their support and co operation. Special thanks to Mr. H R Channakki, Field Investigator of our office for helping us while doing field verification.

We also acknowledge the help of administrative staff of PRC, Dharwad, for secretarial assistance during this study.

The Authors

7th January, 2014.

Table of Contents

1Executive Summary ……………………………………………………………………………………………………….05

2Introduction...... 10

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

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

5Health Infrastructure:...... 11

6Human Resources...... 12

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

8Maternal health...... 14

8.1ANC and PNC...... 14

8.2Institutional deliveries...... 14

8.3Maternal death Review...... 15

8.4JSSK...... 15

8.5JSY...... 15

9Child health...... 15

9.1SNCU...... 15

9.2NRCs...... 16

9.3Immunization...... 16

9.4RBSK...... 16

10Family planning...... 17

11ARSH...... 17

12Quality in health services...... 17

12.1Infection Control...... 17

12.2Biomedical Waste Management...... 17

12.3IEC...... 17

13Clinical Establishment Act...... 18

14Referral transport and MMUs...... 18

15Community processes...... 18

15.1ASHA...... 18

15.2Skill development...... 18

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

16Disease control programmes...... 19

16.1Malaria...... 19

16.2TB...... 19

16.3Other Communicable Disease...... 20

17Non Communicable Diseases...... 20

18Good Practices and Innovations...... 21

19HMIS and MCTS...... 21

20Key Conclusions and Recommendations...... 22

21Annexure...... 23

  1. Executive Summary

In order to monitor the performance and status of the health facility under NRHM a field work has carried out during December16th to 21st 2013 in the Prakasam District of Andra Pradesh as per the instruction of MoHFW New Delhi. Different levels of health facilities viz, District hospital, MCH hospital, CHC, one PHC and a related sub center were visited in the district and interaction was made with the health officials. The prime findings and observations are documented below.

Health infrastructure

  • District hospital functioning in a new building with the capacity of 500 beds. Essential services are given but there is no ARSH clinic. Bio-medical waste management is out sourced.There is an exclusive hospital for MCH with 50 beds in the district.CHC is Functioning in a government building and condition of the building is good. All essential services are provided. PHC is working under government building.

Human Resource

  • At District level most of the key positions are vacant. District Medical and Health officer post is vacant. Of the 18 SPHO posts 45 percent is vacant. 50 percent of Radiographer and all lab technicians Gr. II posts are vacant. At district level, most of the maternal and FP related trainings were given. However PPIUCD training has not given for any staff. In the MCH hospital of the district, all the positions are filled. At CHC out of 28 sanctioned posts 43 percent is vacant. In the visited PHC most of the posts are filled. However there is no regular Lab Technician.

Availability of Drugs and Diagnostics, Equipment

  • There is no computer inventory management for drug stock in district hospital .Most of the other essential drugs and equipments are available. All Diagnostics are also available.
  • In MCH hospital emergency tray with emergency injections and MVA/ EVA equipment were not available. At OT functional ventilators, surgical diathermias, laparoscopies, C-arm units are not available. At the visited CHC, ILR and deep freezer and photo therapy unit are not available. Essential drugs are available. There is no computerized inventory management. In PHC most of the general equipments are available. There is no computer inventory management for drug stock.

Ayush services

  • There is no Ayush service at District hospital, MCH hospital and CHC.

User Fees and Charges

  • There is no user fee in the District hospital and MCH hospital. There is no high OOPS from patients.

Maternal Health

  • In the district hospital and in the visited MCH hospital Emoc facilities are available. In the visited CHC C section deliveries are also being conducted. In the visited PHC only normal deliveries are conducted. All tests related to ANC conducted in both district hospital and MCH hospital.
  • Line listing of severely anemic pregnant women was not found in any of the visited facilities.
  • From April to October 2013, 85 per cent maternal deaths cases were reviewed. The State Task Force has been formed to review the maternal deaths.
  • JSSK is implemented in the district hospital and in the visited MCH hospital and CHC. There is no JSSK in PHC. Display of IEC on JSSK was very poor.

Child health

  • SNCU is functioning in the district hospital. All instruments are available and maintained cleanliness. But there is a problem of manpower.
  • NRC is existed with only 2 rooms. There is no separate room for cocking. Average length of stay is 15 days. All are treated as per the NRC protocol. No death has reported.

Immunization

  • At District level all antigens are immunized twice a day. Area-wise ANM are conducting immunization according to the plan. To cover full immunization at district, immunization drive programs have been conducted in slums and in the areas of floating population. Visited PHCs are having enough vaccines for immunization. Micro plans are prepared by the ANMs accordingly the sessions were conducted.

