POPULATION RESEARCH CENTRE, DEPARTMENT OF ECONOMICS, UNIVERSITY OF LUCKNOW, LUCKNOW

Transcription

1 Series B: Monitoring Survey Report 116 NRHM PIP Monitoring in Uttar Pradesh District: Shahjahanpur Ajay Pandey Assistant Director Sukhdeo Prasad Field Investigator POPULATION RESEARCH CENTRE, DEPARTMENT OF ECONOMICS, UNIVERSITY OF LUCKNOW, LUCKNOW Mar 2014 Page 1 of 35

2 Monitoring Report for the State of Uttar Pradesh: District Shahjahanpur Ajay Pandey Assistant Director Sukhdeo Prasad Tiwari Filed Investigator Field Visit December 2013 Population Research Centre Department of Economics University of Lucknow Lucknow, Uttar Pradesh Page 2 of 35

3 Table of Contents 1 Executive Summary Introduction State Profile and district profile Key health and service delivery indicators Health Infrastructure: Human Resources Other health System inputs Maternal health ANC and PNC Institutional deliveries Maternal death Review JSSK JSY Child health SNCU NRCs Immunization RBSK Family planning ARSH Quality in health services Infection Control Biomedical Waste Management IEC Referral transport and MMUs Community processes Page 3 of 35

4 14.1 ASHA Skill development Functionality of the ASHAs Disease control programmes Malaria TB Other Communicable Disease Non Communicable Diseases Good Practices and Innovations HMIS and MCTS Key Conclusions and Recommendations Annexure Page 4 of 35

5 1 Executive Summary The NRHM PIP implementation monitoring in the District SHAHJAHANPUR of Uttar Pradesh was conducted in the month of December The two officers of the Population Research Centre namely Ajay Pandey and Sukhdeo Prasad visited the identified district health facilities in consultation with the CMO and ACMO of the District. Besides interacting with the CMO of the District to assess the PIP implementation progress range of other health functionaries such as ACMOs, CMS and NRHM-DPM, DCM, DDAO were interacted with too. STRENGTHS AND SHORT COMMINGS OF THE NRHM PROGRAMME IN SHAHJAHANPUR DISTRCIT OF UTTAR PRADESH Specific Strengths CMO SHAHJAHANPUR extended full support to the PIP monitoring activity. Hon ble Health Minister GoUP himself visited Shahjahanpur to moitor program progress on December 7, 2013 i.e. the same month in which PRC team undertook PIP Monitoring. DM also regularly reviews the Health Facilities apart from Health Functionaries from Division and State. District Hospital providing quality services to the people of Shahjahanpur. Trauma Centre is operational at the District Hospital. SNCU at the District Hospital have good case load preventing so many neonatal deaths. NBSU and NBCC in FRU facility functional. Except for cardiac monitor rest all the equipments were in place in SNCU. NRC is functioning in the District Hospital. ASHAs are trained in Module 5, & 6. Incentives under HBNC is being provided to ASHAs Under performing ASHAs have been monitored and 65 such ASHAs have been identified and 9 ASHAs have been disengaged for underperformance. Burns unit available at the District Hospital Blood Component Separation Facility available at District Hospital and is huge advantage. During last quarter 1283 Blood Bags were issued for Blood Transfusion. Though tender for meals to be provided under JSSK is not yet commissioned by DHS. District using the State Budget, meals/ food is being provided to beneficiaries via help of an NGO. This arrangement is seconded by DHS in the interim. Increasing numbers in service delivery reaching even remote areas via chain of governmental health facilities and EMTS referrals. Subcentres functioning optimally inspite of several undocumented /unnoticed challenges Frontline workers functioning well even in difficult conditions. Drug supply adequate even at peripheral facilities. Page 5 of 35

6 NRHM has improved infrastructure - efforts to operationalize more health facilities at FRU level is being made. Cleanliness standards fairly good overall. JSY contributing to increasing number of institutional deliveries. JSY payments by and large prompt and transparent. ANM and ASHA valued by community, contributing to increased demand for MCH services. Detailed micro planning for VHNDs - immunization being done in the community by ANM with the help of AWWs and ASHAs IEC posters, banners, wall-paintings are well spread across NRHM subjects. Rate list for most of the items/services provided at the District/CHC hospital such as X- Ray, Ultrasound, etc. are displayed. EMTS and UP Ambulance Seva has helped the community get speedy health care services. Specific Shortcomings The recent decision of the Government to pay JSY beneficiaries via crossed check is counterproductive to the very idea of speedy settlement of the JSY claims Banks in rural areas are reluctant opening accounts of the JSY Beneficiaries. JSSK tender relating to meals providence not yet commissioned. In the absence of Surgeon high risk pregnancy cases do not get managed at DFH. There is no mechanism in place to redress non payment of JSY cheques due to it being A/C payee. Inspite of NRC in place line listing of SAM is not done and data on SAM not reported. EMTS are not under the direct control/supervision of the DFH-CMS at District hospital or under the Superintendents of the peripheral block facilities. Whenever EMTS gets out of order, it takes long period in resuming operation again. The Data entry operators are agency recruited and are far less paid to what is envisaged in the PIP budget. The process of selecting a lowest bid should be revisited if quality is desired. Due to shortfall in contractual staff for data feeding, feeding load is latched on to person looking after accounts, in effect affecting quality? ANM should regularly be provided with skills up-gradation training as even the best of the ANM failed to correctly measure the BP using standard BP instrument. POL should be made adequate/ proportionate to the power demands. Funds should be made available at the start of the FY and on time. Health Infrastructure: SHAHJAHANPUR Except for the Ayush Hospital facility, Shahjahanpur district has majority of the Government Health Infrastructure in place via network of DH, 13 CHC, 3 BPHC (of these 16 CHC/BPHC facilities 2 are FRU and 14 are 24x7), 36 APHC/NPHC/PHC and 299 Subcentres. Besides there are 7 UHFW/UHP by the Government and 3 are from NRHM. Page 6 of 35

