PROGRAMME IMPLEMENTATION PLAN (2013-14)

IN

PUNJAB

Quarterly Monitoring Report:Sangrur District

Population Research Centre

Centre for Research in Rural and Industrial Development

Sector 19A, Madhya Marg

Chandigarh 160 019

INDIA

Table of Contents

Acknowledgements

1Executive Summary...... 4

2Introduction...... 5

3State Profile and District Profile...... 7

4Key Health and Service Delivery Indicators...... 8

5Health Infrastructure:...... 9

6Human Resources...... 9

7Other Health System Inputs...... 11

8Maternal Health...... 13

8.1ANC and PNC......

8.2Institutional deliveries......

8.3Maternal death Review......

8.4JSSK......

8.5JSY......

9Child Health

9.1SNCU......

9.2NRCs......

9.3Immunization......

9.4RBSK......

10Family Planning

11ARSH

12Quality in Health Services

12.1Infection Control......

12.2Biomedical Waste Management......

12.3IEC......

13Clinical Establishment Act...... 19

14Referral Transport and MMUs...... 19

15Community Processes...... 20

15.1ASHA......

15.2Skill development......

15.3Functionality of the ASHAs......

16Disease Control Programmes...... 20

16.1Malaria......

16.2TB......

16.3Other Communicable Disease......

17Non Communicable Diseases...... 21

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

19HMIS and MCTS

20PC-PNDT

20Key Conclusions and Recommendations

21References...... 25

Acknowledgements

At the outset, we are thankful to the Ministry of Health and Family Welfare (MoHFW), Government of India for assigning the study to this Centre. Our sincere gratitude to Mrs Anuradha Gupta, IAS, Additional Secretary and Mission Director for infusing dynamism to the National Rural Health Mission (NRHM)—a flagship programme—in terms of ideas and sustained guidance. Her initiative in deciding to involve the network of Population Research Centres (PRCs) in the country in meaningful monitoring of the policies, systems and activities under the NRHM is expected to go a long way in ensuring effective management and delivery of health care services.

We are also obliged to Shri Manoj Jahalani, Joint Secretary in MoHFW for his untiring support and motivation to the PRCs in their academic endeavours. Our sincere appreciation are also due to Dr Rattan Chand, Chief Director; Shri PC Cyriac, Deputy Director General; Shri Biswajit Das, Director; and Shri K.K. Bansal, Deputy Director, in the Statistics Division, for their efforts in providing necessary back up help to the PRCs to carry out the task of quality monitoring the PIP in a prompt and smooth manner. We also thank the National Health Resource Centre (NHRC) for the support in debating PIP protocols.

The Study would not have been possible without the active co-operation of the Department of Health and Family Welfare in Government of Punjab. For this, we record our sincere appreciation for the Mission Director, National Rural Mission (NRHM), Punjab. The staff working for the NRHM in the Sangrur district rendered necessary assistance when needed, and for this Civil Surgeon, District Family Welfare Officer (DFWO), District Programme Manager (DPM). Community Mobiliser (CM) and others deserve our admiration. The Senior Medical Officers (SMOs), Medical Officers (MOs), and female Multipurpose Health Workers (MPHWs) at selected health facilities (CHC/PHC/SC) significantly contributed to the success of the assignment by taking time out of their regular work schedule to interact with the visiting team, share experiences, and provide required information. Without their active participation, the assignment could not have been successful. Hence, we sincerely thank them. We also remain indebted to the Executive Vice Chairman, Director General, Honorary Director (PRC), and other colleagues at CRRID for their support while undertaking this study.

We earnestly hope that the findings of this study will go a long way in strengthening the efforts of the Ministry of Health and Family Welfare, Government of India to invigorate NRHM service delivery in Sangrur District. At the end, however, we share the responsibility for inadvertent errors in this report, if any.

Authors

13January 2014

Chandigarh

1Executive Summary

Strengths

  • Streamlining of activities under the PNDT Act including compliance through Form F.
  • Consistent progress in HMIS and MCTS statistics.
  • Enhanced and rapid mobility of targeted clients including referrals to the health institutions under the EMRI 108.
  • Maternal Death Review (MDR) regularly undertaken in required cases.
  • Immunisation process is smooth and effective.

