Population Research Centre

Transcription

1 MONITORING OF NRHM STATE PROGRAMME IMPLEMENTATION PLAN : JAMMU & KASHMIR (A Case Study of Poonch District) Submitted to Ministry of Health and Family Welfare Government of India New Delhi Syed Khursheed Ahmed Jaweed Ahmad Mir Population Research Centre Department of Economics University of Kashmir Srinagar October, 2013

2 Table of Contents 1 Executive Summary Introduction State and District profile Key Health and Service Delivery Indicators Health Infrastructure: Human Resources Other Health System Inputs Maternal Health ANC and PNC...17 Institutional Deliveries...18 Maternal Death Review...18 JSSK For Women...18 JSY Child Health SNCU...21 NRCs...22 Immunization...22 RBSK Family Planning ARSH Quality in Health Services Infection Control...24 Biomedical Waste Management...24 IEC Clinical Establishment Act Referral Transport and MMUs Community Processes ASHA...25 Skill Development...25 Functionality of the ASHAs Disease Control Programmes Malaria...26 TB...26 Other Communicable Disease Non Communicable Diseases Good Practices and Innovations HMIS and MCTS Key Conclusions and Recommendations

3 1 EXECUTIVE SUMMARY The objectives of this exercise is to examine whether the State is adhering to key conditionalities while implementing the approved PIP and to what extent the key strategies identified in the PIP are implemented and also to what extent the Road Map for priority action and various commitments are adhered to by the State and various districts. Poonch is one of the remote and border district of Jammu and Kashmir state situated at Line of Control. The population growth rate is about 28 percent and the sex ratio is 890. The district consists of three medical blocks and has 170 health institutions of different levels. There are 36 RKSs and 167 VHSCs in the district. The following is the summary of findings of this study: Health Infrastructure There are about 210 (120 DH + 90 CHC) secondary care IPD beds in the district and as per norm are short of about 30 such beds. There are about 110 IPD beds at PHC level for primary care. The IPD beds at CHC level are underutilized mainly because of inadequate staff, equipment and other facilities at these institutions. Human Resources In Poonch District, out of sanctioned positions of MBBS doctors/mo, 19 percent are in place. In DH Poonch 82 percent such positions are vacant and in case of CHC Mandi and PHC Loran the situation is much worse. In case of Gynaecologists, out of 7 sanctioned positions in the district, only 4 are in position and out of 6 Paediatrician only 2 are in place (at DH Poonch) while 66 percent positions of Paediatricians are vacant. None of the posts of Radiologist is filled-in in the district. Out of 7 sanctioned positions of Anaesthetists only 43 percent positions are filled-in while out of 3 sanctioned Pathologists only one is in position. Surprisingly the district does not have any filled-in position of ENT Specialist. The other issue that was observed in the field is attachment of various positions (from nursing orderly to Specialist) at their will and wish. The position of para medical staff is somehow the same as out of 77 sanctioned posts of Staff Nurses only 48 percent are in position. Similarly out of 151 sanctioned positions of MPW/FMPHW/FMPHW- 1, 10 percent posts are vacant. Though the district has appointed MBBS doctors, ISM doctors, Staff Nurses/ANMs in place of Staff Nurses and other para medical staff under NRHM but the dearth of specialists in the district has not been taken into account as none of the specialists has been appointed under NRHM. Training status /skills of various cadres During and a total of 8 doctors and 9 para medical personnel have received training for SBA while IMNCI/NSSK training has been received by 3 doctors and 24 para medical personnel. IUD insertion training has been received by 2 doctors and 9 ANMs in the district. During last two quarters 6 doctors have received training for minilap and 2 each for laprolization and NSV. Other various trainings like Emoc, Bemoc, MDR, immunization and cold chain, F-IMNCI, HIV/AIDS prevention, NBC, and MCTS/HMIS trainings have been imparted to few medical and para medical personnel during the last two quarters in the selected health facilities. Strategies for Generation, Retention, and Remuneration There is no standardized mechanism in place to monitor the productivity of the contractual staff, except attendance and routine work assigned to them and in the absence of any standardized monitoring mechanism; the contract of all contractual staff is renewed annually irrespective of their performance. ANMT School The ANMT School Poonch is functioning smoothly and the school is almost fully staffed. 3