7 SHAHJAHANPUR district hospital has the facility of SNCU, NBSU, NBCC, NRC, ICTC or BB/BSU at DFH. Blood separation unit has helped in utilising the blood transfusion needs judiciously for the blood component that is needed for transfusion. The residential accommodation at the District Hospital is available for MOs, SNs and other category of health staff. The type II unit quarters at DH for other category health staff are in shortage. While at CHC Tilhar which is an FRU staff quarters for all category staff are inhabitable. About three fourth of the Hospital RKS used however RKS funds under NRHM for the District Hospital is not utilized (0 %). Though the sub centre Hathaura Bujurg or the other SC from the Tilhar Block that were visited were in government buildings the approach road /reaching the SC facility is a task in itself without proper directions/signages. System for maintenance of equipments at health facilities is not in place either at DFH or at BPHC/CHC or below. Sub centre do not have 24 hour electricity and running water supply. Government hand pump is used for water needs. Biomedical waste management system is not in place at the District Hospital, BPHC/CHC while at SC deep burial pit is used. The radiant warmer at the CHC Tilhar was reported functional by CHC Superintendent while the Staff Nurse had other view. View of the Staff Nurse was considered. No provision for stay for ASHA or relatives/attendants accompanying the JSY patient at health facility Status of Human Resource: SHAHJAHANPUR There is a shortfall of human resource in the SHAHJAHANPUR district with respect to specialists, doctors, and Staff Nurses. Only 52 percent of the Regular HR is in place while only 45 percent of the Contractual positions are filled. There is delay in recruiting and positioning of 2 nd ANMs and MPWs. There is no Surgeon in the in the District. Nor does Gynaecologist are in place at FRU. There is no cardiologist, or Eye specialist in position in the District at DH or FRUs. All categories NRHM contractual staff is in place in the District. BPMU are positioned. There are often delays in renewal of the contractual staff leading to drop-outs. No clear policy for career pathways for contractual staff. No clear guidelines on work policy relating contractual staff, leading to job role conflict and burnouts. Training programmes need to be stepped up. Training needs are largely unaddressed. Training of doctors in multi-skilling of doctors in EmOC, BeMOC and LSAS not yet operationalised as no doctor got training in the district. Service Delivery: SHAHJAHANPUR Increase in numbers of OPD, IPD, investigations, deliveries and other services over the first two quarter period of the FY indicates better utilization of health care services. This has also resulted in increasing workloads for the limited staff available at the health facilities. Page 7 of 35

8 No. of institutional deliveries conducted at DFH over the two quarter period is 2940 (1 st Quarter nd Quarter 1771) against total of expected number of 5000 pregnancies in six months. CHC Tilhar conducted 1062 (1 st Quarter nd Quarter 592) deliveries against the expected 3000 pregnancies in six months. The C-section delivery at DH during Q1 is 54 and in Q2 are 47. No C-Section at CHC Tilhar. While 54 and 103 deliveries were assisted deliveries during the two quarter period at DH. No provision of food or cooking for the patients and their attendants at the facility. About 96 percent of newly born at DH started breastfed within an hour of being born at health facility Children in the first 2 quarters were admitted at SNCU in the DH. Of this 70% were inborn and 30% outborn. Sizeable numbers of pregnant women seek ANC services at the CHC, PHC and SC health facility. DH did not provide data relating to ANC. The number of Tubectomy conducted during the two quarter period at DH is 42 cases. While are CHC Tilahr 18 Tubectomy were conducted during the same period. Only 2 vasectomy cases are conducted at CHC Tilhar while no case of Vasectomy was conducted at DH. Use of IUD needs to be promoted as in two quarters DH reported no case of IUCD insertions. While at CHC Tilhar the IUD insertion was 318. No data is provided on children fully immunized in the first six month of the FY at DFH while at CHC Tilhar 1477 children got fully immunized during six month of FY Equal number of children received Vitamin A and measles shot. No still births or maternal deaths in six month were reported at DFH or at CHC Tilhar. 207 Infant deaths were recorded at the District Hospital. Safe abortions services/mtps are minimal across the District facilities. No evidence of MVA or medical abortion seen. No data on SAM is reported even though NRC and SNCU in place. Maternal death audit initiated in the District Shahjahanpur for both facility as well as home based deaths. No partographs/register present in the DH and below. In District SHAHJAHANPUR, at the District Hospital most of the laboratory service such as Haemoglogin, Urin Albumin and Sugar, Malaria, HIV testing, blood sugar/cbc/rpr/t.b./lft, Ultrasound (General and Obs both), ECG, X-Ray, Blood Transfusion are provided. The optimal use of laboratory services is being made. Endoscopy and CT Scan services are not provided. Privacy for patients in Health facilities inadequate due to overcrowding. Proper signage and IEC materials were visible in health the facilities starting CMO Office, DH, CHC and PHC. The RKS funds at PHC/APHC are not optimally utilized as the RKS funds for PHC/APHC is available with the BPHC/CHC. AYUSH doctors at PHCs/APHC providing allopathic services without any training. Outreach Services: SHAHJAHANPUR A total of 1902 ASHAs are in place. Page 8 of 35

9 ASHA day is celebrated in the District and better performing ASHAs are rewarded. ASHA uniforms are being worked upon and in the process to provide Uniforms. ASHA coordinators recruitment is under process in the District. ASHA diary is not provided. ASHAs are provided with kits and are replenished regularly. HBNC is implemented in the District and 307 ASHA been trained in Module 6 of IMNCI. HBNC kit is under process to be given to ASHAs. 65 poor performing ASHAs have been identified and listed. 9 ASHA been disengaged for underperformance. Sub centers do not have second ANMs and MPWs for support to Outreach activities. MMUs are not operational in the District. However EMTS, UP Ambulance Seva and Other contracted vehicles provide referrals Ayush mainstreaming is done in 15 CHC/BPHC and 1 APHC/NPHC. Nutrition Status: SHAHJAHANPUR NRC is established in the district SHAHJAHANPUR and functional at DH. Line listing of SAM is not done. Early and exclusive breastfeeding is observed widely in the field. National Disease Control Programmes: SHAHJAHANPUR The National Disease Control Programmes mainly NMCP, NLEP, RNTCP were looked in detail at the DFH, and CHC, PHC visited. These programmes are operating under NRHM at district level. During the Q2 quarter period at District Hospital 1717 slides tested for malaria and 3 were found positive. While at CHC Tilhar 1020 slides were tested and none were malaria positive cases. At PHC Dadroul 137 slide were made out of which non found positive. There were nine new cases of leprosy in Shahjahanpur at DH and all were under treatment while at CHC Tilhar 11 cases were detected and were provided treatment. At PHC 10 cases were detected and all were under treatment. At DH in Q2 quarter 542 cases of TB were tested of which 112 were positive. While are CHC Tilhar 388 cases were tested and 48 were positive. At PHC Dadroul 312 cases were tested of which 27 case were found to be positive. DOT medicine is available at Block. RNTCP staffs are paid salaries on time while the DOT providers are paid on yearly basis. Rapid diagnostic Kits for malaria testing are not available. Regarding tuberculosis, there is a need for improvement in supervision and monitoring at district level. Surprisingly Rapid Diagnostic kit for malaria testing is not available at DH, CHC nut available at PHC Dadroul. No separate NCD clinics established in Shahjahanpur nor does an IEC relating to NCD are displayed Only NCD drug available relates to treatment of Diabetics and Hypertension in DH-Male. JSY and JSSK Implementation: SHAHJAHANPUR Beneficiaries of JSY are paid Account payee cheques on time. Few procedural delays due to documentation. Page 9 of 35