Weaknesses

  • Critical medical manpower shortages in the district, particularly shortage in the number of Paediatrician and MOs. All the sanctioned posts of specialists were vacant at the selected CHC Dirba, and no Regular MO was posted in this CHC. Shortage of para-medical staff including staff nurses, LTs etc. affects service delivery, particularly in peripheral areas.
  • Poor impart of training on EmOC, LSAS, BeMOC, NSV, etc. in the district. Allowing staff to proceed for training means disrupting service delivery at the facilities as there is a heavy workload on already less available manpower.
  • Space constraint in the District Hospital affecting service delivery. Need for urgent renovation in many wings as the building is very old.
  • Deliveries in remote and underserved areas are mostly conducted by staff nurses in the absence of Medical Officer.
  • Benefits to pregnant women and new-born children under JSY Scheme in the entire district are not paid to those registered after 1st April 2013 due to glitches in newly launched DBT.
  • JSSK implementation is poor in the district hospital as eligible beneficiaries are being reportedly charged for medicines and other consumables contrary to provisions in the guidelines.
  • RBSK is not yet started in the district.
  • No mechanism in place to enforce or incentivise rational prescription of drugs and diagnostic procedures.
  • Many poor women find it difficult in district to open account in the local nationalised banks to be able to benefit from cash transfer. Lack of identity proof (such as voter ID, Adhar Card, etc) is a bottleneck particularly for couples having the first child. There is reluctance on the part of the designated banks to open zero balance account.
  • The IUCD 375 received recently but remains to be introduced in the district.
  • No Special Newborn Care Unit (SNCU) in the district.
  • No Nutritional Rehabilitation Centre (NRC) in the district.
  • NRHM Logos not displayed at most of the health facilities.
  • Monitoring and supervision and field tours by the district level NRHM staff such as DPM and DMEO are low, and this can be mainly attributed to POL limitations as well as duties assigned at the district headquarter.
  • No standard procedure for patient feedback at government facilities.
  • Unregulated private sector activities need to be brought under the umbrella of state authorities through enactment of Clinical Establishment Act.
  • District level information on critical indicators are not available with the district health authority.

2Introduction

Launching of the National Rural Health Mission (NRHM) as a flagship programme by the Government of India to revamp the basic health care delivery system necessitated a relook at health care systems and policies. As NRHM encompasses structural changes in public expenditure on health, removal of regional imbalances, pooling of resources, organisational structures, optimisation of health manpower, decentralisation of management of health programmes, greater community participation, improvement in the district health systems, operationalisation of the Community Health Centres (CHCs) into functional hospitals, etc. (Government of India 2011), the need for effective monitoring of achievements is enormous. Regular and concurrent quality monitoring is a tested tool to assess the progress of the NRHM for course correction.

Project implementation plan (PIP) helps in successful implementation of projects. It embodies complete description of intended actions in the project in the backdrop of project objectives and goals. It also provides the stakeholders with the confidence that the all possible aspects of project including the tasks, activities and processes involved in producing the deliverables are well deliberated and factored into project goals and objectives. Being a comprehensive document, it captures a range of basic information that is crucial for delivery of health care services in the target area, facilities and programmes.

Quarterly monitoring of the PIP was entrusted to the Population Research Centres (PRCs) across the country because of their state-specific expertise of socio-demographic and health issues. While undertaking evaluation and monitoring assignments, the PRCs work in close coordination with the Government of India as well as the respective State Governments on a regular basis. The PRCs also contribute immensely to the efficiency of the NRHM by undertaking quality checks on selected indicators (as outlined in the PIP document of respective State/Union Territorie) and focusing on challenges involving policy and systemic issues in a regional perspective and reporting same to both the union as well as the respective state government. Quarterly monitoring is found appropriate for assessing the progress of NRHM as it is believed to bring unique feedbacks from field that would not have been otherwise possible through conventional data gathering exercise in limited time.

The main objective of the quarterly monitoring of the PIP in Sangrur District is to assess the progress in health policy, health systems, and health care services under the NRHM at different levels (from sub-centre to the District Hospital). More specifically, the exercise aims at evaluation of the enabling environment for better flow of services from the health facilities in terms of specific indicators outlined in the Punjab PIP (2013-14). The details of scope, objective and methodology of the assignment were finalised in a meeting of the PRCs at the National Health Systems Resource Centre (NHSRC) in the second week of August 2013.

