NIPI REFERENCE BOOK (ORISSA)

Transcription

1 1 11/1/2011 ACCESS HEALTH INTERNATIONAL NIPI REFERENCE BOOK (ORISSA) Ikram Khan, Priya Anant and Prabal Singh

2 2 P a g e NIPI Reference Book- Orissa

3 Purpose of this Book This book is a compilation of data from various sources relevant to our work on the Norway India Partnership Initiative (NIPI) Funded project Government contracting for improved health services in Orissa. We have used data from various sources and structured it to serve as a quick reference guide. We have acknowledged the source in most places, but apologise for omissions if any. This resource book would be updated with data once a year and would be available online, meant for others interested in infant health in Orissa. Priya Anant, Associate Director ACCESS Health International 3 P a g e

4 4 P a g e NIPI Reference Book- Orissa Contents Chapter Healthcare in Orissa Introduction Health System and Structure Health Infrastructure Role of Private Sector in Health Outcomes Human Resource Snapshot of the State Health Budget s Trend Important Issues & Challenges concerning Healthcare Challenges for State Key issues for State Recent Reforms in Health Improving Maternal and Child Health Initiatives for Human Resource Hello Doctor 24 x Chapter Maternal & Child Healthcare in Orissa Status of Maternal and Child Health Maternal Mortality Infant Mortality Child Mortality Key Achievements in MCH of Orissa (in 2009) Public expenditure on reproductive and child health services Scheme in the State for Improving Maternal and Child Health Common program for both Maternal and Infants Health Special Programs on Maternal Health Special Programs on Infants Health Chapter Public Private Partnership (PPP) Key stakeholders in Healthcare s PPP Department for International Development (DFID) Norway- India Partnership Initiative (NIPI)... 57

5 3.2 PPP Initiatives by Health Department, Govt. of Orissa Contracting-out PHC (New) MNGO / FNGO / SNGO Programme PPP in Urban Health: PPP in Malaria Control Janani Express (JE): Accreditation of Private Hospitals for Institutional Delivery Capacity Building of ASHA through MNGO FNGOs Outsourcing the cleaning and security services of Health Institutions Future PPP Program: PPP in other parts of India and World in MCH Chiranjeevi Yojna (CY) Janani Child Helpline International RapidSMS Malawi Vietnam s Nutritious Food Program Karra society for Rural Action Wired Mothers Chapter MCH Trends Home Based Neonatal Care (HBNC) Chapter District Profile Angul Introduction District Health System: Health Infrastructure Angul facility Survey Finding SWOT Analysis Jharsuguda Introduction Health System Health Infrastructure P a g e

6 5.2.4 Jharsuguda facility Survey Finding Sambalpur Introduction Health System Health Infrastructure Sambalpur facility Survey Finding Chapter Maternal and Child Health in NIPI s focus Districts Maternal Health Delivery Care Postnatal Care Newborn Care Breastfeeding and Supplementation Child Morbidity and Treatment Summary observations Child Immunization Vaccination coverage Chapter Resource Persons List of Resource Person at State Level List of Resource persons at District Level Works Cited P a g e

7 List of Figures Figure 1: Fig: Organogram Figure 2 District Health Society-Organogram 15 Figure 3: Mechanism of Health Services in Orissa (NIC, 2005) Figure 4: Time of Initiation of Breastfeeding P a g e

8 List of Tables Table 1: Demographic, Socio-economic and Health Profile of Orissa State vs India Table 2: : Infant mortality Rate by Sex and Residence, 2009 (SRS-09) Table 3: Infant Mortality Rate (SRS-09) Table 4: Health Infrastructure of Orissa (Orissa) Table 5: The other Health Institution in the State are detailed as under Table 6: Facts and Figures of Health Services in Orissa (NIC, 2005) Table 7: H R Requirement for Facilities - as per IPHS & Existing Facilities Table 8: Annual State Plan Ceiling of Different Departments for the year Table 9: Financial Management under NRHM Table 10: Trends in Financial Expenditure on MCH Table 11: Health Infrastructure of Orissa Table 12: Maternal Mortality in Orissa and India Table 13: Trends in Infant Mortality Rate of Orissa and India Table 14: Trends in Under Five Mortality Rate for Orissa and India Table 15: Institutional Delivery and JSY Scheme (CES_Orissa, 2010) Table 16: Maternal Care (Women delivery in previous 12 months) (CES_Orissa, 2010) Table 17: Delivery Care (Women delivery in previous 12 months) (CES_Orissa, 2010) Table 18:Newborn Care (CES_Orissa, 2010) Table 19: Breastfeeding Practises during First 6 Months according to Age of Living Child (CES_Orissa, 2010) Table 20: Child Health (0-2 Years) (CES_Orissa, 2010) Table 21: Public Expenditure on Reproductive and Child Health Services, Orissa, to (in Rs. crore) Table 22: Expenditure on Reproductive and Child Health Services by Sources of Funding, Orissa, to (percentage) Table 23: Composition of Expenditure on Reproductive and Child Health Services, Orissa, to (in Rs. crore) Table 24: Stakeholder roles in a Healthcare PPP Table 25: Anticipated Budget Provision for Different Externally Aided Projects under State Plan During Table 26: Geographical (Angul_NIC) Table 27: Demographic (Angul_NIC) Table 28: Administrative (Angul_NIC) Table 29: The Vital Health Indicators of the District Table 30: Health institutions in the Angul Established by the Govt of Orissa Table 31: District Data of Angul Table 32: Health Institutions in Jharsuguda Table 33: District data: Jharsuguda Table 34: District Data: Sambalpur Table 35: Health Facilities Available and Required Table 36: Place of Delivery v/s Number of Live Children, NIPI P a g e

9 Table 37: Place of Delivery v/s Economic Status of Respondents Household, NIPI Table 38: Average Transportation Expenses, NIPI Table 39: Nature of Institutional Delivery NIPI Table 40: Cost Incurred in Institutional Delivery1, NIPI Table 41: Problems Experienced During Delivery by Women of Different Age Groups, NIPI Table 42: Reason for Home Delivery Table 43: Reasons behind Choosing a Specific Person to Conduct the Delivery Table 44: Cost Incurred in Home Delivery Table 45: Timings of First Postnatal Care Table 46: Number of times PNC Received Table 47: Time of First Neonatal Check-up by Districts Table 48: Breastfeeding Practices Table 49: Initiation of Breastfeeding and Gender of Child Table 50: Feeding of Prelacteal Liquids Table 51: Period of Exclusive Breastfeeding by Background Variables Table 52: Prevalence of Illness in Children under Study Table 53: BCG and Polio 0 Coverage by Background Variables, NIPI Table 54: Child Immunisation Coverage in NIPI Districts, Orissa Table 55: Immunization Coverage All Basic Vaccines Table 56: Problems faced by Mother/Community in Vaccinating the Child P a g e

10 Chapter-1 Healthcare in Orissa 10 P a g e

11 1. Healthcare in Orissa 1.1 Introduction Orissa was separated from Bihar and came into existence on April 1, The historic city of Cuttack situated at the apex of the Mahanadi delta was established as the capital. In 1956, it shifted to Bhubaneswar, a planned modern town of the post-independence period. Orissa can be divided into three broad physiographical regions: a) The Coastal plains b) The Middle mountainous country c) The Plateaus and rolling uplands Table 1: Demographic, Socio-economic and Health profile of Orissa State vs. India S. No. Item Orissa India 1 Total population (Census 2011) (in millions) Decadal Growth (Census 2011) (%) Crude Birth Rate (SRS 2008) Crude Death Rate (SRS 2008) Total Fertility Rate (SRS 2007) Infant Mortality Rate (SRS, 2009 & AHS *) 7 Maternal Mortality Ratio (SRS ) Sex Ratio (Census 2011) Population below Poverty line (%) Schedule Caste population (in millions) Schedule Tribe population (in millions) Female Literacy Rate (Census 2011) (%) Source- (Orissa) The state of Orissa has an area of 155,707 sq. km. and a population of million. There are 30 districts, 314 blocks and villages. The State has population density of 236 per sq. km. (as against the national average of 312). The decadal growth rate of the state is 14 percent (against 17.6 percent for the country) and the population of the state is growing at a slower rate than the national rate. Health indicators of Orissa The Total Fertility Rate (TFR) of the state is 2.4. The Infant Mortality Rate (IMR) is 65 and Maternal Mortality Ratio (MMR) is 303 (SRS ) which is higher than the national 11 P a g e

12 average. The sex ratio in the state is 972 (as compared to 933 for the country). Comparative figures of major health and demographic indicators are as follows: Table 2: Infant mortality rate by sex and residence, 2009 (SRS-09) Total Rural Urban Total Male Female Total Male Female Total Male Female India Kerala Orissa Source- (SRS 2009) Table 3: Infant Mortality Rate (SRS-09) Bihar Orissa Kerala India Source- (SRS 2009) 1.2 Health System and Structure The healthcare services organization in the country extends from the national level to the village level. From the total organization structure, we can slice the structure of healthcare system at national, state, district, community, Primary Health Centre (PHC) and sub-centre (SC) levels. (WHO, 2007) State level - The organization at the state level is under the State Department of Health and Family Welfare in each state. It is headed by a Minister and with a Secretariat under the charge of Secretary/Commissioner (Health and Family Welfare) belonging to the cadre of Indian Administrative Service (IAS). By and large, the organizational Structure adopted by the state is in conformity with the pattern of the central government. The State Directorate of Health Services, as the technical wing, is an attached office of the State Department of Health and Family Welfare and is headed by 12 P a g e

13 a Director of Health Services. But regardless of the job title, each program officer below the Director of Health Services deals with one or more subject(s). Every State Directorate has supportive categories comprising both technical and administrative staff. (WHO, 2007) Figure 1: Organogram The area of medical education which was integrated with the Directorate of Health Services at the state has once again shown a tendency to maintain a separate identity as Directorate of Medical Education and Research. This Directorate is under the charge of Director of Medical Education, who is answerable directly to the Health Secretary/Commissioner of the State. Some states have created the posts of Director (Ayurveda) and Director (Homeopathy). These officers enjoy a larger autonomy in 13 P a g e

14 day-to-day work, although sometimes they still fall under the Directorate of Health Services of the state. (WHO, 2007) Regional level In the state of Orissa, zonal or regional or divisional set-ups have been created between the State Directorate of Health Services and District Health Administration. Each regional/zonal set-up covers three to five districts and acts under authority delegated by the State Directorate of Health Services. The status of officersin-charge of such regional/zonal organizations differs, but they are known as Additional/Joint/Deputy Directors of Health Services in different states. (WHO, 2007) District level - In the recent past, the states have reorganized their health services structures in order to bring all healthcare programs in a district under unified control. The district level structure of health services is a middle level management organisation and it is a link between the state as well as regional structure on one side and the peripheral level structures such as PHC as well as sub-centre on the other side. It receives information from the state level and transmits the same to the periphery with suitable modifications to meet the local needs. In doing so, it adopts the functions of a manager and brings out various issues of general, organizational and administrative types in relation to the management of health services. The district officer with the overall control is designated as the Chief Medical and Health Officer (CM & HO) or as the District Medical and Health Officer (DM & HO). These officers are popularly known as DMOs or CMOs, and are overall in-charge of the health and family welfare programs in the district. They are responsible for implementing the programs according to policies laid down and finalized at higher levels, i.e. the State and Centre. These DMOs/CMOs are assisted by Dy. CMOs and program officers. The number of such officers, their specialization, and status in the cadre of State Civil Medical Services differ from the state to state. Due to this, the span of control and hierarchy of reporting of these program officers vary from state to state. (WHO, 2007) Sub-divisional/Taluka level At the Taluka level, healthcare services are rendered through the office of Assistant District Health and Family Welfare Officer (ADHO). Some specialties are made available at the taluka hospital. The ADHO is 14 P a g e

15 assisted by Medical Officers of Health, Lady Medical Officers and Medical Officers of general hospital. These hospitals are being gradually converted into Community Health Centres (CHCs). (WHO, 2007) Figure 2 District Health Society-Organogram Source- (DHS-Orissa) Community level For a primary healthcare program to be successful, effective referral support is to be provided. For this purpose one CHC has been established for every 80,000 to 1, 20,000 population, and this centre provides the basic specialty services in General Medicine, Paediatrics, Surgery, Obstetrics & Gynaecology. The CHCs are established by upgrading the sub-district/taluka hospitals or some of the block level PHCs or by creating a new centre wherever absolutely needed. (WHO, 2007) PHC level At present there is one PHC covering a population of about 30,000 (20,000 in hilly, desert and difficult terrains). Many rural dispensaries have been upgraded to create these PHCs. Each PHC has one medical officer, two health assistants one male and one female, and the health workers and supporting staff. For 15 P a g e

16 strengthening preventive and promotive aspects of healthcare, a post of Community Health Officer (CHO) was proposed to be provided at each new PHC, but most states did not take it up. (WHO, 2007) Figure 3: Mechanism of Health Services in Orissa (NIC, 2005) Source: (NIC, 2005) Sub-centre level The most peripheral health institutional facility is the sub-centre manned by one male and one female multi-purpose health worker. At present, in most places there is one sub-centre for a population of about 5,000 (3,000 in hilly and desert areas and in difficult terrain). (WHO, 2007) The 73 rd and 74 th constitutional amendments have given the powers to the local bodies in some states of India. The panchayats are given powers to direct, influence and oversee the functioning of healthcare institutions at local level. 1.3 Health Infrastructure 16 P a g e Table 4: Health Infrastructure of Orissa (Orissa) Particulars Required In position shortfall Sub-centre Primary Health Centre Community Health Centre Multipurpose worker (Female)/ANM at Sub Centres & PHCs Health Worker (Male) MPW(M) at Sub Centres

17 Particulars Required In position shortfall Health Assistant (Female)/LHV at PHCs Health Assistant (Male) at PHCs Doctor at PHCs Obstetricians & Gynaecologists at CHCs Physicians at CHCs Paediatricians at CHCs Total specialists at CHCs Radiographers Pharmacist Laboratory Technicians Nurse/Midwife (Source: RHS Bulletin, March 2008, M/O Health & F.W., GOI) Table 5: The other Health Institution in the State are detailed as under Health Institution Number Medical College 4 District Hospitals 32 Ayurvedic Hospitals 8 Ayurvedic Dispensaries 624 Unani Hospitals - Unani Dispensaries 9 Homeopathic Hospitals 6 Homeopathic Dispensary 603 Source- PIP, NRHM- Orissa (08-09) (Orissa) Table 6: Facts and Figures of Health Services in Orissa (NIC, 2005) Health Services Number 1. Community Health Centres Hospitals in the State Primary Healthcare Centres (PHC) Ayurvedic Hospitals and Dispensaries Homeopathic Hospitals and Dispensaries Mobile Health Units Diagnostic Centres Doctors per million Population Beds per million Population 432 Source- (NIC, 2005) 17 P a g e

18 1.4 Role of Private Sector in Health Outcomes Healthcare service outlets are predominantly in the public sector in Orissa. On taking hospital beds as an indicator, private hospital beds account for less than 10 per cent of the total bed strength in the state. This is at variance with the pattern elsewhere in India. (Gupta, 2002) 18 P a g e

19 Percentage NIPI Reference Book- Orissa India: Percentage of Hospitalizations In The Public and Private Sector Among Those Below The Poverty Line, According To State 100% 80% 60% 40% 20% 0% ANDHRA PRADESH BIHAR GUJARAT HARYANA HIMACHAL PRADESH KARNATAKA KERALA MADHYA PRADESH MAHARASHTRA NORTH EAST ORISSA PUNJAB RAJASTHAN TAMIL NADU UTTAR PRADESH States Public Facilities Private Facilities Source: Pearson M, Impact and Expenditure Review, Part II, Policy Issues, DFID 2002 Similarly, for every 1000 patients seeking treatment, 906 rural patients and 810 urban patients get their services from government hospitals. Private Medical Institutions are, by and large, located in urban areas and are unevenly distributed among districts. 64 per cent of private hospitals, with 71 percent of the total private hospital beds, are located in urban areas. The uneven distribution of private hospitals among districts is evident from the fact that while the public private hospital ratio is 77:22 in Cuttack district, the same in Kalahandi (in western Orissa) is 95:5. The actual ratio may be slightly higher in favour of private facilities across the districts, because many single doctor clinics are not officially registered. (Gupta, 2002) Private providers include for-profit institutions (concentrated in urban areas) and not-forprofit outlets (mainly in rural areas). Private medical institutions, with the exception of a few in Bhubaneswar and Cuttack, are usually small with less than 30 beds, and provide both general and specialised care. Private practitioners of ayurveda and homoeopathy also exist; they provide mostly outpatient consultations. In addition, there is a large band of traditional healers spread across 19 districts of the state where the tribal population is high. Not-for-profit 19 P a g e