4 Other Health System Inputs The availability of various health services like family planning, emergency services, minor surgeries, General Medicine and pathology are available at all the levels. Important services like Surgery, obstetrics & gynaecology, delivery for CS, are only available at DH on 24X7 bases. The CHC Mandi does not provide any C-section deliveries as the CHC is without a Gynaecologist and Anaesthetist. Services like emergency obstetric care, 1 st and 2 nd trimester abortion, Ophthalmology, RTI/STI services are provided at almost all levels (up to PHC level) during the day time. The specialists for services like cardiology, ENT and Radiology are not available at any level in the district. The Blood Bank facility is available at the DH only but the blood is given to only those patients who are able to manage a donor. Availability of Drugs and Diagnostics, Equipments Besides supplies received from the Directorate of Health Services, the health institutions also make some purchases from the Hospital Development Funds and Untied Funds which are approved by the RKS. Supply and distribution of drugs is monitored by the State Drug Controller by undertaking audit and stock verification of drugs. There is a Central Quality Assurance Committee that ensures the quality of drugs that are being purchased but recently the QAC has come under severe criticism after the fake drug scam was unearthed in the state. During our visit to various health facilities in the district it was found that no spurious drug was supplied to them. Drugs In Poonch EDL was available and displayed only in DH. The health facilities are provided drugs as per the EDL. The EDL for DH and CHC contain drugs for MCH, safe abortion and RTI/STI. The quantity of drugs supplied to health institutions is generally displayed publicly and is updated on monthly basis. Though the drug stores at the DH and CHCs maintain a daily consumption register of drugs, but the list of drugs supplied to OT, OPD and wards was not found displayed publicly in labour room, OT and wards. Only the DH has a computerized inventory management. Generally non generic drugs are available at various health institutions in district. Diagnostics There is no prescription audit of diagnostic tests or drugs prescribed by the doctors. Various basic diagnostic facilities are available in the district at various levels. The DH is providing almost all the diagnostic facilities (except CT-scan, MRI) to patients at minimal user fee charges. Equipments Almost all the essential equipments/instruments and other laboratory equipment is available at the DH but CHC Mandi and PHC Loran were found short of various essential equipments like Semi autoanalyzer, Rapid diagnostic kit for typhoid, Blood culture bottles with broth, Rapid Plasma Reagents, test kit for Syphilis (RPR), and HIV test kits. AYUSH Services DH has a full strength AYUSH unit where all the three components of AYUSH (Auyerveda, Unani and Homeopathy) are working in the OPD. Besides, a homeopathy doctor in the DH, the DH brings in ISM doctors on rotation basis to run the OPD. The supply of AYUSH drugs was found satisfactory in the district. During the last two quarters the OPD for AYUSH in PHC Loran was 1552 and 2294 respectively while in CHC Mandi it was 3605 and 1664 respectively. Maternal Health ANC and PNC Overall 2745 women were registered during the 1 st quarter in the district while during the 2 nd quarter the number of women registered for ANC come down to The coverage of ANC3 and ANC4 is low in the district. All the women registered get the requisite number of TT doses at their respective health facilities. 4

5 Due to non-availability of IFA in the district none of the pregnant women was given the iron supplement during the last two quarters. The documentation and records regarding the line-listing of severely anaemic, hypertensive identified, B. Sugar, U-Sugar and protein tests is extremely poor at all the levels however, the documentation of follow-up, TT2 and IFA is maintained in all the visited health facilities. Institutional Deliveries Overall 2035 institutional deliveries were conducted during the 1 st quarter in the district and of these; half of them were conducted at DH. Similarly during 2 nd quarter out of a total of 1914 institutional deliveries in the district, 58 percent deliveries were conducted at DH Poonch. The percentage of C-section deliveries during last two quarters amounts to 15 percent of the total deliveries in the district. Most of the c-section deliveries have taken place at DH. Facility for the management of common obstetric problems and abortion services are not available at all the PHCs in the district. None of the SCs in the district have been officially identified to function as delivery points because of the fact that most of SCs lack of space, trained manpower or other infrastructure. Maternal Death Review In Poonch 2 maternal deaths were reported during the first quarter while the number of infant deaths was higher for both the quarters (28 and 29 respectively for Q1 and Q2). No MDR or IDR has taken place in the district during the last two quarters. About 565 informers were given incentives for birth and death reporting during the last two quarters in the district. JSSK for Women Transportation No toll free number is available at the district. Free transportation from home to facility is generally not provided to pregnant women for visiting a health facility for delivery in the district. The provision of free transport among expectant women for visiting a health facility for delivery has increased from 7 percent during the 1 st quarter to 59 percent in the 2 nd quarter. Free referral transport from facility to facility is provided in most of the cases. The drop-back facility has decreased from 52 percent during the 1 st quarter to 32 percent during the 2 nd quarter. Medicines Drugs at the time of delivery are generally provided free in the district. Overall 1704 women were provided drugs free of cost during the 1 st quarter and during 2 nd quarter a lesser number (1626 women) were provided free drugs. Diagnostics Free diagnostics facilities (urine test, various blood tests, etc) are provided to pregnant women at DH, CHCs and PHCs in the district. The USG is provided only in DH because this facility was found unavailable at the CHC and PHC during our visit. The type of tests (other than USG) provided by visited institutions was found encouraging but the monitoring mechanism for maintenance of such records by various labs was found unsatisfactory. The USG at the DH is conducted by a short term certificate holder Doctor. An important issue regarding the diagnostics at DH is that the Gynaecologists in these institutions do not honour the lab tests/ultrasound conducted by public sector institutions, instead recommend private diagnostic facilities for conduct of tests. Meals An amount of Rs. 100/= is earmarked for providing free meals to pregnant women under JSSK in the DH Poonch. The other health facilities in the district have no arrangement for providing free meals to pregnant women due to the non availability of kitchen facilities. Among the health facilities that we visited only DH Poonch has outsourced free meals to the canteen which is within the premises of the hospital. The issue of quality and quantity is an issue of concern in this regard. Overall about 65 percent women each have been provided free meals under JSSK during last two quarters. 5