10 Mandatory 48 hours stay is enforced to the extent possible EMTS (108) brings in the incoming delivery patient at the facility and the drop back is provided using UP Ambulance Seva. Meals are provided three times a day with the Help of Swyam Sevi Sastha using State Budget. Tendering yet to be done. Total of 1064 beneficiaries were provided free transportation (108) for seeking ANC/INC/PNC at DH. 139 were provided drop back using UP Ambulance seva. During the same quarter 64 infants were transported to facility using EMTS 108, while 79 infants got drop back home. At CHC Tilhar during the Q1 & Q2 EMTS brought 222 pregnant women and 13 infants to the facility for treatment while 34 pregnant women got drop back home via UP Ambulance seva. 10 sick infants were sent to DH from CHC Tilhar using EMTS. Institutional Mechanism and Programme Management: SHAHJAHANPUR The Block Programme Management Unit has been established and Staffs are placed The role of District programme manager is to be more clearly defined. DPM Shahjahanpur is doing good work. District is following facility based HMIS data reporting from all blocks. MCTS is not fully functional in the district and the MCTS data is not used for effective monitoring of service delivery/sam/lbw/sick Neonates. Percentage completeness ranges in-between %. 2 Introduction The NRHM- PIP monitoring field work in District Shahjahanpur of Uttar Pradesh was carried out in the month of December 2013 by Ajay Pandey-Assistant Director and Sukhdeo Prasad- Field Investigator at PRC Lucknow. Communication to visit district Shahjahanpur was made by Additional Director PRC and a support letter addressing to CMO Shahjahanpur from the Additional Mission Director-NRHM GoUP was made available to my team. After reaching the district head quarters the Chief Medical Officers was met and briefed upon the purpose of the field visit. The detailed checklist was shared with the CMO Shahjahanpur. The CMO in consultation with his ACMOs and NRHM unit finalized the facilities to be visited for the PIP monitoring. Detailed discussions were held with the CMO Shahjahanpur at his office regarding PIP implementation and various operational issues. Total 5 checklists were used to illicit responses. One each for CMO office, District Female Hospital-Shahjahanpur, Community Health Centre-Tilhar, Primary Health Centre- Dadroul belonging to Dadroul block and peripheral Sub-centre Hathoura Bujurga. SC belonged to adjoining block Bhawalkhera block. Same block SC was not visited due to still birth at the arranged SC and other SC ANMs were administratively engaged so were not available on the day visited. Apart from these health facilities 10 beneficiaries of JSY/JSSK were interacted upon to know quality of services provided under the scheme and their concerns, if any. Page 10 of 35

11 3 State Profile and district profile The district Shahjahanpur is highlighted in the Map of Uttar Pradesh and is one of the 71 districts that belong to State of Uttar Pradesh. As per Census 2011, district Shahjahanpur of Uttar Pradesh recorded a population of 3,006,538 consisting of 1,606,403 males and 1,400,135 females compared to total population of 2,547,855 in Shahjahanpur contributed to 1.5 percent to the total population of Uttar Pradesh. The percent share to State total has marginally declined since2001 which was at 1.53 percent. The decadal growth for the decade was 18.0 percent compared to 20 percent growth for the State. Shahjahanpur consists of 14 blocks and 2088 villages compared to 822 blocks and villages in the State of Uttar Pradesh. Percentage of population in 0-6 age group is somewhat higher in Shahjahanpur (16.72 %) compared to the State average of percent. Population density in 2011 of Shahjahanpur district is 685 people per sq. km compared to 829 for the State of Uttar Pradesh. In 2001, Shahjahanpur recorded density of 571 people per sq. km. Schedule caste constituted percent in Shahjahanpur in 2011 compared to in Uttar Pradesh. Schedule tribes are negligible proportion (0.02 percent) in Shahjahanpur, while 0.57 percent tribes are in State of Uttar Pradesh. Literacy rate of Shahjahanpur in 2011 stood at compared to percent for the State. The gender gap in literacy is lower in Shahjahanpur compared to State. Male female gap in literacy in Shahjahanpur is percent compared to 20.1 percent in the State. Overall Sex Ratio in Shahjahanpur, stood at 872 females per 1000 male compared State average of 912 as per 2011 Census. The overall sex ratio in India is 940 females per 1000 males. The overall sex ratio of 872 females compared to 1000 males is alarming. A closer look at the sex ratio in 0-6 age group reveals 903 females per 1000 males compared to 902 for the State. Intervention programs in Shahjahanpur should focus on the importance of girl child to keep balance in the male to female ratio. Shahjahanpur is less urbanized compared to State of Uttar Pradesh. As per 2011 census only percent lives in urban regions of district while the majority live in rural areas. Sex Ratio in urban region of Shahjahanpur district is 900 as per 2011 census data. The workforce participation rate in the district Shahjahanpur as per 2011 census is 30 percent compared to 33 percent in the State. The female workforce participation rate is far below in Shahjahanpur compared to the State of Uttar Pradesh. Workforce participation rate for female is only 7.78 percent in Shahjahanpur compared to 17 percent in the State. If one looks at category-wise employment data 31 percent of the workers are employed as agricultural laborers compared to 30 percent for the State. Higher percentages of female are employed as agricultural laborer in Uttar Pradesh compared to district Shahjahanpur. Page 11 of 35