20 institutions in the rural areas are mission charities, and are found mainly in southern and south central Orissa. (Gupta, 2002) More than one-third of the private medical institutions in the state are single doctor nursing homes or small clinics. Another one-third has two to five doctors. There are very few private hospitals having more than 10 doctors. (Gupta, 2002) The private medical institutions, with the exception of those in the voluntary sector, focus on curative care, and are not geared for carrying out public health functions. The capacity in terms of trained personnel, time, space, and other resources is an important consideration while persuading private institutions to engage in public health services. Private medical institutions are not concerned about the control of communicable diseases. Instead they are engaged in treating those people who seek services for such conditions. A study conducted in Orissa by the Institute of Management in Government (IMG), Kerala in 1999 showed that only 44 percent of the private hospitals in three sample districts were aware of any major outbreak during a five-year period preceding the survey. The lack of concern was also evident in their responses regarding the Government of India treatment regimen followed under the national programs for various diseases (e.g. leprosy, TB, etc.). About 64 percent of the private medical institutions in the IMG study were aware of this regimen, but did not generally follow the same. However, for institutional services, the private medical institutions are relatively well equipped. Primary stakeholders, cutting across economic and regional status, rated private providers as being more efficient in curative care. (Gupta, 2002) There are two state regulations that control the operations of private providers in the state, besides the Government of India s Acts, viz. the Medical Termination of Pregnancies Act and the Pre-natal Diagnostics Tests Act. The two State Acts are the Orissa Clinical Establishments Act (OCEA) and the Orissa Medical Regulation Act (OMRA). The OCEA, which became effective in 1994, is intended to control and regulate the proper functioning of private nursing homes and other clinical establishments. The Act sets standards and conditions for clinical establishments to register and function, establishes procedures for the supervision, and sets conditions for penalty for offences and also for protection of action taken in good faith. The OCEA, thus, empowers the government to regulate the private medical institutions 20 P a g e

21 in these aspects. However, the IMG study found that the Act was not administered or implemented properly. There are delays in granting registration, and there is no proper system in controlling private medical institutions from doing undesirable practices. The study also found that the district authorities either treated the provisions of the Act casually, or ignored them. The absence of a proper database of private medical institutions at the district level was an indicator of this attitude. (Gupta, 2002) The provisions in the Act are adequate to control the private medical institutions and prevent undesirable practices. But there are no clauses that can direct private medical institutions to participate in government programs. However, some hospitals voluntarily get involved in some such services like immunisation, sterilisation, cataract operation, health camps, and HIV/AIDS awareness programs. Mission hospitals are generally good at ambulatory services, but the area covered by those institutions is restricted due to the very small number of such hospitals. The Act does not have any enabling provisions to encourage private initiatives, except for the clauses that allow the authorities to relax the prescribed requirements in relation to location, accommodation, equipment, and personnel to set up clinical establishments in rural areas. (Gupta, 2002) The OMRA was promulgated by the Legislative Assembly in The Act sets the professional standards and qualifications to practice both in the government and the private sector. It has established administrative machinery in the form of Orissa Council of Medical Registration. However, in its present form, the Act does not have adequate powers to regulate the practising habits in the private sector but can be amended suitably to do so (IMG study). (Gupta, 2002) Besides the state Acts, private clinical establishments which offer abortion services and prenatal tests are regulated by two Central Acts, viz. the Medical Termination of Pregnancies Act, and the Pre-natal Diagnostic Techniques Act. The implementation of both the Acts in the state is somewhat weak. (Gupta, 2002) 1.5 Human Resource The HR data of the available physical facilities was updated through coordinated efforts of State Health Mission and NHSRC. Of the 6688 SHCs available, 212 are without ANMs, P a g e

22 are without Health Worker (male.) and of the 1279 PHCs functioning, 712 are functioning without nurse, 157 are without doctors, 881 PHCs are with either allopathy or AYUSH doctor only where as 98 PHCs are functioning with 4 doctors, 26 with 3 doctors, and 117 with two doctors. The services of lab technicians required for basic diagnostics (Haemoglobin Blood sugar etc) are not available in 1,162 PHCs. (HR-Plan, 2009) Table 7: H R Requirement for Facilities - as per IPHS & Existing Facilities Facilities Required as per IPHS HRH Required HRH Sanctioned, Available & Shortfall DH SDH CHCs PHCs SHCs For IPHS Facilities For Existing Facilities Sanctioned Available Shortfall for IPHS Facilities Facilities , Shortfall for Existing Facilities A Human Resource Nursing & Midwifery Midwifery HR , ANM LHV PHN Nursing HR Staff Nurse Head Nurses Matrons/Asst B Paramedical HW Male Lab Tech , Pharmacist Radiographer C Doctors , MO/GDMO Specialists Total #SDH not included *SDH & DH not included * Considered 7 Staff Nurses per/ CHC as per GOI norms Source- (HR-Plan, 2009) Medical Officers and Specialists (Allopathy): The state requires a large number of additional doctors and specialists for existing facilities and additional facilities required as per Indian Public Health Standards norms for the growing population. As per the State Health Management Information System, of the 1279 functional PHCs, 157 are without doctors whereas 117 PHCs are provided with two MOs and 26 with three 22 P a g e

23 MOs. At present 2033 MOs and 1242 specialists (Obstetrics, Paediatrics, Anaesthesiology, Medicine, Surgery & Ophthalmology) are available. The estimated shortages are 4842 MOs and 626 specialists for existing facilities and additional requirements for facilities as per IPHS would be 9105 allopathy MOs and 2319 specialists. The vacancies at every level of hierarchy are very high at 33 percent due to delays in constituting promotion committees, pending court cases, non-reporting on postings to rural / tribal areas etc., (UNFPA & Xavier Institute 2007). The nonavailability of doctors has been a consistent problem and the high focus backward districts are the most affected. The availability of doctors including specialists in Orissa is largely dependent upon the three Government Colleges with an annual intake of 321 and the seats were increased to 450 from the current academic year Three other medical colleges were started recently with annual intake of 300 seats. These measures would enable availability of additional allopathy doctors. (HR-Plan, 2009) Human Resource Nursing: Orissa needs 7799 Auxiliary Nurse Midwives (ANMs), 297 Lady Health Visitors (LHVs), 231 Public Health Nurses (PHNs), 50 District Public Health Nursing Officers (DPHNOs), Staff Nurses; 417 Head Nurses; 96 Assistant Matrons and 107 Matrons. Orissa is also facing a crisis in availability of nursing teachers 34 teachers are required at General Nurse Midwife (GNM) and ANM level and 23 at the collegiate level. To enable nursing personnel to meet standards many more teachers will have to be prepared. (Prakasamma, 2009) Shortfall of Nursing & Midwifery Human Resources: There is an acute shortage of 6,531 ANMs and 9,027 Staff Nurses for the existing health facilities (SHCs, PHCs, CHCs, and sub-district and district hospitals) excluding the medical college hospitals and private sector facilities across the 30 districts of Orissa state. The promotional vacancies in these two entry level categories would additionally require 659 ANMs and 395 Staff Nurses. The long-term shortfall of these categories for the provision of health facilities as per Indian Public Health Standards (IPHS) would be 13,858 ANMs, 331 LHVs, 481 PHNs, Staff Nurses, 312 Head Nurses and Assistant Matrons / Matrons excluding the requirements for medical college hospitals, faculty requirements and private sector needs. The task of fulfilling these essential HR needs is a mammoth task to be undertaken on top priority basis. (HR-Plan, 2009) 23 P a g e

24 1.6 Snapshot of the State Health Budget s Trend Table 8: Annual State Plan Ceiling of Different Departments for the year State Plan Allocation (INR in Lakhs) Percentage of Total Health & Family Welfare % Total - State Govt. Plan Ceiling Source- (Budget_sheet, 2010) Table 9: Financial Management under NRHM Financial Management under NRHM (INR in crore) Years Allocation Release Expenditure % Release against Allocation % Expenditure against Release Source- (State Health Report, 2009) Table 10: Trends in Financial Expenditure on MCH FY FY FY FY Release Audited Expenditure * * - Audited expenditure for is not yet available; reported expenditure is provided. - Allocation for : Rs crores. 1.7 Important Issues & Challenges concerning Healthcare Challenges for State It is a daunting task for the state to improve the health status of the people especially that of the socio-economically, geographically and educationally vulnerable groups. (Health Equity, 2009) 24 P a g e

25 The health inequity that exists between the different communities of Orissa point out to two important issues that the state must address. The first important issue is obviously within the health sector itself. Within this, both the supply and demand side of health needs to be addressed through appropriate health-seeking interventions respectively. That means the health service providers have to not only provision proper and equitable healthcare services to all sections and categories of population but also appropriately act on the generation of demand of those sections through proper Behaviour Change Communication (BCC), Information, Education, and Communication (IEC), Interpersonal Communication (IPC) and other initiatives. The other important area in which the state needs to work out is in terms of integration of health sector with other sectors such as education, transportation and communication, livelihood promotion, etc. In view of this, the following are the some of the challenges that Orissa needs to overcome in order to improve the health status of the inhabitants of the state. (Health Equity, 2009) Social status more specifically the caste-wise health inequity is quite visible. As seen in almost all health indicators, the general caste population is more privileged as compared to the SCs and STs. These necessitate caste specific measures, more specifically adopting appropriate health strategy needs taking into account the SCs and STs or areas with a higher concentration of SCs and STs. Therefore, understanding the perception of STs and SCs is more crucial in strategising the same. (Health Equity, 2009) The geographical remoteness or inaccessibility is another crucial challenge that needs to be addressed while strategizing health services into those areas. (Health Equity, 2009) Apart from caste and geographical location, the inequity between the educationally deprived and economically superior people also needs to be addressed. The educationally deprived section seems to be more vulnerable as far as health status is concerned. Since education is one of the key factors in health-seeking behaviour of people, appropriate measures in terms of BCC, IEC, IPC etc. need to be initiated. (Health Equity, 2009) 25 P a g e

26 Likewise, economic deprivation is a significant factor in widening the equity gap between economically different sections of the population. This is one area that requires the attention of health service providers as well as other sectors of development such as livelihood, finance, insurance etc. Within the health sector, appropriate provisioning of health resources must be made so that the economically deprived people also have access to health services. (Health Equity, 2009) The 11th five year plan clearly points out that there is under-utilization of health services owing to social, cultural, and economic factors. Some of the problems include difficult terrain, location, disadvantage of health facilities, unsuitable timings of health facilities, lack of IEC activities, lack of transport, etc. (Health Equity, 2009) Taking all the above factors into account, the overall efficacy of the health care provisioning in terms of logistics, manpower deployment, infrastructure etc. needs to be improved. (Health Equity, 2009) Key issues for State 1. Maternal Health, including JSY (State Health Report, 2009) While the number of institutional deliveries under JSY is 3.09 lakhs in 08-09, Orissa is yet to adequately gear up facilities to meet the load: The state has put into operation 39 PHCs that operate 24x7 so far against the target of 1282 PHCs by facilities have been operationalized as FRUs as against the target of 254 by Blood storage units are not fully operationalised. The pace of skill-based training needs to improve. Only 22 MBBS doctors have been trained in Life-saving Anaesthesia Skills (LSAS) and 24 in Comprehensive Emergency Obstetric Care (CEmOC) so far against the target of Staff Nurses/ANMs/LHVs have been trained in (Skilled Birth Attendants) so far against the target of 6288 by 2010, However quality parameters like partograph, skills on delivery and new-born care, availability of drugs etc, need to be properly supervised and practiced. 26 P a g e

27 Only 20 percent of planned Village Health & Nutrition Days were held in (1 lakh out of 5 lakh planned) 2. Child Health (State Health Report, 2009) Neonatal mortality rate or NMR (infant deaths within 4 weeks of life per 1000 live births) at 49 (SRS 2007) accounts for 69 percent of the IMR. Early NMR (infant deaths within one week of life per 1000 live births) at 37 (SRS 2007) accounts for 76 percent of the NMR. An evaluation of JSY in the state in December 2008 highlighted that only 27 percent of the beneficiaries surveyed stayed for at least two days in the health facility after delivery. While there is a huge offtake of JSY in the state (3.09 lakh beneficiaries in ), this is clearly a missed opportunity to address early neonatal mortality. 70 percent of all infant deaths in India are concentrated in eight states (Bihar, UP, Madhya Pradesh [MP], Orissa, Rajasthan, Andhra Pradesh [AP], Maharashtra and Gujarat). But in Orissa, Only one Sick Newborn Care Unit (SNCU) is present. Care-seeking for children with ARI has declined (67.8 percent to 63.4 percent) and only 22 percent of families know the danger signs. 3. Immunization (State Health Report, 2009) The state continues to have a high number of dropouts from BCG to DPT 3 which is critical for further improvement in full immunization coverage. As per DLHS 3 Survey there are 25.7 percent unimmunized children (based on DPT 3 Coverage) which translates to around 2.1 lakh children per year. The state needs to expedite the constitution of adverse events following Immunization (AEFI) committees in the 15 districts. The state also needs to strengthen AEFI reporting further to improve reporting of AEFI cases. The training plan of immunization staff needs to be rationalized based on available training infrastructure and the huge training load. A phased plan covering realistic target this year and remaining in subsequent years may be considered. 27 P a g e

28 4. Infrastructure (State Health Report, 2009) There is a huge backlog of construction activities. Infrastructure development mechanisms (separate engineering unit) initiated by the state need to be strengthened. There is an urgent need to upgrade the infrastructure at various levels including staff quarters. 5. Human Resource (State Health Report, 2009) (HR-Plan, 2009) Creation of a public health cadre in the state is required. Restructuring of cadre of doctors for creating better promotional avenues is under active consideration. There is a shortage of MBBS doctors, Staff Nurses, specialists and lab technicians. This gap must be reduced by hiring contractual manpower. All vacancies for the National Vector Born Disease Control Program (NVBDCP) from District Malaria Officers to Lab. Technicians and Multi Purpose Workers (M) must be filled up. Effective pooling of Lab Technicians to handle investigations such as malaria, TB, HIV/AIDS and other diagnostic tests at the DH/SDH/CHC level. Proposals are under consideration for upgradation of the nursing college. Provision of 3,899 additional health centres (3309 SHCs, 306 PHCs and 284 CHCs) except in Mayurbhanj district with fifty-three surplus SHCs for the estimated population of (HR-Plan, 2009) Provision of human resource for health (HRH) including allopathy MOs at PHCs (New) as per the IPHS norms (HR-Plan, 2009) Provision of HRH (doctors, nurses and specialists) for operationalization of 24x7 PHCs and FRUs (HR-Plan, 2009) Provision of nurses, ANM and paramedical staff at health facilities and hospitals as per IPHS. Provide adequate number of medical, nursing, midwifery training institutions. (HR-Plan, 2009) Ensuring availability of faculty at nursing and midwifery institutions for quality in healthcare delivery. (HR-Plan, 2009) 28 P a g e

29 6. Service Delivery (State Health Report, 2009) There is an increase in patient load and institutional deliveries in CHCs, Subdivisional & District Hospitals. Newborn care equipment, childhood illness care at primary level requires strengthening. There is increase in institutional deliveries as well as male & female sterilisations. 7. Areas for Further Improvement: - (State Health Report, 2009) Need to strengthen PHC and Sub centre services Need to expedite the infrastructure development with priority to sub centre construction. Operate an integrated Mother & Child Health FRU. Operate institutions selected for 24X7 services on a priority basis. Scale- up telemedicine facilities in hard-to-reach areas. Need to improve the HR gap - MBBS doctors, Staff Nurses, Specialists and Lab 1.8 Recent Reforms in Health Any health sector reform aims to improve the health status of the people by improving the organizational structure, governance system and financing variables. The health system has to perform a number of functions in order to enable more people to avail health benefits. (Rout S. K., 2010) In the health and allied sector the state of Orissa has made noticeable improvements in certain specific areas such as success in leprosy control, increase in food availability, good network of government health care institutions that provide free medical care and medicines. However the state has since long been unpopular for one of the highest IMR in the country but there has been a steady decline in the said rate which as per NFHS 3 ( ) has now come down to 65 as compared to the national average of 53. As per SRS 2004, the MMR in Orissa at 358 was higher than the national average of 301. (Health Equity, 2009) The reform effort has not made substantial improvement in rural health indicators as indicated by NFHS-III. Most of the organisational and institutional changes were introduced as a part of a donor support programme and this has not been integrated into the system. Thus the health 29 P a g e

30 system did not improve on a sustained basis in order to achieve health sector goals. As a part of public financing, the state has not allocated resources as per the policy stance. The fiscal crisis has also resulted in reducing share of state expenditure towards health. There was also a substantially low allocation for inputs and infrastructure which affected the service delivery in rural areas. So equity and efficiency have remained two concerns in the future of the health sector development of the state. (Rout S. K., 2010) Looking at the gap between the existing and required health facilities / infrastructure, it can be said that the state has a long way to go before it can meet the targets for centres of healthcare delivery. (Health Equity, 2009). Table 11: Health Infrastructure of Orissa Particulars Required In position shortfall Sub-centre Primary Health Centre Community Health Centre Multipurpose worker (Female)/ANM at Sub Centres & PHCs Health Worker (Male) MPW(M) at Sub Centres Health Assistant (Female)/LHV at PHCs Health Assistant (Male) at PHCs Doctor at PHCs Obstetricians & Gynaecologists at CHCs Physicians at CHCs Paediatricians at CHCs Total specialists at CHCs Radiographers Pharmacist Laboratory Technicians Nurse/Midwife (Source: RHS Bulletin, March 2008, M/O Health & F.W., GOI) All is not dismal and thus in order to bring about an overall improvement in the health sector in Orissa, the performance of the public health system is regularly been analyzed and assessed and thereafter modifications and changes are incorporated. The state has undertaken several initiatives which have helped in strengthening the health system. The state initiatives can be divided into: The programmatic improvement achieved under the umbrella cover of the National Rural Health Mission (NRHM), Integrated Child Development Scheme (ICDS) and under various state and national health programs. Improving the staffing and working/service conditions of the service providers that include doctors, nurses and paramedics. 30 P a g e