6 User Charges and Consumables All user charges at delivery points in the district were found to be free. However, consumables like cotton and sanitary napkins are not provided in the hospital as was reported by the clients. Blood DH Poonch has a Blood Bank without a blood bank officer but some technical staff is available in the blood bank. During the last quarter none of the women has been given free blood under JSSK as there is no blood available in the blood bank. Patients who need blood transfusion have to arrange a donor themselves. Blood storage facility is not available at CHC Mandi. JSY As a high focus district, all pregnant women in J&K are entitled to JSY payments. The payment for home deliveries has been made for very few cases as out of 1677 home deliveries during the last two quarters only 29 women have been given JSY payments in the district. Payments are made through Account Payee Cheques to the beneficiaries. The beneficiaries were critical of getting account payee cheques as in most of the cases they do not have any operational bank account. Child Health SNCU The district has established 1 SNCU at DH, 3 NBSUs at CHC level and 11 NBCCs at PHC level. The SNCU at the district hospital is functioning smoothly with the requisite staff however, all the staff is not trained. The NBSU at CHC Mandi is not functioning well as it lacks equipment, manpower, space and other related facilities. In PHC Loran in Mandi block (24X7 PHC) the NBCC has not yet been established. Almost all those children who were referred for higher facility from district hospital were provided referral transport. Free medicine under JSSK is also provided to all those children who were admitted in SNCU/NBSU. Most of the women in the district had only partial information regarding early and exclusive breast feeding and most of the women who had delivered in DH Poonch during our visit had not even initiated breastfeeding even after more than 6 hours of delivery. Immunization The State has identified Poonch district with low immunization and plan for intensification of routine immunization for this district has been prepared. Facility for birth doze of immunization is available at 3 identified PHCs, CHCs and DH in the district. Most of the SCs in the district do not provide birth doses (BCG) at all. Micro plans for institutional immunization services are prepared at sub centre level in the district. Cold Chain Mechanics for the maintenance of Cold Chain Machine and a paramedic trained in Cold Chain Handling is in place in the District. VHNDS, outreach secessions are used to improve DPT-1 Booster and Measles-2. Mobility support for supervision and monitoring has been approved in the district. AEFI committees have been established and meetings are held on regular basis. Family Planning There are no fixed days for IUCD services; instead, services are available on all days. Overall about 60 health providers have been provided some training regarding insertion and removal of IUCD during the last two quarters. The IEC component is not much strong as only some information on various contraceptive methods was found available at DH and CHC level. The spacing methods like condoms and oral pills are available at all levels while as IUD insertion is provided at 20 selected SCs, PHC level and other higher levels. Facilities for sterilization are available at DH and CHCs in the district. Sterilization camps are organized to clear backlog at block level in the district. About 13 such camps have been organised in the district during

7 ARSH The ARSH clinic at DH Poonch was established during but presently the clinic is virtually defunct due to resignation of the ARSH Counsellor. Menstrual Hygiene Scheme (MHS) is operational in the district and is currently running smoothly. The SNs are provided to ASHAs on regular basis and on an average each ASHA has identified about 60 clients from her area. Infection Control Overall the general cleanliness, practices of health staff, protocols, fumigation, disinfection, was found satisfactory in the DH hospital but at other levels such issues are not taken seriously. Biomedical Waste Management The segregation of bio-medical waste was found satisfactory in the DH but at other levels segregation of bio-medical was either unsatisfactory or not available at all. The awareness amongst the staff was found satisfactory and practice of segregation was being done properly at the DH. IEC Display and availability of appropriate IEC material related to MCH, FP related IEC, services available, working hours, EDL, clinical protocols, phone numbers etc., at the DH and CHC level but such material was insufficient at PHC and SC level. Clinical Establishment Act The clinical establishment act is in vogue and is implemented strictly in the district booth at public as well as private institutions/clinics. The district has constituted a team in this regard that makes surprise checks to private UGC clinics and the data by these clinics regularly received by the district. Referral Transport and MMUs The district has a total of 34 ambulances for all the health institutions of the district. All the health facilities that we visited were found short of ambulances and the vehicles are also not in good condition. These vehicles are not fitted with GPS, a uniform toll free number or a control room is not available in the district for availing free transport in the district. An effective and transparent system of monitoring the usage of vehicles has not been put in place by various health facilities in the district. Community Processes ASHA In district Poonch the number of ASHAs sanctioned is 525 and out of that only 71 percent (374 ASHAs) are in position. The ASHA Facilitators and Coordinators in the district have received Home Based New Born Care (HBNC) training. Module 6-7 (IMNCI) t raining has been initiated for ASHAs and all the 374 inposition ASHAs have received training for module-6. So far none of the ASHAs have been provided with HBNC kit in the district. The meetings are regularly organised on monthly basis at the block headquarter and information regarding various components of NRHM is being provided to ASHAs in these meetings. So far none of the ASHAs has been disengaged from the system on performance bases. Functionality of the ASHAs During the drug kit of ASHAs has not yet been refilled. Payments to ASHAs on account of various activities have been made recently (during July-August) in all those facilities that our team visited. On an average most of the ASHAs reported that they earn about Rs /= per month. Disease Control Programmes Malaria There is no separate staff for the Malaria cell at the district level but some positions of BHWs and JHI are available at CHC level. The screening and testing facility is available at PHC, CHC and DH level. 7

