EVALUATION OF PROGRAM IMPLEMENTATION PLAN (PIP) UNDER NRHM IN VIRUDHUNAGAR DISTRICT OF TAMILNADUSTATE
N.DHANABAGHYAM
N.KALA
POPULATION REASEARCH CENTRE
THE GANDHIGRAM INSTITUTE OF RURAL HEALTH AND FAMILY WELFARE TRUST, GANDHIGRAM, DINDIGUL, TAMIL NADU
December 2013
1
CONTENTS
TABLES………………………………………………………………….... / iiEXECUTIVE SUMMARY………………………………………………. / iv
CHAPTER / Page
I / Introduction………………………………………………… / 1
II / State and District Profile…………………………………… / 1
III / Key health and service delivery indicators………………… / 2
IV / Health Infrastructure
4.1 / Accessibility and availability………………………………. / 3
4.2 / Physical Infrastructure……………………………………... / 3
V / Human Resource
5.1 / Human resource- Medical………………………………….. / 5
5.2 / Human resource- Paramedical……………………………... / 6
VI / Other Health System Inputs
6.1 / Clinical services……………………………………………. / 6
6.2 / Laboratory and Diagnostic services………………………... / 7
6.3 / Other Supportive services and Health system inputs……… / 9
6.4 / Pharmacy/Drugs and supply……………………………….. / 9
6.5 / Equipments……………………………………………….... / 10
VII / Maternal Health
7.1 / Maternal Health care Infrastructure………………………... / 10
7.2 / Maternal health care utilization……………………………. / 11
VIII / Child Health……………………………………………….. / 13
IX / Rastriya Bal Swastha Karyakram / School Health Program. / 13
X / Adolescent Reproductive and Sexual Health (ARSH)…….. / 14
XI / Quality in Health services………………………………….. / 14
XII / Referral transport and MMU………………………………. / 15
XIII / Community Process
13.1 / Skill Development…………………………………………. / 16
XIV / Disease control programs
14.1 / National leprosy eradication program……………………... / 18
14.2 / National TB Control Program……………………………... / 18
XV / Community process
15.1 / Hospital committees……………………………………….. / 19
15.2 / Utilization of funds………………………………………… / 19
15.3 / Supervisory management…………………………………... / 20
XVI / Good practices and Innovations……………………………. / 20
XVII / HMIS and MCTS………………………………………….. / 21
XVIII / Conclusion and recommendations…………………………. / 21
Recommendations………………………………………….. / 24
Abbreviations………………………………………………. / 25
TABLES
PageChapter - II / STATE AND DISTRICT PROFILE
Table 2.1 / Profile of Virudhunagar district in Tamil Nadu………………... / 2
Chapter - III / KEY HEALTH AND SERVICE DELIVERY INDICATORS
Table 3.1 / Health and Service delivery indicators of Virudhunagar ditrict in Tamil Nadu…………………………………………………... / 2
Chapter - IV / HEALTH INFRASTRUCTURE
Table 4.1 / Accessibility and availability of the selected health facilities in Virudhunagar district in Tamil Nadu…………………………... / 3
Table 4.2 / Physical Infrastructure of the selected health facilities in Virudhunagar district…………………………………………… / 4
Chapter - V / HUMAN RESOURCE
Table 5.1 /
Availability of Human Resource in the selected health facilities in Virudhunagar district in Tamil Nadu………………………...
/ 5Table 5.2 /
Human Resource-Availability of paramedical staff in the selected hospitals in Virudhunagar district……………………...