31 NRHM is one program that started in 2005 and initiated an integrated approach and effort towards the fulfilment of Health for All goals for the country and thus unifying all health personnel to achieve the set targets of the programs. (Health Equity, 2009) Improving Maternal and Child Health To improve access to facilities, Janani Express, an emergency referral transport scheme, was initiated in 124 health institutions. The institutional deliveries in have increased from percent to 61 percent (CNAA) This increase is due to the successful implementation of Janani Sahayata Yojana and the motivation undertaken by ASHA. JSY has increased institutional deliveries in all districts and especially in the Koraput Balangir - Kalahandi (KBK) districts that have high mortality rates. This increase has almost doubled in over This is indeed laudable for the state which focuses on developing, strengthening and operationalizing facilities. Apart from this, SBA training of staff nurses, ANMs and LHVs has been an important initiative to improve safe deliveries and to also man FRUs and 24X7 facilities under NRHM. The new schemes that have been introduced in promoting safe deliveries are: (Health Equity, 2009) 1. Janani Sahayata Yojana scheme aims to increase availability of delivery and newborn care services through private providers for BPL families. The accredited health facilities would be combined to offer services in the following manner: The charges for a normal delivery or a delivery by caesarean section would be INR The beneficiary will not receive the JSY benefit for this, but instead an incentive of INR 500 would be offered to meet the immediate needs. (Health Equity, 2009) 2. Matru Smruti Yojna: Directed toward seven districts particularly Korapet, Rayagada, Nawarangpur, Malkangiri, Gajapati and Kalahandi where institutional deliveries are less than 40 percent. The scheme aims to encourage families toward institutional delivery and provide support for the upkeep of the 31 P a g e

32 child in case of the mother s death. It offers a National Saving certificate or Kisan Vikas Patra of INR4000 in the name of the child, which would be handed over to the father or the legal guardian. (Health Equity, 2009) 3. Integrated Management of Neonatal Childhood Illness (IMNCI) is being used as a major strategy for newborn care in the state. Training of the providers and health functionaries is a key element of this program. Through a cascading model different service providers in Orissa are being trained with the technical support of agencies like UNICEF and Sishu Bhavan, Cuttack. It is being done in a manner that a district will simultaneously be able to develop teams at all levels. This training has been taken up in twelve districts that have been identified with high IMR. The quality of training is ensured through monitoring and supervision of the existing organizational set up. Implementation has also commenced in two districts viz. Mayurbhanj and Koraput. (Health Equity, 2009) 4. Prustikar Diwas: To combat malnutrition and for effective treatment of malnourished children the 15 th of every month has been declared as Prustikar Diwas. (Health Equity, 2009) 5. Sick Newborn Care Unit Implementation: As a part of the IMNCI, a Sick Newborn care unit has been established at Mayurbhanj, DHH Baripada with 15 beds (10 intensive care beds with 5 step-down beds). (Health Equity, 2009) Initiatives for Human Resource 1. Steps taken to improve availability of doctors: With three medical colleges in the government sector and another three in the private sector which have only recently by been established, there is still a large gap in the supply of doctors in the state. Therefore, the MBBS seats in the two government medical colleges have been increased. In VSS Medical College, Burla and MKCG 32 P a g e

33 Medical College, Berhampur seats have been increased by forty-three each. (Health Equity, 2009) 2. Steps taken to improve the availability of paramedics: Another major constraint with regard to human resource in the health sector is the nonavailability of technical manpower. Very often, lack of trained manpower hinders the delivery of services in health institutions. Therefore the number of seats for the laboratory technician course and the X-ray technician course in the three medical colleges has been doubled. There has also been a 33 percent increase in seats in all the 16 ANM training centres. This will lead to an increase in the availability of technical manpower for this sector. (Health Equity, 2009) 3. Enhancement in remuneration of contractual doctors: To improve the availability of doctors, appointment of contractual doctors has been a practice in the state. To improve their overall service condition remuneration for these contractual doctors has been increased keeping in view the nature of districts. (Health Equity, 2009) 4. Incentive for regular doctors: To improve the retention of doctors in the eleven remote and backward districts, an additional incentive has also been provided to the regular doctors. (Health Equity, 2009) 5. Policy Decisions such as up grading the entry level status of MBBS doctors from Class II to Junior Class I, increasing specialist allowances, restructuring of cadre for increasing promotional avenues, etc. have been taken. In addition, the state government in collaboration with OMSA (Orissa Medical Service Association) is also in the process of developing a rational transfer & deployment policy. These measures are expected to improve the motivational level of doctors and thereby improve their services. There are different categories of health institutions that exist in the state. Despite being established under a particular population area norm, over the years they have outgrown the prevailing norms. Therefore it was considered essential to re-organize the health institutions and the categories of their level of operation. A complete 33 P a g e

34 exercise in this regard is being undertaken to bring about re organization and re-alignment of the different health units in the state. (Health Equity, 2009) Hello Doctor 24 x 7 Hello Doctor 24 x 7 was launched in 2010 as a social enterprise and dedicated to public service with several benefits. It aims to reach the unreached population and provide them easy and anytime access to healthcare information. Services offered include online and telephonic doctor appointment fixing, first aid/home remedy, voluntary blood donation, ambulance, etc. Some of the services offered are first of its kind in India. (odisha diary, 2010) The concept was incubated at KIIT s Technology Business Incubator (KIIT-TBI), which is supported by the Department of Science & Technology, Govt. of India. (odisha diary, 2010) Their healthcare associates effectively and proactively educate and encourage customers to take the right decision at the right time. (Hello Doctor 24*7) 34 P a g e

35 Chapter-2 Maternal & Child Healthcare in Orissa 35 P a g e

36 2. Maternal & Child Healthcare in Orissa NIPI Reference Book- Orissa 2.1 Status of Maternal and Child Health Maternal Mortality Maternal Mortality Ratio (MMR) in India stood at 301 per 100,000 live births, while the figure for Orissa was 358 (Table 12). The table shows three surveys conducted between 1997 and 2003 that show a declining trend in MMR in India while it is fluctuating in the case of Orissa. (Orissa_Baseline, 2009) Table 12: Maternal Mortality in Orissa and India Source Retrospective MMR Survey SRS Prospective Household Survey Special Survey of Deaths Maternal Mortality Rate2 Maternal Mortality Ratio3 India Orissa India Orissa Source: Maternal mortality in India: : Trends, causes and risk factors (2004): Registrar General of India, New Delhi Infant Mortality Historically, Orissa is a high infant mortality rate (IMR) state compared to other states of India, though the IMR has declined drastically in the last two decades. In , the IMR was 112 per 1000 live births in Orissa compared to 79 for all India (NFHS-1). According to the latest NFHS-3 ( ) the figure for Orissa was 65 per 1000 live births. SRS 2006 estimates the IMR of Orissa to be 73 per 1000 live births (Table 13). (Orissa_Baseline, 2009) 36 P a g e

37 Table 13: Trends in Infant Mortality Rate of Orissa and India Infant Mortality Rate Source/Year Orissa India NFHS1 ( ) NFHS2 ( ) NFHS3 ( ) SRS SRS SRS NRHM Goal by Source: NFHS 2 and 3, SRS Bulletin (1997), SRS (2003), SRS (2006) & State PIP ( ) Child Mortality Under 5 mortality (U5MR) in Orissa as per NFHS-3 is 91 per 1000 live births, one of the highest in India, but U5MR has declined by about 30 percent since NFHS-1. (Orissa_Baseline, 2009) Table 14: Trends in Under Five Mortality Rate for Orissa and India Under 5 Mortality Rate Source/Year Orissa India NFHS1 ( ) NFHS2 ( ) NFHS3 ( ) NRHM Goal by 2012 <50 <50 Source: NFHS 2 and 3, State PIP ( ) Direct estimates of infant and child mortality indicators at the district level are not available. However estimates using census data on children born and children surviving are available but are inconsistent and not reliable. Hence this data is not presented in this report. The District Level Household Survey (DLHS ) does not provide district level infant and child mortality estimates. Thus no reliable estimate of infant and child mortality is available at the district level. (Orissa_Baseline, 2009) Another area of concern is the difference in indicator values from different data sources. For example SRS figure for IMR in Orissa is 73 whereas, NFHS-3 ( ) shows an IMR of 65. (Orissa_Baseline, 2009) 37 P a g e

38 2.2 Key Achievements in MCH of Orissa (in 2009) 1. Maternal Health, including JSY (State Health Report, 2009) The number of JSY beneficiaries in the state increased from 2.27 lakh in to 4.91 lakh in and decreased to 3.09 lakh in P a g e

39 NIPI Reference Book- Orissa 22 MBBS doctors have been trained in LSAS while 24 have been trained in emergency obstetric care against the target of 254. Selection of trainees for multi-skilling is done through open advertisement and counselling before admission. Post-training placement is also decided simultaneously. Further, in a unique step the state has decided to place interested couple doctors at FRUs before training, so as to ensure their sustainability. 856 SNs/ANMs/LHVs have been trained in SBA against the target of They have also established referral linkages through Janani Express Yojana which has been proposed for three each in 118 tribal blocks and one each in 196 non- tribal blocks in ) In order to strengthen the implementation of VHNDs (Mamta Diwas) guidelines have been published & widely circulated. Programmes are being organised during the VHND sessions to improve awareness and initiate action. This includes Health Quiz, Bangle Ceremony, Healthy Baby Show, Adolescent Mela, Health Rally, and Award for best maintained house with respect to cleanliness, maintenance & sanitation etc. Table 15: Institutional Delivery and JSY Scheme (CES_Orissa, 2010) Indicator Number of women who delivered in the previous 12 months (n) Orissa Low Performing States India Proportion aware of JSY scheme* (%) Proportion received any assistance under JSY during delivery* (%) Number of women who delivered in institution in previous 12 months (government + private) (n) Proportion women reported that ASHA accompanied her to health facility for institutional delivery** (%) Proportion women reports ASHA stayed at health facility** (%) Number of women who delivered in government institution in previous 12 months (n) Proportion of women who delivered in Government institution and received assistance under JSY*** (%) Proportion women reported that ASHA accompanied her to Government facility for institutional delivery*** (%) Proportion women reports ASHA stayed at health facility*** (%) P a g e

40 Number of women who delivered in institution in previous 12 months (government + private) (n) Women who delivered in institution by Bed facility** (%) Separate bed Shared bed No bed (CES_Orissa, 2010) * Base= all women who delivered in 12 months prior to the study (all government & private institutional and home deliveries); ** Base= all women who delivered in an institution (both Government and Private); *** Base= all women who delivered in a Government institution; (Note: Segregation of states into low/high performing is as per JSY scheme) # Janani Suraksha Yojana Scheme Table 16: Maternal Care (Women delivery in previous 12 months) (CES_Orissa, 2010) Indicator Rural Urban Total Women who delivered in the last 12 months (n) Pregnancy registration Percent registered during last pregnancy Government doctor ANM Anganwadi worker ASHA Private doctor Others Stage of Pregnancy at the time of first ANC (%) No. of antenatal checkups (n) First trimester Second trimester Third trimester Don't Remember No. of days IFA tablets/syrup consumed during pregnancy (%) < = > = None TT Injection Full ANC* Distance travelled to get ANC services (%) <1 Km Km Km Km Mean distance (in Kms) P a g e

41 Time taken to reach the place to avail ANC Services (in minutes) < Oct Do Not Remember Mean time taken (in minutes) (CES_Orissa, 2010) Table 17: Delivery Care (Women delivery in previous 12 months) (CES_Orissa, 2010) Indicator Rural Urban Total Number of women who delivered in last 12 months Institutional Delivery (%) Public Facility Private Facility Skilled Birth Attendance (institutional + home deliveries) For all Institutional Deliveries Distance of health facility (in Km) < = Do not Know/Can t say Mean Distance from House (in Km) Time taken to reach the facility (in minutes) < = > Mean time taken (in minutes) to reach the facility (CES_Orissa, 2010) 2. Child Health (State Health Report, 2009) Integrated Management of Neonatal & Childhood Illness (IMNCI) is ongoing in sixteen (out of thirty) districts of the state personnel have been trained in IMNCI so far. Orissa has taken some innovative measures to address malnutrition. These include a positive deviance approach to complementary feeding practices, 41 P a g e

42 Prustikar Diwas for management of severely malnourished children and hospital-based health workers or Yashodas to initiate early breastfeeding. Table 18: Newborn Care (CES_Orissa, 2010) Indicators Rural Urban Total Number of newborns in the last 12 months (n) Proportion of newborns checked up <24 hours after birth Number of checkups done within 10 days after birth (%) None (CES_Orissa, 2010) Table 19: Breastfeeding practises during first 6 month according to age of living child (CES_Orissa, 2010) Age in months Number of living Children (n) Never Breast fed Exclusive breast feeding till 6 months of age Breast Feeding+ Water Not Exclusive Breast Feeding Breast Feeding + Other milk Breast Feeding + Other supplements Breast Feeding + Other food < < < (All figures in percentage) (CES_Orissa, 2010) Table 20: Child Health (0-2 Years) (CES_Orissa, 2010) Indicator Rural Urban Total Number of children 0-2 years of age (n) Acute Respiratory Infection (ARI) in previous 2 weeks (%) Proportion seeking ARI treatment at (multiple response) (%) Govt. Health Facility/Provider Pvt. Health Facility/Provider Any health facility Proportion not seeking any healthcare for ARI P a g e

43 Acute Diarrhoea in previous 2 weeks (%) Proportion seeking Diarrhoea treatment at (multiple response) (%) Govt. Health Facility/Provider Pvt. Health Facility/Provider Any health facility Others Proportion not seeking any healthcare for Acute Diarrhoea (CES_Orissa, 2010) 3. Other Initiatives (State Health Report, 2009) Management of PHCs through NGOs Application of GIS Technology for mapping of existing healthcare facilities, spatial mapping of incidence of diseases, mapping of service coverage of subcentres, and identification of unserved areas. 2.3 Public expenditure on reproductive and child health services The study done by Rout, 2010, examines the proportion of resources meant for reproductive health as a part of the overall health budget. The public expenditure on reproductive and child health services has tripled from INR 108 crore in to INR 336 crore in In real terms, however, the increase was only 5.09 percent. While the expenditure fluctuated from to , it increased thereafter largely due to an increase in allocations routed outside the state budget and in the expenditure on nutrition. Contributions from the Health and Family Welfare Department accounted for between half to two-thirds of the total expenditure on reproductive and child health services from to However it declined thereafter to between one-quarter and two fifths of the total as a result of an increase in off-budget spending particularly after the introduction of NRHM funds which comprise a substantial share of RCH expenditure. (Rout S..., 2010) 43 P a g e

44 44 P a g e NIPI Reference Book- Orissa Table 21: Public expenditure on reproductive and child health services, Orissa, to (in Rs. Crore) Year Health and Family Welfare Department Outside budget Nutrition Total % share of total health and healthrelated expenditure % share of Gross State Domestic Product (RE) (BE) NA Average Sources: Finance Department, Government of Orissa Demand for Grants of Health and Family Welfare Department. Government of Orissa Budget at a Glance. Government of Orissa. (Rout S..., 2010) The expenditure on reproductive and child health services fluctuated considerably during the 12-year study period. Between 13 and 26 percent of the total health and health-related expenditure was allocated for reproductive and child health services; in the most recent year, , it was 21 percent. Nonetheless, as a share of gross state domestic product, expenditure on reproductive and child health services remained below one percent throughout this period. (Rout S..., 2010) Table 22: Expenditure on reproductive and child health services by sources of funding, Orissa, to (percentage) Year State share Central share Donor Agencies Total (RE) (BE) NA 100

45 Average NIPI Reference Book- Orissa Sources: Finance Department, Government of Orissa Budget at a glance. Government of Orissa Demand for Grants of Health and Family Welfare Department. Government of Orissa. (Rout S..., 2010) Central government contributions comprised as much as percent of the expenditure on reproductive and child health services during to , with a contribution of 83 percent in The state government s contribution ranged from 5 21 percent during the same period and stood at 18 percent in While contributions from donor agencies remained modest till , they increased thereafter. For example, percent of the expenditure on reproductive and child health services during came from donor agencies. Increased donor contributions bring about greater flexibility in funding and utilisation of resources based on planning, leading to the achievement of targets within the stipulated time. While this is a clear advantage in comparison to normal budgetary spending, the main issue is that of sustainability of the programme on completion of the project cycle. (Rout S..., 2010) Table 23: Composition of expenditure on reproductive and child health services, Orissa, to (in Rs. crore) RCH Services Rural family Welfare services and Centres Urban family Welfare services and Centres (RE) (BE) District family Health Bureau Postpartum Centre Training Regional Health and family welfare training centres Revamping of urban slums State Family Welfare Bureau Village health guide scheme Child survival and safe motherhood programme State Institute of He alth & Family welfare Maternal and child health Reproductive and child health project Infant mortality reduction mission P a g e

46 Compensation and mass education Purchase of contraceptive, MCH extension supplies, education kits Institute of Paediatrics, Cuttack Other Grand Total Note: 1 Includes expenditures on a range of issues including: Expansion of medical termination of pregnancy (MTP) services; Activities of the UK Aid schemes, UNFPA; State health transport organisation; Printing of eligible couple registers; 2 Expenditure incurred by the Health and Family Welfare Department. Source: Finance Department, Government of Orissa Demand for Grants of Health and Family Welfare Department. Government of Orissa. (Rout S..., 2010) The table above presents a break-up of the reproductive child health expenditure incurred by the Health and Family Welfare Department alone as actual and as a percentage of the total expenditure on reproductive and child health services, respectively. Findings indicate that of the total expenditure, a major share between 7 13 percent was allocated for rural family welfare services and centres during to In contrast, during the same period, urban family welfare services and centres received only 2 percent or less of the total expenditure. Likewise, maternal and child health services received just 2 7 percent of the total expenditure on reproductive and child health services. Notably, scant resources were also allocated for training of healthcare providers. (Rout S..., 2010) 2.4 Scheme in the State for Improving Maternal and Child Health In order to improve the implementation of several child and related maternal health activities, certain programs are ongoing programs currently such as of Janani Suraksha Yojana, Janani Express, Yashoda, Mamta Divas, Pustikar Diwas and IMNCI program. (Orissa_Baseline, 2009) Common program for both Maternal and Infants Health Mamata Diwas Village Health and Nutrition Day (VHND), Mamata Diwas, a concept for interdepartmental convergence having desirable health outcomes of children below five years, is being introduced in the state of Orissa by the Department of Health and 46 P a g e