RBSK

  • RBSK programme has not yet implemented in state as well as in district.

Family Planning

  • Spacing method and limiting methods are followed. Of the assigned target 62 per cent sterilization have been conducted for males and female. At the visited PHC, since last six months Tubactomy has not been performed due to the absence of the Surgeon.

ARSH

  • During the visit to the different facilities we have not find any ARSH clinic.Staff had no awareness on ARSH clinic as such.

Quality in health services

  • General cleanliness is poor in the district hospital. At DH and MCH hospital the wastes are found around the hospital. In the visited PHC only one color coded bin was found. Fumigation is done at district hospital, MCH, and CHC.

IEC

  • There is no IEC Materialsdisplayedin the visited District hospital at all.In the visited MCH hospital, CHC and PHC and sub center, only some of the IEC materials are displayed. No JSSK entitlements are displayed in most of the visited facilities

Clinical Establishment ACT

  • In AndraPradesh Clinical Establishment Act is known as‘AndraPradesh Allopathic Private Medical Care Establishment (registration and Regulation) Rules 2007’. Progress of regime under this is satisfactory.

Referral transport and MMUs

  • In the district hospital there are two Ambulances available, in MCH hospital there is one Ambulance. In most of the cases people used to prefer 108 services.There is no MMU service in the district.

Community Development

  • Available number of ASHAs is 90 per cent against the required number. There isan ASHA resource center with one ASHA mentor.Ashas are formed their own Union, they are demanding the fixed payment monthly.

Malaria

  • Prakasam district is area of high prevalence for Malaria. The trend in malaria shows a decreasing sign. In the District Malaria Office out 68 per cent of the sanctioned posts are filled.Drugs are in sufficient number. Some innovative measures were taken to control the incidence.

TB

  • Over the period, the TB indicators are at decreasing trend.Most of the staff positions are filled. At District level, MMR machine is not functioning, there is no regular technician to handle the machine. There is a need for DRTB ward at Medical College.

NLEP

  • Leprosy rate is showing a decreasing trend. More number of migrants is the major cause of Leprosy. Out of total sanctioned 66 per cent staffs are working. One separate ward is meant for the Leprosy cases at MCH hospital.

Non Communicable Diseases

  • PIP submitted on NCD for the financial year. All eighteen clusters are having NCD clinics. Training is given to the concerned staff. Of the sanctioned fund very less amount is utilized. State purchasing unit has not been supplied the drugs since last six months

Good practices and Innovations

  • There is an exclusive hospital for MCH in the district. Further, in CHC there is good community participation.

HMIS and MCTS

  • In the district all the clusters having data entry operators for HMIS and MCTS entry. They are trained on the same. Timeliness and completeness of data is ensured.
  • MCTS generated forms are being used to track the mother and child.
  • Despite the training to the ANM, the performance of HMIS and MCTS entry are poor.

Conclusions and Recommendation.

Since most of the key positions are vacant at District level, there is needed to take necessary steps by analyzing the actual staff position in the district.

MCH hospital being a specialized facility for MCH cares the fulfillment of basic equipment and surgical is a critical need of the time. Such approach would enhance the efficacy of the facility.

Computerized inventory management system need to be introduced at District hospital and visited CHC to ensure timely availability of the drugs and consumables. This would also minimize/prevent the probable high OOPS from the patients.

High priority shall be given for the general cleanliness. There is a need to educate the patients too in this direction by displaying the related IEC materials.

It was observed that none of the visited facilities displayed JSSK entitlements. Further in some of the facilities very less IEC of all kinds were observed. Therefore more instructions may be given to materialize the task.

In the district hospital it was reported that, as most of the patients are using 108 facilities for transport, the budget for transport facility is not very much necessary, instead hospital management asked more budget to be allocated for Dietary. Taking this sort of decision may result in judicial utilization of the allocated resources.

RBSK programme not yet implemented in the district as well as in the state. As per the requisition of government the action plan is prepared and sent to the concerned authority but not yet received any guidelines pertaining to the implementation of program. Therefore there is a need to provide guide lines at the earliest.

Despite the training being received by the ANMs the performance of HMIS and MCTS entry are not up to the expected level. More focused attention is necessary by the ANMs, which may be realized through offering training to the ANMs.