8 Overall 4 percent cases of malaria were detected in the district and were treated in the district. TB The TB Control programme is being run at the district level by the District Tuberculosis Officer (DTO) and the office is almost fully staffed. The TB Control programme is working efficiently in the district as there is involvement of ANMs and ASHAs (DOT providers) at SC and village level. The testing facility is available in the district hospital and other FRUs and PHCs. The prevalence of TB in the district is about 9 percent. Overall thirteen cases (about one percent) were referred to specialized hospital. The drugs for the treatment of TB is being provided free of cost to all the patients at all levels. Other Communicable Disease NLEP programme is looked after the Chief Medical Officer at the district level and screening is done by organizing camps and through school health check-up programmes. Besides, regular screening is done at DH and CHC level. Non Communicable Diseases Screening for NCD is done on routine basis at DH and CHCs. Besides, the district is intending to organize some camps regarding screening of NCD. HMIS and MCTS MCTS The data regarding mother and children is uploaded and updated regularly however due to very poor internet facility in the district there are some problems regarding the timeline for uploading the data. Registers are maintained for MCTS at all the institutions that we visited but the quality of those registers (space for entry of various items) is not satisfactory. MCTS call centre to monitor the service delivery and SMS alert service centre for delivery and monitoring of service delivery to severely anaemic women, low birth weight babies and sick neonates is not effective at any level in the district. Based on various records about 60 percent MCTS is complete in the district. The completeness of MCTS is 100 percent in DH while it is only 12 in Mandi block. Micro birth planning is also not done for all severely anaemic pregnant women, as the information on the status of anaemia of pregnant women, hypertension, and other problems are missing on ANC registers. Computer generated job charts/due lists of services for women and children tracked under MCTS are not provided to ANMs. HMIS Data reporting is regular. Though the data quality in the district of Poonch has improved to a great extent but there is still a lot of scope for improvement in all the facilities particularly in CHCs and DH and in this regard there is need of further training to all the stakeholders. Most of the services provided by the DHs are underreported. The district is now only using HMIS data both for reporting and reviewing its progress and the dual reporting system has been stopped. 8

9 2. INTRODUCTION Ministry of Health and Family Welfare, Government of India has approved the State Programme Implementation Plans (PIPs) under National Rural Health Mission (NRHM) for the year While approving the PIPs, States have been assigned mutually agreed goals and targets and they are expected to achieve them, adhere to key conditionalities and implement the road map provided in each of the sections of the approved PIP document. Though, States were implementing the approved PIPs since the launch of NRHM, but there was hardly any mechanism in place to know how far these PIPs are implemented. However, from the last financial year, Ministry decided to continuously monitor the implementation of State PIP and has roped in Population Research Centres (PRCs) to undertake this m onitoring exercise. During the last meeting, it was decided that all the PRCs will undertake qualitative monitoring of PIPs in the states/districts assigned to them on monthly bases. PRC Srinagar undertook this exercise in the districts of Poonch and Rajouri for this month. Objectives The objectives of the exercise is to examine whether the State/district is adhering to key conditionalities while implementing the approved PIP and to what extent the key strategies identified in the PIP are implemented and also to what extent the Road Map for priority action and various commitments are adhered to by the State/district. Methodology and Data Collection The methodology for monitoring of State PIP has been worked out by the MOHFW in consultation with PRCs in workshop organized by the Ministry at NIHFW on August, It was decided that all the districts of the State will be covered in a phased manner during In the first phase this PRC was asked to cover Poonch, Rajouri, Leh and Kishtwar Districts. The present study pertains to Poonch district. A schedule of visits was prepared by the PRC and two officers consisting of Research Officer and Research Assistant visited Poonch District and collected information from the Office of Chief Medical Officer (CMO), District Hospital (DH), CHC Mandi, PHC Loran and SC Banpat. We also interviewed 26 IPD and 55 OPD patients who had come to avail the services at various health facilities visited by us. The check list provided by the Ministry was modified to suit the local requirements and to include all items that are covered in the template. The following sections present a brief report of the findings related to mandatory disclosures and strategic areas of planning and implementation process as mentioned in the road map. 3. STATE AND DISTRICT PROFILE Situated on the northern extremity of India, Jammu and Kashmir occupies a position of strategic importance with its borders touching the neighboring countries of Afghanistan, Pakistan, China and Tibet. The total geographical area of the State is 2,22,236 square kilometers and presently comprises 22 districts and 84 medical blocks in three divisions namely Jammu, Kashmir and Ladakh. According to 2011 Census, Jammu and Kashmir had a population of million, accounting roughly for 1 percent of the total population of the country. The sex ratio of the population (number of females per 1,000 males) in the State according to 2011 Census was 883, which is much lower than for the country as a whole (940). Twenty- seven percent of the total population lives in urban areas which is almost the same as at the national level. Scheduled Castes accounts for 8 percent and Scheduled Tribe population account for 11 percent of the total population of 9

10 the State. As per 2001 Census, the literacy rate among population age 7 and above was 55 percent as compared to 65 percent at the national level. Poonch is one of the remote and border district of Jammu and Kashmir situated at the Line of Control (LOC) between India and Pakistan. The total population of Poonch district is , which constitutes 4 percent of the total population of the state (Table 1). The district has a huge concentration of ST population (40 percent). Half of the population in the district is still illiterate. The population growth rate is about 28 percent and the sex ratio is 894. Half of the population age 6 and above are literate with female literacy lower than male literacy. The district consists of three medical blocks namely Surankot, Mendhar and Mandi. The health services in the public sector are delivered through a network of 1 District Hospital, 3 CHCs, 17 PHCs and 102 SCs. Table 1: Demographic Profile of District Poonch. Demographic Character Total Population of the district as per census Male Female Number/percentage/Ratio ST Population (40%) SC Population 952 (0.3%) Literacy rate 51.2% 0-6 Yrs population as per census Population Growth rate Sex ratio 894 Total Area 1674 Sq. Km Total No. of Health blocks Total Villages 3 (Mandi, Mendhar, Surankote) 179 (167 Inhabited) Total No. of Health Institution =170 Total No. of ASHA s =374 Total No. of RKS (Rogi Kalyan Samitis) 36 Total No. of village Health & sanitation committees