47 Family Welfare. This would provide the first point of contact for essential primary healthcare and would work as the common platform for convergence amongst service providers of Health, ICDS and the community. Strategically, training would be given at state, regional district and sector level to various categories of functionaries. (Sanatan Bisi, 2009) Under the program, the primary clients are pregnant women, lactating mothers, children below five years and adolescent girls. Basic components of primary healthcare services, including early registration, de-worming, counselling on early breastfeeding, identification and referral of high risk cases of children and pregnant women, as well as basic ANC and PNC will be provided at community level in order to address the essential requirements of pregnancy, delivery, referral, childhood illnesses and adolescent health. (Sanatan Bisi, 2009) The programme would be organized once a month in every Anganwadi Centre on a fixed day basis (either Tuesday or Friday) with joint efforts of ANMs, AWWs and ASHAs. On an average, there are six to eight AWCs under the operational jurisdiction of one sub centre and thus there would be about eight fixed days in a month per sub centre. There should be advanced fixation of the day with all AWCs for the entire month, so that the service providers and the community are aware of it much in advance. (Sanatan Bisi, 2009) NRHM Orissa is one of the focus states. It has as its key components provision of a female health activist in each village (in case of the focus state); a village health plan prepared through a local team headed by the Health & Sanitation Committee of the panchayat; strengthening of the rural hospital for effective curative care made measurable and accountable to the community through Indian Public Health Standards (IPHS); integration of vertical health & family welfare programmes for optimal utilization of funds and infrastructure and strengthening delivery of primary healthcare. It seeks to revitalize local health traditions and mainstream AYUSH into the public health system. It aims at effective integration of health concerns with determinants of health like 47 P a g e

48 sanitation & hygiene, nutrition and safe drinking water through a District Plan for health. The state has set up the institutional arrangements for implementing the activities under the NRHM. If NRHM is implemented effectively, it is expected that the state may have indicators like other better performing states. Reproductive and Child Healthcare (RCH) Services These services basically include three major packages. The first package is for mothers, which includes early registration, antenatal care, institutional deliveries and deliveries by SBAs, home-based PNC and increased facilities for MTP. The second package is for newborns which includes skilled care at birth, IMNCI for common childhood illness and immunization. Other services include increased choice and availability of family planning services, gender sensitization and gender equality, and prevention and management of RTIs & STIs etc. Revamping of urban slum In order to provide regular health services, immunization and other FW activities at urban slums, revamping urban slum scheme is included in the 3 major cities of Bhubaneswar, Cuttack and Rourkela (Sundargarh). (Schemes on MCH) 48 P a g e

49 2.4.2 Special Programs on Maternal Health Janani Suraksha Yojana (JSY) To promote institutional delivery, pregnant mothers are provided with cash assistance of INR 1,400 for institutional delivery. JSY integrates cash assistance with ANC 49 P a g e

50 during pregnancy, institutional care during delivery and the following post partum period. It involves co-ordinated care by field workers like ANMs, AWW and ASHAs. (Schemes on MCH) The objective of JSY is to reduce overall MMR, IMR and to increase institutional delivery in BPL families. (Schemes on MCH) Maternal and Perinatal Death Inquiry - (MaPeDI) This is a contribution towards reduction of MMR and improvement of maternal health status in Orissa. It also contributes towards reduction in neonatal and perinatal mortality. (Schemes on MCH) Modalities of implementation: - Death reported by front line workers, supervisors home visits for notification, collection of VA data by investigating teams from homes/institutions, data analysis and sharing at the community, block, district levels. 50 P a g e

51 Objectives: - Strengthen the implementation of NRHM, JSY & Navojyoti, identify bottlenecks at various levels to improve delivery care service, strengthening of facilities to manage complications better, empower household level action and also promote community participation Special Programs on Infants Health Navajyoti Scheme The Navajyoti scheme was launched in December 2005 in 14 districts (including Angul and Sambalpur) that showed a high IMR. In these selected districts dais are being trained to provide safe delivery and home-based newborn care in home delivery. (Schemes on MCH) Yashoda The Orissa Government is to implement Yashoda scheme to take care of newborn babies across nine districts in the state. According to a statement released by the State Health Department on Thursday, it was launched in Sambalpur, Angul and Jharsuguda districts. While 12 Yashodas were appointed in each of the district headquarter hospitals of Sambalpur and Angul, nine were absorbed in Jharsuguda district hospital. Other districts, which are to be covered include Balasore, Keonjhar, Koraput, Rayagada, Malkanagiri and Kalahandi. (Yashoda_Hindu, 2008) 12 Yashodas at an honorarium of Rs 3,000 per month have been appointed in the headquarters hospital to bring a transformation in PNC. (Yashoda_OT, 2009) Immunisation Immunisation is one of the most well-known and effective methods of preventing childhood diseases. The Universal Immunisations Programme (UIP) was established in India in Since then morbidity and mortality due to vaccine preventable diseases have declined over the years in all districts of the state. It works with an objective to protect infants from 6 killer diseases like Diphtheria, T.B. Polio, Whooping Cough, Tetanus, and Measles. 51 P a g e

52 Integrated Management of New born and Child Health (IMNCI) Reducing infant and child mortality rate and improving child health and survival has been an important goal. Prevention of death due to Acute Respiratory Infection (ARI), was implemented as vertical health programmes. These programmes were integrated in 1992 under Child Survival and Safe Motherhood Programme (CSSM) which are being integrated with the Reproductive and Child Health programme implemented since Children presenting any illness often suffer from more than one disease. For instance a child with diarrhoea may also have signs of malnutrition, and may not have received immunisation as per schedule. Infant Mortality Rate Mission Due to the high IMR in the state, the state government implemented the Infant Mortality Reduction Mission in the state from August which is functioning effectively in Orissa. The IMR was 91 per 1000 live births in 2001 which has come down to 65 as per 2009 SRS. As per the programme of the Mission, referral transport facility was being provided to the pregnant mother to promote institutional delivery. But after implementation of JSY programme, the mission is providing the mobility support for treatment of puerperal mothers and sick infants. This is exclusively a state budgetary programme covering all districts of the state. (Schemes on MCH) IMR continues to be high in Orissa. It is recognized that about 60 percent infant deaths occur during neonatal period (first four weeks of life). Most of these deaths are due to pre-maturity, low birth weight, respiratory infections, diarrhoea and malnutrition. It is also acknowledged that infant mortality is higher in lower socioeconomic groups residing in backward tribal districts of Orissa. Notwithstanding the fact that several strategic interventions are being implemented to reduce MMR and IMR, the decline has been marginal. (IMRM) In the year 2001 when IMR was 97 per 1000 live births, the state government decided to lunch IMR Mission to focus more on interventions addressing more proximal determinants of infant mortality. The strategy was; To strengthen the ongoing programmes so as to deliver the desired output. 52 P a g e

53 New interventions to reduce neonatal deaths. 1. Referral Transport Home delivery by unskilled persons is a major cause of high infant mortality and morbidity. To promote institutional delivery cash assistance was provided to beneficiaries to reach the health facility for delivery. After implementation of Janani Suraksha Yojana (JSY) in 2005 under NRHM which provided the same support, cash assistance was also provided for transportation of sick neonates and puerperal mothers with complications, for institutional care. This will compliment JSY and cover the most vital stages of maternal and neonatal care. The outcome of the initiative can be seen after a couple of years of operation. 2. Chemoprophylaxis The upsurge of malaria in Orissa adversely influences pregnant mothers and infants Apart from maternal and infant deaths, malaria during pregnancy also results in the birth of under-weight babies who may be at a disadvantage for the rest of their lives. (WHO 2000) Under the mission prophylactic chloroquin tablets are given to pregnant mothers after 12 weeks of pregnancy and this is continued up to four weeks after delivery in recommended weekly doses. UNICEF was supporting this activity until now by providing the required number of chloroquin tablets. But indications are that the support may not be available from the coming year onwards. The cost proposed for this activity can be revised if Govt. of India supplies are available. 3. Information Education & Communication Lack of awareness and traditional beliefs remain as hindrances to the access of available services. Ongoing community awareness programmes under various schemes are not enough to reach the people in far flung areas. It is proposed to use a variety of communication tools during the coming years including display boards, hoardings, telefilms, traditional media and focus group discussions. It is necessary to maintain these activities, evaluate their impact from time to time and bring about required changes in strategy. 4. Supervision and Monitoring 53 P a g e

54 Close and consistent monitoring is essential to get the desired output. Sector level and block level monitoring and district level supervision is in place. It is proposed to provide for better mobility of field level supervisors. 5. Capacity building and Motivation Training of doctors and frontline workers is an important component of RCH-II with focus on maternal care. Frequent supervisory visits will enhance the confidence of field functionaries. Focus group discussions with PRI members, SHGs and other agencies at panchayat level will provide a pleasant work environment for grass-root workers. Female health workers and Anganwadi workers constitute the main work force. The success of any health program largely depends on the motivation level of these workers. It is proposed to introduce a performance linked incentive system in which one ANM and one AWW will be rewarded every year from each block based on their overall performance 54 P a g e

55 Chapter-3 Public Private Partnership 55 P a g e

56 3. Public Private Partnership (PPP) NIPI Reference Book- Orissa 3.1 Key stakeholders in Healthcare s PPP There are five key stakeholders in any healthcare service system as shown below. Implementing a healthcare PPP will have an impact on all these stakeholders and the PPP itself can be structured along any of the roles where private sector participation is applicable. (PPP in Healthcare_CII) Table 24: Stakeholder roles in a Healthcare PPP Provider Payer Beneficiary Regulator IT Infrastructure Participant Type Public or Private Public or Private Neutral Public Public or Private Source- (PPP in Healthcare_CII) Role Description Entity providing the core services of designing, building and operation of healthcare units. Entity or person paying for the service rendered to the end user. Outof-pocket expenses which the end user pays for himself/herself still forms a large part of this segment in India. Formal sector consists of insurance players both in public and private sectors where the end user comes under medical cover. End user or the ultimate recipient of the healthcare service. Currently impacted by high costs as percentage of income and significant vagaries in quality of service across the country. An apex body governing the formal healthcare market in the system. The role of a central regulator will be key to monitor the expansion and sustainability of a scalable PPP model. Resource, expertise and management provider for connectivity and sharing of data on patients, specific medical cases, diagnoses and treatment techniques is an area of development that can bridge the quality and accessibility gap across regions in the country. Probable Donors DFID-Department for International Development DANIDA-Danish International Development Agency ECTA- European Commission Technical Assistance EEC- European Economic Community EU- European Union IMF- International Monetary Fund NIPI-Norway India Partnership Initiative 56 P a g e

57 ODA- Overseas Development Assistance OECD- Organization of Economic Co-operation & Development UN- United Nations UNFPA- UN Population Fund UNICEF- United Nations International Children s Emergency Fund WB- World Bank WHO- World Health Organization UNOPS- United Nations Office of Project Services Department for International Development (DFID) There has also been an enhancement of the support to the Orissa government for Health Sector reforms by DFID. The original budget of GBP 50 million has been increased to GBP 100 million. Within this, funds for Department of Women and Child Development increased from GBP 5 million to 38 million. The Orissa TAST team will provide support to the government for the optimal utilization of these additional funds. This is another example of the increased DFID commitment to the health sector reforms in these states. (Medha Soni, 2010) Table 25: Anticipated Budget Provision for Different Externally Aided Projects under State Plan During Name of the Project Donor Orissa Health Sector Dev. Plan Agency DFID Source- (Budget_sheet, 2010) Implementing Department H & FW / W &C.D Project cost Anticipated Budget Provision for (in Crore) Total External Assistance Local Cost Remarks Grant Norway- India Partnership Initiative (NIPI) The Norway- India Partnership Initiative is an outcome of commitment by the Hon ble Prime Minister of Norway and the Hon able Prime Minister of India, focusing on the issue of reducing child mortality and improving child health to attain the Millennium Development Goal 4 by the year Norway has contributed USD 80 million over five years for this purpose to the five states of Orissa, Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh. These states together constitute 40 percent of India s population and contribute almost P a g e

58 percent of child deaths in India. The NIPI activities are for five years ( ) and corresponds with the duration of the NRHM. (NIPI_GoO) The activities under NIPI are put into operation through UN organizations like UNICEF, WHO and United Nation s Office for Project Services (UNOPS). While UNOPS is a local fund agency and operates through the NIPI Secretariat, UNICEF and WHO have a grant of USD 20 million and 10 million respectively for program implementation in the five focus states. Many of the recent initiatives of UNICEF in the child health sector in Orissa are funded by NIPI. (NIPI_GoO) Aims & Objectives With sustained effort by the Government of Orissa, child health indicators have shown improvement, but extra efforts are needed to achieve the MDG 4. (NIPI_GoO) NIPI aims at accelerating the Child health interventions: 1. Based on block, district, region and state specific situations 2. Through partnership and collaborative arrangements with professional organizations, NGOs, local elected bodies and administration within the state 3. Making child health visible through catalytic input and create a mechanism that will ensure sustainability under NRHM processes. Core Interventions The core interventions of NIPI are: Capacity building of frontline workers in home-based newborn and child care and community mobilization; Institutional strengthening at block and district levels to meet the increasing requirements related to quality child and related maternal health service delivery. (NIPI_GoO) Complimenting these, NIPI will support the state and national governments in developing and optimizing a Management Information System on child health and related maternal health. The Partnership is deeply committed to equity-driven, gendersensitive, and pro-poor principles approach and it would endeavour to draw upon and enhance the strong equity rubric of the NRHM. (NIPI_GoO) Institutional mechanism 58 P a g e

59 The institutional mechanism of NIPI is led by a Joint Steering Committee with Secretary, Health and Family Welfare, Government of India as Chairperson and the Norway Ambassador to India as the Co-Chair. Additionally, there are representatives of the Government of India, Government of Norway, WHO, UNICEF and the NIPI focus States. At the state level, activities under NIPI will be implemented by the Orissa State Health & Family Welfare Society, chaired by Secretary, Health & Family Welfare, Government of Orissa. (NIPI_GoO) NIPI Initiatives in Orissa (Health Equity, 2009) 1. Establish a Child Health Resource Network at the state and district levels. 2. Strengthen routine immunization and plus (RI+ Vit.A) services. 3. Strengthen IMNCI implementation in state with focus on Navajyoti districts (Angul and Sambalpur and others). 4. Strengthen implementation of SBA services in the state with focus on Navajyoti districts. 5. Strengthen institutional level case management of severe malnutrition and prophylactic anthelmintic treatment. 3.2 PPP Initiatives by Health Department, Govt. of Orissa To further augment the PPP initiatives, a Regional Resource Centre (RRC) has been established to provide technical support for PPP NGO activities in the State. Orissa PPP policy in the health sector has also been drafted besides guidelines on PPP in PHC management, PPP in Urban Health, and PPP in Malaria Control etc. Some of the on-going PPP arrangements of NRHM, Health & Family Welfare Department, and Government of Orissa include the following: (DoHFW,GoO) 59 P a g e Contracting out Primary Health Centre (N) Mother NGO (MNGO) Service NGO (SNGO) Programme Urban Health centres for slum population PPP in Malaria Control Janani Express Accreditation of private NGO Hospitals for Institutional Delivery Capacity Building of ASHA involving MNGO / FNGO.