/ 6Chapter - VI /
OTHER HEALTH SYSTEM INPUTS
Table 6.1 / Availability of Clinical Services in the selected hospitals in Virudhunagar district in Tamil Nadu…………………………... / 7Table 6.2 / Availability of laboratory and diagnostic services in the selected health Facilities in Virudhunagar district in Tamil Nadu…………………………………………………………….. / 8
Table.6.3 / Availability of laboratory tests in the selected hospitals in Virudhunagr district in Tamil Nadu……………………………. / 8
Table 6.4 / Availability of Hospital Ancillary and Supportive services in the selected hospitals in Virudhunagar district in Tamil Nadu… / 9
Table 6.5 / Drug supply and availability of drugs / 10
Chapter - VII / MATERNAL HEALTH
Table 7.1 / Maternal Health care infrastructure in the selected hospitals in Virudhunagar district in Tamil Nadu…………………………… / 11
Table 7.2 / Maternal Health care Utilization (April 2013 to August 2013) in the selected hospitals in Virudhunagar district in
Tamil Nadu……………………………………………………... / 12
Chapter - VIII / CHILD HEALTH
Table 8.1 / Child health care infrastructure and Utilization in the selected health facilities in Virudhunagar district in Tamil Nadu……….. / 13
Page
Chapter - IX / RASTRIYA BAL SWASTHA KARYAKRAM/ SCHOOL HEALTH PROGRAM
Table 9.1 / Performance of School Health Progarm in the selected hospitals in Virudhunagar district in Tamil Nadu………………………... / 14
Chapter - XII / REFERRAL TRANSPORT AND MMU
Table 12.1 / Utilization of referral transport in the selected hospitals in Virudhunagar district…………………………………………… / 16
Chapter - XIII / COMMUNITY PROCESS
Table 13.1 / Essential Skill development of the staff in the selected hospitals in Virudhunagar district in Tamil Nadu………………………... / 17
Table 13.2 / Number of persons attended the essential skill development training in the selected health facilities in Virudhunagar district…………………………………………………………... / 17
Chapter - XIV / DISEASE CONTROL PROGRAMS
Table.14.1 / Levels and trends of leprosy prevalence in Virudhunagar district in Tamil Nadu…………………………………………... / 18
Table.14.2 / Levels and trends of Tuberculosis in Virudhunagar district in Tamil Nadu……………………………………………………... / 18
Chapter - XV / COMMUNITY PROCESS
Table 15.1 / Utilization of various hospital funds in the selected health facilities in Virudhunagar district in Tamil Nadu………………. / 19
Table 15.2 / Supervisory management of the selected health facilities in Virudhunagar district in Tamil Nadu………………………….. / 20
EVALUATION OF PROGRAMIMPLEMENTATION PLAN (PIP) UNDER NRHM IN VIRUDHUNAGAR DISTRICT OF
TAMILNADUSTATE
EXECUTIVE SUMMARY
This report focus on program implementation plan monitoring of important components of NRHM in Virudhunagar district in Tamil Nadu. In Virudhunagar district, one district headquarters hospital, eight sub divisional hospitals, 11 community health centers, 30 primary health centers and 245 health sub centers are providing health care services along with 11 mobile medical units (hospital on wheels).DistrictGovernmentHeadquartersHospital at Viruhunagar, Community Health Centre at R.Reddiapatti, PrimaryHealthCenter at Mamsapuram and HealthSubCenter at Idayankottai were selected for the present study based on their average maternal and child healthindicators performance. The district hospital is CeMONC center and the CHC is a BeMONC center. The study was conducted from 17thSeptember to 21thSeptember 2013.
All the selected health facilities are easily accessible and providing OPD services from four (PHC) to eight (DH) hours per day. Physical infrastructure is up to the expected level except sufficient water supply and security. They are functioning in their own building. CHC is lacking staff quarters for nursing staff. In the CHC, bed strength is not sufficient, as a BeMONC center, the sanctioned bed strength six and effective bed strength is 15.
Human resource in terms of medical, paramedical and supportive staff is adequate. In the CHC gynecologist, anesthetist and surgeon are hired from private hospitals according to the requirement. Laboratory and diagnostic services are functioning well with adequate equipments and manpower. District hospital has a regional diagnostic center. Along with the basic and specialty clinics, separate non communicable disease clinic is functioning in the district hospital, CHC and PHC. Separate Health insurance scheme ward is functioning in the District hospital and CHC. Mobile medical unit is functioning in the CHCunder the control of block medical officer with a preplanned program schedule.