11 4. KEY HEALTH AND SERVICE DELIVERY INDICATORS On the demographic front, State has progressed well as the Total Fertility Rate has come down to 2.0. According to Sample Registration System (SRS, 2013), Jammu and Kashmir had an infant mortality rate of 39 per 1,000 live births, a birth rate of 17.6 and a death rate of 5.4 per 1,000 population. District level estimates of fertility and mortality are not yet available for the State. The sex ratio at birth in the district Poonch is 894 females per thousand males as per HMIS data. HMIS data ( ) shows that ANC first trimester registration is about 51 percent. More than two third (64 percent) have received at least 3 ANC checkups. All the women registered for ANC receive 100 IFA tablets and 88 percent have received TT injections. Institutional deliveries have improved and 70 percent of the deliveries take place at institutions. All the institutional deliveries have taken place in public hospitals and the Caesarean section deliveries account for 15 percent of institutional deliveries. Almost all the women who have delivered in a public health facility are reported to have received JSY benefit. Only 44 percent new born were weighted at birth and 24 percent of the weighted new born are less than 2.5 kg. HMIS immunization data of Poonch district is unreliable. However, as per DLHS-3 full immunization is only 23 percent despite the fact that 80 percent have received polio drops, signifying a huge dropout rate in immunization. As far as family planning is concerned, only 23 percent of couples are using a modern method of family planning and the total unmet for family planning in the district is 25 percent. Table 2 Key Health and Service Delivery Indicators of District Poonch S. No Key health and service delivery indicators Q1 Q2 1. OPD IPD ANC PNC NA NA Child Immunization coverage 5. BCG DPT 1, Polio DPT 3, Polio Measles Note: (Q1 is from January-March, 2013 and Q2 is from April-June, 2013) 5. HEALTH INFRASTRUCTURE There are a total 170 health institutions in the district consisting of 1 DH, 3 CHCs, 32 PHCs and 114 SCs/MACs, 3 MMACs 1 TB Centre and 1 District Family Welfare Centre. However most of the health institutions particularly SCs and Ads are housed in rented buildings. PHCS located in rented buildings have acute shortage of accommodation and are in depilated conditions. The condition of the PHCs and CHCs located in Government buildings is also not good as they are either short of space or are not maintained properly. The institution-wise detail of health facilities is given in Table 3. The district is in the process of upgrading ADs into PHCs to mitigate the shortage of PHCS, however as per the requirement, the district has a shortage of 31 Sub Centres. A new building for the district Hospital has been made operationalized which has increased the Bed capacity of DH to 120. The cumulative bed capacity of the 3 CHCs is only 90 as against a requirement of 150 beds. None of the CHCS and PHCs has bed capacity as per IPHS norms. All the PHCs and ADS generally have 5 beds. However, it was also seen that the IPD beds at CHC and PHC level are underutilized mainly because of inadequate staff, equipment, lack of heating arrangement and proper electricity back up. The underutilization of CHCs and PHCs increases the work load of District Hospital. 11

12 Table 3: Health Infrastructure (As on ) of District Poonch: S. No Type of Health Facility Number available Number required No of IPD beds available 1 District Hospital Govt 2 Maternity Hospital 0 3 Sub-district Hospital 0 4 FRU/CHC 3-90 Govt 5 PHC (24x7) Govt Status of the building (Govt./Rented) 6 PHC/AD 7/15= Govt/15 Rented 7 SC/MAC= 102/10= Govt/78 Rented 8 RFWC and Child welfare Centre Govt/1 Rented 6. HUMAN RESOURCES Number and types of HRH required, Available, Postings Jammu & Kashmir is facing the challenge of shortage of Specialists and Assistant Surgeons/MOs in its health institutions particularly in high focus districts. Since Poonch is a high focus district and is facing the same problem. In Poonch District out of 117 regular positions of MBBS doctors/mo, only 23 (19 percent) are in place. In DH Poonch 82 percent of such positions are vacant and in case of CHC Mandi and PHC Loran the situation is much worse. In case of Gynaecologists, out of 7 sanctioned positions in the district, only 4 are in position and out of 6 Paediatrician only 2 are in place (at DH Poonch) while 66 percent positions of Paediatricians are vacant in the district. There is no paediatrician in any of the CHCs of district Poonch and the entire work load is on DH alone. None of the posts of Radiologist is filled-in in the district and in DH hospital a doctor with 3 months training in radiology is performing USGs. Similarly out of 7 sanctioned positions of Anaesthetists, only 43 percent are filled-in while out of 3 sanctioned Pathologists only one is in position. Surprisingly the district does not have any filled-in position of ENT Specialist and as such ENT department in the hospital has virtually become defunct. As the district is one of the border and remote districts in the State, therefore, doctors and specialists are hardly willing to work in this district. Such state of affair has badly affected the health care delivery system in the district. However, if a transparent policy of transfers and postings is put in place strictly and other political interventions are kept aside then such situations cannot arise. The other issue that was observed in the field is attachment of various positions (from nursing orderly to Specialist) at their will and wish. This has also proved fatal in the health care delivery system. The position of para medical staff is somehow the same as out of 77 sanctioned posts of Staff Nurses only 37 (48 percent) are in position. Similarly out of 151 sanctioned positions of MPW/FMPHW/FMPHW- 1, 136 are in position while 10 percent posts of MPW/FMPHW/FMPHW- 1 are vacant. However, the position of other para medical staff in the district is somehow better. Though the district has appointed some MBBS doctors (21), ISM doctors (21), Staff Nurses/ANMs in place of Staff Nurses (29) and other para medical staff under NRHM and it proved helpful in filling up some critical gaps in the availability of human resource but the dearth of specialists in the district has not been taken into account as none of the specialists (particularly for MCH purposes) has been appointed under NRHM. Though State Health Society has decentralized the process of recruitment of contractual staff and guidelines for the appointment of contractual staff, qualifications, salaries, increments, nature of 12