60 Outsourcing cleaning and security services at health institutions. Contracting-out PHC (New) Three PHCs (New) namely Khankira in Dhenkanal, Atta in Jajpur and Nayakhidiha in Bhadrak are being managed under PPP and have completed more than one year of services. Interact World Wide, UK provides funding to NYSASDRI for the management of Khankira and Atta PHCs (N). The funding is expected to continue until The government has also contracted out 32 PHCs (N) under the PPP. NGOs are currently in the process of recruitment of staff and to sign a MoU at district level. One corporate agency, Nayagarh Sugar Complex Ltd. has also been contracted out under Corporate Social Responsibility (CSR) as a PHC (N) in Nayagarh district. The government has handed over the PHC (N) with its staff and infrastructure to Nayagarh Sugar Complex Ltd. Nayagarh in turn will meet the operational cost of the PHC (N) under CSR. (DoHFW,GoO) MNGO / FNGO / SNGO Programme NRHM, Orissa has successfully established partnerships with civil societies including NGOs to provide Reproductive and Child Health (RCH) services through mother NGO (MNGO) to the marginalized population of the un-served and under-served area. As of December, 2007, 17 MNGOs and 97 FNGOs are working in 207 sub-centres in 21 districts of the state providing RCH services to a population of about 13, 00,000. In addition to this there are two SNGOs that initially targeted a population of 2 lakh people. Basically the MNGO & FNGOs are working concertedly in eco- inhospitable blocks and sub-centres to demand generation at the grass-root level, have access to RCH services and information and to address the unmet needs of the identified target population. Orissa is perhaps the only state where the MNGO scheme is fully operational. This achievement is only for effective decentralization, flexibility in decision-making, timely release of funds and adequate accountability systems. (DoHFW,GoO) 60 P a g e

61 PPP in Urban Health: Under NRHM, eleven urban health centres (tier one urban health centre) have been started through NGOs in Rourkela, Balasore, Bhubaneswar, Sambalpur and Cuttack covering a slum population of about 3,50,000. NRHM, Orissa has also proposed to start tier-2 urban health centres in Bhubaneswar, Ganjam and Rourkela during A guideline (draft) on PPP in urban health has been developed. Such PPP models involve partnerships between Orissa Health & FW Department and qualified NGOs to serve the urban slum population. The NGOs have hired their own staff and provide all needed primary health services including outreach. This model is being tested before being fully expanded throughout the state s slum population. (DoHFW,GoO) PPP in Malaria Control A one day workshop on PPP in Malaria Control was held on October 13, 2006 under the Chairmanship of Principal Secretary, Health & FW Department in the presence of all Health Directors, Jt. Director, ADMO (Public Health) and NGOs of Orissa. The PPP guidelines for malaria control given by Government of India was discussed and shared. A state-specific operational guideline on PPP in Malaria Control was also developed on the occasion. 30 district level workshops and four regional workshops on PPP in malaria were conducted. Applications were invited from NGOs for implementing the following programs under PPP in malaria control. (DoHFW,GoO) Scheme I : Provision of Outreach Services DDC/FTD Scheme II : Provision of microscopy and treatment services. Scheme III : Promotion of insecticide treated bed nets. Scheme IV : Promotion of Larvivorous Fish. Scheme V : Indoor Residential Spraying (IRS) Under these initiatives, a partnership has been established with 42 NGOs in six districts namely Angul, Keonjhar, Sundargarh, Mayurbhanj, Kandhamal, and Nawarangpur. Japan Bank for International Corporation (JBIC) has provided funds of INR 43 lakhs to Dhenkanal district for the Malaria Control Programme. In other districts more than 62 NGOs including MNGO & FNGO have been involved in IRS activity. Under the 61 P a g e

62 PPP in malaria control, initiatives have been taken to scale-up the IRS and Bed Net Distribution in 18 districts. (DoHFW,GoO) Janani Express (JE): In a novel attempt to encourage institutional delivery and make transportation available to pregnant women around the clock, the National Rural Health Mission, Health & Family Welfare Department, Government of Orissa has launched Janani Express. (DoHFW,GoO) Under the scheme all expectant mothers gets transportation facility to health centres and hospitals for delivery. It helps the pregnant women in dealing with emergencies arising during pre and post-delivery periods. The scheme is being implemented in 124 blocks where there are a minimum of 50 deliveries in a month. Besides pregnant women, sick infants are also eligible to avail of the transportation service. The vehicle used for transportation is available at government hospitals, CHCs, PHCs and other such suitable places in the respective blocks. They are equipped with necessary facilities to carry the expectant mothers to the health institutions while drivers carry mobile phones that enable them to furnish information on the health status of the patient to the hospital. Janani Express is clearly mentioned on the front and rear of the vehicle along with the contact telephone numbers. In areas where mobile phone facility is not available, the land line telephone numbers of the hospital are mentioned. The initiative is expected to help reduce both infant and maternal mortality rates in the state. The scheme will be scaled up during based on the experiences and lessons learnt. (DoHFW,GoO) Accreditation of Private Hospitals for Institutional Delivery Seventeen private hospitals including those of corporate bodies have been accredited by the district to conduct institutional deliveries. JSY money is provided to the accredited hospitals to conduct institutional deliveries for women below the poverty line. The achievements in terms of institutional delivery including CS operation at accredited hospitals have increased remarkably. There is a proposal to scale-up the initiatives during (DoHFW,GoO) 62 P a g e

63 Capacity Building of ASHA through MNGO FNGOs Training of ASHAs at the block level is conducted through MNGOs, FNGOs and PPP NGOs. MNGOs have been trained as district level trainers and FNGOs have been trained as block level trainers of ASHA. The quality of training conducted by MNGOs/FNGOs in majority of the districts has been found to be satisfactory. There is a proposal to undertake hand-holding and follow-up training of ASHAs through MNGO & FNGOs in the state. ASHAs have also been trained on NISCHAY homebased pregnancy test card by PPP NGOs. This has been done with the technical support of HLFPPT under a PPP model. (DoHFW,GoO) Outsourcing the cleaning and security services of Health Institutions Under the PPP the District Headquarter Hospitals, Capital Hospital, Rourkela Government Hospital etc. have outsourced housekeeping and security services to private agencies. There has been visible improvement in the cleanliness level and security operations in all the above hospitals through the PPP initiatives. Help Desk for Patient is also being established in these health institutions under PPP to provide quality and timely services to people especially the poor segment of the population. (DoHFW,GoO) Future PPP Program: (DoHFW,GoO) The following PPP programs have been planned for the future: o Formation of Village & Sanitation Committee and their training through FNGOs /CBOs. o Mobile Medicare Unit. o Running CHC under PPP. o Health Advocacy through NGO networks. o Social marketing of contraceptives through CBD approach. o Sponsoring SC / ST students for GNM Course Swasthya Sevika Nijukti Yojana. o Build Own Operate (BOO) model for Diagnostic centres. 63 P a g e

64 3.3 PPP in other parts of India and World in MCH Chiranjeevi Yojna (CY) CY was created to significantly reduce maternal and infant mortality by harnessing the existing private sector and encouraging it to provide delivery and emergency obstetric care at no cost to families living below the poverty line. Under the scheme the government contracts private providers that volunteer to render their services by signing a memorandum of understanding with the district government. In return, they receive an advance payment to commence services and are compensated at about USD 4,500 per 100 deliveries (normal, caesarean, or with other complications). Any qualified private provider with basic facilities, such as labour and operating rooms, and access to blood and anaesthetists can enroll in the program after a thorough orientation. CY beneficiaries are enrolled through their family health workers. The scheme uses the existing cards issued by the rural development department of the state government to families living below the poverty line to access services. In the first six months since the launch of the scheme, each provider performed an average of 116 deliveries. The institutional delivery rate has increased to more than 81 percent from about 54.7 percent in CY s long-term goal is to achieve an institutional delivery rate of 95 percent by (CHMI, 2011) The key components of the program are: Benefits package. CY uses demand-side financing to provide families living below the poverty line with access to a comprehensive benefits package that covers both direct and indirect costs, including free delivery (with no condition exclusions), free medicines after delivery, and transport reimbursement. In addition, it offers support to the attendant in exchange for lost wages. The payment method and formula encourage providers to reach a certain volume of work, avoid complicated transaction costs, and create a disincentive for unnecessary Caesarean sections. The provider compensation package is designed to account for all potential complications during delivery (estimated at 15 percent of cases). (CHMI, 2011) Contract management. CY s district management authorities require participating doctors to maintain a case file for each patient they serve. Weekly records of the deliveries 64 P a g e

65 conducted by the providers are submitted to local authorities and the block (sub-district) health officer, who regularly visits beneficiaries to monitor service quality and addresses grievances. Payment to providers is also made through block health officers based on instructions from district authorities. All districts send a monthly report to state authorities for review and feedback. (CHMI, 2011) District management capacity. CY employs a decentralized management model that engages health officials at four government levels (state, district, block, and village) as facilitators and organizers of health services. To implement the scheme state-wide, officials at various levels play interlinked and overlapping roles. These roles are divided into state level (state-wide planning, implementation, and monitoring of the scheme), district level (district-wide implementation, provider enrolment and orientation, provider compensation, and report collection), block level (registration of beneficiaries, bill collection from providers, and overall supervision), and village level (motivating expectant mothers to use institutional delivery and facilitating their visit). (CHMI, 2011) Janani Janani started as a social marketing and social franchise program that uses India's large private health sector network of practitioner and facilities to provide safe and low-cost options for family planning, health, and reproductive health services in rural areas. (CHMI, 2011) The conventional social marketing infrastructure of shops (more than 31,000 of them) and stockists sells products (such as contraceptives) in urban and semi-urban areas and replenishes supplies to rural health franchisee centres and franchisee medical clinics. This is complemented by a social franchisee program through which doctors in rural areas provide low-cost clinic-based services. The social franchise has a network of rural health practitioners who work in partnership with a female family partner. She serves as the conduit between the clinics and rural communities. After receiving Janani training, rural practitioners are franchised as Titli (Butterfly) Centres, and they sell nonclinical products and over-the-counter test kits. Clients who require clinical services are counselled and referred to the nearby Surya (Sun) Clinic, which earns the Titli Centres a commission. Under the private-public partnership of the NRHM, the government has accredited 15 of Janani s Surya Clinics as authorized sterilization centres, which the government reimburses USD 35 per sterilization. The plan is to set up 40 free clinics at the district 65 P a g e

66 headquarter town by the end of December Field teams set up by entrepreneurs monitor the more than 40,000 trained rural providers while Janani supervises the 620 franchisee medical clinics. (CHMI, 2011) The key components of the program include: Social marketing for the under-served. The conventional social marketing franchise uses shopkeepers (mostly in urban centres) to deliver primarily nonclinical products (mainly condoms and oral contraceptives) to the development sector. In contrast, Janani s model focuses on expanding service delivery from urban to rural areas, integrating a strong clinical component, and catering to the poorest segments of the population. (CHMI, 2011) Profitable franchisee product bundle. The rural health providers find the franchise profitable and worthy to be a part of it. This is due to the broad mix of incomegenerating services that it offers including the sale of non-clinical products, charges for over-the-counter diagnostic tests, and commissions for referring clients to the Surya clinics. (CHMI, 2011) Formalizing the private sector. Janani has played an important role in bringing rural providers and private doctors into a formal operational framework. The Surya Health Promoters in the network receive training in nonclinical skills to function as the first contact point in villages, while the surgical skills of doctors in the Surya clinics are upgraded to provide quality family planning services and comprehensive abortion care services. This has effectively complemented the network of shops that have long worked with the well organized private sector. (CHMI, 2011) Fostering community-level ownership. Janani seeks to transform participants into stakeholders at both the village and urban levels. About half of Janani s budget is allotted towards communication and education campaigns. A critical component of the campaigns is empowering clients on quality services that empower them to maintain pressure on providers for good-quality care. To complement this, Surya health promoters are selected from within communities. (CHMI, 2011) Child Helpline International Child Helpline International (CHI) facilitates the establishment of helplines in countries were these facilities and services do not exist. They also help in improving helplines that work primarily on a district level. In developing nations where state 66 P a g e

67 mechanisms are unable to reach children in crisis, it has been seen that helplines provide an efficient link between children and the system. (CHMI, 2011) Additionally, CHI also concentrates its efforts on advocacy and child participation. CHI hopes to bring the issues and concerns of children from around the world to the attention of policy makers in all corners of the world, ensuring that children have a voice and that their voices are counted. (CHMI, 2011) Objectives: To place children on the global telecom agenda. To pass a resolution in International Telecommunication Union (ITU) which make helplines a global strategy in reaching out to children. To allocate funding for bridging the digital divide and ensure that children, especially the marginalised child have access to telecom. In 2004, 11.5 million calls were received at child helplines across the globe. By establishing and scaling-up helplines, CHI endeavours to bring helpline services to as many children, especially the most marginalised, as possible. (CHMI, 2011) In May 2004, the helpline was officially launched in Vietnam. The helpline is a partnership between Plan Vietnam and the Committee on Population, Children and Families (VNCPFC). The helpline operates in Hanoi and is now looking to expand to other cities in Vietnam. The helpline has a toll free number ( ) that operates from 7:00 a.m. 9:00 p.m. daily. Since its inception in 2004 the helpline has received around 12,000 calls. The helpline number can be directly called from anywhere in Vietnam, so it is very easy to reach. Most phone calls have been received seeking advice on domestic violence, child sexual abuse, abandoned children and child accident etc. (CHMI, 2011) The helpline has also started an on-line counselling service relating to reproductive health, children s rights and psychology as an addition to the telephone service already provided. In addition, two centres for children protection have been operated in Ho Chi Minh (in the south) and Da Nang city (in central Vietnam) to make the helpline more efficient. (CHMI, 2011) 67 P a g e

68 RapidSMS Malawi RapidSMS works to address serious constraints within Malawi's National Integrated Nutrition and Food Security Surveillance (INFSS) System, which faces slow data transmission, incomplete and poor quality data sets, high operational costs and low levels of stakeholder ownership. (CHMI, 2011) RapidSMS allows health workers to enter a child s data, and through an innovative feedback loop system, it instantly alerts field monitors of their patients nutritional status. Automated basic diagnostic tests are now identifying more children with moderate malnutrition who were previously falling through the cracks. This system also increases local ownership of the larger surveillance program through two-way information exchange. Operational costs for the RapidSMS system are significantly less than the current data collection system. (CHMI, 2011) From the successful results of the pilot the Government of Malawi plans on scaling-up RapidSMS nationally later in They are also interested in escalating this to a countrywide campaign to register child births, as well as introducing it in other areas such as including education and HIV/AIDS. (CHMI, 2011) Vietnam s Nutritious Food Program The goal of the project is to reduce the incidence and severity of malnutrition among the low-income vulnerable rural children. This can be achieved by providing access to improved feeding practices and giving fortified complementary foods to children 6-24 months of age. Based on an alliance between the government, food producers, and NGOs the project has enabled the National Institute of Nutrition (NIN) to further develop an innovative model that can increase production capacity by expanding sales, reducing unit costs, and thereby offer a lower the price to consumers that improves its sustainability. (CHMI, 2011) Specific objectives are to: (i) expand localized commercial production of a fortified, low-cost complementary food; (ii) develop and expand the system of community-based complementary food sales, distribution, and enhanced nutrition education; (iii) address barriers to accessing complementary foods among the most poor and vulnerable; and (iv) address policy development and advocacy for long-term support for fortified 68 P a g e

69 complementary food (as part of a range of options that should be available for addressing malnutrition). (CHMI, 2011) The expected outcome of the project is to increase the access of approximately 325,000 poor children to fortified complementary food. Over 3 years, the project has worked to open community-based channels for distribution, marketing, and nutrition education in 6 provinces and sixty districts. (CHMI, 2011) Vietnam s Country Investment Plan (CIP) for food fortification prepared under the ADB s regional Technical Assistance (TA) project outlines a 10-year expansion of this model to sustainably reach 25 percent of vulnerable 6 to 24-month-olds around the country. This project is a strategic first step in expansion, with a focus on developing strategies for scaling-up and sustainability as well as ensuring that the product and project benefits reach the poorest and most vulnerable. The new mechanisms for financial sustainability have been actively adopted by using the strengths of public private partnership. (CHMI, 2011) Karra society for Rural Action The Karra Society for Rural Action, in partnership with the Government of Jharkhand and district healthcare facilities, established a referral network in six blocks of Kunti District in Jharkhand. (CHMI, 2011) To address this issue, the Karra Society initiated the establishment of quality referral services for obstetric and infant healthcare facilities in 320 villages of six blocks in the Kunti district. The project's objective is to create a pool of village health volunteers with awareness on reproductive and child health, increase safe births by facilitating institutional deliveries, and encourage community ownership by establishing a call centre in each block for instant access to referrals. (CHMI, 2011) To help this initiative achieve its goals, the society has engaged in mobilization of the community in health by strengthening Self Help Groups (SHGs) and creating a health fund to be used in case of emergencies. The society has also established a call centre in each block that operates 24X7 and provides transport vehicles for all villages within the network to facilitate quick referrals. Furthermore, training is conducted for TBAs, SHGs and Sahiyyas (individuals who educate pregnant women in rural areas). 69 P a g e

70 Awareness sessions are also conducted for future mothers on the right precautions to be taken during pregnancy. (CHMI, 2011) As the program helps deliver government maternal and child health programs, the government has decided to partner with the Karra Society and UNICEF to support the design and development of this model. In 2009, about 1354 patients utilized the society's services and 769 were referred to higher levels of care. (CHMI, 2011) The model appears to be to successful in the control of maternal and infant deaths in the region, documenting about two maternal and 12 neonatal deaths since it began operations. (CHMI, 2011) Wired Mothers The study aims to examine the beneficial impact of the use of mobile phones for health care on maternal and neonatal morbidity and mortality, and to seek innovative ways to ensure access to skilled attendance during delivery through an intervention called "wired mothers". Wired mothers are pregnant women linked to a primary healthcare unit through the use of mobile phones. The mothers receive standard SMS reminders regarding healthcare appointments and the primary provider to be contacted in case of acute or non acute problems. The study also aims at understanding the health system's response in relation to obstetric emergencies by using mobile phones to strengthen communication between the different levels (from TBA to referral hospital). (CHMI, 2011) Specific objectives To investigate attendance to routine primary healthcare appointments amongst wired and non-wired women. To investigate the level of facility-based deliveries amongst wired and non-wired women. To investigate the morbidity amongst wired and non-wired women. To investigate the quality of services provided to wired and non-wired women. To investigate neonatal morbidity and mortality amongst children delivered by wired and non-wired mothers. Project started in January 2009 and finished by December P a g e

71 Chapter-4 MCH Trends 71 P a g e

72 4. MCH Trends 4.1 Home Based Neonatal Care (HBNC) In the continuum of care, home-based care for the newborn is recognized as a weak link. The NIPI focus states now recognize that if a difference is to be made in neonatal and child health, it is important to address and affect what happens in the home. Since the NRHM has already provided for a voluntary grass root worker, the ASHA, state health societies of the focus states have chosen to build on the presence and competency of ASHA to create a structured follow-up system for both the mother and the newborn. The intervention consists of three parts. (CHPNC, 2009) o o o A special training module (2+5 days) in home-based newborn care. An incentive to the ASHA for completing PNC check-up routine. A referral fund to ensure that sick newborns and mothers can be referred to a facility where proper care is available. The ASHA will under this scheme visit the home of the beneficiary six times. The first visit will be during the last phase of pregnancy (eight month). This will be in addition to the already established antenatal care that is provided within NRHM, and the main purpose of the first visit is to motivate the mother for an institutional birth, make sure she is aware of JSY and to identify any risk factors that the mother may have, indicating that the birth should take place at a higher level facility. After the birth, the ASHA will visit the home on day 1 (in case of home delivery), three, seven, 15, and 28. In Rajasthan there will also be a visit at day 42. (CHPNC, 2009) The ASHA will fill a postnatal check-up card (PNC-card) during the visit, and the card will be submitted for validation and payment after the total check-up has been completed. In addition to information on birth and weight, the card will provide information about morbidity and mortality, referrals, immunization, breastfeeding status etc. (CHPNC, 2009) 72 P a g e

