Monitoring Report: Kerala. Apr Jun 2013

Transcription

1 Monitoring Report: Kerala Apr Jun 2013

2 Table of Contents 1. Executive Summary Introduction State and District profile Health Infrastructure: Human Resources Maternal health ANC Institutional deliveries JSSK JSY Maternal death Review Child health SNCU NRCs Immunization RBSK Family planning ARSH Quality in health services Infrastructure and Equipments Infection Control Biomedical Waste Management IEC Referral transport and MMUs Community processes ASHA Skill development Functionality of the ASHAs Disease control programmes Malaria TB Non Communicable Diseases Alternate system of medicine (Ayurveda/ Homepathy) Other initiatives by the state Findings from PRC reports Annexure 1 - HMIS ANALYSIS FROM NATIONAL WEB PORTAL, NHSRC Monitoring Report, Kerala Page 2

3 1. Executive Summary The quarterly report for Kerala has been put together based on the HMIS data analysis and field visit to Malappuram district from to The following key observations and follow up actions are noted based on the monitoring visit conducted: Unique to Kerala, all the delivery points are concentrated at the tertiary levels in the State. In Malappuram, there are 10 delivery points of the 889 public health facilities - the GH, DH, 5 Taluk hospitals and 3 CHCs conduct deliveries. Of the 10 delivery points in the district, 8 provide round the clock CEmOC services and 2 provide BEmoC services. This is reflective of the very high degree of empowerment of the local people who demand skilled manpower and specialists. Of the 21 designated 24 x 7 PHCs, there are no delivery points. They provide round the clock services for in-patients. The number of deliveries at private facilities far exceeds that in the public sector, with 75 private facilities recording 82% deliveries and 10 public health delivery points reporting 18% deliveries. The rate of C-section in the state, at 40%, is considerably higher than the acceptable norm of 15% C-sections. Malappuram records a C-section rate of around 28%, which is one of the lower rates across all the districts in Kerala. There is no functional SNCU or NBSU in the district and the nearest referral is the Kozhikode Medical College, which is 50 kms away from the district. The well-equipped SNCU at the GH must be operationalised at the earliest. There are no NRCs in the district. The CAG report (2012) highlighted that malnutrition among children below the age of six stood at 27-39% for the state. 110 out of the 1,180 children who died during the year were severely malnourished. Measures to address this needs to be taken at the state as well as district level. JSSK is functioning well in the state. With almost cent per cent institutional deliveries in the state, the scheme has been beneficial in terms of improving the quality of care provided at the public health facilities. All the JSY beneficiaries receive the JSY amount in their bank accounts. JSY payment backlog was noted at a few places. This needs to be improved and managed better as the absence of the concerned personnel should not in any way hamper the rendering of services at the facility. Monitoring Report, Kerala Page 3

4 There is only 1 ARSH clinic in the entire district of Malappuram. Outreach activities through the JPHNs at SCs and schools can be further strengthened to cater to the target group of adolescents. Dedicated school health Junior Public Health Nurse (JPHN) are appointed at the State, who are posted at the government schools and provide a range of services such as first-aid, guidance and counselling, health education to the school-going children in addition to the WIFS and health screening activities. There is a very strong involvement of the local self government and panchayat bodies in the various programmes undertaken by the community volunteers and health staff. The palliative care programme is one such programme where this co-ordination is wonderfully evident. While there is shortage of specialists, the most acutely felt need is for posting adequate numbers of lab technicians. With a 36% shortage of regular and 18% for contractual staff respectively, many facilities are unable to provide laboratory services as desired. This needs to be improved and strengthened through new posts as well as providing training facilities. Kerala is the diabetes capital in the country with nearly 27% males and 18% females living with diabetes. The NCD clinic is very well functional with huge turnouts. Of the patients screened in Malappuram, 18% were newly detected cases and 48% were follow up cases. In both the categories, the majority were hypertensives followed by diabetics. Malaria is a major public health problem in Kerala. The ABER is 10% and the API less than 0.1 per thousand population. The key concerns of the state are also to address this in the context of rapid urbanization as well as migrant population within the state. There are 5 ambulances (1 ALS and 4 BLS) for referral transport in the district. There are also 4 MMUs in the district which cater to an average of 19 villages. Biomedical waste management system needs to be improved in the district. Paradoxically, the general cleanliness maintained is excellent at all the facilities but BMW protocols need to be adhered to. Kerala is well known for its alternative system of medicine across the globe. The 185 AYUSH facilities are not co-located with existing facilities but housed in independent buildings. The facilities require strengthening in order to further improve the service delivery. The ASHAs in the state play an important role, both in the RCH context, as well as in terms of their involvement in the NCD programmes, pain and palliative care programme and various other programmes, which are unique to the state and its health profile. There is no ASHA co- Monitoring Report, Kerala Page 4

5 ordinator/ facilitator either at the district or at the block level. Further support and strengthening is required. 2. Introduction A 3-day monitoring visit was carried out in the month of June to the District of Malappuram in the southern state of Kerala. The report is based on the findings from the visits to the following health facilities: Date Facilities Visited Porathur CHC 2. Tirur DH 3. Ayurveda Hospital DH 4. Kuttipala SC Pothukal PHC 6. Nilambar PHC 7. Manjeri GH Areacode CHC 9. Kavanoot Homeo Dispensary 10. Morayur Mini PHC 11. Kodur SC 3. State and District profile Kerala, regionally referred as Keralam, is a state located in the south-west region of India on the Malabar coast. The state is wedged between the Lakshwadeep sea and the western ghats. The state's 14 districts are distributed among Kerala's six regions: North Malabar (far-north Kerala), South Malabar (northern Kerala), Travancore (southern Kerala) and Southern Travancore (far-south Kerala). The district of Malappuram lies in northern Kerala and is bounded on the north by Wayanad and Kozhikkode districts, on the northeast by Tamil Nadu, on the southeast and south by Palakkad District, on the southwest by Thrissur District, on the west by the Arabian Sea, and on the northwest by Kozhikode District. Monitoring Report, Kerala Page 5

6 Kerala Malappuram Area (Sq Kms) 38,852 3,554 No. of Districts 14 - No. of Villages No. of 60 7 Municipalities No. of grampanchayats Population Male 16,027,412 1,960,328 Population 17,378,649 2,152,592 Female Population Density Sex Ratio (females per 1000 males) Literacy Rate (per cent) Source Census Health Infrastructure: There are a total of 889 health institutions in the district. The types of health facilities available in the district are highlighted below: Type of Health facility Kerala (Numbers) As on March 2012* DH 15 1 Malappuram (Numbers) As on March 2012* SDH 80 5 CHC 217 NA PHC SC TOTAL *RHS 2012 Monitoring Report, Kerala Page 6

7 Malappuram Type of facility Numbers As on visit - June 2013 # GH 1 DH 1 Taluk Hospitals (THQH) 5 CHC x 7 PHC 21 Mini PHC 63 Govt. Fisheries Dispensary 3 Ayurveda hospitals 10 Ayurveda dispensaries 68 NRHM Ayurveda dispensaries 25 NRHM Unani dispensaries 6 Homeo Hospitals 2 Homeo dispensaries 45 NRHM Homeo dispensaries 29 SC 589 TOTAL 889 # District HMIS In addition to the DH, there is also a 500 bedded GH at the district. Of the 84 PHCs present in the district, in-patient services are not provided in the 63 Mini PHCs. The 24 x 7 PHCs provide round the clock medical care services except delivery. An addition of 75 SCs were confirmed upon visit as compared to the RHS 2012 figures. Apart from these, there are also govt. Fisheries dispensaries, ayurveda dispensaries, NRHM ayurveda dispensaries, NRHM unani dispensaries and NRHM homeo dispensaries which provide OPD services. The ayurveda hospitals and the homeo hospitals provide inpatient services Categorization of facilities Facility type No. Level of Facility (L1/2/3) L1 L2 L3 GH 1 1 DH 1 1 THQH 5 5 CHC x 7 PHC 21 MINI PHC 63 SC 589 TOTAL Monitoring Report, Kerala Page 7

