Wayanad - PIP Report

POPULATION RESEARCH CENTRE

KERALA

1Executive Summary

Implementation of NRHM in Kerala has reinforced the health system in the state remarkably. The implementation of various programmes under NRHM has improved the quality of health services in Kerala and made health care affordable to public. As part of the monitoring of NRHM activities in the state, Population Research Centre, Trivandrum, Kerala was assigned the responsibility to review the activities under NRHM. The present report presents the findings of the second round of monthly monitoring activities done by PRC Kerala in the district of Wayanad. The health facilities selected in Wayanad district are General Hospital Kalpetta, CHC Ambalavayal, PHC Vazhavatta, and SC Kalluvadi. The field work was done during the third week of November 2013.

All the four selected centres were functioning in Govt. buildings. GH faces the problems of space constraints. Construction of a new building for the hospital is going on.There are facilities for power backup and 24*7 water supply. Labour room is clean and thetoilet attached to the labour roomneeds urgent repairing. Newborn care corner has adequate facilities but there is no functional SNCU in the hospital.CHC Ambalavayal is situated in Sulthan Bathery Block of Wayanad District and is about 20 Kms from Kalpetta, the district head quarters. No specialty is functioning in the centre. At present there is no facility for the electricity power back up and the work of setting up a power backup system is almost complete. A tribal Mobile medical unit, pain & palliative unit, sickle cell patient care unit functions in this CHC.

PHC Vazhavatta which comes under CHC Ambalavayal is situated about 50 Kms from the District head quarters.Accommodation facility is available for MOs and SNs. But the quarters need maintenance. SC Kalluvadi which comes under PHC Vazhavatta is functioning in a Govt. building and is in good physical condition. It is about 1 km away from the PHC and located in an area of habitation. The catchment population under the SC is 5000. There is no water supply in the sub centre. The JPHN fetches water from the well of a nearby house.

GH Kalpetta reports inadequate human resources on regular basis. The number of sanctioned posts is 42 which is inadequate for the functioning of the hospital. At present GH manages with additional temporary staff (13) including NRHM staff (5).The staff pattern of the CHC is also insufficient for its smooth functioning. It was set before the up gradation of the centre. There is a JPHN and three ASHAs in the sub centre Kalluvady. The JPHN received trainings on RCH and the ASHAs received training up to the 5th module and received ASHA kit.

All the equipments mentioned in the check list except MVA/EVA equipment are available in the GH. All the equipments of OT mentioned in the checklist except functional OT lights, functional ventilators, functional laparoscopes and C-cam units are present in the General hospital. All the records are maintained properly in the centres. All the women registered for ANC1 are included in MCTS. Nutrition Rehabitation Centre (NRC) is not available in the selected GH, CHC and PHC. AYUSH services are not offered in any of the selected facilities. Only GH had delivery services and around 150 deliveries are conducted in the hospital in a quarter. About 18 percent of the deliveries in the hospital are caesarian section deliveries. There is no separate register for the anemic women and children. JPHNs note the name of the anemic persons in their area for follow up services.Under JSSK, free entitlements are provided to the beneficiaries. Free and cashless delivery, free C-section, free drugs and consumables, free diagnostics and free diet during stay at the hospital are provided. There is no transportation facility in the hospital to take women home after delivery. Instead the hospital authorities pay Rs. 500/- to each woman towards the expenditure for the travel. JSY payments in the centres are given through account payee cheques, before the discharge of mothers. No Nutrition Rehabilitation Centre is present in the facilities selected. The MCTS coverage is almost complete in all the centres under study. Most of the staff involved in HMIS/MCTS data entry complained about the inadequacy of number of available computers and slow internet connection.

2. Introduction

Implementation of NRHM, the novel programme launchedin the last decade, changed the profile of Govt. health facilities in India. The programme, which is named as ‘Arogya Keralam’ in Kerala has reinforced the health system in the stateremarkably. The implementation of various programmes under NRHM has made health care affordable, equitable and good quality to the population. As part of the monitoring of NRHM activities in the state, Population Research Centre, Trivandrum, Keralawas assigned the responsibility to review the activities under NRHM. The present report is the one among the second round of monthly monitoring activities done by PRC Kerala. Wayanad district forms the area of present study. The health facilities selected in Wayanad district are General Hospital Kalpetta, CHC Ambalavayal , PHC Vazhavatta, and SC Kalluvadi. The field work was done during the third week of November 2013.