A questionnaire was developed for data collection, interview and discussion based on the template from the NHSRC. The Questionnaire focused on strategic areas namely: Health infrastructure, Human Resources, Health Systems Inputs, Maternal Health, Child Health, Family Planning, ARSH, Quality in Health Services, Community Involvement, etc. Each identified theme was investigated for assessing the progress. Current status/situation was recorded, and in case of non-achievement of targets the background or constraints were mentioned. The reference point for examination of issues and status was 30th September 2013 for all selected institutions in the district and the district as a whole. The field survey in Sangrur District was undertaken in the month of January 2014 whenbesides the District Hospital (DH) in Sangrur, the CHC at Dirba, PHCat Chhajli and SC at Rogla also visited.

In the selected facilities, different levels of medical and paramedical staff, with varying position and job responsibility, were interviewed. Civil Surgeon, District Programme Mangers, District Monitoring and Evaluation Officers, District Statistical Assistant, at the district level; Senior Medical Officer (SMO), Block Statistical Assistant and Block Information Assistant at the CHC level; Medical Officer (MO), and Lady Health Visitor (LHV) at the sector level, female multipurpose health workers (MPHWf) at the SC level were the main health functionaries with whom detailed discussions were carried out regarding the PIP and related aspects. Individual observations and suggestions were recorded with regard to functioning of NRHM in the respective jurisdictions.

3State Profile and District Profile

Figure 1: Districts of Punjab, 2013.

Selected socio-demographic indicators, Punjab and Barnala District

Data source / Name of the Indicator / Punjab / Sangrur
Census 2011 / Population / 27743338 / 1655169
% of urban population / 37.4 / 31.2
Sex ratio / 895 / 885
Child Sex-ratio (0-6 years) / 846 / 840
% of Scheduled Castes Population / 31.9 / 21.7
% of total literacy / 67.4 / 60.5
% of female literacy / 63.1 / 55.5
% of workers in total population / 35.7 / 34.4
% of female workers in total female population / 13.9 / 10.8

4Key Health and Service Delivery Indicators

Data source / Indicators / Punjab / Sangrur
DLHS-3 (2007-08) / Mean age at marriage (Boys) (in years) / 24.2 / 23.3
Mean age at marriage (Girls) (in years) / 21.3 / 21.0
Percentage of marriages below legal age (Boys) / 15.5 / 23.5
Percentage of marriages below legal age (Girls) / 5.8 / 6.1
Percentage of currently married women (20-24) marrying before age 18 / 15.5 / 18.3
Percentage of women receiving antenatal check-up in the first trimester of pregnancy* / 62.5 / 68.0
% of women receiving 3 or more antenatal check-ups* / 64.1 / 51.0
% of women receiving at least one TT injection* / 82.5 / 82.1
% of women receiving 100 IFA tablets during pregnancy* / 33.4 / 35.5
% of women receiving full antenatal check up (at least 3 visits for antenatal checkup, at least one TT injection and 100+ IFA tablets/syrup consumed) * / 14.3 / 17.6
% of women who had institutional deliveries* / 63.1 / 72.4
% of women who had complication during pregnancy / 46.8 / 62.5
% of women who sought treatment for such complications / 81.3 / 86.1
% of women who had delivery complication / 54.4 / 50.3
% of women who had post delivery complications / 21.2 / 37.1
% of children received colostrums/khees* / 89.9 / 77.4
% started breastfeeding within first hour* / 44.1 / 42.3
% started breastfeeding within 24 hours of birth* / 80.6 / 72.3
% of children fully vaccinated* / 79.8 / 52.7
% of contraceptive prevalence rate (CPR) by any method* / 69.3 / 64.4
% of contraceptive prevalence rate (CPR) by any modern method* / 63.2 / 57.9
% Unmet need for family planning services* / 11.4 / 13.4
% Unmet need for spacing* / 3.0 / 3.3
% Unmet need for limiting* / 8.4 / 10.1
Average population covered by a SC / 6185 / 6193
Average population covered by a PHC / 29157 / 111791
Average population covered by a CHC / 127033 / 118835
% of ANMs residing at SC quarter / 17.8 / 50.0
Civil Surgeon and SRS / Crude Birth Rate (CBR) / 15.9 (2012) / -
Infant Mortality Rate (IMR) / 28 (2012) / -
Maternal Mortality Rate (MMR) / 155 (2010-12) / -
% institutional deliveries / - / 89
% Full immunization coverage / - / 91

Note: *: For the currently married women aged 15-49 years at the time of survey.