District hospital is a CeMONC centre and the Community health centre is a BeMONC center. They haverequired infrastructure, adequate manpower, equipments and transport and referral services for providing maternal and child health services except bed strength and blood storage centre in the CHC. Severely anemic women, low birth weightbabies and sick neonates were traced and referred to the first referral units. JSY funds were distributed after delivery through account payee cheque along with the state maternity benefit scheme “Dr.Muthulakshmi Reddy maternity benefit scheme”. Immunizations were done at the CHC and PHC level.
Health screening of primary school children and early intervention services are done under school health programon every Thursday and Friday. Schools comes under the jurisdiction of each PHCwere visited by the concerned PHC medical officer along with the VHN and SHN. In each school three visits will be made by the health officials for health screening and the defected children are referred to higher facilities for treatment.
In the district hospital and in the CHC separate ARSH clinics were not functioning. All the adolescents who had registered in the OPD were given counseling on nutrition, anemia, personal hygiene and reproductive health. At the sub center level, every Thurs day IFA tablets and sanitary napkins were distributed along with ARSH counseling to the adolescents by the VHN or through the Anganvadi centers.
To maintain the quality in health services, infection control measures were taken and bio medical wastes are segregated as per SOP. In the district hospital and CHC, bio-medical wastes are segregated and lifted to CTF and in the PHC and HSC they are buried. IEC materials on JSY, PCPNDT ACT, Health insurance, blood donation and NCD (Breast cancer, cervical cancer and cardiovascular diseases) are displayed in all the hospitals. .
Referral system is functioning well. Government ambulance “108” is used for referral from home to facility. Hospital ambulance is used for inter facility referral and hospital private vehicles are used for facility to home with the help of JSSK fund.
While considering about the skill development, staff in the district hospital and in CHC received the training to manage high risk pregnancy, essential new born care (thermoregulation, breastfeeding and asepsis) and management of sick neo-natal infants. Even though, staff in CHC and PHC had had training they refer the complicated pregnancies and sick new born to the first referral units.
Under leprosy eradication program, since September 2013, survey on leprosy screening is going on in Kariapatti block, where the prevalence rate is 1. Twenty five ASHAs, (one in each PHC) were appointed for screening of leprosy. Awareness about leprosy was created among factory workers, community and schools. Currently 53 persons were under treatment.Currently 60 leprosy patients are getting old age pension as well as pension from district rehabilitation centers.
District Tuberculosis centre is functioning in the district hospital premises. Public private partnership is practiced to create awareness in schools, factories and community. Monthly once health campaigns were conducted in the four TUs, Virudhunagar, Panthalgudi, R.Reddiapatti and Narigudi. Patient provider meetings were conducted and self help group women were also engaged to create awareness among community through street play.
For the good governance of the hospitals at all level committees are established. Review meetings were conducted regularly (weekly once) and grievances of the staff were discussed and solved. Complaints/suggestions received from patients were discussed and efforts were taken immediately. Records are maintained properly. Record related to untied fund and AMG are well maintained. Frequent supervisory visits were taken by the higher officials at the concerned state, district and PHC level officials helps to maintain the quality of the service provided.
Village Health Nurse (VHN) entered PICME data in the HMIS portal. District manager and SHN arecompiled the data at the block and district level. There is no validation mechanism prevailing in the district to check the competency of the data.
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I. INTRODUCTION
National Rural Health Mission was launched by the Govt. of India in April 2005 with the aim of providing equitable, affordable and quality health care services to the vulnerable sections of the population, particularly among the poor, women and children residing in rural areas. Monitoring of this program has to be done during the implementation ofthe project/programto ensure the achievement of desired results. The feedback regarding the progress of the implementation of the program and the enhanced advancement in the key components of the program could be helpful for further planning and resource allocation. NRHM program implementation plan monitoring covers the physical achievements against planned expectations as per thetimeliness defined, financial expenditure reports, strengthening of health institutions and thequality service delivery at all the levels.