73 Chapter-5 Districts Profile 73 P a g e

74 5. District Profile 5.1 Angul Introduction Angul came into existence as a separate district subsequent to the re-organization of district s in Orissa on April Covered with lush green forests, the district is rich in wildlife. The river Mahanadi passes through the district forming a 22 kilometre long narrow gorge, one of the mightiest gorges in India, popularly known as 'Satkosia'. The district is surrounded by Cuttack & Dhenkanal in the east, Sambalpur & Deogarh in the west, Sundargarh & Keonjhar in the north and Phulbani in the south. (Angul_NIC) Angul is a centrally located district in the state of Orissa. Angul is the home to many big industries like National Aluminium Company (NALCO), Mahanadi Coalfields Limited (MCL), National Thermal Power Corporation (NTPC), Heavy Water Plant, Talcher, Indian Aluminium Product Ltd. The district of Angul also provides proper education to all the inhabitants. Several schools, colleges, technical and medical institutions have been established in this district to help the locals derive maximum benefits out of it. The district covers a geographical area of 6232 square kilometres and supports a population of about lakhs. Although it is new it is strategically the most advanced because it gives highest return of revenue to the government from the vast coal mines located within its boundaries. (Orissa_Baseline, 2009) Table 26: Geographical (Angul_NIC) 1. Area 6,232 Sqr.Kms. 2. Latitude 20.5" North 3. Longitude 85.0" East 4. Altitude Varies from 564 to 1187 Mtrs. The district has a population of 11, 39,341 as per 2001 census (Males - 5, 87,234, Females - 5, 52,769) with a population density of 179 per km². Angul, the district headquarters is about P a g e

75 kilometres from the state capital Bhubaneswar. It is situated on the National Highway No. 42, making it well accessible from all parts of the state. (Orissa_Baseline, 2009) Table 27: Demographic (Angul_NIC) 1991 Census 2001 Census 1. Male 4,95,000(51.5%) 5,87, Female 4,66,000 (48.5 %) 5,52, Scheduled Caste 1,61,000(16.6 %) 1,96, Scheduled Tribe 1,12,000(11.6 %) 1,32, Rural 8,51,000(88.5 %) 9,81, Urban 1,10,000(11.5 %) 1,58, Total 9,61,000 11,40,003 There are four subdivisions with eight blocks and nine census towns. The total number of gram panchayats is 209. Assembly constituencies are 4 1 in number, and parliamentary constituencies 2 (coming under Deogarh and Dhenkanal). (Vision_angul, 2009) Table 28: Administrative (Angul_NIC) Sl. No Name of the Sub- Division 1 Angul 2 Talcher Name of the Name of the Tehsil Blocks 1. Angul 1. Angul 2. Banarpal 2. Banarpal 3. Chhendipada 3. Chhendipada 4. Talcher 4. Talcher 5. Kaniha 5. Kaniha 6. Athamalik 6. Athamalik 3 Athamalik Kishorenagar Kishorenagar 4 Pallahara 8. Pallahara 8. Pallahara No. of Police Stations -20 No. of R.I. Circles-55 No. of Revenue village-1705 Name of the NAC/Municipalities 1. Angul 2. Talcher 3. Athamallik NO. of G.Ps To include partial constituencies the total number is P a g e

76 Other Information (Angul_NIC) 1. Assembly Constituencies : 5 2. Towns (Census Town) : 9 3. Density of Population : 179 per Sq. Km. 4. No. of Fire Stations : 5 5. Climate : Sub-Tropical 6. Temperature (Optimum) : degree C (a) Lowest : 10 degree C (b) Highest : 47 degree C District Health System: A Zilla Swasthya Samiti (ZSS) has been formed under the chairmanship of the Collector for management and development of a medical wing and to oversee implementation of National Health Programmes. A scheme called five diseases treatment scheme (Panchabyadhi) was initiated in July 2002 that covers five most common diseases namely Respiratory Tract Infection (RTI), malaria, scabies, leprosy and diarrhoea. Drugs required for treatment of these diseases is provided free of cost at government health institutions. (Orissa_Baseline, 2009) Table 29: The Vital Health Indicators of the District Indicators Angul Orissa India Sex Ratio Population Growth Rate (2001) Crude Birth Rate (2002-DLHS) Crude Death Rate (2002-DLHS) Maternal Mortality Rate (2002-DLHS) Infant Mortality Rate (2002-DLHS) Total Fertility Rate (1999-DLHS) Neonatal Mortality Rate (1999-DLHS) Couple Protection Rate (1999-DLHS) % 44% Source- (Perspective plan_angul, 2009) Allopathy Services: The Chief District Medical Officer based at Angul is in overall charge of family welfare and health services in the district. The NRHM works under the supervision of the CDMO, and is presently the chief source for funding of healthcare development services. (Perspective plan_angul, 2009) Doctor and PHC density in diff. Blocks of Angul 76 P a g e

77 Angul Athmallik Banarpal Chhendipada Kaniha Kishorenagar Pallahada Talcher No. of doctors per population, and No. of PHCs per 100 sq.km. NIPI Reference Book- Orissa Highly uneven services of allopathic medical care(govt.)in different blocks: Blocks Allopathic doctors/10000 population PHCs per 100 sq. km Source: District Statistical Hand Book Angul, 2005, (Vision_angul, 2009) The treatment and prevention of diseases, family welfare activities and other public health activities are managed by three different wings of health and Family Welfare department I. Medical Wing II. Family Welfare Wing III. Public Health Wing I. Medical Wing The medical wing provides treatment to patients. The government charges these drugs at INR 0.50 per out-patient and INR per in-patient. A Zilla Swasthya Samiti (ZSS) has been formed under the chairmanship of the Collector for the management and development of the medical wing and also oversee implementation of National Health Programmes. (HFW_angul) 77 P a g e

78 Source- District PIP,07-08_angul Rogi Kalyan Samitis (RKS) have been formed as registered societies constituted in the hospitals as an innovative mechanism to involve the people s representatives in the management of the hospital with the aim to improve its functioning through levying user charges. They have people's representatives, health functionaries, local district officials, leading members of the community, and representatives of the Indian Medical Association, members of the urban local bodies and panchayat raj institutions as well as leading donors as their members. (Perspective plan_angul, 2009) 78 P a g e

79 The RKS is empowered to mobilize resources through the levy of user charges, commercial use of assets like land of the institution, donations in cash or kind from the public at large, allotments / grants from the government or non-government bodies, and loans from financial institutions. (Perspective plan_angul, 2009) A scheme called five diseases treatment scheme (Panchabyadhi) was initiated in July 2002 to cover five most common diseases namely Respiratory Tract Infection, malaria, scabies, leprosy & diarrhoea. All drugs required for the treatment of these diseases is provided free of cost at government health institutions. (HFW_angul) II. Family Welfare Wing Reproductive & Child Health (RCH) Programme is being implemented in this district since One health sub centre has been established for every 5000 population in rural area. Immunization, registration of pregnancy, care of pregnant women, popularization of family welfare measures, & measures for reduction of infant mortality are some of the important activities under RCH care. All these services are provided through the health sub-centre. Registration of birth is done at PHC level. Apart from routine immunisation activities, pulse polio immunization is being conducted in a campaign made on National Immunisation Days since Vitamin A supplementation campaign has been conducted done since March (HFW_angul) III. Public Health Wing It deals with prevention of epidemic diseases in the district. The epidemic diseases common in Angul district are gastroenteritis, ARI and bloody dysentery. The Public Health wing disinfects wells, homes and ghats to prevent epidemics. Malaria, blindness, leprosy, tuberculosis are major public health problems of the district. (HFW_angul) Many National Health Programmes such as National Anti Malaria Programme (NAMP), Enhanced Malaria Control Programme (EMCP), AIDS Control 79 P a g e

80 Programme, National Leprosy Eradication Programme (NLEP), and National Programme for Control of Blindness (NPCB) are being implemented in the district. (HFW_angul) Malaria is endemic in Angul District due to its vast forest area, illiterate tribal population and large numbers of immigrant population staying in unhygienic conditions. NAMP was started in the year 1995 with an aim to identify highrisk areas as per epidemiological parameters. Steps are taken for surveillance and DDT spray. (HFW_angul) EMCP was initiated in Only one block i.e. Pallahara has been included in EMCP. Spraying of DDT, door-to-door surveillance, presumptive radical treatment with Primaquine, IEC activities and distribution of Chloroquine tablets through drug distribution centres (DDC) are being undertaken in the EMCP block. Since the mosquitoes are becoming resistant to DDT, a new initiative has been taken to control the vector through Larve oral fish. A proposal to medicate the mosquito net is also under active consideration. (HFW_angul) Orissa Health System Development Project (OHSDP)-(World Bank Assisted) The Orissa Health system Development Project was implemented in Four medical institutions i.e. DHH Angul, SDH Talcher, SDH Pallahara and UGPHC Khamar have been taken up for upgradation of the existing building to provide more beds for patients, supply of equipments and medicines for better treatment and proper waste management and field service by task force. (HFW_angul) Health Infrastructure The District Headquarter Hospital (DHH) at Angul, three sub-divisional hospitals at Talcher, Athamallik & Pallahara, 1 UGPHC, 1 CHC, and 27 PHCs (N) caters to the healthcare needs of the people. There are also nine ayurvedic & 8 homeopathic dispensaries. (Orissa_Baseline, 2009) 80 P a g e

81 Table 30: Health institutions in the Angul established by the Govt of Orissa NIPI Reference Book- Orissa No. of Hospitals(DHH) No. of Sub-Divisional Hospitals 01 (Angul) 03 (Talcher, Athmallik, and Pallahara) No. of Community Health Centres 02 No. of Upgraded Primary Health Centres 01 No. of Primary Health Centres (New) 29 No. of Primary Health Centres 06 No. of First Referral Units(F.R.U) 02 No. of Rural Family Welfare Centres No. of Urban Family Welfare Centres No. of Postpartum Centres 04 No. of Mobile Health Units Nil Nil Nil No. of Field Sub-centres 155 No. of A.N.M. Training Schools No. of M.P.H.W.(Male) Training School No. of Ayurvedic Dispensaries 16 No. of Ayurvedic Dispensaries (Private) - Harijan & Adibasi Ayurvedic Hospital No. of Homoeopathic Dispensaries 19 Nil Nil 01 No. of Unani Dispensaries (Perspective plan_angul, 2009) Nil Public Sector Units working in the district, namely NALCO, MCL & NTPC also have their own health institutions, which mostly cater to their employees. NALCO has established one hospital. NTPC has established two hospitals, one at Kaniha & the other at Talcher. MCL has established one hospital and eight dispensaries at Talcher coalfields. Rengali Multipurpose Project (RMP) authorities maintain two hospitals, one at Rengali & the other at Samal. (Perspective plan_angul, 2009) Blood Bank Service The Blood Bank Service has been available at DHH Angul & SDH Talcher since 1974 and 1986 respectively. One voluntary Blood Donor s Association has also been functioning. (Perspective plan_angul, 2009) Ambulance Service 81 P a g e

82 Ambulance service is available at DHH Angul, SDH Talcher, and Athamallik. NIPI Reference Book- Orissa The hospitals are managed by NALCO, Pallahara, CHC Chhendipada, UGPHC Khamar, and PHC Kaniha & PHC (N) Purunakote. All ambulances are managed by the ZSS. (Perspective plan_angul, 2009) MCL & NTPC have their own ambulance service. Few social organizations like Marwadi Yubamanch and Lions Club also run ambulance services. (Perspective plan_angul, 2009) 82 P a g e Table 31: District Data of Angul DLHS-2 (2002 DLHS-3 ( NIPI BASELINE INDICATORS - 04) 08) ( ) MATERNAL HEALTH Total Rural Total Rural Total Rural Mothers registered in the first trimester of pregnancy with last live birth/still birth (%) Mothers who had at least 3 antenatal care visits during the last pregnancy (%)

83 Mothers who got at least one TT injection during pregnancy with their last live birth / still birth (%) NIPI Reference Book- Orissa Institutional births (%) Delivery at home assisted by a doctor/nurse /LHV/ANM (%) Mothers who received postnatal care within 48 hours of delivery of their last child (%) CHILD IMMUNIZATION AND VITAMIN A SUPPLEMENTATION Children (12-23 months) fully immunized (BCG, 3 doses each of DPT, and Polio and Measles) (%) Children (12-23 months) who have received BCG (%) Children (12-23 months) who have received 3 doses of Polio Vaccine (%) Children (12-23 months) who have received 3 doses of DPT Vaccine (%) Children (12-23 months) who have received Measles Vaccine (%) Children (9-35 months) who have received at least one dose of Vitamin A (%) Children (above 21 months) who have received three doses of Vitamin A (%) TREATMENT OF CHILDHOOD DISEASES (Children under 3 years, based on last two surviving children) Children with Diarrhoea in the last two weeks who received ORS (%) Children with Diarrhoea in the last two weeks who were given treatment (%) Children with ARI/fever in the last two weeks and treated (%) Children had check-up within 24 hours after delivery (based on last live birth) (%) Children had check-up within 10 days after delivery (based on last live birth) (%) CHILD FEEDING PRACTICES (Children under 3 years) Children breastfed within one hour of birth (%) Children (age 6 months above) exclusively breastfed (%) Children (6-24 months) who received solid or semisolid food and still being breastfed (%) P a g e

84 Problems faced during pregnancy (% of Mothers) Post Delivery Retention Period of Mother at Health Facility (average in hours) Age at first cohabitation / Average age of marriage Angul facility Survey Finding The study done by VYK for Access Health International in September 2010 was an attempt to provide insights into the infrastructure available and current capacity of both Governments, corporate and private health services providers of Angul district in neonates and infant care. Neonate Outpatients Attended It was found that the doctor (Paediatrician) in-charge of the hospital at the block and sub-division (PHC/CHC/SDHQ) sees 35 to 300 neonates in a month depending upon the size of the population of the area. The number is higher in urban areas and very low in tribal or rural area hospitals. At the district headquarter hospital experts attend to about 500 neonates per month. Three out of four private hospitals do not provide care for neonates due to unavailability of pediatricians and proper infrastructure. The fourth hospital attends to about 50 cases per month through its regular visiting doctors. The corporate hospitals i.e. NALCO and MCL cover one hundred and forty-five cases per month most of them being their employees. (VYK_angul, 2010) Infant Outpatients Attended The district headquarter hospital attends to largest number of cases of infants (29 days to one year) in the district. The hospital attends to 300 cases per month whereas the lowest is in community health centre at Kishorenagar which attends to 35 cases only. With the exception of two private hospitals, no one provides for care of infants in their hospital. This is due to the unavailability of physicians, equipment and other facilities at these hospitals. (VYK_angul, 2010) Charge for Outpatient Consultation 84 P a g e

85 The private physicians charge INR 50 to 100 as out-patient consultation fees from the patients for the first time. For each visit thereafter they charge about 50 percent The RKS (Rogi Kalyan Samiti) in government hospitals charges only a nominal amount of INR 2 as user fee from the patients. In some cases some RKSs take only INR 1 as user fee from the out-patients. (VYK_angul, 2010) The corporate hospitals do not charge a consultation fee for their employees. The MCL (Mahanadi Coal Fields Ltd.) hospital does not charge its patients. However NALCO hospital charges INR. 100 for non-employees. (VYK_angul, 2010) Distance Covered by Patients The government hospitals serve patients within a radius of about 10 to 40 kms whereas the corporate hospital covers a radius of 5 to 15 kms. In case of DHQ hospitals and private hospitals/nursing homes; they treat patients of the entire district covering a radius of100 kms. This is so because complicated cases are referred to the district headquarter for better treatment and care. (VYK_angul, 2010) Common Ailments of Outpatients below the age of One Year During the study the team interacted with the medical staff, professionals and the parents of the children suffering from various diseases and have been hospitalized. It was found that most of the children were suffering from malaria, diarrhoea, pneumonia, malnutrition, asphyxia, sepsis, hypothermia, jaundice, vomiting, lower/upper respiratory tract infection etc. (VYK_angul, 2010) Out-of-Pocket Expenditure on Drugs & Diagnostics The patient spends INR 100 to 200 towards the cost of drugs for a common illness in government hospitals. But one hospital located in a neglected tribal area was found to charge INR 500 per patient. For drugs and diagnosis in private hospitals the patients spend INR 200 to 500. Corporate hospitals charge a fee of INR 1000 form patients who are not employees. (VYK_angul, 2010) 85 P a g e