5Health Infrastructure(as on 31.12.2013)

Type. of Health institutions / Current number / Located in government buildings
(Yes/No) / Felt need for additional number of health facilities / No. of health facilities
having inpatient facility / Total No. of beds
District Hospital / 1 / YES / NA / NA / 100
Exclusive MCH hospital / 0 / NA / NA / NA / NA
SDH / 4 / YES / NO / 4 / 100-50
CHC / 8 / YES / NO / 8 / 30
PHCs/24x7 PHCs / 10 / YES / NO / 10 / 25
SHC (under PRIs) / 68 / YES / NO
SCs / 192 / 106 / NO
AYUSH facilities (Ayurvedic) / 5 / 5 / NO / 0 / 0
AYUSH facilities(Homoeop.) / 4 / 4 / NO / 0 / 0
AYUSH facilities (Others) / NO
Others / - / NO
Total number of delivery points (24X7) / 10 / YES / NO / 23 / 10-5
Shortage of institutions (if any)
Is there a felt shortage of institution which impacts health service delivery in the district? / MCH Centres in all 4SDHs and 1DH. Moreover, existing health facilities need to be made fully equipped and operational.
What is being done now to fill the existing gaps in institutions? / Continue to workin the same old buildings. There is an urgent need for new one.

NA: Not applicable

6Human Resources(as on 31.12.2013)

Type of health functionary / Sanctioned / In position
Dist. / DH / CHC / PHC / SC / Dist. / DH / CHC / PHC / SC
Gynecologist / Not available / 3 / Not available / 10 / 3 / 0
Pediatrician / 2 / 7 / 1 / 0
Anesthetists / 1 / 1 / 1 / 0
ENT specialist / 1 / 6 / 1 / 0
Ophthalmologist / 1 / 3 / 2 / 0
Radiologist / 1 / 1 / 1 / 0
Pathologist / 1 / 3 / 2 / 0
Medicine specialist / 2 / 7 / 2 / 0
Dermatologist / 1 / 3 / 1 / 0
TB specialist / 1 / 3 / 1 / 0
MOs / 169 / Not available / 1 / 102 / 0 / 3 / 0 / Regular + NRHM = 102 filled out of 169
Dental: 14 filled out of 17
LHV / 44 / 0 / 1 / 29 / 0 / 0 / 1 / 0
ANM / 204 / 0 / 2 / 190 / 2 / 2 / 2 / 2
MPHW (M) / 189 / 0 / 1 / 129 / 0 / 0 / 1 / 0
Staff nurses / 208 / 3 / 0 / 126 / 30 / 1 / 1
(only one staff nurse at 24X7 PHC) / 0
Manpower deployment and mobilization
What are the strategies for recruitment? / Vacancy positions are intimated to State Headquarter regularly for further action.
Incentives for retention of manpower in difficult areas? / Yes
Whether extra remuneration is provided in high focused area? /
  • Yes (Rs. 5000/- and Rs. 10000/- to NRHM obstetrician/gynaecologist, paediatrician and female Medical Officers for 24x7 PHC posted in difficult and more difficult areas respectively) vide NRHM circulator No. NRHM/Pb/13/MHR dated 14.08.2013.
  • No extra salary for other staff.