Virudhunagar district was selected for the evaluation of PIP under NRHM as per the requestof Ministry of Health and Family Welfare, Government of India, New Delhi. District Government Headquarters hospital (GH), Community Health Centre (CHC) at R.Reddiapatti, Primary Health Center (PHC) at Mamsapuram and Health Sub Centre (SC) at Iddayankottai were selected for the present study. Framed interview schedules were used for collection of information from the selected Districts, CHC, PHC and SC level health facilitiesapart from observational analysis. The study was carried out from 17thSeptember to 21thSeptember 2013.
II.STATE AND DISTRICT PROFILE
Population of Virudhunagar district is 19.4 lakhs as per the 2011 census and it constitutes 2.7 percent of the population of the state. The growth rate of the district during 2001-11 is 11.0 which is lower than that of the state 15.6. Sex ratio of the district (1009) is higher than the state average of 995. Nearly half of the population lives in rural areas (Table 1). The district has a population density of 454 persons per sq.km., which is low compare to 555 in the state. Eighty one percent of the population is literate. Female literacy is 73 percent.Table 2.1 Profile of Virudhunagar district in Tamil Nadu
Indicators / Virudhunagar / Tamil NaduNumber of districts / 32
Number of blocks / 11 / 385
Number of Villages / 455 / 17371
Population / 19,43,309 / 7,21,38,958
Male / 9,67,437 / 3,61,58,871
Female / 9,75,872 / 3,59,80,087
Decadal growth rate / 11.0 / 15.6
Sex ratio / 1009 / 995
Sex ratio (0-6 years) / 962 / 946
Percentage rural / 49.5 / 51.6
Population Density / 454 / 555
Percent of literate population age 7+years / 80.8 / 80.3
Male / 88.5 / 86.8
Female / 73.1 / 73.9
Source: Census of India 2011.
Table 2.1 presents the key health and service delivery indicators in Virudhunagar district. One district headquarters hospital, eight sub divisional hospitals, 11 community health centers, 30 primary health centers and 245 health sub centers are providing health care services along with 11 mobile medical units (hospital on wheels). . Crude birth rate was 14.8 and the death rate was 7.1. The neo-natal mortality was 14. Infant mortality and under five mortality was 21.9 and 26.8 respectively. Maternal mortality ratio was 126, which is higher than the state average.
III.KEY HEALTH AND SERVICE DELIVERY INDICATORS
Table3.1Health and Service delivery indicators of Virudhunagar ditrict in Tamil Nadu
Health and Service delivery indicators / Virudhunagar / Tamil NaduNumber of Medical college hospitals / 0 / 18#
Number of district Hospitals / 1# / 21#
Number of Taluk (sub divisional hospitals) / 8# / 230#
Number of Primary Health centre / 30# / 1227#
Number of Health sub centre / 245# / 8706#
Number of community Health centre / 11# / 385#
Number of mobile medical units / 11# / 385#
Crude death rate / 7.1@ / 7.4*
Total Fertility rate / 2.2@ / 1.7*
Neo-natal mortality / 14.0@ / 16
Infant mortality / 21.9@ / 22*
Child mortality / 4.9@ / 7*
Maternal mortality / 126@ / 73
Still birth / 11.1@ / 10*
Percentage of eligible women/husband using contraception / 47.7@ / 60.0**
Source: * SRS Bulletin October, 2012, Sample Registration System, Office of Registrar General, India.
# Monthly bulletin of Family Welfare performance in Tamil Nadu, September 2013
@ Reproductive and Child health Project District level household survey 2002
*National Family Health Survey III
IV. HEALTH INFRASTRUCTURE
4.1.Accessibility and availability
Accessibility and availability of the spectrum services are the main attraction for utilization of health care services. Table 4.1 gives a summary of the accessibility and availability (duration ofworking hours) of the selected hospitals in Virudhunagar district. The district head quarter hospital is located at Virudhunagar, the district head quarters. Distance between the nearest bus stopand the district hospital is just few feet’s. It is easily accessible by road. Nearest medical college (referral unit) hospital is Madurai, located at a distance of 40 kms. Similarly, the Community Health Centre, Primary Health Centre and Health Sub Centre are also well connected with road through public transport, but the transport facilities are very limited to reach these hospital.