12 Table 1 Population and Socio-economic Indicators of Uttar Pradesh and district SHAHJAHANPUR Characteristics State (UP) District (Shahjahanpur) No of Districts 71 NA No of Tehsils No of Blocks No of inhabited Villages Population (2011) Decadal Population Growth Rate ( ) Share to total Population Share of 0-6 age group to total Population Population Density ( per sq km) Urban Population (%) Schedule Caste Population (%) Schedule Tribe Population (%) Page 12 of 35

13 Characteristics State (UP) District (Shahjahanpur) Sex Ratio (0-6 age group) Literacy (%) 2011 Males Females Total Workforce Participation (%) 2011 Males Females Total Workers as Agricultural Labourers (%) 2011 Males Females Total Key health and service delivery indicators Table 2 below provides the comparative picture of the key health and service delivery indicators for Uttar Pradesh and the district Shahjahanpur. According to Annual Health Survey of the Crude Birth Rate of district Shahjahanpur is 28.4 births per 1000 population compared to State average of 25 births per 1000 population. In contrast, the CDR in Shahjahanpur is less than the State average. The CDR in Shahjahanpur is 7.9 deaths per 1000 population compared to 8.4 deaths per 1000 population in the State. Infant mortality rate is very high in Shahjahanpur at 82 infant deaths per 1000 live births compared to Uttar Pradesh at 70 deaths per 1000 live births. Neonatal mortality constitutes more than 2/3 rd of all infant deaths at 58 per 1000 live birth in Shahjahanpur compared to 50 per 1000 live births in the State. The very fact that SNCU and NRC are made functional in the District is to lower down the neonatal deaths. The Maternal mortality rate estimates for the Barelly division to which the district Shahjahanpur belongs to stands at 331 maternal deaths per 100,000 live births against a state average of 300 maternal deaths. The unmet need or the latent demand for family planning services as per the AHS is very high at 35 percent in the district Shahjahanpur compared to around 30 percent unmet need for family planning services in the State of Uttar Pradesh. The unmet demand for spacing contraceptives is high in Shahjahanpur at 25 percent compared to 17 percent in Uttar Pradesh. The demand for limiting contraception is higher in the State at 10 percent compared o the demand in the district Shahjahanpur at about 8 percent. Page 13 of 35

14 Health Management Information System data for the year 2013 provides detail on the range of service delivery indicators. The information on HMIS has their own limitations as many of the information are not complete on various parameters and not just that these information s are scanty but no appropriate justification is provided with, against such repetitive omissions. For example columns on inventory and deaths are seldom complete. The justification to this anomaly is that only the inventory staff does not work in collaboration with the data feeding staff and deaths that occurred at the facility (infant or the maternal) only get reported. The deaths that occur in community do not get updated/ reported on the portal. Now that the MDR and IDR are in place for hospital as well as community based deaths and incentives are provided to ASHA to report, the situation might improve. Another reason that works against the reporting deaths is the lengthy format on which the death information is to be sent/ reported by peripheral staff discouraging reporting such events. About 8.9 lac OPD cases were registered in Shahjahanpur district compared to 5.4 crores in Uttar Pradesh in the year About 44 lac ANC cases were registered in the State of Uttar Pradesh in 2013 as against 1.01 lac ANC cases in district Shahjahanpur. Roughly about 89 percent of the total ANC cases in Uttar Pradesh are registered on HMIS portal in-itself is commendable. However, the ANC registration on HMIS portal for the year 2013 in case of Shahjahanpur is about 84 percent. The detailed quality check should be carried out by the HMIS handlers in the State as well as district. About 92 percent of the pregnant women got TT1 shots in Shahjahanpur as well as Uttar Pradesh. Neonatal tetanus is the root cause of deaths during first 28 days of birth. Coverage relating to TT injection should be increased and made universal. Special campaign to increase TT injections should be undertaken. Two third of the deliveries are institutional in Uttar Pradesh while about 54 percent in Shahjahanpur. Table 2: Demographic and Service Delivery Indicator for Uttar Pradesh and District Shahjahanpur Characteristics State District UP Shahjahanpur Demographic Indicators (AHS ) CBR (per 1000 pop.) CDR (per 1000 pop.) IMR (per 1000 live births) MMR (per live births) MMR of the Mandal where district is located Service delivery indicators (HMIS 2013) OPD IPD Page 14 of 35

15 Characteristics State District UP Shahjahanpur ANC registered with first trimester (%) Percentage of women given TT Percentage of women given 100+ IFA Natal Care SBA (percent to home delivery) Percentage of Institutional Delivery Post Natal Care Percentage 0f women receiving post partum check-up within hours after delivery Percentage of newborns visited within 24 hours of Home Delivery Immunization Immunization sessions planned Percent of session held Percentage of ASHAs present Family Planning No. of NSV/Conventional Vasectomy conducted No. of Female Sterilisations Conducted Number of New IUCD insertions Number of Oral Pills cycles distributed Number of Condom pieces distributed Unmet need for Family Planning (AHS ) Spacing Limiting Both Source: Table provided by Additional Director PRC for the PIP report The post partum checkup within 48 hours of delivery in Shahjahanpur is only 44 percent compared to State average of 60 percent. Similarly, about 51 percent of neonates born in at home in Shahjahanpur are attended by ASHAs within 24 hours of birth compared to State average of 60 percent. About immunization sessions were planned in Shahjahanpur in 2013 of which 97 percent were met and ASHAs were present in about 74 percent of such sessions held. Compare to this 88 lac immunization session were planned in Uttar Pradesh of which 93 percent were met and ASHAs were present in 80 percent of such session held in the year On family planning front Shahjahanpur reported just 3 case on NSV/Conventional Vasectomy against 2047 NSV/CV in Uttar Pradesh. The Female Sterilization in Uttar Pradesh in 2013 was recorded at while only 221 cases were reported from Shahjahanpur. This is gross underachievement compared to 10 percent limiting unmet demand for family planning in Shahjahanpur. About 4 lac IUCD were inserted Page 15 of 35