8 The trend of institutional deliveries being conducted only at the tertiary care centres in Kerala is observed. The GH, DH and Taluk Hospitals cater to Level 3 services with provision for emergency obstetric care. In addition, of the 21 CHCs in the district, 3 of these provide delivery services (2 CHCs as Level 2 and 1 CHC as Level 3). Therefore, there are a total of 10 delivery points in the district. 5. Human Resources The following tables highlight the various category of personnel available in the district and the corresponding vacancies: Regular Category of personnel Sanctioned posts In position Vacancy 1 st ANM 2 nd ANM % MPW/ Male HW % Staff Nurse total % LTs % Pharmacists % MOs Total % Specialists total % Obstetricians &Gynaecologist % Anaesthetist % Paediatrician % Source: District HMIS NRHM Staff Category of personnel Sanctioned posts In position Vacancy NRHM Contract Doctors (MBBS) 87 NRHM Contract Doctors Urban 105 Health 5 11% Medical Officer (Palliative Care) 1 Specialist Contract Doctors DGO 1 DA % DCH 0 Epidemiologist % MO (Ayur) % MO (Homeo) % MO (Unani) 6 6 0% MO(Sidha) 1 1 0% Staff Nurse (Palliative Care) % Monitoring Report, Kerala Page 8

9 NRHM Staff Category of personnel Sanctioned posts In position Vacancy Staff Nurse on Contract Staff Nurse on Bonded % Lab Technician % Pharmacist (5 on daily wages) 10% JPHN (School Health) % JPHN (Urban RCH) % X-Ray Technician 9 10 Opthalmic Assistant 1 0% Source: District HMIS The vacancy of staff is less than 50% across all categories of the staff. The JPHNs for School Health programme are posted at various schools. The highest projected vacancy is among the lab technicians with a 36% shortage of regular posts and 18% for contractual posts for e.g. there are only 2 LTs (of which 1 is on working arrangement) at the DH Tirur and no LT at Pothukal PHC (hence no lab services are provided and the patients are referred to private labs around the facility). This is followed by 13% vacncy for regular specialists and 67% for contractual specialists. Among the specialists, there is a shortage of anesthetists for e.g. the DH Tirur with an average of 150 deliveries per month has only 1 anesthetist. For a state, which is acknowledged for their nursing cadre across the globe, it is not surprising that there is only a 7% shortage in the regular staff. The practice of hiring staff nurse on a daily wage basis (with salary from the Hospital Management Committee) was also observed for e.g. at CHC Porathur, which is noteworthy. SERVICE DELIVERY Kerala has one of the best maternal and child health indicators in the country with almost cent per cent antenatal care and institutional deliveries along with a low MMR (81) and IMR (13). Literacy rate (94%) and female literacy rate (92%) in particular is also the highest in the country and at par with developed countries. This along with participatory involvement and decentralization down to the grass roots is a major reason for the state boasting of some of the best health indicators in the country. Simultaneously, while Kerala ranks highest in terms of social development indices such as primary education, healthcare and elimination of poverty, it is also grappling with a steadily ageing population, highest rates of unemployment and suicides as well as the highest prevalence of noncommunicable diseases in the country. Monitoring Report, Kerala Page 9

10 Malappuram, the most populous district in the State, also mirrors these characteristics despite being a backward district. This can be attributed to the rapid urbanization (from 9.8% to 44.2% - an astounding 350% decadal growth rate) and a thriving economy (a major driving force being the high remittances of migrants in the middle east to the district nearly 20% of total remittances received in Kerala) have resulted in growing affluence, thereby improving the socio-economic status of the population. There is a significant seasonal migrant population who are engaged in labour, construction and agricultural works. All these factors have contributed to the changing scenario of health and health care in the State and across its districts. 6. Maternal health 6.1 ANC Although the percentage of antenatal care registrations and 3 ANC check ups are very good, a similar pattern as observed in the rest of the states emerges. The percentage of ANC registrations as against the expected pregnancies is recorded at 137% in the district. This can be a result of double or faulty reporting of cases. In the state however, the percentage of ANC registrations as against the expected pregnancies is 92%. The percentage of 3 ANCs is 82% and 89% in the district and the state respectively (Source: HMIS Web portal), indicative of lack of regular follow ups and maybe a preference for check ups at the private facilities. Kerala demonstrates a trend of preference for health care services at the private sector as compared to the public facilities. Upon visit, the district HMIS confirmed this trend although the percentage varies from that recorded in the web portal. Indicator (April) ANC registration 90,270 94,478 8,389 3 ANC 61,732 74,251 6,137 Source: District HMIS Monitoring Report, Kerala Page 10

11 3% 0.10% 0.10% 0.50% 0.70% 4.50% 16.30% 22.80% 80% 78% 76% 74% 72% 70% 68% 66% 64% 62% Percentage of 3 ANC as against ANC Registration 68% 79% 73% (April) The above table also reflects an almost 11% increase in the coverage of the 3 ANC registrations in as compared to , which can be attributed to efforts to strengthen their follow-up mechanisms. Management of complications against reported ANC registration 25% 20% 15% 10% 5% 0% Hypertensive cases detected at institution Eclampsia cases managed during delivery ANC women having Hb Level < 11 ANC women having severe anemia (Hb Level < 7) treated at institution Kerala Malappuram Source: HMIS Web Portal The quality of ANC services is reflected in the above table and the management of complications against reported ANCs is poor with only 3% hypertensives and 16% anemic reported. This could mean that despite very good ANC registration, the detection rates for anemia/hypertension are lower than what is known (24% mildly anaemic, 24% moderately anaemic and 1% who suffer from severe anemia for Kerala as per NFHS III). This could either be due to failure to capture the correct Monitoring Report, Kerala Page 11

12 number of anaemic cases or because of a faulty reporting mechanism. During the visit, it was observed that all facilities had provision for Hb testing and line listing of anaemic women is carried out. On the contrary, lab facilities were not available at all the levels of health facilities and the highest staff shortage reported is that of the lab technicians in the district. For e.g. at the Pothukal PHC although provision for basic lab test is available, there is no laboratory and no LT in the facility. Hence the patients have to avail these services from the private facilities (where reimbursement for the same is provided for the tribal population). 6.2 Institutional deliveries The trend observed in Malappuram is reflected across the State, with the number of institutional deliveries being much greater at the tertiary care centres. The concentration of delivery cases in private facilities is also a noteworthy trend. Although there is a marginal increase in the deliveries at the public facilities at Malappuram in , the difference between the deliveries at the private and public facilities is still very large, with 82% deliveries recorded at private facilities and 18% in the public health facilities. Of the 75 private hospitals conducting deliveries, 48 are accredited for JSY. 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Trends in Institutional Delivery 83% 83% 82% 17% 17% 18% Public facilities Private facilities (April) Only the General Hospital, DH, Taluq Hospitals and 3 CHCs (out of 21 CHCs) in the district cater to the entire load of the deliveries at the public health facilities. The reasons attributed to this is the preference of the general population to avail delivery services at a private facility as a connotation of high status and the demand for delivery care only by specialists i.e. gynecologists at the hospitals. Facility-wise segregation of deliveries at public facilities Monitoring Report, Kerala Page 12

13 Facility Deliveries Deliveries Deliveries (April) GH 4, DH 1,639 1, THQH 8,210 8, CHC Total 14,858 14, Source: District HMIS Indicators (April) Institutional Deliveries 88,489 88,129 7,681 C-sections 23,684 24,851 2,104 Home deliveries Source: District HMIS Kerala records a very high rate of C-sections, much greater than the acceptable norm of 15% C- sections, cited reasons being increased awareness and demand for the C-sections by the patient themselves who want to avoid labour pains. Although the 28% C-section deliveries recorded at Malappuram is also quite high, this is one of the least in comparison with the other districts and the 40% C-section rate for Kerala. There are 38 blood storage units which are non functional in the state. At the time of visit, there were 3 licensed and fully functional blood banks in the district. On the day of visit to the DH Tirur, the previous days stock was 22 and the collection for that day was 16. Indicator Kerala Malappuram No. of Blood bank licensed and functional 33 3 No. of Blood Storage Units licensed and 16 5 functional No. of Blood Storage Units non functional 38 0 Source: PIP Home deliveries are very minimal and where recorded are from the tribal blocks of the district which are far away from the health care facilities. Monitoring Report, Kerala Page 13