Table4.1Accessibility and availability of the selected health facilities in Virudhunagar
district in Tamil Nadu
Accessibility / DH / CHC / PHC / SCDistance from the first referral unit (Km) / 40 / 12 / 10 / 8
Distance from the nearest bus stop/Railway station km / 0 / 0* / 0 / 0
Availability (duration of working hours)
OPD Working hours (in hours) / 8 / 6 / 4
Total population covered / 19,43,309 / 1,35,000 / 43,515 / 10,800
Total villages covered / 455 / 54 / 16 / 8
Number of outpatients per day / 662 / 140 / 120
Note: Frequent buses are not available.
To utilize the services of the hospital to the best, the duration of the working hours of the hospital play a major role. District hospital and Community Health Centre are providing services throughout the day (24 hours). Out patients department (OPD) was functioning on fixed time basis. On an average, in the district hospital OPD functioned for eight hours, CHC and PHC are functioning on an average of sixand four hours respectively. All these hospitals are accessible by road and are connected by Government transport. Coverage populations of these facilities are more than their besieged population.
4.2.Physical Infrastructure
A number of facilities must be created in order to make a hospital to function effectively and efficiently. Table 4.2 shows the infrastructure facilities of the DH, CHC,PHC and SC in the sample hospitals Virudhunagar district. All these hospitals are functioning in the Government building. The district hospital is well fenced. Total sanctioned bed strength of the district hospital is 326 but the effective bed strength available is 310. Even though water supply is available it is not sufficient in the district hospital. Electricity, alternative power supply is available and functioning. Separate male female outpatient toilets, staff duty rooms, complaint/suggestion box, patient waiting shed, functional help desk are available in the district hospital. Separate pucca registration counters for male, female and ANC mothers were available the district hospital. Staff quarters are available for the medical, paramedical as well as other health care personal, but at present they are not occupied by the staff. District hospital had its own generator, intercom, telephone, computer and internet. The CHC and PHC are not fenced.There is a proposal for reconstruction of the Health Sub Centre at Idayankottai. Total sanctioned bed strength of the CHC is only six, but the effective bed strength is 15, as theywere donated by private industries and Patient Welfare Society. As a BeMONC centre this CHC has only six sanctioned beds. Electricity supply and alternative power system is also available in all CHC and PHC. Water supply is insufficient in the CHC. PHC has sufficient 24x7 water supply. Staff duty room, separate male female toilets, complaint box/ suggestion box are available in the CHC as well as PHC.
Table4.2Physical Infrastructure of the selected health facilities in Virudhunagar
district
Infrastructure facility(available=1; Not available =0) / District hospital / Community health centre / Primary health centre / Subcentre
Own Government building / 1 / 1 / 1 / 1
Total bed strength sanctioned / 326 / 6 / 5 / 1
Effective bed strength / 310 / 15 / 5 / 1
Fencing (complete) / 1 / 0# / 0 / 0
Water supply (sufficient) / 0 / 0 / 0 / 0
Running water (24x 7) / 1 / 1 / 1 / 0
Electricity / 1 / 1 / 1 / 1
Generator (Functional) / 1 / 1 / 1 / 0
Separate male/female toilets / 1 / 1 / 1
Separate male/female wards/cubic’s / 1 / 1 / 1
Staff quarters
Medical officers / 1* / 1 / 0
Staff Nurse / 1* / 0 / 1
Other categories / 1 / 1 / 1 / 1
Staff duty room
Doctors / 1 / 1 / 1
Nurses / 1 / 1 / 1
Complaint/suggestion box / 1 / 1 / 1
Functional Help desk / 1 / 0 / 0
Communication
Telephone / 1 / 1 / 1 / 1
Intercom / 0 / 0
Display/sign board mentioning the services and directions / 1 / 1 / 1
Note:#Partial fencing