86 Number of Neonate Inpatients The DHQ hospital provides treatment to 120 neonatal inpatients per month whereas the sub-division H.Q. hospital provides treatment to 25 neonates. The CHC and PHC extend inpatient treatment to seven and three patients respectively whereas the corporate and private sector hospitals treat five and four neonates per month respectively. (VYK_angul, 2010) Common Neonatal Complications of Inpatients Children are usually found to suffer from malaria, diarrhoea, pneumonia, malnutrition, asphyxia, sepsis, hypothermia, jaundice, vomiting etc. on admission to the hospital. (VYK_angul, 2010) Duration of Stay of Neonate Inpatients Neonates stay in the hospital for a period of one to three days in case of normal cases. The caesarean cases stay for seven to 10 days both in government and private hospitals. Sick neonates stay for about three to seven days. (VYK_angul, 2010) Hospitalization Costs of Neonates The government hospitals do not charge any fee for a delivery. On the other hand they provide financial support of INR 1400 and INR 1000 to the rural and urban women respectively from NRHM fund. Some BPL people also receive money for their which is borne by the government hospitals from RKS fund. (VYK_angul, 2010) Private hospitals usually charge about INR 5000 for normal deliveries that includes the cost of service, room rent etc. In the case of complicated or caesarean deliveries they hospital charges about INR15, 000. (VYK_angul, 2010) Number of Inpatient Infants 86 P a g e

87 Due to various reasons like diseases and other complications, infants also require admission to hospitals. While PHC s admit thirty-five children in a month, the CHC s admit twenty-three and SDHQ hospitals admit one hundred and twenty-three children. However the number of inpatients usually varies from one to another. For example; SDHQ hospital at Athmallik admits fifty infants, whereas Pallahara admits one hundred and twenty and Talcher admits two hundred children every month. The private and corporate hospitals have 8 to ten inpatients per month while the DHQ hospital has two hundred inpatients. (VYK_angul, 2010) Common Complications of 29day-12month Old Inpatient Children The children hospitalized both in private and government hospitals within the age group of 29 to 365 days suffer from diseases like; RTI, ARI, vomiting, paediatric diarrhoea, jaundice, pneumonia, malnutrition and fever/common cold. But the incidence of diarrhoea, jaundice, pneumonia is found to be higher than other diseases in all the hospitals. (VYK_angul, 2010) Duration of Stay of 29 day-12 month Old Inpatient Children The study shows that; duration of stay at a hospital of children within the age group of 29 days to one year mainly depends upon the severity of the disease. In all cases the children usually stay for about 2-4 days. But in corporate hospitals children stay for about 3 to 10 days. (VYK_angul, 2010) Hospitalization Costs of 29 day -12 month Old Children The cost for treatment of children within the age group of 29 days to 12 months is INR 500 approximately which is spent for medicines and laboratory testing. Government hospitals have a small provision for medicines to children. However the cost of transportation of children from their home to hospital and back is not included. (VYK_angul, 2010) 87 P a g e

88 The corporate hospitals vary from one to another. NALCO hospital offers free treatment for children, but MCL hospital charge about INR 100 per day (hospital bill), INR 1000 for medicines and INR 400- to INR 500 (diagnosis). Private hospitals charge INR 7000 approximately for everything. (VYK_angul, 2010) SWOT Analysis In the report made by PRIA for District Vision 2020 in consultation with district planning and coordination, a SWOT analysis of district Angul was carried out. (Vision_angul, 2009) Strengths (Vision_angul, 2009) Basic infrastructure is available Corporate hospitals of NALCO and Coal India working in the district Health Index of Angul is higher than the state average, as per Orissa Human Development Report(2004) Weaknesses (Vision_angul, 2009) Inadequate infrastructural, equipments and service facilities Lack of Super-specialty services at district headquarter hospital Most of the blocks in the district are malaria prone Considerable IMR & MMR Non-availability of doctors Lack of reliable health care services in remote areas Lack of awareness among people regarding health and family welfare Opportunities (Vision_angul, 2009) Possibility of creating adequate infrastructure with the help of industrial houses. Coal India has also proposed a Medical College in the district 88 P a g e

89 Implementation of Yoshoda Yojana Threats (Vision_angul, 2009) Increase in the number of lung and skin diseases, TB etc. Biological and other waste material from Hospitals may create pollution 5.2 Jharsuguda Introduction Jharsuguda is a district in Orissa with Jharsuguda town as its headquarters. This region is rich in coal and other mineral reserves. IN recent times many small and medium scale iron and steel units have been set up in the vicinity of Jharsuguda town, giving impetus to the industrial growth of the district. (Orissa_Baseline, 2009) The district comprises five blocks that include Lakhanpur, Kolabira, Laikera, Kirmira and Jharsuguda. Jharsuguda district has three urban agglomerations, municipalities of Jharsuguda town and (Brajrajnagar) and municipality of Belpahar. (Orissa_Baseline, 2009) Brajrajnagar is an industrial town is believed to be the prime location for Open Cast Coal Mine of Mahanadi Coalfields Limited. Brajrajnagar also boasts of a large scale paper mill, Orient Paper Mills of the Birla Group of Industries. However, this mill has been defunct for more than a decade now. Since the re-organisation of the Garhajat states in 1936 under the British rule, Jharsuguda became a part of Sambalpur district. The new district of Jharsuguda came into existence on April and was created by amalgamation of the erstwhile zamindars of Rampur, Kolabira, Padampur & Kudabaga. Jharsuguda town is the headquarters of the new district. (Orissa_Baseline, 2009) As of the 2001 India census, Jharsuguda had a population of 75,570. Males constitute 52 percent of the population and females 48 percent. It has an average literacy rate of 69 percent, higher than the national average of 59.5 percent: male literacy being 77 percent and female literacy at 60 percent. It is a one of the rich districts in mineral wealth, especially coal and is 89 P a g e

90 one of the most industrialized districts of Orissa. Jharsuguda town is situated at the western end of Orissa on the state Highway No. 10. It is situated at a distance of 515 kms from Calcutta and 616 kms from Nagpur Health System Health Infrastructure Jhasuguda is a new district, which came into existence on April Previously the District HQ Hospital was a sub-divisional hospital under the erstwhile-undivided Sambalpur district. All the constraints common to a new district persists here as well. There is one District Headquarter Hospital, 4 old PHCs and fourteen new PHCs and 2 CHCs. There is one government hospital at Belpahar and sixty-three SCs. Table 32: Health Institutions in Jharsuguda No. of District Hospitals 1 No. of Sub-Divisional Hospitals / Area Hospital (Govt. Hospital) 1 No. of Community Health Centres 3 No. of Primary Health Centres (Block PHC) 3 No. of Primary Health Centres SiD and other 14 No. of First Referral Units(F.R.U) 1 No. of Rural Family Welfare Centres 5 No. of Urban Family Welfare Centres - No. of Postpartum Centres 1 No. of Sub-Centres 63 No. of Ayurvedic Dispensaries 8 No. of Homoeopathic Dispensaries 7 No. of Unani Dispensaries - Source- (PIP_Jharsaguda, 2007) There are 3 other hospitals under the Health department and 4 more outside the purview of the H&FW Department, viz. (Orissa_Baseline, 2009) E.S.I. Hospital, Brajrajnagar O.S.A.P. Hospital, Jharsuguda E.S.I. Dispensary, Jharsuguda 90 P a g e

91 Railway Hospital, Jharsuguda In addition, there are 3 public sector undertaking hospitals, viz. Central Hospital, M.C.Ltd, IB Thermal Hospital and Rampur Colliery Hospital. The TATA group also has a hospital called the Tata Refractories Hospital. (Orissa_Baseline, 2009) The same health programs running in Angul District are running here as well. A snapshot of the health status of Jharsuguda district is given below. Table 33: District data: Jharsuguda DLHS-2 (2002 DLHS-3 ( NIPI BASELINE INDICATORS - 04) 08) ( ) MATERNAL HEALTH Total Rural Total Rural Total Rural Mothers registered in the first trimester during pregnancy of last live birth/still birth (%) Mothers who had at least 3 antenatal care visits during the last pregnancy (%) Mothers who got at least one TT injection during pregnancy with their last live birth / still birth (%) Institutional births (%) Delivery at home assisted by a doctor/nurse /LHV/ANM (%) P a g e

92 Mothers who received post- natal care within 48 hours of delivery of their last child (%) CHILD IMMUNIZATION AND VITAMIN A SUPPLEMENTATION Children (12-23 months) fully immunized (BCG, 3 doses each of DPT, and Polio and Measles) (%) Children (12-23 months) who have received BCG (%) Children (12-23 months) who have received 3 doses of Polio Vaccine (%) Children (12-23 months) who have received 3 doses of DPT Vaccine (%) Children (12-23 months) who have received Measles Vaccine (%) Children (9-35 months) who have received at least one dose of Vitamin A (%) Children (above 21 months) who have received three doses of Vitamin A (%) TREATMENT OF CHILDHOOD DISEASES (Children under 3 years, based on last two surviving children) Children with Diarrhoea in the last two weeks who received ORS (%) Children with Diarrhoea in the last two weeks who were given treatment (%) Children with acute respiratory infection/fever in the last two weeks who were given treatment (%) Children had check-up within 24 hours after delivery (based on last live birth) (%) Children had check-up within 10 days after delivery (based on last live birth) (%) CHILD FEEDING PRACTICES (Children under 3 years) Children breastfed within one hour of birth (%) Children (age 6 months above) exclusively breastfed (%) Children (6-24 months) who received solid or semisolid food and still being breastfed (%). Problems faced during pregnancy (% of Mothers) Post Delivery Retention Period of Mother at Health Facility (average in hours) Age at first cohabitation / Average age of marriage P a g e

93 5.2.4 Jharsuguda facility Survey Finding The study done by DCOR Consulting for Access Health International in September 2010 was an attempt to provide insights into the infrastructure available and current capacity of both governments, corporate and private health services providers of Jharsuguda district in neonates and infant care. Neonate Outpatients Attended The findings of the study reveal the fact that parents of neonates prefer to visit private physicians and private hospital/nursing homes than government health facilities. The average number of neonate outpatients in PHCs are 12 per month (minimum 1) whereas it is 25 in private hospital/nursing homes and 50 in the clinics of private physicians. Dr. P. K. Das, a retired Paediatrician from government service sees 150 neonates at his clinic situated in Jharsuguda town. (S. Mohanty, 2010) Outpatient Infants Attended Similarly, the average number of infant outpatients seen by private physicians (80) is higher than those visiting PHCs/CHCs. On an average, 193 infants visit corporate health facilities available in their locality. (S. Mohanty, 2010) Consultation Charges for Outpatients Consultation The minimum consultation charges of private physicians start at INR 30 with a maximum of INR 100. Private physicians based in semi-urban /rural areas charge different for each patient depending on their socio economic condition. Corporate hospitals charge INR100 per visit. (S. Mohanty, 2010) Distance Covered by Patients The study shows that patients visit private practitioners from as far away as 70 kilometres. Patients visit PHCs from a maximum distance of 20 kilometres while they travel 45 kilometres to a CHC. (S. Mohanty, 2010) Common Ailments of Outpatients Below the Age of One Year 93 P a g e

94 Diarrhoea, ARI and malnutrition are the most common diseases among the below one year outpatients. Majority of them suffer due to poor sanitation, unhygienic conditions of living, non availability of safe drinking water and poverty. Number of Neonate Inpatients The study shows that many PHCs are managed by a single doctor or by AYUSH doctors due to the absence of a paediatrician and other facilities, at PHCs/CHCs. As a result neonates are not provided in patient treatment. The average number of neonates getting in patient treatment in private hospital/nursing homes are two in a month where as only one in-patient is treated at a PHC & three are seen at CHCs. The case load of neonate in patients is six in the three corporate health facilities in the district. (S. Mohanty, 2010) Common Neonatal Complications of Inpatients Common complications that neonates suffer from and require in patient treatment are for hypothermia, birth asphyxia, sepsis, jaundice, LBW and gastroenteritis. (S. Mohanty, 2010) Hospitalization Costs of Neonates Patients admitted in government health facilities are treated free of cost. This includes doctor consultation, bed charges, nursing charges, available medicines and diet of the patients. However private hospitals/nursing homes charge INR 2338 on an average to a maximum of INR 5000 for the same treatment and services. This does not include the diet for the patients. (S. Mohanty, 2010) On an average, the cost of medicines at a private hospital/nursing homes, would be INR 500 and diagnostics cost INR The same services at a corporate hospital cost INR 800 and INR 500 respectively. (S. Mohanty, 2010) Number of Inpatient Infants The study findings show that majority of infants get treated at a private hospital/nursing homes (average 15). At the same time only two patients go to a PHC 94 P a g e

95 and 13 visit a CHC. In the case of corporate hospitals, the patients load is 17 because of better health facilities that are available at affordable prices. (S. Mohanty, 2010) Common Complications of Infant Inpatients: Some of the major common complications of infants include diarrhoea, fever and ARI. (S. Mohanty, 2010) Duration of Stay of Inpatient Infants Inpatients The average duration of stay of infant inpatients in a health facility is four days where as it is 3 days in PHCs and 4 days in CHCs and private hospitals. (S. Mohanty, 2010) Hospitalization Costs of Infants The average hospital charges for inpatient infants at a private hospital/nursing homes is INR 2875 with a maximum of INR The cost of medicines and diagnostic tests is approximately INR 2600 and INR 1050 respectively which is comparatively higher than government health facilities and corporate health facilities. (S. Mohanty, 2010) 5.3 Sambalpur Introduction Sambalpur is a municipality in the western region of Orissa. It is the headquarters of Sambalpur district. Sambalpur derives its name from that of the Goddess Samaleswari; an incarnation of Shakti, who is regarded as the reigning deity of the region. Sambalpur lies at a distance of 321 km from the capital city of Bhubaneswar. (Orissa_Baseline, 2009) Sambalpur had a population of 154,164. Males constitute 52 percent of the population and females 48 percent. Sambalpur has an average literacy rate of 66 percent, higher than the national average of 59.5 percent: male literacy is 74 percent, and female literacy is 58 percent. The place is famous for its globally renowned textile bounded patterns and fabrics; locally known as Baandha. In the past Sambalpur has been known for its diamond trade. Apart from textiles, Samabalpur has a rich tribal heritage and lush forestlands. (Orissa_Baseline, 2009) 95 P a g e

96 96 P a g e NIPI Reference Book- Orissa Sambalpur serves as the gateway to the beautiful western part of Orissa. It is the divisional headquarters of the northern administrative division of the state - also a very important commercial and educational centre. Presently, Sambalpur is the break-bulk city between the states of Chhattisgarh and Orissa. (Orissa_Baseline, 2009) Most of the villages of the district are inaccessible during the rainy season. The presence of a number of nalas and the absence of bridges cuts off the villages from the nearby roads. The district is served by National Highway No.6, National Highway No.42, major district roads and a section of South Eastern Railways. Rural electrification has been extended to 63.6 percent of the villages of the district. Telecommunication network is not adequate to cater to the needs the people in the rural areas. Drinking water facilities are available in villages mostly from tube wells. (Orissa_Baseline, 2009) Health System Health Infrastructure The health infrastructure in the district is as follows: Department of Health, GoO District Headquarters Hospital - 1 (116 beds) Sub-divisional Hospital - 2 J.P. Maternity Hospital - 1 P.H.C - 2 UGPHC - 1 CHC - 5 Sub Centres PHC (N) 26 Ayurvedic Hospital & Dispensaries - 08 Homoeopathic Hospital & Dispensaries - 07 Quasi-government Hospitals in district E.S.I. Hospital, Brajrajnagar O.S.A.P. Hospital, Jharsuguda E.S.I. Dispensary, Jharsuguda Railway Hospital, Jharsuguda Public Sector undertaking Hospital

97 Central Hospital, M. C. Ltd, Brajrajnagar Ib. Thermal Hospital, Banharpali Rampur Colliery Hospital, Brajrajnagar Belpahar O.C.P. Dispensary Bandhbahal Dispensary Private Sector Hospital Tata Refractories Hospital, Belpahar Ambulance service: Available at District Headquarter Hospital, Jharsuguda, Lakhanpur CHC Hospital, Mudrajore CHC-II & Brajrajnagar CHC Blood banking facilities: Available at District Head Quarter Hospital, Jharsuguda 97 P a g e

98 Table 34: District Data: Sambalpur DLHS-2 (2002 DLHS-3 ( NIPI BASELINE INDICATORS - 04) 08) ( ) MATERNAL HEALTH Total Rural Total Rural Total Rural Mothers registered in the first trimester during the time of pregnancy with last live birth/still birth (%) Mothers who had at least 3 antenatal care visits during the last pregnancy (%) Mothers who got at least one TT injection during pregnancy with their last live birth / still birth (%) Institutional births (%) Delivery at home assisted by a doctor/nurse /LHV/ANM (%) Mothers who received post natal care within 48 hours of delivery of their last child (%) CHILD IMMUNIZATION AND VITAMIN A SUPPLEMENTATION Children (12-23 months) fully immunized (BCG, 3 doses each of DPT, and Polio and Measles) (%) Children (12-23 months) who have received BCG (%) Children (12-23 months) who have received 3 doses of Polio Vaccine (%) Children (12-23 months) who have received 3 doses of DPT Vaccine (%) Children (12-23 months) who have received Measles Vaccine (%) Children (9-35 months) who have received at least one dose of Vitamin A (%) Children (above 21 months) who have received three doses of Vitamin A (%) TREATMENT OF CHILDHOOD DISEASES (Children under 3 years, based on last two surviving children) Children with Diarrhoea in the last two weeks who received ORS (%) Children with Diarrhoea in the last two weeks who were given treatment (%) Children with ARI/fever in the last two weeks who were given treatment (%) Children examined within 24 hours after delivery (based on last live birth) (%) Children examined within 10 days after delivery (based on last live birth) (%) P a g e