14 6.3 JSSK Awareness and display of entitlements The JSSK entitlements are well displayed across the facilities. A point to be noted though is that the displays were available at all the delivery points and not at all the facilities. Since, deliveries are concentrated at the tertiary centres in Kerala, prominent displays were available primarily at these centres. All the SCs visited also had good displays of the JSSK entitlements. This could be expanded to include the PHCs and the ayurveda/homeo dispensaries as well in order to further increase the awareness. There was also a high awareness of JSSK entitlements amongst the beneficiaries with whom interactions were carried out. Of the 17 women interacted with, all were aware of the JSSK entitlements and benefits. The source of information cited was other reasons i.e. newspapers, friends and relatives by 14 (82%) of the women, while 1 each responded that they came to know about the entitlements at the facility and through the ASHA respectively. The extension of the entitlements for the sick newborns from 30 days to up to 1 year has not been disseminated to the state and the districts, hence the officials were not aware of the same. Monitoring Report, Kerala Page 14

15 Out of pocket expenditure User Charges None of the beneficiaries interacted with reported having to pay user charges, either formal or informal for availing delivery services. Drugs and consumables Except for one beneficiary, there were no expenses incurred on the drugs and consumables by any of the 17 beneficiaries. With the launch of the JSSK scheme, patients reported that they did not encash on their RSBY cards for delivery care and were able to use this amount for any other ailment when required. The beneficiary who reported expenditure had to buy medicines worth Rs. 300 from a private pharmacy, which was to be reimbursed through the RSBY. The Kerala Medical Services Corporation (KMSC) has launched the Karunya Community Pharmacy project wherein karunya outlets at the facility provides for medicines at a 20-30% discount. Diagnostics None of the beneficiaries reported expenditures on the diagnostic services and tests availed during their pregnancy. Provision for lab services should be ensured right from the CHCs to the PHC level as all the 24 x 7 PHCs do not have lab facilities, e.g. at Pothukal PHC there is no lab facility and only basic HB, UPT tests are conducted; at Areacode CHC with an average monthly delivery of 30, no UPTs are done. The reason cited was that most of the patients attend only after confirmation of pregnancy at their homes. Moreover, at the Porathur CHC the UPT charges for Rs.40/- per test were displayed and being charged. As cited, the facilities which are not identified delivery points do not receive funds for the implementation of JSSK. This may be looked into by the district and state officials, as it is JSSK s mandate to provide for the desirable and essential investigations free of cost during ANC. Meanwhile, provision for core JSSK funds were made by the state to upgrade facilities in order to improve the services before the launch Monitoring Report, Kerala Page 15

16 of JSSK for e.g. the lab at DH Tirur has been completely upgraded using RSBY and core JSSK funds - a haematology analyser and electrolyte analyser were purchased from these funds. Diet Dietary provision, under JSSK was present at all the delivery points visited, except CHC Areacode, where the diet being provided was not through the JSSK funds. The reason cited was that there were no takers/quotations for the allocated amount of Rs. 100 per day for the diet. As food is already being provided to all the inpatients, it was recommended that the JSSK fund for diet may be used to accommodate for fruits etc. to supplement the diet given to the beneficiary. The quality of the diet provided was very good and this was done either through various self help groups or charitable institutions. Simple, hot food in keeping with the prevalent eating habits such as milk and bread for breakfast, rice, sambar for lunch, fried plantains, evening tea and kanji/khichdi for dinner were served to the beneficiaries. Referral transport There is 1 ALS and 4 BLS available in the district. There is no provision for pick up and drop back for pregnant women established in the state. Reimbursement for referral transport amounting to Rs.500 (for pick up and drop back) is provided to the beneficiary. All the beneficiaries interviewed were aware of the facilities under the JSSK and intended to avail the amount upon discharge. The maximum out of pocket expenditure was reported to be incurred on the transport by the patients. Out of the patients interviewed, 8 (47%) reported hiring vehicles to get to the facility while 2 (7%) used their own vehicles and the remaining 7 (41%) used either a friend s car, an auto or a bus. The average expense incurred on transportation from the home to Monitoring Report, Kerala Page 16

17 facility was Rs.226. The patients interviewed intended to return in hired vehicles, along with their newborns. Grievance Redressal Mechanism There is no separate grievance redressal mechanism for JSSK although complaint boxes for general grievance redressal were placed at the centres. Records and Registers JSSK-related records and registers were very wellmaintained. Meticulously kept records detailing each component of the JSSK such as JSSK cash book, JSSK diet book etc. were available at all the facilities visited, except at the Areacode CHC where record keeping needs improvement. Separate slips for diet were given to the patients, at the GH and the Nilambur Taluk hospital, who had availed these and a copy retained by the staff. Majority of the staff nurses interacted with reported having to spend a lot of time on clerical work rather than clinical work, such as filling the diet receipt slips, reimbursing the referral transport amount and additional registers in relation to JSSK. To deal with this, for e.g. at the GH Manjeri, with an average monthly delivery load of around 400, separate staff has been hired on a daily wage basis (Rs.300/day) through the HMC (Hospital Management Committee) funds who maintained all the relevant records and registers. Monitoring Report, Kerala Page 17

18 6.4 JSY JSY is implemented across the State. It was confirmed upon visit that all the institutions where deliveries are taking place disburse JSY cheques in accordance with the GOI norms. Records and registers were well maintained. There was no JSY backlog at any institution, except one. At Porathur CHC, JSY backlogs since the year 2011 was noted. The last payment was made on The block co-ordinator and the LHA ensure that the payments are made, and with the post of the LHA being vacant at the CHC, delay in the payment was cited by the officials at the facility. 6.5 Maternal death Review Maternal deaths in Kerala are at 81 per 100,000 live births, again one of the best indicators across the country. Regular maternal death reviews and audits are conducted. In Malappuram, maternal death reviews had been conducted for all the 40 maternal deaths reported in At the time of visit, 4 maternal deaths had been reported, but reviews were yet to be conducted. The primary cause of maternal deaths reported was haemorrhage, sepsis and hypertensive disorders of pregnancy. Indicator (April) Maternal deaths reported Maternal death review conducted Source: District HMIS FBMDR IN MALAPPURAM DISTRICT 0 12 FBMDR IN CALICUT DISTRICT 5 AT THRISSUR DISTRICT 5 CBMDR AT HOME 7 Child health 7.1 SNCU Along with maternal health, Kerala also has very good child health indicators. The IMR for the state is 13 per 1000 live births. Monitoring Report, Kerala Page 18

19 Status of SNCU, NBSU and NBCC Indicator Kerala* Malappuram# SNCU 10 1 (not functional) NBSU 49 6 (not functional) NBCC *PIP #District HMIS There is a fully equipped SNCU at the GH, Manjeri, ready for operationalization but due to the development of a leakage issue and seeping of water at the corner of the room, this could not be operationalized. The nearest centre for referral is the Calicut Medical College, approximately 50 kms away from Malappuram. There are 10 radiant warmers and all other equipments, including oxygen cylinders, digital weighing machine etc. have been supplied. The SNCU construction was completed in May 2013 and the authorities cited having written to the P.W.D but not having received any response. A new NBSU at the DH Tirur was also yet to be operational. Though given the State s low IMR, an SNCU is not automatically required; we must still be concerned as to whether the sick newborns in the district are being seen at private facilities for lack of facilities in public hospitals. If this is so, then this needs to be addressed. 7.2 NRCs There are no NRCs in the State. According to the CAG report for the year 2012, malnutrition among children below the age of six stood at 27-39% for the state. The report stated that 110 out of the 1,180 children who died during the year were severely malnourished. Figures were based on data collected from various AWCs across the states as well as test check records of Idukki, Malappuram, Palakkad and Thiruvananthapuram districts. 7.3 Immunization The full immunization rate as against the reported live births is 82% and the measles given against the reported live births is 85%. The full immunization is less and there should be adequate tracking or follow up of the drop-outs. It is also observed that there is a huge variation between the DPT 3 immunization (5% at State; 6% at Malappuram) and OPV 3 immunization in the age group of 0-11 Monitoring Report, Kerala Page 19