What is being done to fill the gaps in manpower availability? / Vacancy positions are intimated to the State Headquarters regularly for further action.
Whether details of facility wise deployment of all HR engaged under NRHM displayed on website? / No
For SCs with 2 ANMs, whether target population divided between ANMs / Yes
Whether SC remain open through the day while the other ANM undertakes field visit. / No
Whether staff productivity monitored regularly. How? / Yes (by undertaking field tours)

Training status/skills of various cadres viz a viz service delivery during last one year

Training programmes / Dist
(total) / CHC
DIRBA / PHC
Chhajli / SC
Rogla
EmOC / 2 Doctors and 1TOT / 0 / 0 / 0
LSAS / 1 trained / 0 / 0 / 0
BeMOC / 2 Trained / 0 / 0 / 0
SBA / 2480
(SBA TOT ) / 0 / 0 / 2203
(deliveries by trained ANMs)
MTP/MVA / 264 / 0 / 0
NSV / 176 Cases / 0 / 0
F-IMNCI/IMNCI / NIL / 0 / 0
NSSK / All Staff nurses
are trained / 0 / 0
Mini Lap-Sterilisations / 803 / 0 / 0
Laproscopy-Sterilisations / 2286 cases / 0 / 0
IUCD / 17003 / 0 / 1
PPIUCD / Nil / 0 / 0
Blood storage / 2 / 0 / NO
IMEP / MOS are trained / 0 / NA
Immunization and cold chain / Maintained / 0 / YES
Others (specify) / Nil / Staff nurse (HIV/AIDS and PAP smear training) / EPI training to both ANMs, birth-death registration training last month

MO-Medical Officer, LHV-Lady Health Visitor, SN-Staff Nurse, OTA-Operations Theatre Assistant.

C. Need for further training

Indicators / District / Remark
Type and staff requiring training / Decided by the State headquarter/authorities
Problems associated with impart of training / No proper training annexe in the district. .So proper trainings are not undertaken.

7Other Health SystemsInputs(as on 31.12.2013)

Indicators / District / DH(Sangrur) / CHC
(Dirba) / PHC(Chhajli) / SC
(Rogla) / Remark
Drugs
Availability of EDL drugs / YES / YES / YES / YES / NO
Type of EDL drugs Not available / NA / NA / NA / NA / No details
Laboratory and other diagnostics tests for
Haemoglobin / YES / YES / YES / NO / YES
CBC / YES / YES / NO / NO
Urine albumin and sugar / YES / YES / NO / NO
Blood sugar / YES / YES / NO / NO
RPR / YES / YES / NO / NO
Malaria / YES / YES / YES / NO / YES
T.B / YES / YES / YES / NO
HIV / YES / YES / NO
Liver function tests(LFT) / YES / YES / NO
Ultrasound scan (Ob.) / YES / YES
Ultrasound Scan (General) / YES / YES
X-ray / YES / YES
ECG / YES / YES
Endoscopy / NO / NO
Others (specify) / NO / NO / NO / NO / NO
Essential equipments
Functional BP Instrument and Stethoscope / YES / YES / YES / YES
Sterilised delivery sets / YES / YES / YES / YES
Functional Neonatal, Paediatric and Adult Resuscitation kit / YES / YES / YES / NO
Functional Weighing Machine (Adult and child) / YES / YES / YES / YES
Functional Needle Cutter / YES / YES / YES / YES
Functional Radiant Warmer / YES / YES / NO / YES
Functional Suction apparatus / YES / YES / YES / YES
Functional Facility for Oxygen Administration / YES / YES / YES
Functional Foetal Doppler/CTG / YES / YES / YES
Functional Mobile light / YES / YES
Delivery Tables / YES / YES / YES / YES
Functional Autoclave / YES / YES / YES / NO
Functional ILR and Deep Freezer / YES / YES / YES / YES
Emergency Tray with emergency injections / YES / YES / YES / YES
Manual Vaccuum Aspiration (MVA)/ Electric Vaccuum Aspiration (EVA) Equipment / NO / NO / NO / NO
Functional phototherapy unit / NO / NO / NO / NO
Check-list for SC
Haemoglobinometer / YES
Any other method for Hemoglobin Estimation / YES (Book)
Blood sugar testing kits / NO
BP Instrument and Stethoscope / YES
Delivery equipment / NO
Neonatal ambu bag / NO
Adult weighing machine / YES
Infant/New born weighing machine / YES
Needle &Hub Cutter / YES
Color coded bins / YES (red and black only) / ASHA takes it to PHC monthly
RBSK pictorial tool kit / NO

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