13 appointment, renewal of contracts, etc are more or less in line with the GOI guidelines. District Health Societies have been delegated powers to appoint contractual staff. Preference is given to local candidates. However, in case of non-availability of locals the posts are filled-up with candidates from other areas and in this case government has already issued an order. Though the state is offering higher incentives (graded as per remoteness) to the doctors who are willing to work in far flung and remote areas of the state irrespective of the fact whether they are recruited under NRHM or on regular basis but the response in this regard is not so good in case of Poonch district. Some of the doctors have already joined and process is on to fill other vacant positions. Besides, to overcome the shortage of doctors, more appointments are to be made in the district Poonch. All the sanctioned positions (102) of second ANMs have also been filled up in the district. A time table/job responsibilities of the 2 ANM has been devised. However, timetable of the 2 ANMs or their tour programme was not displayed in any of SCs visited by monitoring teams either in the district. The job description and reporting relationships of various categories of staff has been defined but the services of the staff of the PMUs are also utilized for other activities also. As, there is no plan for their inclusion in the State budget and also due to the instability of tenure; the contractual appointees leave the job once they get a permanent job. Apart from some training courses, there are hardly any opportunities for their professional development. Training Status /Skills of Various Cadres The two Regional Institutes of Health and Family Welfare located in Nagrota (Jammu) and Dobiwan and the Regional Family Planning Training Centre at Barzulla have been strengthened in terms of infrastructure and manpower to impart various trainings under NRHM. A calendar of trainings to be organised by these institutes has been framed. District Training Centre (DTC) located in District Hospitals have been strengthened, however, requisite number of Staff Nurses have not been posted in DTCs. There are no quality assurance measures which monitor the quality of the trainings imparted by these training institutions. None of the training institutions in the State is accredited by any National Accreditation Agency. State has also deputed some doctors to various training institutions outside the state for multi skilled trainings and also for diploma and PG Degrees in Public Health. The district Poonch has imparted some training to various categories of doctors and para medical staff during and The information collected shows that a total of 8 doctors and 9 para medical personnel have received training for SBA while IMNCI/NSSK training has been received by 3 doctors and 24 para medical personnel in the district during IUD insertion training has been received by 2 doctors and 9 ANMs in the district during the same period. Further, during last two quarters 6 doctors have received training for minilap and 2 each for laprolization and NSV in the district. Other various trainings like Emoc, Bemoc, MDR, immunization and cold chain, F-IMNCI, HIV/AIDS prevention, NBC, and MCTS/HMIS trainings have been imparted to few medical and para medical personnel during the last two quarters in the selected health facilities. Strategies for Generation, Retention, and Remuneration There is no standardized mechanism in place to monitor the productivity of the contractual staff, except attendance and routine work assigned to them and in the absence of any standardized monitoring mechanism; the contract of all contractual staff is renewed annually irrespective of their performance. The 13

14 district has recently received 6 point guidelines from SHS for monitoring the performance of ANMs and such guidelines for other staff are also in the offing. There are as such no incentives either for the health service provider or for the health facility based on functioning or performance, however, the State has introduced best doctor, best ANM, best district, best block, best PHC and best SC cash awards to encourage good performance, but no such cash awards have been given in the district so far. State has increased the intake capacities of Medical colleges of the State. Rural posting for newly appointed doctors by Public Service Commission (PSC) has been made compulsory. Seats for PG admission have been reserved for doctors posted in rural areas. State has also started to revamp the existing ANMT schools and establishment of new ANMT schools in new districts and 3 GNM training centres at Jammu, Pulwama and Kargil. Private paramedical institutions are encouraged to enhance the supply of paramedical staff. The ANMT School Poonch is situated in DH Pooch premises and is functioning smoothly and from the current year the intake capacity of various courses has been increased. The school is almost fully staffed. Table 4.1: Details of NRHM/Contractual Human Resource appointed in selected Health facilities and in the district Number Appointed Category of the Staff DH CHC Mandi PHC Loran SC Banpat Total in District MBBS Doctors ISM Doctors PARA MEDICAL STAFF Staff Nurse ANM in place of Staff Nurse FMPHW/MMPHW Lab. Assistant OT Technician X-Ray Technician Dawasaz Table 4.2: Trainings Name Training of DH Poonch CHC Mandi PHC Loran SC Banpat Total District Doctors Para Medical Staff Doctor Para Medical Staff Doctors Para Medical Staff Doctors Para Medical Staff Doctors SBA IMNCI/NSSK IUD Insertion Mini Lap Laprolization NSV Para Medical Staff 14