20 months (101% at State and 82% at Malappuram) against the reported live births as reported in the HMIS from the web portal. The state may explore the reasons for this as this increases the vulnerability to vaccine preventable diseases as well as follow up on whether the DPT 3 vaccines are administered at the recommended age of 14 weeks. The JPHN and ASHAs are actively involved in the immunization programme but further strengthening of the programme is required in order to effectively track and motivate the drop-outs. Fixed day clinics as well as routine immunization is carried out. The JPHN submits a tentative advance tour programme for the coming month and subsequently at the end of the month submits a tour diary detailing upon the actual work done (pictured above). 7.4 RBSK Dedicated school health JPHNs, under the School Health Programme (RBSK), are posted at the govt. schools in the State. In Malappuram, there are 93 School Health JPHNs. Interaction with the JHPN at a school elicited that part of their regular duties at the school includes conducting health education classes, administration of WIFS tablets every Monday, screening of children through medical camps along with the PHC MO, providing first aid and treatment as well as referral for children who are in need. Various records and registers were Monitoring Report, Kerala Page 20

21 maintained for all the activities and the JPHN in co-ordination with the teachers at the school provides health care delivery to the target population at the school. An early intervention centre (DEIC) should be established for streamlining the referral and follow-up from the schools to the centre. 8. Family planning The unmet need for family planning in Kerala is 15.8, with a greater unmet need for limiting than spacing. In Malappuram, the unmet need is slightly higher at 19.1, with a greater unmet need for spacing than limiting. Analysis of the facility-wise percentage of sterilizations and IUDs shows that a majority of the IUD insertions take place at the PHCs in Kerala as well as Malappuram. Post partum sterilizations and minilap, laparoscopic as well as NSVs occur only at the DH and Taluk hospitals keeping in line with the trend of deliveries and surgical facilities concentrated only at these tertiary levels. Female sterilization contributes to majority of the reported sterilizations, with post partum sterilization being the most preferred choice. Indicator (April) No. of sterilizations conducted NSV: NSV: 61 NSV: 10 Lapro: 1542 Lapro: 1699 Lapro: 238 Minilap: 331 Minilap: 284 Minilap: 47 Source: District HMIS Post partum: 9278 Post partum: 9155 Post partum: ARSH There are 18 functional AFHCs in the state, which are concentrated at the DH, taluk hospitals and the CHCs. There is 1 ARSH clinic in the district of Malappuram, operationalized in , which is located in the Malappuram Taluk hospital. An average case load of beneficiaries per month is recorded in the Outreach activities for ARSH are carried out by the JPHNs. Setting up of adolescent friendly help-desks or kiosks at prime locations such as malls, amusement parks etc. can be explored. Monitoring Report, Kerala Page 21

22 10. Quality in health services 10.1 Infrastructure and Equipments All the facilities visited have good approach roads. There is also a lot of public initiative in the improvement of these facilities for e.g. at Porathur CHC all the wards and the buildings except the OP block were constructed from public donations to the centre. Strengthening of the existing facilities at the GH, Manjeri was also done by the donations received from the public. Separate registration counters were present at all the facilities and a token system was observed in the OPD, where the token OPD number was displayed on a screen for the patients to meet the consulting physician. There were also guards posted both male and female who managed the crowd and streamlined the entry of the patients to the examining cubicles. The DH Tirur, also had a new fully digitized registration counter. Planting of trees in the campus by local school children, initiatives like donation of the NRHM staff to house a birdcage in the campus and maintenance by the auto drivers of the casualty stand in front of the GH are noteworthy initiatives. Staff quarters were under construction at the Porathur CHC. The OT was not functional at the Porathur CHC. Telemedicine units at the DH and Porathur CHC were noted to be non-functional since 2011, with all the equipments and provisions packed and out of use. As the telemedicine unit is not operational, plans of converting it to a CT scan room at the DH, Tirur are being considered. There is provision of round the clock water supply and power back up at all the facilities. The OT at the DH, Tirur (with 98 C-secs recorded in May 2013) was found to be inadequate. Labour room equipments were available at all the facilities. One issue noted was that of the SNCU at the GH and the telemedicine unit where the despite the facility and availability of equipments, they were non-functional. Monitoring Report, Kerala Page 22

23 10.2 Infection Control General cleanliness is good at the facilities and the wards are well -maintained. The labour room at the GH, Manjery is especially well organized and extremely neat and clean. The delivery care wards though crowded, were clean Biomedical Waste Management Considering that the general cleanliness is good, it was surprising to note that the BMW practices were quite dismal. Discarded I.V bottles under a patients bed in a makeshift area at the Pothukal PHC and discarded syringes with needles at the Areacode CHC are a cause for concern. The non availability of the space for disposing the discarded waste and lack of timely collection of waste was cited by the officials at the PHC IEC There are good IEC displays covering a broad range of programmes across all the facilities visited. All relevant material was displayed at the sub-centres as well, with prominent JSSK display. At the Morayur Mini PHC, newsletters and health magazines were printed through the initiatives by the staff. The television in the OPD waiting area showcased relevant health talks and issues. 11. Referral transport and MMUs There are 50 ALS ambulances in the state of which 5 1 ALS and 4 BLS state-owned ambulances are in the district, all of which are functional. There are 29 MMUs in the state and 4 MMUs in the district (Source PIP ). The district has 1 govt. and 3 NRHM MMUs. They cover an average of 19 villages. The MMU at the Nilambur TQHQ covers 180 tribal colonies. The cholanaikan and kattunayakan - one of the most primitive tribal groups in South India, inhabit the interior forest areas of the district without any access to health care services. The MMU, manned by an MO, pharmacist, a nursing assistant, a health assistant and a team of field staff, visits the hamlets to deliver health care services. An average monthly OPD of patients are treated. Monitoring Report, Kerala Page 23

24 Immunization services, drugs etc. are provided by the MMU. (Photo above courtesy MMU team, Nilambur taluk hospital). 12. Community processes 12.1 ASHA There are 32,854 ASHAs in the state. There is no DCM, BCM or ASHA facilitator in the state. In Malappuram district, there are 3640 ASHAs. Nearly 400 ASHAs have dropped out. The basis for identifying the dropouts is if they fail to turn up at the review meetings and trainings. Once a month review meetings are held at the respective PHCs with the MO and the LHI. Family reasons and low honorarium is cited as a reason for the dropout of ASHAs. Four ASHAs were interacted with. All the ASHAs had cleared their 10 th std Skill development All the ASHAs have completed Module 6 training. The ASHAs preferred non-residential training as they had small children and had to get back home Functionality of the ASHAs ASHAs are actively involved in the ANC, immunization, NCD clinics, Pariraksha - the pain and palliative care programme as well as home visits. The ASHAs had not received any drug kit and took only the medications for fever etc. from the JPHN to distribute to those requiring it. The ASHAs reported being members of the WHSNC (Ward Health Sanitation & Nutrition Committee). The WHSNC funds for were disbursed at all the facilities visited except Kodur SC, where the JPHN reported not having received any funds for WHSNC meetings were conducted once a month. The state pays a fixed honorarium of Rs.500 per month in addition to their incentives. Delay in the payments of the honorarium and the incentives was reported by the ASHAs. In addition, they are required to attend monthly meetings at the PHC and for this they travel by autos/buses which is problematic as they do not get the incentives on time. Grievance issues are taken up either at the monthly meetings or at with the Block co-ordinators. Monitoring Report, Kerala Page 24