16 in Uttar Pradesh as against 4130 in Shahjahanpur. This again is an underachievement considering 25 percent demand for spacing in Shahjahanpur lac, cycles of Oral pills were distributed in Uttar Pradesh while in Shahjahanpur about 3249 cycles of Oral Pills were distributed lac, condom pieces were distributed in 2013, while in Uttar Pradesh 1.8 crore such pieces were distributed to those in want of them. 5 Health Infrastructure: Shahjahanpur with a population of 30 Lac has district hospital with separate male and female wings, 16 CHC of which 2 is FRU. Three Block level PHC and 36 APHC/NPHC/PHC. Out of these 36 APHC/NPHC/PHC one Katra APHC is upgraded to CHC. So in effect only 35 APHC/NPHC/PHC remains. All these facilities are in government building. In addition to these there are 299 Subcentre majority of which are in Government building. There are 7 UFWC/UHP funded by Govt. and of these 7 only one is in government building. Another 3 UFWC/UHP are with the support of NRHM. These government facilities have total bed (100+2x30+14x4+36x2=288) in-patient hospital beds available through the network of Government Health Care Facilities. Apart from these government health care facilities, two other hospitals one as Police Hospital and other as Jail Hospital exits in Shahjahanpur. Shahjahanpur District Female Hospital (DFH) which has a catchment of 3.5 lac populations has most of the listed physical infrastructure facility in place including SNCU, NRC, BB/BSU, ICTC and functional help desk at the registration counter. ICTC and PPTCT counselling is provided at the DFH but not at CHC Tilhar. Staffs quarter for all category staff are in good condition at DH however at CHC Tilhar they are mostly inhabitable. NBSU is functional at DFH but at CHC Tilhar radiant warmers are required to make it functional. SNCU at Shahjahanpur has good case load and the record keeping at the SNCU is good. Sex-wise list of male and female admitted neonates are maintained. DFH has separate toilet facility for females. Wards were clean; facility accessible by road has power facility 24x7 with running water. Labour rooms are functional and are clean. 10x10 feet space available for each of the 4 labour tables at DFH. Each quipped with foam mattress, sheet, pillow, mackintosh, kellys pad and stepping stool. NBCC is equipped with radiant warmers and neonatal ambu bags. The entire physical infrastructure relating to OT was in place. At DFH there is provision for spate male and female wards. Males are admitted to the Male wing of the District Hospital. Bio Medical waste is neither outsourced not do have any mechanism in place for BMW management. DH caters to 2083 villages in the District. Page 16 of 35

17 CHC Tilhar which has a catchment population of lacs covering 212 villages has most of the listed physical infrastructure in place except for functional NBSU and NBCC. SNCUs and NRC are only for DH. CHC Tilhar is 25 KM away from the District Head Quarter. BB/BSU is also not available at CHC Tilhar. CHC Tilhar does not have separate room for ARSH clinic. No complaint or suggestion box is available too. Superintendent of the facility himself acts on the complaint brought to him. As not much was there to observe at the APHC/PHC under the CHC Tilhar a non FRU PHC PHC Dadroul was visited which was in km range from DHQ catering to the population of covering 173 villages. Facility has staff Quarters for MOs but not for Sattf Nurse. Do not had functional NBCC as the radiant warmer was not there and the ambu bag was an old one. No NBSU either at the facility. BMW was buried inside the deep pit. Sub Centre Hathaura Bujurg which was 10 Km from the DHQ catered to 7944 population covering 3 villages. SC was in the middle of the habitation and had erratic power supply. Hand pumps used for water supply. SC does not have NBCC nor does had compliant/suggestion box. Toilet attached to labour room were clean and ANM use to reside at the SC. Deep burial pit outside the compound of SC is used for BMW waste management. 6 Human Resources Human Resources relating to all categories of staff is inadequate. Only 52 percent of the District Health Human Resource is in place. This HR do not include the DH hospital as the DH has its own set of HR. Annexure Table 1 A show there is a huge shortfall of human resource in the SHAHJAHANPUR district with respect to all category of Staff. Of the sanctioned post of Gynecologist none are in-position. Against the sanctioned post of pediatrician only 1 is in position. This reflects HR inadequacy in running the facilities at an optimal level providing specialized quality care services in the District. Due to lack of surgeon C-section deliveries are managed somehow at the DFH. In-spite of such a shortfall in HR, the volume of services provided is commendable. Contractual staffs under NRHM are able to fill gaps in providing basis health care services however they cannot be replacement to specialized care. Of the total sanctioned strength under contractual arrangement District has only 45 percent HR in place. UP government at its level is trying its best and should incentivize pay packages to attract specialist doctors join government health care system. The HR status, Regular and Contractual both, relating to National Disease control program is shown in Annex. Table A2. Page 17 of 35

18 7 Other health System inputs Major listed equipments are available at the DFH. This includes BP Instrument and Stethoscope; Sterilized delivery sets ; Neonatal, Paediatric and Adult Resuscitation kit; Weighing Machine (Adult and child); Needle Cutter; Radiant Warmer; Suction apparatus; Facility for Oxygen Administration; Foetal Doppler/CTG; Mobile light; Delivery Tables; Autoclave; ILR and Deep Freezer; Emergency Tray with emergency injections ; MVA/ EVA Equipment; O.T Equipment; O.T Tables; O.T Lights, ceiling & mobile; Anesthesia machines; Pulse-oximeters; Laparoscopes; Autoclaves (H or V); Laboratory Equipment ; Microscope Hemoglobinometer; Centrifuge;; Reagents and Testing Kits ; and Functional Ultrasound Scanners; phototherapy unit; C-arm units; Multi-para monitors; Surgical Diathermies; Semi autoanalyzer; X-ray units; and ECG machines. The equipments that are not functional include ventilators. CT scan and Endoscopy Machines are not available at Distrcit Hospital. The CHC Tilhar has all the listed equipments functional except functional Radiant Warmer; MVA/ EVA Equipment; phototherapy unit; and Semi autoanalyzer. PHC Dadroul had functional equipments such as BP Instrument and Stethoscope; and Weighing Machine (Adult and child), Needle Cuter, Facility for Oxygen Administration, Autoclave, neonatal and paediatric resuscitatin kit, ILR and Deep Freezer, Deep Freezer, Emergency tray with emergency injections, Microscope, Hemoglobinometer, and Reagents and Testing kits. Among the equipment not functional include Semi Autoanlyzer, centrifuge, MVA/EVA equipments, suction apparatus, radiant warmer, Adult Resuscitation kit, sterilized delivery sets. At Sub centre level Delivery equipments that are available and functional are delivery equipment, Adult Weighing machine, and color coded bins. Equipment that is available but not functional is Needle and Hub Cutter. The equipments that are not available include th neonatal ambu bag and color coded bins were functional and haemoglobinometer, Any other method of Hemoglobin estimation, blood sugar and testing kits, BP instrument and stethoscope, Neonatal Ambu Bag, Infant/New Born weighing machine, RBSK pictorial kit. Ayush facilities are available in 16 CHC/BPHCs. The supply of Ayush medicines are erratic and most of the time the supply is not available. Ayush doctors are involved in the monitoring and implementation of NRHM programs in the field apart from their routine work. Page 18 of 35