15 Table 4.3: Details of Regular Human Resource sanctioned, available and percentage of vacant positions in selected Health facilities and in the district as a whole Category of the Staff DH CHC Mandi PHC Loran SC Banpat Overall District San IP % vacan t San IP % vacant MBBS Doctors /MO Gynecologist Pediatrician Radiologist Physician Surgeon Spt Anesthetist Pathologist E.N.T Dental Surgeon Dermatology Ophthalmologist Orthopedics Blood Bank Officer ISM Doctors PARA MEDICAL STAFF Staff Nurse MPW/FMPHW/FMPHW - 1 Head/ Sr./Jr. Pharmacists/MMPHW San IP % vaca nt San IP % vaca nt Head/ Sr./Jr. Lab. Tech Sup Head/ Sr./Jr. X-Ray Sr./Jr. O.T Tech CHO/BHO/H Educator Sr./Jr. Dental Technician Head/ Sr./Jr. Ophthalmic Driver San IP % vacan t 7. OTHER HEALTH SYSTEM INPUTS The availability of various health services at different levels shows that the services like family planning, emergency services, minor surgeries, General Medicine and pathology are available at all the levels at any point of time in the district. Important services like Surgery, obstetrics & gynecology, delivery for CS, are only available at DH on 24X7 bases. The CHC Mandi does not provide any C-section deliveries because of the fact that the CHC is without a Gynecologist. Services like emergency obstetric care, 1 st and 2 nd trimester abortion, Ophthalmology, RTI/STI services are provided at almost all levels (upto PHC level) during the day time. The specialists for services like cardiology, ENT and Radiology are not available at any level in the district. The Blood Bank facility is available at the DH only but the blood is given to only those patients who 15

16 are able to manage a donor. The advanced tests like, CT-Scan, MRI facility, etc. is not available in the district. Availability of Drugs and Diagnostics, Equipments Presently, the district receives the drugs as per the state policy of system of procurements of drugs, consumables and equipments and their distribution to various health centres in the State which is centralized at the divisional level. The central purchase committees with the two Directorates assess the need of drugs and equipments of various health institutions located in their divisions and grade different types of health facilities depending upon the work load and performance. The drugs are procured through competitive biddings and bid documents and tenders are uploaded on The supplies are made available to various health institutions in two instalments by the 2 Directorates of Health Services directly on the basis of the grading. Besides, the supplies received from the Directorate of Health Services, the health institutions also make some purchases from the Hospital Development Funds and Untied Funds. The items to be purchased are approved by the RKS and procured on the basis of lowest quoted rates through quotations. Supply and distribution of drugs is monitored by the State Drug Controller by undertaking audit and stock verification of drugs. There is a Central Quality Assurance Committee that ensures the quality of drugs that are being purchased but recently the QAC has come under severe criticism after the fake drug scam has unearthed in the state. During our visit to various health facilities in the district it was found that no spurious drug was supplied to them. Drugs State has developed essential drugs list (EDL) for various types of health facilities depending upon work load and performance. In Poonch EDL was available and displayed only in DH. The health facilities are provided drugs as per the EDL. The EDL for DH and CHC contain drugs for MCH, safe abortion and RTI/STI. The quantity of drugs supplied to health institutions is generally displayed publicly and is updated on a monthly basis in the district. Though the drug stores at the DHs and CHCs maintain a daily consumption register of drugs, but the list of drugs supplied to OT, OPD and wards was not found displayed publicly in labour room, OT and wards. Only the DH has a computerized inventory management. Generally non generic drugs are available at various health institutions in district. Very few generic drugs are also available in some health institutions that we visited. The district is providing free drugs to MCH patients, and most of the women in both the districts reported to have received free drugs during delivery. None of the health institutions in the district is doing a prescription audit. Diagnostics The State has a policy for rational prescription of diagnostic tests, and drugs but it is hardly implemented. There is no prescription audit of diagnostic tests or drugs prescribed by the doctors. However, CMO mentioned that due to the shortage of doctors they are unable to implement the policy of prescriptions audits. Information collected from the district revealed that there is no partnership with any private service providers for diagnostic tests and neither outsourcing of diagnostics is taking place. Various basic diagnostic facilities are available in the district at various levels. The DH is providing almost all the diagnostic facilities (except CT-scan, MRI) to patients at minimal user fee charges. 16