25 13. Disease control programmes 13.1 Malaria Malaria is a major public health problem in Kerala and is endemic in four districts viz. Trivandrum, Malappuram, Kozhikode and Kannur. The ABER is 10% and the API less than 0.1 per thousand population. All the staff required for the malaria programme are available in Malappuram district. In Malappuram district, immigration screening camps are conducted to identify the cases of malaria. Of the 436 MPW posts, 432 are in position. Almost 94% of the total malaria cases in the state are reported to be imported cases with nearly one third of them being immigrants who came with malaria, one third being Keralites who were residing outside and the remaining one third who had visited other states for business, employment or study. The recent changes attracting a huge immigrant labour force has been a reason and source for malaria. Malappuram district witnessed a large number of indigenous malaria cases in This happened in the town of Valancherry, a business town where nearly 850 immigrant labourers were lodging. In Kannur, which also witnessed a similar outbreak of indigenous cases, the over head tanks were a source of breeding. Lack of lab facilities at some of the peripheral institutions, vacant posts of LTs also pose a serious problem. As a result, the slides are sent to higher centres where this provision is available and confirmation of cases is delayed. RD kits, which are not being used, are useful to confirm the suspects in PHCs and remote areas where lab facilities are not available and diagnosis within 24 hrs is not possible. Indicator No. of blood slides examined for MP 2011 Calendar year No. of Pf/Pv +ve Pf -29 Pv Calendar year 2013 Calendar year Pf -7 Pv Pf -3 Pv TB There are 73 TUs in the State of which there are 8 in Malappuram district. The state has 385 DMCs in the public sector, 107 in the private sector and there are 1160 private providers enlisted. Eleven ART centres are available across the state with 163 ICTCs. The total number of patients put on treatment is 25,669 in the state of which Malappuram contributed 10%. The annual case detection rate is Monitoring Report, Kerala Page 25

26 in Kerala and 65% for Malappuram. The proportion of TB patients tested for HIV is 80% in Kerala and 76% in Malappuram. The priority areas for the state are a reduction in the failure and default rate amongst the newly detected and previously treated cases and improving the case detection rate No. of sputum sample collected/examined Indicator (April) No. of sputum +ve cases Non Communicable Diseases With 27% of total male population and 19 % of female population being diabetic in Kerala is considered as the diabetic capital of India. The NPCDCS was introduced in 2010 in Pathanamthitta district and subsequently extended to the other districts. The state NCD control program with the focus on health education, early detection and prompt treatment and regular supply of medicines was introduced in The programme is implemented in all the govt. institutions. The following are key components of the programme: Fixed-day Sub Centre clinics (from 2 4 pm) Three screening camps in the Sub Centre area and Fixed day clinics in PHC/CHC Provision for medicines are made from the CHC/PHC. The JHI,JPHN, Staff Nurse and MO are available at these camps. BP, Blood Sugar, BMI are recorded by the JHI, JPHN and staff nurses. Life style modification advices and counselling (including tobacco cessation counselling) is an important part of the BCC at these clinics. The ASHAs are also actively involved in the clinics and ensure turnouts at the clinics from their respective areas. Monitoring Report, Kerala Page 26

27 With 54% of the population in Malappuram above the age of 30 yrs, 8% of the patients were screened. Of these, 18% were new cases which were detected and 48% were follow up cases. 60% 50% 54% Malappuram NCD % 40% 30% 20% 17% 10% 8% 0% Population above 30 years No.of Patients Screened No.of new cases detected No.of follow up cases Of the newly detected cases, majority are hypertension followed by diabetes. This is also mirrored in the follow up cases. New Detected Cases 0.04% 0.02% 4% 7% 5% No of New DM cases detected No of New HT cases detected No of New DM & HT cases detected Follow up Cases 11% 18% 19% No of Follow up DM cases No of Follow up HT cases No of Follow up DM & HT cases Monitoring Report, Kerala Page 27

28 15. Alternate system of medicine (Ayurveda/ Homeopathy) Kerala is famous for its alternative system of medicine across the globe. It is not surprising therefore that the world renowned Kottakal Arya Vaidya shala located in Malappuram caters to huge numbers of patients from all parts of the world every year. There are ayurveda, homeo and unani hospitals as well as dispensaries in the state which are not co-located with the existing allopathic facilities. There are also NRHM ayurveda/homeo and unani dispensaries which are named thus as the doctor is posted through the NRHM funds. An ayurveda hospital and a homeo dispensary were visited in Malappuram. The ayurveda hospital is a 50-bedded facility, which requires better maintenance. The dispensary was in a dilapidated state with seepage across the entire room. Inadequate water supply was cited to be a problem in the preparation of ayurvedic medicines. The Kavanoor homeo dispensary is a rented building with an examination room, a small waiting area and a dispensary. There is no toilet facility. This dispensary caters to an average OPD of per day, which has reduced from the previously recorded 150 patients per day. The rent is borne by the local panchayat. There is 1 MO (from NRHM) and 1 retired pharmacist who works on a daily wage basis (Rs.350/day). The pharmacist reported not receiving his salary for the last two months. As per a GO dated , the state govt. has accorded sanction for payment of wages to the pharmacists/attenders/part time sweepers working at the NRHM ayurveda/siddha/unani/homeo dispensaries in gram panchayats to be handed over to the NRHM. As a result, the panchayat is not willing to pay the wages in disobeyance of the order. Drug shortage was also cited due to shortage of HMC (Hospital management committee) funds. Panchayat funds to buy medicines for Rs.30,000 was granted when it started functioning in 2010, but thereafter no funds have been received. Monitoring Report, Kerala Page 28

29 16. Other initiatives by the state Some other key state specific programs are: Palliative care project or the pariraksha (additional care) program involves the health, local self government and social departments. With more than 1,25,000 incurably ill, bed-ridden and dying patients in Kerala, the palliative care programme is intended for persons affected by end stage cancer, strokes, very old people, end-of-stage systemic diseases, AIDS, head injury, spinal injury and mental and physical incapacitation. Follow up visits by the trained palliative care nurse is conducted and the following components are looked after empowering family in the care of bed ridden patients, wound care, catheter care and change, naso gastric tube care and change, special care for lymphoedema and ostomy care. For e.g. in the Morayur Mini PHC area, there are 72 bed ridden patients. Every first Tuesday, and every Saturday is for Home care visits to the patients. All the patients are covered on a priority basis. The 7 th working day is for evaluation/ review meeting by the panchayat president, LSG members, the MO, Health inspector and the co-ordinator. Medicines are also supplied through the panchayat funds. Medicines are bought from the pharmacy every Wednesday or Thursday. At Morayur Mini PHC, however, problems with procurement of medicines for the pariraksha programme were cited by the officials. The stock indent had been mailed to the KMSCL and despite payment of the same, no medicines had been supplied at the PHC. At the time of visit, the last supply had been received on Indicator Nos. Total number of volunteers trained 40,000 Total number of community nurses working 430 Total number of LSGI members trained 5720 Total patients under care Completely bedridden 18,015 Catheter care 6,171 Wound care Gender based violence management the project provides medical care, counseling and referral to the victims of gender based violence. A female counselor is posted at each GBV centre to coordinate the activities and counseling of the cases. Where required, they also facilitate the referral to different departments like social justice, legal cells, police etc. Nearly, 3200 cases were addressed by the GNBV centres in across Kerala. Monitoring Report, Kerala Page 29