19 At DFH the Essential Drug List is available and displayed ; IFA tablets,; IFA syrup with dispenser; Vit A syrup; ORS packets; Inj Magnesium Sulphate; Inj Oxytocin; Misoprostol tablets; Mifepristone tablets; Drugs for hypertension, Diabetes, antibiotics; Labelled emergency tray ; common ailments drugs such as PCM, metronidazole, anti-allergic drugs etc.; and Vaccine Stock are available at DFH. DFH does not have computerized inventory management, zinc and IFA blue tablets. is not available. Wherever these medicines are in short supply state budget is used to replenish them. At CHC Tilhar EDL was not available or displayed. Except for IFA (Blues), IFA syrup with dispenser, Inj Magnesium Sulphate, Misoprostol tablets, and Mifepristone tablets rest of the medicine are available. At PHC Dadroul EDL was available and displayed, Vit. A, ORS, Zinc tablet, Inj Magnesium sulphate, Inj Oxytocin, antibiotics, Labeled emergency tray, drugs for BP, Diabetics, PCM and anti allergic and adequate vaccine stock was available. Computerized inventory was not available, IFA tablets and IFA blue tablets or IFA syrup with dispenser was not available. Tablets Misopostol and Mifepristone were also not available. Except for Vit A and Zinc tablets and some PCM tablets Sub-centre didn t had much supply. To minimize the OOPS government provides essential supplies and lab testing facilities at the health facilities. DFH has following essential supplies such as; Pregnancy testing kits, Urine albumin and sugar testing kit, OCPs, EC Pills, IUCDs, Sanitary napkins and Gloves, Mckintosh, Pads, bandages, and gauze etc. DFH provides laboratory service such as Ultrasound Scan, (General and Obs. both) X-ray, ECG,, blood transfusion, Haemoglogin, Urin Albumin and Sugar, Malaria, and HIV testing are provided. Also blood sugar/cbc/rpr/t.b./lft test are provided. Endoscopy and CT Scan is not provided at the DFH. 8 Maternal health 8.1 ANC and PNC Line listing of SAM is not done by any of the health facilities in Shahjahanpur in-spite of NRC in the district. DFH did not provide data on ANC registration data. At DFH 96 percent of the infants born during Q1 and Q2 had breastfeeding initiated within one hour of birth. Page 19 of 35

20 At CHC Tilhar total of 2173 (75%) pregnant women got registered for ANC 1 and 1858 for ANC 3 (64%). Total of 1844 (63%) women in last six months at CHC were given IFA tablets. ANC 4 was given to 1825 (62%) women. 925 (87%) initiated breastfeeding in an hour among 1062 born at the CHC Tilhar. PHC Dadroul 114% ANC 1 registration was recorded during the first six month of the FY Of the 2200 expected number of births 2526 got ANC 1 at PHC Dadroul. Possible explanation other catchment area population got registered for the ANC 1 services at the PHC. ANC 3 registration was recorded at 95 percent. Total of 2098 got ANC 2 registration. Only 16 percent were given IFA at PHC Dadroul. Total of 350 women got IFA tablets at PHC. SC recorded 116% ANC 1 during first six months at 131 women getting services from the centre. SC expected 112 deliveries in six month in her catchment area. ANC 3 was received by 129 women. The ANC 3 registration was recorded 114%. AS IFA was not in supply at the sub centre no one was provided IFA tablets. 8.2 Institutional deliveries Total number of deliveries in the first two quarters conducted at an institution is 2940 against an expected number of 5000 pregnancies in the DFH covering the population of 3.5 lac. Approximately 60 % of the birth in the catchment area of the DFH occurred at an institution. C Section deliveries during the first six months of FY at DFH were 101 while the assisted (ventouse and forcep) deliveries were 157. These services were provided in the absence of no emergency obstetric care management facility at DFH. DFH in last six month has not managed single obstetric complications. CHC Tilhar conducted 1062 deliveries (35%) at institution against the expected 3000 pregnancies in six months of the FY At CHC data is not maintained on number of assisted deliveries due to lack of specialist. No Obstetric complications are handled at CHC, they are referred to DFH. At PHC Dadroul total number of 227 deliveries in six months was conducted of the expected number of 2200 institutional deliveries. At Subcentre in first six months total of 36 deliveries were conducted of the expected 112 pregnancies i.e. around 32% institutional birth. 8.3 Maternal death Review The Maternal death review is initiated in Shahjahanpur district and is now done at DHS meetings as well as at the level of Additional Director in Bareilly. Regular meeting at the Page 20 of 35

21 CMO level are also carried out. MDR has gained impetus recently and health functionaries are sensitized and trained to collected information on MDR on the form provided to each of the facility. Shahjahanpur has started the Facility as well as home based MDR. Taking an MMR of 331 per one lakh live births on an average 24 maternal deaths in one month are expected in the District Shahjahanpur. In the first 2 quarter total of 3 maternal deaths got reviewed which is grossly under reported and reviewed maternal deaths. Of these 3 recorded and reviewed deaths incentive was provided all the three cases. It was told by the DPM NRHM that ICDS functionaries have reported 56 MD to CMO as the details were not sent, MoICs have been asked to prepare details on MDR form in collaboration with the ICDS functionaries so that these deaths can be reviewed. The main casue of death are Hemorrhage. 8.4 JSSK With the help of Government Health Facilities and the designated delivery point facilities in Shahjahanpur district total of JSSK deliveries are conducted during the first two quarter of the FY At DFH total of 1064 beneficiaries were provided free transportation (EMTS 108) for seeking ANC/INC/PNC in six months. 139 were provided drop back using UP Ambulance seva. During the same quarter 64 infants were transported to facility using EMTS 108, while 79 infants got drop back home. At CHC Tilhar during the Q2 EMTS brought 222 pregnant women and 13 infants to the facility for treatment while 34 pregnant women got drop back home via UP Ambulance seva. 10 sick infants were sent to DH from CHC Tilhar using EMTS. At Dadroul PHC EMTS 108 brought 176 pregnant women to the facility while 205 mothers and infants were provided drop back home via UP ambulance seva. EMTS was used to ship interfaculty emergency cases 14 pregnant mothers and 7 infants were transported to DFH from Dadroul. Though of Rs. 100 to be provided the DHS Shahjahanpur has not yet made the tender. Food is being provided via NGO using State Budget. Money on travel to facility incurred by some of the beneficiaries, mainly as they were not aware free EMTS and in case if the EMTS being out of order. Couple of beneficiaries reported having paid money for delivery to Nurse and Dais. This was taken up to CMS of the DFH and he assured he will listen to the grievances and if found guilty appropriate action will be taken. Under JSSK free referral transport, medicines, diagnostics, free blood and consumables are provided at the DFH and facilities at Block. No user charge is collected for any of the services provided. Page 21 of 35