17 Equipments The two directorates have also done an equipment needs assessment survey of all health institutions and have provided equipments as per the requirement. Equipments are purchased by the Central Purchase Committee. The newly procured equipments have inbuilt Annual Maintenance Contract (AMC) with the supplier during warranty period. After the warranty is over, health institutions undertake repairs of the equipments out of HDF. Almost all the essential equipments/instruments and other laboratory equipment is available at the DH but CHC Mandi and PHC Loran were found short of various essential equipments like Semi auto-analyzer, Rapid diagnostic kit for typhoid, Blood culture bottles with broth, Rapid Plasma Reagin test kit for Syphilis (RPR), and HIV test kits. The condition of PHC Loran (which is designated as 24X7 PHC) is much worse. Health institutions in the two districts reported that they do not have any unused/faulty equipment. Table 5.1: Service Delivery DH Poonch CHC Mandi PHC Loran SC Banpat Facility available Yes,24*7=1 Yes, day time=2 No=3 Dental NA Ophthalmology NA Obstetrics & gynaecology NA General medicines NA Surgery minor NA Surgery major NA Delivery for CS NA Emergency Obstetric Care NA 1st and 2nd trimester abortion NA RTI/STI services NA Table 5.2: Equipment DH Poonch CHC Mandi PHC Loran SC Banpat Equipment Yes,=1 No=2 Functional BP Instrument and Stethoscope Sterilized delivery sets NA Functional Neonatal, Paediatric and Adult Resuscitation kit NA Functional Weighing Machine (Adult and child) 1 1 NA Functional Needle Cutter 1 1 NA Functional Radiant Warmer NA Functional Suction apparatus NA Functional Facility for Oxygen Administration NA Functional Foetal Doppler/CTG NA Functional Mobile light NA Delivery Tables NA Functional Autoclave NA Functional ILR and Deep Freezer NA Emergency Tray with emergency injections NA Oxygen Cylinder 660 ltrs. With regulator & mask NA Nitrous Oxide Cylinder 1760 Ltrs NA 17

18 Table 5.3: Laboratory Equipment DH Poonch CHC Mandi PHC Loran SC Banpat Equipment Yes,=1 No=2 Functional Microscope NA Functional Hemoglobinometer Functional Centrifuge NA Functional Semi auto-analyzer NA Functional X-ray units NA Functional ECG machines NA Refrigerator NA Rapid diagnostic kit for typhoid NA Blood culture bottles with broth NA Rapid Plasma Reagin test kit for Syphilis (RPR) NA HIV test kits NA Table 5.4: Essential Drugs DH Poonch CHC Mandi PHC Loran SC Banpat Drugs Yes,=1 No=2 Out of Stock =3 EDL available and displayed Computerised inventory management IFA tablets/syrup Vitamin A syrup/ ORS packets/ Zinc tablets Inj Magnesium Sulphate Inj Oxytocin Misoprostol/ Mifepristone tablets Availability of antibiotics Drugs for hypertension & diabetes PCM, Metronidazole, anti-allergic Adequate Vaccine Stock available Essential Obstetric care drug Table 5.5: Other Services DH Poonch CHC Mandi PHC Loran Sc Banpat Lab Services Yes,=1 No=2 Haemoglobin CBC NA Urine albumin and sugar NA Blood sugar NA RPR (Rapid Plasma Reagin) NA Malaria NA T.B NA HIV NA Ultrasound Scan NA X-Ray NA ECG NA 18

19 AYUSH Services In district Poonch DH has a full strength AYUSH unit where all the three components of AYUSH (Auyerveda, Unani and Homeopathy) are working in the OPD. Besides, a homeopathy doctor in the DH, the DH brings in ISM doctors on rotation basis to run the OPD at the DH. The district ISM units which function under the administrative control of Director ISM are co-located with DH in the district. Remote areas, where there are no MBBS doctors have been prioritized for the deployment of AYUSH. As already mentioned above, all the 21 sanctioned positions of AYUSH doctors under NRHM have been put in place in the district. The supply of AYUSH drugs was found satisfactory at all the health facilities that we visited. The working of the AYUSH unit of the PHCs in the district is monitored by the concerned CMO/BMOs along with the OPD of the PHCs as a whole. During the last two quarters the OPD for AYUSH in PHC Loran was 1552 and 2294 respectively while in CHC Mandi it was 3605 and 1664 respectively. All the PHCs where an AYUSH doctor is posted also have an AYUSH Pharmacist in place. At most of the places it was seen that AYUSH Pharmacists have been engaged with other works also. The District ISM Medical Officer and the PHC AYUSH Medical Officers are the members of the respective RKS committees in the district. In fact, PHCs where the post of a MBBS doctor is vacant, AYUSH MO is the member secretary of RKS. AYUSH doctors besides their routine work are also involved in the implementation of National Health Programmes in the district. 8. MATERNAL HEALTH ANC and PNC Overall 2745 women were registered during the 1 st quarter in the district while during the 2 nd quarter the number of women registered for ANC come down to The number of women registered during the 2 nd quarter has come down in all the visited institutions in the district. The information collected shows that the coverage of ANC3 and ANC4 is low in the district. All the women registered get the requisite number of TT doses at their respective health facilities and this was confirmed by clients during the exit interviews also. Due to non-availability of IFA in the district none of the pregnant women was given the iron supplement during the last two quarters. MCTS entry on percentage of women registered in the first trimester is low in the district particularly at CHC Mandi. The main reason for low percentage of entry is because of poor internet connectivity. DH Poonch has a distinction of 100 percent MCTS entry. The records verified in the visited health facilities shows that the documentation and records regarding the line-listing of severely anemic, hypertensive identified, B. Sugar, U-Sugar and protein tests is extremely poor at all the levels however, the documentation of follow-up, TT2 and IFA is maintained in all the visited health facilities. Table 6.1: Service Delivery of ANC Record Maintenance DH Poonch CHC Mandi PHC Loran SC Banpat District Q1 Q2 Q1 Q2 Q1 Q2 Q1 Q2 Q1 Q2 ANC1 registration ANC 3 Coverage NA NA ANC 4 Coverage MCTS entry on percentage of women registered in the first trimester TT1, TT2 and Booster No. of pregnant women given IFA All the women receive required TT doses at their registered facility regularly