30 17. Findings from PRC reports A summary of the key findings from the PRC report for the period of July-September 2012 is as follows: Infrastructure Improvements& Human Resources Supportive supervision and higher allocation of funds is provided to bridge critical gaps especially in infrastructure and human resources. New construction and renovation of existing buildings has been progressing BCC/IEC strategy for the state has been developing (will start in the next quarter) The ASHAs has been vibrant in the state for providing the services as expected. Trained ASHAs filled the gap between community and health facilities. Contractual appointment under NRHM is helpful to meet the requirement of health personnel in the state as well as in health facilities. Recruited 110 specialists and 462 SNs on contractual basis Mainstreaming of AYUSH cell in the entire state is improving. Services Detected STI cases Conducted 92 RCH outreach camps and 8637 VHND Institutional Delivery and Home delivery in rural-38 Screening of blood in 47 JSSK & JSY beneficiaries increased. The new initiative Janani Shishu Suraksha Karyakaram (JSSK),which entitles all pregnant women delivering in all the public health institutions absolutely free. Similar entitlements have been given for all sick newborns accessing public health institutions for treatment till 30 days after birth EC has approved the setting up of SNCUs &NBSUs Organised 55 female sterilisation camps and 5 NSV camps Given compensation for 12381FS cases and 1986 NSV Acceptance cases Incentives are given to ASHA for mobilizing 285-FS and 15-MS in Wayanad. Establishment of new ARSH clinics at DH level is progressing. Activities under ARSH and School health programmes are efficiently advancing. Regular meetings and camps is conducted at the Tribal areas of all the district especially in Thrissur and Wayanad Services of 2 nd ANM at Sub centres is to be planned at PIP Weak Areas: State need to move ahead the activities like CH (0.54%), ARSH (5.47%), training Monitoring Report, Kerala Page 30

31 (5.69%) Hospital Strengthening (3.62) New Constructions/ Renovation and Setting up (8.49%) Action Plans (1.75%) Referral Transport (3.99%) Supportive services (1.69%).Utilization of funds under vulnerable groups, PPP/ NGOs, Innovations and procurement is zero. However most of the activities under these programmes are to be planned in the next quarter. Various disease control disease programme cells are functioning smoothly. However, the state is being always vigilant against the control of communicable and non-communicable disease and is giving more attention to the disease surveillance programmes against the outbreak of vector borne diseases. Monitoring Report, Kerala Page 31

32 Annexure 1 - HMIS ANALYSIS FROM NATIONAL WEB PORTAL, NHSRC Population - Census Sex Ratio ( No. of Females per1000 males) State Statistics - Kerala Kerala - District - Malappuram District Statistics - Malappuram Person 33,387,677 Indicators DLHSIII Male 16,021,290 ANC Female 17,366,387 ANC Check-up in first trimester 96.2 Census or more ANC Check-up 99.1 Sex Ratio 0-6 years Census Atleast 1 TT received 98.5 MMR ( per 100,000 live births) IFA Tablets 56.5 CBR ( per 1000 population) 15 Deliveries CDR ( per 1000 population) SRS Institutional Delivery 100 IMR 13 Home Delivery 0 Neo- natal Mortality Rate Home Delivery by SBA 0 Under Five Mortality Rate New born & post natal care District Statistics - Malappuram Still Birth 0.7 Person 4,110,956 Live Birth 87.9 Population - Census Male 1,961,014 Breastfed within 1 hour of birth 65.1 Female 2,149,942 PNC within 48 hrs of delivery 100 Population in the age group Census Person 552,771 Immunisation Male 281,958 BCG 98.2 Female 270,813 DPT Sex Ratio ( No. of Females per1000 males) 1096 Measeles 75.7 Sex Ratio 0-6 years 960 Full immunisation 63.9 Person Unmet need for Family Planning Literacy Rate - Census Male Spacing 11.1 Female Limiting 8 % Decadal Growth Rate Total 19.1 Population Density per Sq.K.m 1158 Infrastructure - District Statistics - Malappuram SC 514 PHCs RHS - March CHCs 21 Monitoring Report, Kerala Page 32

33 Kerala - Mallapuram- Key Performance Indicators -Apr'12 to Mar'13 ANM Related % ANC Registration in First Trimester against Reported ANC registration 75% % PNC visits within 48 hours and 14 days against total deliveries 101% % Three ANC check ups against estimated pregancies. 113% % DPT3 immunisation against Estimated Live Births 8% % Hypertension in pregnancy- detected against ANC Reported 4.5% % Measles Immunization against Estimated Live Births 119% % Severe anaemia (Hb<7) treated gainst Reported ANC registration 0.7% % Full immunisation against Estimated Live Births 114% ASHA Related % Newborns weighed at birth against Estimated live Births 140% JSY Paid to ASHA as % of reported Institutional deliveries 0% % of Newborns having weighed less than 2.5 kg against newborns weighed 12% % ASHAs present during immunisation Sessions 90% % Newborns visited within 24 hrs of Home deliveries 95% Facility Related OPD per 1000 population IPD per 1000 population 2, % C- Section against Institutional Deliveries 28.1% Abortion Rate against Reported pregnancies 4.7% Major surgeries per lakh population. 1,087 Total sterilisation done per 1000 eligible couples. 16 Institutional deliveries against estimated deliveries. Institutional deliveries against Reported deliveries. 139% Total IUD inserted per 1000 eligible couples % Monitoring Report, Kerala Page 33

34 Kerala - Mallapuram- Summary -Apr'12 to Mar'13 ANC ANC Registration against Expected Pregnancies 137% TT2/ Booster given to Pregnant women against ANC Registration 77% 3 ANC Check ups against ANC Registrations 82% 100 IFA Tablets given to Pregnant women against ANC Registration 80% Deliveries Reported Deliveries against Expected Deliveries 139.0% Home Deliveries( SBA& Non SBA) against Estimated Deliveries 0.4% Institutional Deliveries against Estimated Deliveries 138.7% Home Deliveries( SBA& Non SBA) against Reported Deliveries 0.3% Institutional Deliveries against Reported Deliveries 99.7% C Section Deliveries against Institutional Deliveries( Pvt & Pub) 28.1% Births & Neonates Care Live Births Reported against Estimated Live Births 140.0% Newborns weighed against Reported Live Births 100% Still Births against reported 1000 live Births 5.3 Newborns weighed less than 2.5 kgs against newborns weighed 12% Sex Ratio at Birth 936 Newborns breastfed within one hr of Birth against Reported live Births 94% Child Immunisation( 0 to 11 mnths) Measles given against Expected Live Births 119% Measles given against Reported Live Births 85% Fully Immunised Children against Expected Live Births 114% Fully Immunised Children against Reported Live Births 82% Required numbers of VHNDs per thousand population in 12 mnths 49,950 Immunisation Sessions held as percentage of required VHNDs 56% Family Planning & Abortions Family Planning Methods Users ( Sterilisations(Male &Female)+IUD+ Condom pieces/72 + OCP Cycles/13) 24,276 Total Sterilisations ( Male & Female) 11,220 MTP up to 12 weeks 16 Abortion (spontaneous/induced) 3,068 MTP more than 12 weeks - Abortion Rate against Expected pregnancies 6.5% Monitoring Report, Kerala Page 34

35 Demographic Denominators - Kerala - Mallapuram IMR of the state - Kerala - Mallapuram CBR - Kerala - Mallapuram Total Population Expected Pregnancies Apr'12 to Mar'13 Expected Deliveries Apr'12 to Mar'13 Eligible Couple ( 17% of total population) Source SRS SRS Census 2011 Derived Derived Derived ,162,467 69,596 63, ,619 Kerala - Mallapuram- Deliveries - Apr'12 to Mar'13 Total Population 4,162,467 Expected Deliveries - Apr'12 to Mar'13 63,649 Home SBA Home Non SBA Institutional ( Pub & Pvt) Total Deliveries Reported Over Reported Deliveries ,281 88,504 (24,855) Home SBA % Home Non SBA% Institutional % Total Deliveries Reported % Over Reported Deliveries % 0% 0% 139% 139% -39% Kerala - Mallapuram- Home ( SBA & Non SBA) & Institutional Deliveries against Expected Deliveries - Apr'12 to Mar'13 Over Reported Deliveries % -39% Institutional 139% Monitoring Report, Kerala Page 35