99 CHILD FEEDING PRACTICES (Children under 3 years) Children breastfed within one hour of birth (%) Children (age 6 months above) exclusively breastfed (%) Children (6-24 months) who received solid or semisolid food and still being breastfed (%). Problems faced during pregnancy (% of Mothers) Post Delivery Retention Period of Mother at Health Facility (average in hours) Age at first cohabitation / Average age of marriage Sambalpur facility Survey Finding The study done by DCOR Consulting for Access Health International in September 2010 was an attempt to provide insights into the infrastructure available and current capacity of both governments, corporate and private health services providers of Sambalpur district in neonates and infant care. Neonate Outpatients Attended The study finding reveals the fact that parents of neonates prefer to visit private physicians and private hospital/nursing homes than government health facilities. The average neonate out patients in CHCs are 18 per month (minimum five) whereas it is 23 in private hospitals/nursing homes and 28 in the clinics of private physicians in a month. The case load of neonate out patients at V.S.S. Medical College & Hospital is 450 in a month. (S. Mohanty, 2010) Outpatient Infants Attended Similarly, private physicians see an average of 118 infant out patients per month which is higher than the number of patients (49) who visit CHCs. who get forty-nine outpatients. (49). (S. Mohanty, 2010) Consultation Charges for Out-patients 99 P a g e

100 The minimum consultation charges of private physicians start at INR 50 with a maximum of INR 100. Private physicians in semi-urban and rural areas usually charge for the first consultation and the charge may vary from person to person depending on their socio economic condition. The average consultation charges at a private hospital are INR 118. (S. Mohanty, 2010) Distance Covered by Patients The study shows that patients visit the V.S.S. Medical College & Hospital from as far as 250 kilometres for treatment. People visit a private hospital/nursing home from a maximum distance of 200 kilometres and a radius of 15 kilometres. (S. Mohanty, 2010) Common Ailments of Outpatients below the Age of One Year Diarrhoea, ARI and malnutrition are the most common diseases among the below one year outpatients. This is mostly caused due to poor sanitation, unhygienic conditions of living and non availability of safe drinking water and poverty. (S. Mohanty, 2010) Number of Neonate Inpatients On an average about six neonates get admitted to a private hospital/nursing home while only two patients are seen at a CHC. The case load of neonate in patients is 150 per month in V.S.S. Medical College & Hospital and 30 in DHH, Sambalpur. (S. Mohanty, 2010) Common Complications of Neonate Inpatients Common complications that neonates suffer from and require in patient treatment are for hypothermia, birth asphyxia, sepsis, jaundice, LBW and gastroenteritis. (S. Mohanty, 2010) Hospitalization Costs of Neonates Neonates admitted at government health facilities are treated for free. This also includes doctor consultation, bed charges, nursing charges, medicines and diet of the patients. On the other hand, a private hospital/nursing home charges approximately 100 P a g e

101 INR 3,375 (minimum of INR1,500) for the same. This does not include diet for the patient. (S. Mohanty, 2010) Number of Infant Inpatients The study findings show that majority of the infants get admitted to a private hospital/nursing home (average 20) while only four get treated at a CHC. This usually occurs due to non availability of better health care facilities at CHCs. (S. Mohanty, 2010) Common Complications of Infants Inpatient Some of the major common complications that infants suffer from are diarrhoea, fever, convulsion and ARI. (S. Mohanty, 2010) Duration of Stay of Infant Inpatients The average duration of stay of infant in patients at a health facility is five days. (S. Mohanty, 2010) Hospitalization Costs of Infants The cost of hospitalization for an infant is usually higher at INR 3045 in a private hospital/nursing home as compared to a government facility. This includes the cost of medicines at INR 1455 and diagnostics at INR 700. (S. Mohanty, 2010) 101 P a g e

102 Chapter-6 Maternal & Child health in NIPI s focus Districts 102 P a g e

103 6. Maternal and Child Health in NIPI s focus Districts In this section, the data was collected for NIPI Baseline Report of Orissa from the three NIPI focus districts of Angul, Jharsuguda and Sambalpur with additional and relevant information from the State. The districts were selected by NIPI in consultation with the state NRHM for implementation of the interventions. Table 35: Health Facilities Available and Required Sl. No. 1 Districts Orissa State Population 2010 (est.) Beds Available Facilities Available Required Total DH &SDH DH SDH CHC PHC SHC Beds DH CHC PHC SHC facilities Shortfall Angul 12,51, Jharsuguda 5,59, Sambalpur 10,26, Source- (HR-Plan, 2009) 6.1 Maternal Health Maternal healthcare is a concept that encompasses family planning, preconception, prenatal, and postnatal care. The goals of preconception care include providing education, health promotion, screening and interventions for women of reproductive age to reduce risk factors that might affect future pregnancies. Antenatal care is the comprehensive care that women receive and provide for themselves throughout their pregnancy. Women who begin prenatal care early in their pregnancies have better birth outcomes than women who receive little or no care during their pregnancies. Postnatal care issues include recovery from childbirth, concerns about newborn care, nutrition, breastfeeding, and family planning. (Orissa_Baseline, 2009) Delivery Care One of the important thrusts of the program is to encourage deliveries under proper hygienic conditions (delivering under clean conditions, washing hands with disinfectant before delivery, etc.) and under the supervision of qualified/ experience 103 P a g e

104 health professionals. For each live/still birth during two years preceding the survey, we had asked the women the place of delivery, who assisted in the delivery in the case of home deliveries, characteristics of delivery and any problems that occurred during the delivery process. (Orissa_Baseline, 2009) According to NFHS, t h e trend shows that the percentage of women w h o h a d delivered in a health facility has steadily increased in both India and Orissa. In Orissa, institutional deliveries were only 14 percent in (NFHS1), which has increased almost threefold to 39 percent in (NFHS3). Assistance of trained health personnel during delivery is critical in maternal and child survival. A steady increase was also noted in the number of pregnancies assisted by health personnel in both Orissa and India. When compared to All India, Orissa is still lagging behind in terms of both institutional delivery and births assisted by health personnel. (Orissa_Baseline, 2009) A recent DLHS-3 reported institutional deliveries at 44.3 percent while NIPI Phase II survey also clearly indicates that the trend has increased to nearly 58 percent of all deliveries, which took place in government hospitals (73.5 percent in institutions), while only 26 percent took place at home. (Orissa_Baseline, 2009) Influence of background characteristics choice of place of delivery The following section explores the relationship between the place of last delivery and critical background variables, viz. age of respondent, her education level, child s birth order and standard of living level of her household based on Asset Ownership Index. (Orissa_Baseline, 2009) The preference for institutional deliveries is strong among all women irrespective of her literacy level. However, with literacy, the propensity to deliver at home comes down quite drastically (from 45.7 percent for illiterate women to 9 percent or lower for those who have passed their 10th standard). Again, the preference for private institutional delivery also increases with education of the pregnant mother. (Orissa_Baseline, 2009) 104 P a g e

105 Birth Order Total Table 36: Place of delivery v/s number of live children, NIPI-08 NIPI Reference Book- Orissa Institutional Home Total Govt Private In-laws Home Parental Other All Births Hospital N % N % N % N % places N % N % The hypothesis that younger women having their first child would rather have a risk-free institutional delivery than have it at home while more experienced women with children can afford to think otherwise is more or less validated in the above table. Institutional deliveries come down from 81 percent for women with 1-2 live children to 52 percent for those who had more than two. (Orissa_Baseline, 2009) Wealth Index Lowest Second Middle 29 8 Fourth 20 2 Highest 22 9 Total Table 37: Place of delivery v/s economic status of respondents household, NIPI-08 Institutional Home Total Govt Hospital Private In-laws Parental Other places All Births N % N % N % N % N % N % The generic trend was that women at a lower economic profile tended to favour having deliveries at government facilities as against those who belonged to better-off households and could afford private treatment. (Orissa_Baseline, 2009) Arrangement and cost of transport Family members, usually the husband, had the responsibility of arranging the transport to take the pregnant woman to the health institution. On an average, the cost of transport worked out to be as follows: 105 P a g e

106 Table 38: Average transportation expenses, NIPI-08 NIPI Reference Book- Orissa DISTRICT Total Angul Jharsuguda Sambalpur Rural Urban Total Rural Urban Total Rural Urban Total Rural Urban Total N , ,329 Median There are wide variations in the transportation costs incurred both across urban and rural areas as well as across districts. The urban-rural differences are most stark across Jharsuguda and Sambalpur districts which range from as high as INR 600 in rural Jharsuguda to as low as INR130 in urban Sambalpur the differences are far more modest in Angul district. The cost of transportation was in general highest in Jharsuguda (INR500) and lowest in Angul (INR350) Institutional delivery This section elaborates on issues dealing with the nature of delivery and attending service provider, costs incurred, health problems/complications experienced during delivery, nature of advice received post delivery and from whom, and finally, opinion on quality of service and facility standards. (Orissa_Baseline, 2009) Who conducted the delivery Government Doctor Table 39: Nature of Institutional Delivery NIPI-08 Angul Jharsuguda Sambalpur Rural Urban Total Rural Urban Total Rural Urban Total % % % % % % % % % Private Doctor ANM / Nurse Other Type of Delivery Normal Caesarean Assisted Total N P a g e

107 In line with where the delivery actually took place, the person actually performing the delivery was primarily a government doctor in rural areas and government and private doctors in urban areas. While most deliveries were normal, the percentage of caesarean deliveries was more in urban areas. Approximately 15 percent of the deliveries across both urban and rural areas were assisted deliveries. (Orissa_Baseline, 2009) Table 40: Cost incurred in institutional delivery1, NIPI-08 Rupees Angul Jharsuguda Sambalpur All District Rural Urban Total Rural Urban Total Rural Urban Total Rural Urban Total N , ,531 Median 2,000 2,000 2,000 2,000 2,000 2,000 2,000 2,200 2,000 2,000 2,000 2,000 The average (or mean) cost incurred on institutional deliveries came to around INR 3921, while the median value was INR The differences between urban and rural areas were quite pronounced across all the Districts even though the median value was exactly the same. The biggest difference between rural and urban costs was observed in Angul district where the difference is nearly INR (Orissa_Baseline, 2009) Table 41: Problem experienced during delivery by women of different age groups, NIPI-08 Premature Excessive Prolonged Obstructed Breech Labour Bleeding Labour Labour Presentation Other Total Yes Yes Yes Yes Yes Yes Yes Age N % N % N % N % N % N % N % Obstructed labour was one of the major problems experienced by almost a third of the women respondents. This is consistent across the age groups. Prolonged labour and premature labour were problems faced by a quarter of the respondents across most age groups. (Orissa_Baseline, 2009) 107 P a g e

108 Home deliveries 108 P a g e

109 This section deals with the details of home delivery cases, including reasons behind choosing to have the baby delivered at home and not in an institution, the actual place where the delivery took place and whether it is influenced by the background of the pregnant mother, the person who actually conducted the delivery and finally, why this person was chosen to begin with. (Orissa_Baseline, 2009) In rural areas, people preferred home deliveries either because they perceived institutional deliveries to be prohibitively expensive (33.2 percent), did not get time to plan for the trip to the hospital (27.3 percent), felt it unnecessary because alternate arrangements at home was equally good if not better (26.9 percent) or the facility was too far to make the trip (25.1 percent). In urban areas, the reasons were more polarized with 54 percent women preferring home deliveries to institutional deliveries because of the time issue (emergency delivery) and 28 percent women not feeling the necessity. The trends across the three districts were similar except for the fact that the cost issue was a major determinant in rural Angul. (Orissa_Baseline, 2009) Table 42: Reason for home delivery Reasons (multiple responses) Rura l District Angul Jharsuguda Sambalpur Urba n Tota l Rura l Urba n Tota l Rura l Urba n Tota l All NIPI Districts Rura l Urba n % % % % % % % % % % % % High Cost Facility not open Too Distance Lack of trust on facility Tota l No one to accompany Did not get time Absence of female provider at facility Husband/famil y did not give permission 109 P a g e Not necessary

110 Not customary Any Other Total Table 43: Reasons behind choosing a specific person to conduct the delivery Specification District Angul Jharsuguda Sambalpur All NIPI Districts Rural Urban Total Rural Urban Total Rural Urban Total Rural Urban Total % % % % % % % % % % % % Why did you choose the person to conduct delivery Past Experience Economical Safe Delivery Reliable Behaviour of the service provider Recommended Others Total The above table clearly indicates that across all three districts and across both urban and rural areas, the choice of a person to make the delivery is taken on the basis of past experience (37 percent) or because it is clearly perceived that their experience would result in a safe delivery (39 percent). (Orissa_Baseline, 2009) The following section looks at the different steps followed during the delivery process at home by the person who delivered the baby. (Orissa_Baseline, 2009) Table 44: Cost incurred in home delivery Rupees Angul Jharsuguda Sambalpur All District Rural Urban Total Rural Urban Total Rural Urban Total Rural Urban Total N Median P a g e

111 The average (or mean) cost incurred on institutional deliveries came to around INR 3921, while the median value was INR The differences between urban and rural areas were not quite pronounced in any of the districts. (Orissa_Baseline, 2009) Postnatal Care Table 45: Timings of first postnatal care Timings of First PNC District All NIPI Districts Angul Jharsuguda Sambalpur Rural Urban Total Rural Urban Total Rural Urban Total Rural Urban Total % % % % % % % % % % % % <4 Hrs Hrs days days >41 days DK/CS No Check-up Total Under this section, the responding women were tested for the timing of their first PNC checkup, the number of times PNC was received, the type of service provider and place where the PNC was provided. (Orissa_Baseline, 2009) An overwhelming similar trend in DLHS-3 and NIPI survey showed that nearly 70 percent of all responding mothers had reported that they had not received any PNC check-up. This figure was 73 percent in rural areas and 58 percent in urban areas. (Orissa_Baseline, 2009) There were district level variations as well. In urban Sambalpur, more than 50 percent had reported to have had a PNC check-up within 4 hours of delivery and only 27 percent had reported not having had any check-up at all. (Orissa_Baseline, 2009) The situation was just the reverse in rural Sambalpur. The situation in Angul was dismal with as high as percent of respondents across both urban and rural areas reporting not having received any PNC. The situation in Jharsuguda was also bad with 75 percent reporting no PNC. 111 P a g e

112 (Orissa_Baseline, 2009) Table 46: Number of times PNC received All NIPI District PNC Rural Urban Total % % % Total As given in table 46 less than half had received only 1 PNC but this was by and large the majority category. Over a third had received three or more PNCs and around a quarter had received only two. (Orissa_Baseline, 2009) Most of the PNC was provided by the healthcare personnel/doctor and in this regard, there was marginal difference between urban and rural areas (88 95 percent) and Angul (63 percent each) but quite a difference in Jharsuguda district (73-96 percent). The roles of the ANM/nurse/midwife in providing PNC seem to have been confined to the district of Angul alone. The PNC check-up took place either at a government hospital, PHC or a private clinic. Less than 10 percent of the cases received PNC at home by trained personnel who came over. (Orissa_Baseline, 2009) 6.2 Newborn Care Care provided during the perinatal and neonatal periods is critical to ensuring the health of mother and baby. Maternal health and newborn health are inextricably linked. Newborn Care comprises: (a) Basic preventive newborn care such as care before and during pregnancy, clean delivery practices, temperature maintenance, eye and cord care, and early and exclusive breastfeeding on demand day and night; (b) Early detection of problems or danger signs (with priority for sepsis and birth asphyxia) and appropriate referral and care-seeking. (Orissa_Baseline, 2009) Table 47: Time of first neonatal check-up by Districts Angul Jharsuguda Sambalpur Rural Urban Rural Urban Rural Urban N % N % N % N % N % N % 112 P a g e

113 <6 Hrs Hrs Days Day Days Week or more DK/CS No checkups Total base District-wise analysis seems to indicate that the situation in rural Angul is quite bad with 65 percent of mothers indicating they have not had any check-up at all. The situation is also bad in rural Jharsuguda where 50 percent of mothers had claimed likewise. In fact, the urban situation in both districts is also quite dismal, with nearly 45 percent of mothers and 38 percent of mothers respectively indicating no check-ups for their newborns. The situation in Sambalpur district is marginally better, at least in the urban locations where only 12 percent had reported no checkups and 72 percent had reported the first check-up within 6 hours of delivery. (Orissa_Baseline, 2009) Breastfeeding and Supplementation This section looks at breastfeeding practices among the eligible women, the attitude and practice pertaining to feeding of pre-lacteal liquids and period of exclusive breastfeeding and introduction of supplementary feeding. (Orissa_Baseline, 2009) Did you breastfeed your child? 113 P a g e Table 48: Breastfeeding practices Angul Jharsuguda Sambalpur Rural Urban Rural Urban Rural Urban N % N % N % N % N % N % Yes No Total Anybody helped in initiating the breastfeeding Yes No Total Government Doctor Sources that helped in initiating breastfeed

114 Percent NIPI Reference Book- Orissa Private Doctor Nurse ANM/ASHA/LHV Dai Mother/ Mother-inlaw Friends/Relatives Others Total The status of breastfeeding practices in Orissa was better than the country as a whole and there is improvement since NFHS-2 in the state. About 54 percent of children below three years were breastfed within one hour of birth during NFHS-3. The NIPI Baseline Survey indicates that nearly all interviewed women had breastfed their children. H o w e v e r m ajority of the women (from 67 to 94 percent) admitted that they had received help in initiating breastfeeding. Many sources have been responsible for this initiation. In rural areas, it was primarily the government doctor (no doubt the same doctor who had performed the delivery), the ANM/ASHA/LHV (12-20 percent) or the mother/mother-in-law or nurse. (Orissa_Baseline, 2009) Figure 4: Time of Initiation of Breastfeeding Angul Jharsuguda Sambalpur ORISSA Within one hour after birth After one hour but within same day After more than 24 hours P a g e