22 8.5 JSY JSY beneficiaries are paid account payee cheque and cheques are provided after verification of documents on time. The data uploaded on portal is verified. JSY deliveries are back-checked by the CMO and other health staff by conducting more than 5 % verification of cases. 9 Child health 9.1 SNCU SNCU is functional at the DFH. The SNCUs are well equipped to handle the emergency cases and have all the equipments is place except for cardiac monitors. Case load is good and data on register is well maintained. Sex wise admission is maintained on registers with baby weights mentioned against each admitted case. Volume of services provided at SNCU in first six months of FY is 1151 neonates of which 797 (70%) are inborn cases and 354 (30%) are out born cases. Ward is neat and clean and has a different look compared to entire hospital. Due to space crunch on one machine two babies were kept. I am not sure if protocol permits keeping more than one neonate on a single machine. Page 22 of 35

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24 9.2 NRCs NRC is established in Shahjahanpur and functional. However, data on SAM is not reported by the DFH and no reason was provided. 9.3 Immunization Data on immunization was not provided by the DFH however, CHC Tilhar During the first two quarters fully immunized 1477 children. Equal number of children received Vitamin A and measles shot. At PHC Dadroul 2171 children got fully vaccinated, received measles and vitamin A dose. While at Subcentre-Hathaura Bujurg 115 got fully vaccinated, Vit., A and measles shot. SC had planned 36 sessions during Q2 and 32 were held. The four sessions got missed due to holiday or the vaccine did not reach the facility. Immunization schedule is displayed at the SC. 9.4 RBSK The District nodal person identified for child health screening and early intervention service being outlined and established and the screening under RBSK is done with the help of district screening teams that have been constituted. However, no data on RBSK is reported for the first six months of FY from any of the visited health facilities. The data on how many school children screen directly gets reported under BSGY to the State. 10 Family planning During the two quarters Q 1 & Q2 a total of 42 Tubectomy was carried out at DFH. Data relating to use of IUCD, OCP and Condoms were not made available. No Vasectomy was performed at the DFH either. At CHC Tilhar 318 IUCDs were inserted, while 18 Tubectomy and 2 vasectomies were performed in six months of the first 2 quarters. Mostly cases are referred to camps. PHC Dadroul reported 490 IUCD insertions, and 27 Tubectomy. While Subcentre reported zero cases of IUCD insertion during first six month of FY ARSH ARSH clinics are Functional in Shahjahanpur district and program is being implemented in the District. District had constituted district level screening committees for screening the adolescents for services. The ARSH services are provided through VHND session. Eight VHND and VHSNC sessions were held in the first 2 quarters of at the Sub centre visited. The menstrual hygiene program under ARSH is not in operation in the district yet. However WIFS tablets are being distributed under the ARSH. This is in contrast to the statement provided earlier that IFA blue is not available! Page 24 of 35

25 12 Quality in health services 12.1 Infection Control Wards at the DFH and CHC and PHC were clean. The DFH being a new building had a different look and feel in comparison to the overall facility outlook. Regular fumigation is not done at the DFH. Regular Fumigation at CHC is also not carried out and is major challenge toward infection prevention. Autoclaves are functioning both are DFH and CHC, PHC. Laundry and washing services available at Male hospital are used Biomedical Waste Management Bio medical waste is segregated in the color coded dustbins. Staffs are aware and practice the waste disposal criterion. The BMW is burnt at DFH and CHC while at SC level deep burial pit is used for disposal of BMW. There is no incinerator in the Entire district of Shahjahanpur. The earlier agency that use to collect BMW got blacklisted and the new tenders are yet to float IEC IEC materials relating to MCH and FP are prominently displayed at DFH and CHC Tilhar. The display of IEC material is scanty at PHC and SC. At DFH and CHC the JSY entitlements and the JSSK entitlements are displayed. Various protocol posters are displayed at DFH and CHC. Citizen charter is also displayed at the DFH and CHC. At DFH list of services available and the cost of such services such as X-Ray, Ultrasound is also displayed. Timing of Health Facility is prominently painted/ displayed at DFH, BPHC and SC. HIV infection prevention message is also communicated at DFH. Page 25 of 35

26 13 Referral transport and MMUs As on September 30, 2013 total of 15 Ambulances from the Government of UP and 17 EMTS are in use for referral and shipment of patients to facilities. All of these are on road. Apart from these vehicles there are 11 other ambulances of which 7 are on road besides one vehicle with DPM NRHM and one with DTO. EMTS 108 District Hospital Female log:-q July August September Total Number of Clients utilized 108 services Total Number of Clients utilized 108 services at Night (after 6 pm) EMTS has revolutionized and brought speedy access to health care services to the common person s door step-up. This initiative needs to be applauded. CMO himself monitors the use of Ambulances regularly. No Mobile Medical Unit is in place in Shahjahanpur. Control room for the EMTS is independent and health facility has no role in the operation of linked EMTS. No call center or control room setup by the CMO for use of UP ambulance seva. The facility in-charge acts as a facilitator. There is however issues relating to the way these ambulances operate. There is tendency to shrug of responsibilities that these EMTS are not under the control of CMS of the DFH or the Superintendent of the CHC/BPHC and beneficiaries have to fend for themselves and locate the driver for drop back home. On asking CMS he said these vehicles are not under Page 26 of 35