36 Kerala - Mallapuram- Home ( SBA & Non SBA) & Institutional Deliveries against Reported Deliveries - Apr'12 to Mar'13 Home Non SBA 0.2% Institutional (Pub) 16.8% Institutional (Pvt) 83.0% Kerala - Mallapuram- C sections & Complicated Deliveries Apr'12 to Mar'13 Institutional Deliveries (Public) Institutional Deliveries (Pvt) Total Institutional deliveries Total Deliveries 14,859 73,422 88,281 C Section 4,379 20,472 24,851 C Section% 29.5% 27.9% 28.1% Complicated Pregnancies attended Complicated Pregnancies attended % 3,791 17,166 20, % 23.4% 23.7% Kerala - Mallapuram- C-Section, Complicated & Normal Deliveries against Reported Institutional Deliveries ( Pvt. & Public) Apr'12 to Mar'13 C- section % 28.1% Normal deliveries % 48.1% Complicated Pregnancies attended % 23.7% Monitoring Report, Kerala Page 36

37 Kerala - Mallapuram- Facility wise %ge of C sections & Complicated Deliveries Apr'12 to Mar'13 PHC CHC SDH/DH Other State owned institution Private Facilities Total Complicated deliveries managed ( Reported) Complicated deliveries managed as %ge of total reported ,592-17,166 20, % 0.9% 17.1% 0.0% 81.9% C Section (reported ) ,162-20,472 24,851 C Section as percentage of total reported 0.0% 0.9% 16.7% 0.0% 82.4% Kerala - Mallapuram- Complicated Pregnancies & Deliveries Treated - Apr'12 to Mar'13 Reported Deliveries 88,504 Complicated Pregnancies attended Complicated Pregnancies Rate C - Section Deliveries PNC Maternal Complications Abortions Still Births 20, % 24, , IV Antibiotics Complicated Deliveries Treated with IV antihypertensive/magsulph injection IV Oxytocis Blood Transfusion No Of Eclampsia cases Treated No Of severe anemia cases treated 22, ,605 1, Kerala - Mallapuram- Stay duration as percentage of Reported Institutional Deliveries - Apr'12 to Mar'13 Stay for less than 48 hrs after delivery 6% Stay for more than 48 hrs after delivery 94% Monitoring Report, Kerala Page 37

38 Kerala - Mallapuram - JSY Paid to Mothers as % of reported deliveries - Apr'12 to Mar'13 Deliveries JSY Paid to mothers %age JSY paid against reported deliveries Home % Institutional (Public) 14,859 2, % Institutional ( Accredited - Pvt ) 73, % 16% 14% 12% 10% 8% 6% 4% 2% 0% Kerala - Mallapuram -JSY Paid to Mothers as % of reported deliveries - Apr'12 to Mar'13 15% 2% 1% Home Institutional (Public) Institutional (Pvt) Kerala - Mallapuram-ANC Services - Apr'12 to Mar'13 1,20,000 1,00,000 80,000 69,596 95,518 72,094 78,595 77,728 73,718 76,199 60,000 40,000 26,442 20,000 - Expected Pregnancies - Apr'12 to Mar'13 Total ANC Registration ANC Registration within first trimester ANC registration for JSY 3 ANC check ups TT1 TT2 or Booster 100 IFA tablets given Kerala - Mallapuram- Management of Complications (Reflecting Quality of ANC )against Reported ANC Registration- Apr'12 to Mar'13 Reported %age against reported ANC Registration Hypertensive cases detected at institution % Eclampsia cases managed during delivery % ANC women having Hb level< % ANC women having severe anaemia (Hb<7) treated at institution % Monitoring Report, Kerala Page 38

39 Kerala - Mallapuram- Management of Complications (Reflecting Quality of ANC )against Reported ANC Registration- Apr'12 to Mar' % 22.8% 20.0% 15.0% 10.0% 5.0% 0.0% 4.5% Hypertensive cases detected at institution 0.1% Eclampsia cases managed during delivery ANC women having Hb level<11 0.7% ANC women having severe anaemia (Hb<7) treated at institution Kerala - Mallapuram- Post Natal Check up against Reported deliveries -Apr'12 to Mar'13 120% 100% 97% 101% 80% 60% 40% 20% 0% PNC within 48 hours after deliveries PNC between 48 hours and 14 days of Deliveries Kerala - Mallapuram-Births - Apr'12 to Mar'13 1,00,000 90,000 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000-63,269 Estimated Live Births - Apr'12 to Mar'13 88,565 88,573 Reported Live Birth - Apr'12 to Mar'13 Newborns weighed at birth 10,371 Number of Newborns having weight less than 2.5 kg 83,275 Newborns breast fed within 1 hour Kerala - Mallapuram - Births - Apr'12 to Mar'13 Live Birth - Males Live Birth - females Live Birth - Total Still Births Sex Ratio at birth Still Birth per 1000 live births ( reported) 45,749 42,816 88, Monitoring Report, Kerala Page 39

40 Kerala - Mallapuram-Immunisation ( 0 to 11mnths) Against Estimated Live Births- Apr'12 to Mar'13 160% 140% 120% 100% 80% 60% 40% 20% 0% 141% 114% 119% 114% 8% BCG % DPT3% OPV3% Measles % Fully Immunised % Kerala - Mallapuram-Immunisation ( 0 to 11mnths) Against Reported Live Births- Apr'12 to Mar'13 120% 100% 80% 101% 82% 85% 82% 60% 40% 20% 0% 6% BCG % DPT3% OPV3% Measles % Fully Immunised % 30,000 25,000 Kerala - Mallapuram-Immunisation Sessions- Apr'12 to Mar'13 28,101 27,973 25,298 20,000 15,000 10,000 5,000 - Immunisation sessions planned Immunisation sessions Held Sessions where ASHAs were present Kerala - Mallapuram- Adverse Event Following Immunisation(AEFI) - Apr'12 to Mar'13 Abscess 76 Death 1 Others 206 Kerala - Mallapuram- Immunisation - Dropouts - Apr'12 to Mar'13 Dropout from BCG to DPT3 Dropout from BCG to Measles Dropout from DPT3 to Measles 94% 16% -1393% Monitoring Report, Kerala Page 40

41 Kerala - Mallapuram - Abortions - Apr'12 to Mar'13 MTP Less than 12 weeks MTP More than 12 weeks Abortions (spontaneous/induced) Abortions in Pvt Facilities Abortion Rate against expected pregnancies 16-3,068 1, % Kerala - Mallapuram-Abortions - Apr'12 to Mar'13 MTP less than 12 weeks 0.52% Abortion (spontaneous/induced) 99.48% Kerala - Mallapuram - RTI Cases - Apr'12 to Mar'13 Total OPD Total RTI/STI cases - Male Total RTI/STI cases - Female Total RTI/STI cases RTI/STI cases as %ge of Total OPD Number of wet mount tests conducted 10,859,764 2,421 1,816 4, % 83 Kerala - Mallapuram- RTI Cases -Apr'12 to Mar'13 Female 43% Male 57% Kerala - Mallapuram-Sterilisations - Apr'12 to Mar'13 Monitoring Report, Kerala Page 41

42 Reported %age of Reported Sterilisation Total Sterilisation 11,220 NSV 73 1% Laparoscopic 1,699 15% MiniLap 293 3% Post Partum 9,155 82% Male Sterilisation 73 1% Female Sterilisation 11,147 99% Kerala - Mallapuram-FP Methods - Apr'12 to Mar'13 Reported %age of All Reported FP Methods Total Reported FP Method (All types) Users 24,276 - Sterilisations 11,220 46% IUD 6,701 28% Condom Users 6,068 25% OCP Users 287 1% Limiting Methods 11,220 46% Spacing Methods 13,056 54% Kerala - Mallapuram- Distribution of Family Planning Methods against Total Reported -Apr'12 to Mar'13 Condom Users 25% OCP Users 1% Sterilisations 46% IUD 28% Kerala - Mallapuram- Facility wise % of Sterilisations & IUDs - Apr'12 to Mar'13 Subcenter PHC CHC SDH/DH Other State owned institution Private Facilities NSV as % of total reported 0.0% 0.0% 100.0% 0.0% 0.0% Laparoscopic as % of total reported 0.0% 0.0% 40.3% 0.0% 59.7% Monitoring Report, Kerala Page 42