2. Introduction

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 December16th to 21st 2013 in the Prakasam District of Andra Pradesh.The district head-quarter is situated at Ongole.Prakasam (Ongole) District hospital, MCH hospital, one CHC, one PHC and a related sub center were selected for the field analysis. During the visit, discussion was held with Director of RIMS,DM&HO, district programme officers, 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

District hospital is functioning since 1970, with a capacity of 500 beds. In 2008 Medical College (RIMS) is established in the District.The hospital in the District is attached to the Medical (RIMS) College.Apart from the District hospital, one CHC at Addanki, one PHC (24x7)at Ethamukkala, one sub center attached to PHC was visited. Also a MCH hospital at Ongole was visited. The information and data are gathered in the order prescribed by the NHSRC. The specific objectives of the visits are asfollows.

  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. District profile

There are 7 Talukas in the district with 1083 villages. Total population of the district is 3392764, Male population is 1712735 (51 per cent) and female is 1680029 (49 per cent). SC population is 21 per cent and ST is 4 per cent. Density is 192. Urban population is 20 per cent. Literacy rate of the district is 63 per cent with female literacy of 53 per cent. Number of persons living below poverty line of the district is 55 per cent.

4. Key health and service delivery indicator

The state ratio of IMR is 43, MMR 134, TFR 1.8.Family Planning methods are followed by 65 per cent (DLHS3), CBR is 17.5 (2011)CDR is 7.5 (2011). Under 5 Mortality rate is 43(2011). Prakasam DistrictIMR is 44, MMR is 127, CBR is 19.20, TFR 1.75,under 5 mortality is 11.60 (FWS) SBAis 70 per cent.

5. Health infrastructure

Due to the rationalization in 2009, the total health system is decentralized in 3 tire structure.

1. District Medical and health office: All PHC and Sub- centers are working under the same

2. Director of Medical education: Rajiv Gandhi Institute of Medical Science (RIMS) and MCH hospital are working

3. Andhra Pradesh Vidhaya Vidhana Parishat (APVP): All 18 clusters and 2 Post Partum Units are working under APVVP.

Prakasam district has one District hospital with a medical college. There are Eight CEMOC and 3 Area hospitals. Six CHCs, all are up graded as FRU, All CHCs are working under government building. Number of PHCs in the District are 85, out of which 43 per cent are 24x7 PHCs. There are eight urban health centers.Out of 535 Sub-centers in the District Only 10 per are under non government building.

There are 12 private specialty hospitals, 9 maternity hospitals, apart from this there are 177 private dispensaries. There are 141 registered ultra sound clinics in the District.

District hospital is functioning since1970, recently the hospital is functioning in a new building with the capacity of 500 beds. Districthospital is providing all the essential services. There ispsychiatricdepartment, separate blood bank,dietary section. The general cleanliness is good. Only staff nurses are having the quarters. There is no ARSH clinic. Complaint/ suggestion box is not available. Bio-medicalwaste managementis out sourced.

There is an exclusive hospital for MCH, started in 1999 with the capacity of 50 beds. Health facility is nearest to the road head.There are quarters for the staff but not provided by hospital.NBSU is functional. There is a separate building for the laboratory, but condition is not good. Cleanliness is poor and rooms of the laboratory are very dark without proper ventilation and air. Wards are cleanly maintained. There is regular water and electricity supply.PPTCT is functioning.Complaint box is available.

In the visited CHC, health facility is accessible from the nearest road head. It is Functioning in a government building and condition of the building is good. However quarters are not available for the staff. Electricity with power back, water supply is regular. There are separate toilets for male and females. Labour room is clean and functional with attached toilet facility. New borne care corner is functional. Functional stabilization unit is available. There are separate wards for male and female, wards are maintained well. ARSH clinic and ICTC are functional. Bio-medical waste management mechanism is functioning. However the complaint/suggestion box were not available.

The PHC is function since 1951. Since 1972 it is under government building. The visitedPHC is nearest to the road and is functioning in the government building, whereas the condition of the building is not good. Quarters for the staff are not available. Electricity facility and supply of water is regular. Labour room is clean and functional with attached toilet facility. Functional stabilizer unit is available. There are no separate wards for males and females. Complaint box is available.

Sub center is located near to the road and functioning in a private building. Physical condition of the building is good. Electricity with power backup is available, where as there is no regular water supply. There is no complaint box in the facility.

6. Human Resource

At District level most of the key positions are vacant. For example, of the one sanctioned post, District Medical and Health officer post is vacant. Of the 18 SPHO 8 are vacant. 50 per cent of Radiographer and dark room assistants post are vacant. No posts have been filled under Lab Technician Gr. II posts. Further, out of eight sanctioned post of Record assistants only one post has been filled.

At district level, Bemoc, Minilap, ARSH, RTI and STI, SBA, NSSK,IUD training has given to MOs, SN, MNO (Male Nurse Orderly), MPHA and concerned staff. However PPIUCD training has not given for any staff.