3State Profile and district profile

Kerala / Wayanad District
No. Districts / 14
No. of Blocks / 152 / 4
No. of Villages / 1018 / 49
Population / 33406061 / 816558
Literacy / 93.91 / 89.92
Sex Ratio / 1084 / 1035
Density of Population / 860 / 383

Source: Census of India 2011

The state of Kerala situated in the south-west corner of India has 14 districts. There are 152 blocks and 1018 villages in the state. The population of the state as per Census of India 2011 is 33406061 out of which 16027412 are males and 17378649 are females. The sex ratio of 1084 females to 1000 males gives Kerala the distinction of having the only state with sex ratio favourable to females in the country. Kerala is also the most literate state with 93.91 percent of its population literate. The density of population is 860 persons per sq.km.

The hilly District of Wayanad is situated on the northEastpart of Kerala.It is bounded on the east by Nilgigris and Mysore districts of Tamilnadu and Karnataka respectively, on the north by Coorg district of Karnataka, on the south by Malappuram and on the west by Kozhikode and Kannur. Wayanad district stands on the southern top of the Deccan plateau and its chief glory is the majestic Western ghats with lofty ridges interspersed with dense forest, tangled jungles and deep valleys, the terrain is rugged. The district is devided in to three taluks, namely Sulthan Bathery, Vythiri and Mananthavady. There are 49 villages under these taluks. There are four Block Panchayats and 25 Grama Panchayats in this district. Kalpetta is the headquarters of the Wayanad District Administration. One important characteristic feature of this district is the large tribal population. Among the districts in Kerala Wayanad district stands first in the proportion of tribal population (about 36%). The district of Wayanadhas a population of 816558 persons, which is only 2.45 percent of the state population.The district has a population density of 383 inhabitants per square kms, which is also the second lowest among the districts in Kerala.Wayanad has a sex ratioof 1035 femalesfor every 1000 males. The literacy rateis 89.92%, which is the second lowest rate among the districts in Kerala. Female literacy of Wayanad is only 85.94.

4Key health and service delivery indicators

The decentralized health care delivery system in the state has helped to achieve low levels of fertility and mortality. The CBR in the state is 15.2, and the TFR is 18 as per the latest report of SRS (2011). Child Mortality rate (3) , U5MR (13), IMR (12), NMR (7), Peri-natal MR (10), Still BR (6) are the lowest for any state in the country. The TFR in Wayanad district as per indirect estimates based on Census 2011 is 1.7 which is a decline from 2.0 during 2001. The CBR in the district declined from 19.5 to 16.3 births per thousand during 2001-11 period. The estimated sex ratio at birth in Wayanad district is 960 during 2011. There are 231 Govt. health facilities in the district, which includes 1 GH, 1 DH, 2 TH, 8 CHC, 21 PHCs and 198 SCs.

5Health Infrastructure:

General Hospital Kalpetta- GH Wayanad which is functioning in a Govt. building nearKalpettais easily accessible from the main road.But the board put up near the main road is not legible and there is a chance to go unnoticed. The hospital building is in good condition.There is a limitation of space in this hospital.Constructions and renovation works are going on in the hospital. A separate building is under construction for the hospital near Kalpetta and the work is going on. But as Govt. Kerala plans to start a Medical college in Wayanad there is a chance for utilizing the building for the purpose till a new building is constructed for the medical college.There are no quarters available for the hospital staff. But they can avail the hostel facility for the Kerala state Government employees andsome of themare currently using the facility. There are facilities for power backup and 24*7 water supply.

There are clean toilet facility separately for males and females. Clean wards are there in the hospital separately for males and females. Labour room is clean and there is toilet attached to the labour room which needs urgent repairing. There is no Blood Bank in the GH, instead it has a BSU. There is an ICTC and a separate room for ARSH clinic in the centre. There is no nutritional rehabilitation centre. There is a no functional help desk in the hospital. They are planning to set a complaint/suggestion box in the hospital. In the GH patients mostly approach PRO for grievance redressal. At the same time they approach the medical officer in the PHC for the same

The biomedical waste management is outsourced in the hospital.

The number of OPD cases attended in the GH during the quarter from April-June 2013 was 27317and 35660 during July-September 2013 which is a hike of about 30 percent. At the same time the number of IPD cases decreased from 1011 in Q1 to 938 in the quarter ended in September 2013.

CHC Ambalavayal: CHC Ambalavayalis situated in Sulthan Bathery Block of Wayanad District and is about 30 Kms fromKalpetta, the district head quarters. The CHC directly covers 38500 population. The CHC is functioning in a Govt. building and it is easily accessible from the road. There is a sign board by the side of the road which helps the people to identify the CHC easily. At present there is no facility for the electricity power back up and the work of setting up a power backup system is almost complete. There is facility for 24*7 water supply in the CHC.Clean toilets are there separately for males and females. There is no labour room in the CHC. Separate wards for males and females are there and they are clean. Nutritional Rehabilitation Centre, Blood Bank and ARSH clinic are not there in the CHC. There is a complaint/suggestion box in the CHC. In the CHC patients mostly approach PRO for grievance redressal.