27 his supervision so he can t do much. Some time issues relating to power and authority in governing the vehicle mitigate the very purpose for which these services are meant for. 14 Community processes 14.1 ASHA A total of 1902 ASHAs are in place in the District. ASHA day is celebrated in the District and better performing ASHAs are rewarded. ASHA diary is not provided while ASHAs are provided with ASHA kits and are replenished regularly. HBNC is implemented in the District and 307 ASHA have been trained in Module 6 of IMNCI. HBNC kit is under process to be given to ASHAs. 65 poor performing ASHAs have been identified and listed. 9 ASHA been disengaged for underperformance. Sub centers do not have second ANMs and MPWs for support to Outreach activities. MMUs are not operational in the District. However EMTS, UP Ambulance Seva and Other contracted vehicles provide referrals. Ayush mainstreaming is done in 15 CHC/BPHC and 1 APHC/NPHC. ASHA has been provided umbrella looking at their nature of job and travel. ASHA uniforms are being worked upon and guidelines are formulated /in the process to provide Uniforms. ASHA coordinators are not in place in the District and the process is on to place them Skill development The identified underperforming ASHA are provided training at Block under the supervision of MoICs. Every month there is meeting at the Block were skill upgradation training is done Functionality of the ASHAs Detailed micro planning for VHNDs is available; however VHNDs sessions are mainly used for immunization sessions and not for other purposes. ASHAs are provided with kits which are replenished regularly. 15 Disease control programmes The National Disease Control Programmes mainly NMCP, NLEP, RNTCP were looked in detail at the DFH, and BPC/CHC visited. These programmes are operating under NRHM at district level. The NDCP progress for the district can be seen in the Annexure Table A Malaria During the Q2 quarter period at District Hospital 1717 slides tested for malaria and 3 were found positive. While at CHC Tilhar 1020 slides were tested and none were malaria positive cases. At PHC Dadroul 137 slide were made out of which non found positive. Surprisingly Page 27 of 35

28 Rapid Diagnostic kit for malaria testing is not available at DH, CHC nut available at PHC Dadroul TB At DH in Q2 quarter 542 cases of TB were tested of which 112 were positive. While are CHC Tilhar 388 cases were tested and 48 were positive. At PHC Dadroul 312 cases were tested of which 27 case were found to be positive. DOT medicine is available at Block. RNTCP staffs are paid salaries on time while the DOT providers are paid on yearly basis. Regarding tuberculosis, there is a need for improvement in supervision and monitoring at district level Other Communicable Disease There were nine new cases of leprosy in Shahjahanpur at DH and all were under treatment while at CHC Tilhar 11 cases were detected and were provided treatment. At PHC 10 cases were detected and all were under treatment. 16 Non Communicable Diseases No separate NCD clinics established in neither Shahjahanpur nor does an IEC relating to NCD are displayed. However, NCD drug available relates to treatment of Hypertension and Diabetics 17 Good Practices and Innovations: SNCU being operation helps in saving life s of so many neonates. 18 HMIS and MCTS There is one staff for HMIS data handling at DFH and each of the BPHC/CHC. At block level they are called Block Data Assistant or BDA. For MCTS data entry at Blocks DEO or the Data entry operators are provided. Data operators are agency recruited and are far less paid to what is budgeted in PIP. All the data operators post are not filled up. District is reporting facility wise on HIMS and monthly review is taken by the DPM who is Nodal for HMIS in the District. HMIS data is validated before uploading. MCTS data are not complete and only about percent of the data gets uploaded to the portal compared to the volume of data for the given period. District authorities themselves do not use MCTS data from the portal for Monitoring of service delivery or other activities. Page 28 of 35

29 Main challenges are of data operate not being in place in full strength for the reason that State has stopped the tendering process. Secondly ANM do not provide data correctly from the field and on time. Besides the Medical Officers are reluctant passing necessary instruction to the field functionaries as they themselves are not very conversant on data and computer related tasks of timely uploading and validation and quality checks. So the seriousness somewhere in the process get diluted. DPM being Nodal for HMIS is not taken very seriously by the regular staffs such as HEO/AROs. 19 Key Conclusions and Recommendations A sustainable long term policy for human resource planning needs to be developed including transfer and recruitment policies. Pending recruitment of various positions, especially Specialist doctors 2 nd ANM, MPW and BPMU staff should be expedited. Temporary attachment of health staff needs to be discouraged. Time bound completion work for FRU up gradation, and facilities to be operationalized as per the FRU criteria laid down. Diagnostic facilities should be made available to the peripheral lowest unit i.e. SC. Maintenance of infrastructure and equipment need to be improved. AMC should be upto date and should be renewed. Lengthy process of getting it approved by DHS should be expedited and made flexible. Good practices should be encouraged and innovations should be taken up in positive spirit. Capacity building of health staff needs to be initiated at the earliest. SBA trainings of ANMs, multiskilling of doctors need to be given high priority. Training programmes need to be resumed immediately. Recognition of meritorious staff may be considered to increase staff motivation levels. Especially due to increased work load in the absence of range of health staffs. Subcentres need to be strengthened through provision of regular power and running water supply. Sterilizers/autoclave need to be provided at subcentres. Drugs to manage obstetric emergencies should be made available at subcentres on regular basis. Provision of 2nd ANM and male worker at subcentres should be expedited, especially in Accredited Subcentres. In service training for AYUSH doctors in provision of primary health care needs to be provided. Involvement of ASHAs in implementation of National Disease Control Programmes needs to be expanded and enforced. Accreditation of private hospitals for delivery and other services needs to be encouraged. Page 29 of 35

30 Maternal death audits need to be expedited and taken up rigorously. IEC activities at SC and APHC/PHC need to be strengthened. ASHA trainings for Modules 7 need to be completed. JSSK tender on meals to be processed quickly by DHS. ASHAs when accompany cases to district they do not usually have place to sit and have to be at bed side all the time. Some proper sitting place for ASHA at facilities may be considered. VHSCs need to be strengthened. Civil society and Panchayat representation needs to be ensured. Better utilization of RKS and VHSC funds to be ensured. Community monitoring to be initiated. Utilisation and release of RKS/AMG/UF should increase. It abysmally low in the district during the first six months of FY The joint account of ANM with Pradhan needs to be revisited. ANM not feeling conformable operating account alongside Pradhan due to trivial issues. 20 Annexure Shahjahanpur Page 30 of 35