43 MiniLap as % of total reported Post Partum as % of total reported IUD inserted as % of total reported 0.0% 0.0% 64.2% 0.0% 35.8% 0.0% 1.8% 38.2% 0.0% 60.0% 1.4% 31.7% 14.8% 13.7% 0.0% 38.4% Kerala - Mallapuram- Unmet need ( DLHSIII) met by reported FP Methods - Apr'12 to Mar'13 Estimated total Eligible Couples ( 17% of population) 707, Eligible Couples for unmet need- Calculated Using DLHSIII Unmet need - Kerala - Mallapuram Total reported FP Users - HMIS - Apr'12 to Mar'13 Unmet need met by Reported Family Planning Methods - Apr'12 to Mar'13 Unmet Needs Total ,155 24,276 18% Limiting 8 56,610 11,220 8% Spacing ,546 13,056 10% Kerala - Mallapuram- Service Delivery - Apr'12 to Mar'13 Total OPD Total IPD Operation major (General and spinal anaesthesia) Operation minor (No or local anaesthesia) AYUSH Dental Procedures Adolescent counselling services 10,859, ,504 45,242 55, ,260 3,117 OPD Visit Per 1000 Population IPD per 1000 population Operation major (General and spinal anaesthesia) per Population Operation minor (No or local anaesthesia)as %ge of OPD AYUSH as %ge of OPD Dental Procedures as %ge of OPD Adolescent counselling services as %ge of OPD % 0.0% 0.18% 0.0% Kerala - Mallapuram- Childhood Disease - Vaccine Preventable -Apr'12 to Mar'13 Diphtheria Pertussis Tetanus Neonatorum Tetanus others Polio Measles Kerala - Mallapuram-Childhood Disease - Others - Apr'12 to Mar'13 Diarrhoea and dehydration Malaria Number admitted with Respiratory Infections 6, ,200 Kerala - Mallapuram- Lab Services - Apr'12 to Mar'13 Total Population Total HB tested Total HIV tested Total VDRL Tested Total Widal Test Conducted Blood Smear Examined Monitoring Report, Kerala Page 43

44 4,162, , ,666 65,522 29, ,258 Total OPD HB test conducted as %age of OPD HB<7gm as %age of HB tested HIV test conducted as %age of OPD HIV positive as %age of HIV tested VDRL test conducted as %age of OPD Widal test conducted as %age of OPD Blood Smear Examined as % of Population 10,859, % 1.1% 1.0% 0.1% 0.6% 0.27% 5.77% Monitoring Report, Kerala Page 44

45 Kerala - Mallapuram - Mortality Data - Apr'12 to Mar'13 Monitoring Report, Kerala Page 45

46 Kerala - Mallapuram - Mortality - Major Causes Group - Apr'12 to Mar'13 Death Groups Cause-wise deaths included in the group Reported deaths Communicable Disease, Maternal & Perinatal Maternal & Perinatal, Diarrhoea, Tuberculosis, Respiratory (excluding TB), Malaria, Other Fever related, HIV/AIDS 511 Non communicable disease Heart Disease/ Hypertension, Neurological including Stroke 108 Injuries Others Trauma, Accidents, Burns, Suicide, Animal Bites Other known acute diseases, Other known chronic diseases, Other diseases (Causes not known) Kerala - Mallapuram - Mortality - Major Causes Group -Apr'12 to Mar'13 Others 14.8% Injuries 1.0% Non communicable disease 14.7% Communicable Disease, Maternal & Perinatal 69.5% Kerala - Mallapuram- Still Births, Neonatal, Infant,Under 5 and Maternal Deaths - Apr'12 to Mar'13 Live Births - Reported Live Births -Estimated Still Births Early Neonatal deaths 88,565 63, Monitoring Report, Kerala Page 46

47 Late Neonatal Deaths Infant Death Under 5 Child Deaths Maternal Deaths Kerala - Mallapuram- Still Birth Rate, Perinatal,Neonatal & Infant Mortality Rates - Apr'12 to Mar'13 Against Reported Live Births ( 1000) Against Estimated Live Births ( 1000) Reported Still Birth Reported Perinatal Mortality Reported Neonatal Mortality Reported Infant Mortality Reported Under 5 Child Deaths Reported Maternal Deaths Kerala - Mallapuram - Infant & Child Deaths - Apr'12 to Mar'13 Infant Deaths within 24 hrs of birth Infant Deaths between 24hrs & under 1 week Infant Deaths between 1 week & under 1 month Child Deaths between 1 month & under 1 year Total Infant Deaths Child Deaths between 1yr & under 5years Total Deaths Total Reported % against total deaths 12.3% 39.7% 19.2% 21.9% 93.2% 6.8% Monitoring Report, Kerala Page 47

48 Infant & Child Deaths against reported Infant & Child deaths - Kerala - Mallapuram-Apr'12 to Mar'13 Child Deaths between 1yr& under 5years 6.8% Infant Deaths within 24 hrs of birth 12.3% Child Deaths between 1 month & under 1 year 21.9% Infant Deaths between 1 week & under 1 month 19.2% Infant Deaths between 24hrs & under 1 week 39.7% Kerala - Mallapuram- Causes of Infant & Child Deaths - Apr'12 to Mar'13 - Total Deaths - 64 Sepsis Asphyxia LBW Up to 1 Weeks of Birth Between 1 week & 4 weeks of birth Total Up to 1 Weeks of Birth Between 1 week & 4 weeks of birth Total Up to 1 Weeks of Birth Between 1 week & 4 weeks of birth Total Pneumonia Diarrhoea Fever related Between 1 month and 11 months Between 1 year & 5 years Total Between 1 month and 11 months Between 1 year & 5 years Total Between 1 month and 11 months Between 1 year & 5 years Total Measels Others ( For age upto 4 weks of Birth) Others( For age from 1 month to 5 yrs) Between 1 month and 11 months Between 1 year & 5 years Total Up to 1 Weeks of Birth Between 1 week & 4 weeks of birth Total Between 1 month and 11 months Between 1 year & 5 years Total Monitoring Report, Kerala Page 48

49 Kerala - Mallapuram - Causes of Infant & Child Deaths against total reported infant & child deaths-apr'12 to Mar'13 Asphyxia 17% LBW 14% Others 62% Pneumonia 5% Fever related 2% Kerala - Mallapuram - Known Causes of Infant & Child Deaths against total reported known causes of infant & child deaths -Apr'12 to Mar'13 Pneumonia 13% Fever related 4% Asphyxia 46% LBW 38% Monitoring Report, Kerala Page 49

50 Kerala - MallapuramMaternal Deaths & Causes-Apr'12 to Mar'13 Causes Reported % against total reported % against total reported known causes Abortion - 0.0% 0.0% Obstructed/prolonged labour - 0.0% 0.0% Severe hypertension/fits - 0.0% 0.0% Bleeding % 100.0% High Fever - 0.0% 0.0% Other Causes - 0.0% Total 2 Kerala - Mallapuram - Causes of deaths above 6 yrs of age-apr'12 to Mar' yrs yrs. Above 55yrs Total Diarrhoeal Diseases Tuberculosis Respiratory Diseases (Other than TB) Malaria Other fever Related HIV/AIDS Heart Disease/ Hypertension related Neurological Disease including strokes Trauma/Accidents/ Burn Cases Suicide Animal Bites & Stings Known Acute Disease Known Chronic Disease Causes not known Total Deaths Monitoring Report, Kerala Page 50

51 Kerala - Mallapuram - Known causes of deaths 6 yrs & above against total reported Known causes of deaths 6 yrs & above - Apr'12 to Mar'13 Known Acute Disease 1.7% Suicide 3.3% Known Chronic Disease 20.7% Diarrhoeal Diseases 0.8% Tuberculosis 0.8% Respiratory Diseases (Other than TB) 16.5% Malaria 0.8% Other fever Related 0.8% Trauma/Accidents/ Burn Cases 2.5% Neurological Disease including strokes 16.5% Heart Disease/ Hypertension related 35.5% Monitoring Report, Kerala Page 51