In the CHC there were 20929 OPD attendance during the quarter ended in June 2013which increased to 22,816during July to September 2013. At the same period the number of OPDs increased to only 255 from 247 during the same period. No specialties other than medicine are available in the CHC. A tribal Mobile medical unit, pain & palliative unit and sickle cell patient care unit exists. School health programme is going on well.

PHC Vazhavatta: PHC Vazhavattawhich comes under CHC Ambalavayalis situated about 20Kms from the District head quarters. There is a sign board by the road to indicate the way to the PHC. But near PHC there is no board and a newcomer may be confused a little bit. The centre is functioning in the Govt. building and the building is in good condition. But the available space is inadequate for the functioning of the PHC. Construction works are going on. The population covered by the Centre is 32056. There are two villages under the area of the PHC. In the PHC there were 10447 OPD attendance during the quarter ended in June 2013. The number of OPDs increased to 11848 cases in the quarter from July to September 2013. There is proper arrangement for power backup. Water supply is available on 24*7 basis.

There are separate toilets for males and females and are also clean. But there is only one ward for inpatients. The ward is also clean. Accommodation facility is available for MOs and SNs. But the quarters need maintenance. Labour room and related facilities are not available in the PHC. BP instrument, stethoscope, weighing machine, needle cutter, autoclave and freezer are there in the centre and are in working condition.

SC Kalluvadi: SC Kalluvadi which comes under PHC Vazhavatta is functioning in a Govt. building and is in good physical condition. It isabout 1 km away from the PHC and located well within the area of habitation. The building is near by the road and is about 20feet above the road level.The board of the subcentre is placed above and there is chance for a newcomer, especially for those who come by a vehicle to miss the board. The catchment population under the SC is 5000. There is no facility for water supply in the sub centre. The JPHN fetches water from the well of a nearby house.Human Resources:

6Human Resources:

GH Kalpetta:As per the sanctioned posts a total of 42staff are required in the General hospitalKalpetta.But it is difficult to run the hospital with this staff strength. The hospital presently manages with 13 temporary staffincluding 5 appointed from NRHM fund in addition to regular staff. There are 16 posts of MOs and 19 posts of SNs in the hospital. At present there are 15 MOs and 25 SNs there in the hospital. Three MOs work under NRHM. There is no sanctioned post of Lab technician in the GH . But at present there are 5 LTs working now in the lab. Similarly there are no sanctioned posts of store keeper and physiotherapist in the GH.The temporary staff now fills the gap.

CHC Ambalavayal:The staff pattern of the CHC is insufficient for its smooth functioning. It was set before the up gradation of the centre. There is only one post of medical officer in the CHC. Two more medical officers are working in the CHC under NRHM. One assistant surgeon works in the Tribal Mobile Medical Unit. A total of six staffs are there for the MMU. Five SNs/GNMs, nine JPHNs, six JHIs, two school health JPHNs, one Lab Technician, one pharmacist, one LHI and one HI work in the CHC.There are 35 posts of ASHAs in the CHC and now there are 33 in position. They received training up to the 5th module and received ASHA kit recently. ASHAs get regular payment. JPHNs in the CHC received training on immunization and cold chain operation.

PHC Vazhavatta: Three posts of MOs, four posts SNs/GNMs and eight posts of JPHNs are sanctioned in the PHC. One of the MOs is appointed under NRHM. There is no Lab Technician in the Centre. Hb testing,measuring BPetc in the NCD clinic are done by JPHN. There is shortage of two JPHNs in the School Health Programme.

SC Kalluvadi: There is a JPHN and three ASHAs in the sub centre Kalluvady. The JPHN received trainings on RCH and the ASHAs received training up to the 5th module and received ASHA kit. The JPHN regularly attended VHND meetings.

7Other health System inputs

GH Kalpetta: All the equipments mentioned in the check list except MVA/EVA equipment are available in the GH. All the equipments of OT mentioned in the checklist except functional OT lights, functional ventilators, functional laparoscopes and C-cam units are present and functional in the General hospital. All the laboratory equipments in the list excluding CT scanner, Ultra sound scanner, and ECG machine are present and in working condition in the GH. X-ray unit is present in the hospital but is not functional. The other services are the testing of Hemoglobin, Urine albumin and sugar, blood sugar, RPR, malaria, TB, HIV, Liver function test. There is no facility for ECG, endoscopy, X-ray and ultrasound scanning in the hospital.

EDL is available but not displayed in the GH and there is computerized inventory management.. About 90 percent of the essential drugs are available in the pharmacy. IFA syrup, Vitamin-A syrup and Zinc tablets are out of stock in the hospital. Mifepristone tablets are also not available. Storage facility of drugs is not adequate and the renovation of the store is going on with the funding of Municipal corporation and NRHM. The store has no air-conditioning facility. All the records are maintained properly in the GH.