Fact-Finding on NRHM Facilities in Sikkim. Introduction

Fact-Finding on NRHM Facilities in Sikkim 20 th 21 st May 2014 Introduction From May 20 th to 21 st 2014 two health activists from Delhi and Gangtok travelled to a District Hospital (DH), a Primary Health Centre (PHC), Pakyong PHC and Sir Thodup Namgyal Memorial (S.T.N.M.) Hospital Gangtok to investigate the standards of care of National Rural Health Mission (NRHM) facilities in Sikkim. At the various institutions the activists were able to speak to a wide range of people, including doctors, nurses, administrators and patients. While they were inspired to meet many dedicated medical professionals working hard for their communities, they found that every institution they visited failed to comply with basic NRHM service guarantees as set by the Indian Public Health Standards (IPHS). Allowing NRHM institutions to suffer from frequent electricity shortages, a lack of necessary equipment or severe understaffing that does not meet IPHS stipulations is a failure on the part of the state to protect the fundamental rights to life, health, and dignity enshrined in Article 21 of the Constitution. Below is a report of the outcomes of this two-day fact-finding, and the major issues of concern that the health activists would recommend to the NRHM as critical to be improved upon as soon as possible. Major Issues of Concern Based on visits to four facilities and interviews with medical professionals, patients, and families, the fact-finding team identified the following major issues of concern: 1. Roads and Transport. Almost every medical professional we spoke to said the biggest challenge they face is that of transportation given the dispersed population, difficult terrain and poor roads of the state. Although the Janani Shishu Suraksha Karyakram (JSSK) guarantees free transport from patients homes to the facilities, there are still no services in all of Sikkim to help patients reach the first level of care from their villages. A delay in reaching care, especially emergency obstetric care, is one of the primary causes of maternal mortality. According to the International Covenant on Economic, Social and Cultural Rights, which India is a state party to, the state has an obligation to create accessible health facilities. Sikkim should look to provide something similar to the 108 ambulances that exist in other states. In the meantime, it is vital that careful attention is made to ensure all those who are

entitled to JSSK payments to help them cover the costs of private transportation receive them. The team also found that limited transportation results in substandard postnatal care and adequate discharge procedures as patients often rush to get back to their villages before the last shared taxi of the day, around 2pm. Doctors cannot keep patients for monitoring or provide adequate follow-up care. Under JSSK, the government has an obligation to provide adequate transport to pregnant and lactating women. Moreover, to ensure the right to health as enshrined in the Constitution, all patients should have easy access to health facilities. Therefore it is necessary that the District Hospitals provide transportation services to help patients get back to their villages. Another complaint we heard from doctors is that sometimes the hospital does not have money for petrol, so the ambulances are there, but cannot run. Some doctors are dedicated enough to pay for fuel out of their pocket but say they are still waiting for many years worth of reimbursements from the state. Any doctors currently awaiting reimbursement should receive it as soon as possible and care should be made to ensure sufficient funds are made available for fuel costs. 2. Staffing. Almost every institution we visited had complaints about insufficient staffing. The most necessary measure is to hire more nurses to ensure doctors have the support they need and avoid them spending time on simple procedures that nurses can handle. This will then free up doctors time for more urgent matters, as patients in critical condition wait several hours before seeing a doctor. It is also important to make sure all the DHs have all the necessary specialists under NRHM guarantees. Measures should also be taken to help remote outposts get sufficient staff by providing incentives. 3. Equipment. Every single institution we visited had some vital equipment that was either not available or broken. For example, DHs should have ECGs to prevent avoidable infant deaths, and basic lab facilities and a pathologist to prevent over-referring to STNM Gangtok. For these and other reasons, the state must ensure that all necessary equipment is made available at the appropriate institutional levels, with all the necessary parts and technicians for it to function. A list of necessary equipment according to the IPHS for Sub Centres, PHCs and DHs can be found below. When equipment is broken or parts are missing, doctors should not have to waste time making applications for over two years waiting for it to be fixed. In the meantime expensive equipment may rust or become unusable leading to a waste of resources. 4. Blood banks. Two District Hospitals in Sikkim are still not compliant with the Indian Public Health Standards (IPHS) in ensuring they are able to provide

this essential and life-saving facility. At the District Hospital we visited, funding has already been approved so we hope that the process is completed on time to prevent any further delay of this critical aspect of emergency care. 5. Operating theatres (OT). That the District Hospital visited below does not have an OT is shocking and a denial of life saving services for patients. PHCs should also have minor OTs as required under the IPHS, the one we visited did not have a minor OT, nor were any plans evident to construct one anytime soon. 6. Electricity. That the PHC visited below does not have electricity most days of the week is shocking and should not be the case. Electricity is vital to operate much life-saving equipment, and according to the IPHS must be available even at the Sub-Centre (SCs) and PHC level. We therefore demand that all PHCs in Sikkim get functioning generators as soon as possible, and SCs get invertors or solar equipment. 7. Referrals. STNM Hospital in Gangtok is still greatly overburdened. There are massive bed shortages and patients have to wait many hours before they are able to see a doctor. The state should implement a centralised and accountable referral system that sends patients to the most appropriate facility according to the patient s medical needs and provides patients with the following minimum information at the time of their referral: (1) the name of the referral facility, (2) the contact information of the referral facility, including the name, address, and phone number of the receiving staff member, (3) the reason for referral, (4) the diagnosis and treatment to be sought at the referral facility, (5) the contact information of the referring hospital in case of questions or concerns, (6) copies of all medical records and discharge slip(s), and (7) free transport for BPL patients. The state should also undertake a comprehensive investigation into referrals in the state. How many people come directly to STNM without being referred from their local NRHM institution? How many are referred from SCs, PHCs and DHs and for what reasons? How many die enroute? Where are most referrals coming from? These results should illuminate where interventions in the referral system are most urgent. 8. STNM Hospital Gangtok and Manipal Hospital. STNM itself makes many referrals to Manipal Hospital, a private institution, either because the cases are too complicated and STNM doesn t have the capacity to treat them, or it is too crowded. Because Manipal is a private hospital, patients have to pay for care, leaving many low-income patients unable to access emergency care due to prohibitive costs. As the highest level of government care in the state, STNM should ensure it has all the necessary equipment, staff and beds to deal with all cases. Patients should also not have to wait long hours to see a doctor

or get a bed. In the meantime, BPL and APL patients referred to Manipal from STNM should receive all care free of charge. 9. Trauma centre. Given the poor condition of roads in many parts of Sikkim, the risk of landslides and the high number of road accidents it is vital that DHs have trauma centres and resident orthopaedists to be able to deal with emergency cases. Such trauma patients cannot afford to make the long and difficult road journey to STNM Gangtok and often die enroute. 10. Medicines. We found several cases of drug shortages during our fact-finding, including iron folic acid and calcium pills necessary for women in pregnancy, hypertension medication and antacids. We met pregnant women who then had to buy the necessary pills from chemists at their own cost, when they should be available free of charge under the guarantees in the NRHM and the National List of Essential Medicines. Moreover, the High Court ordered the state to ensure adequate provisions of medicines in its order dated XXXXX. 11. Reproductive Services The DH we visited is no longer conducting medical termination of pregnancy (MTP), a guaranteed service under NRHM at that level of care. They also do not provide sterilizations. Women have to travel all the way to Gangtok s already overcrowded gynaecology ward to receive these basic reproductive services. Given that there is a high incidence of complications from illicit abortions it is clear that MTP is a highly needed service and the fact that women are not able to access it is greatly endangering their health. 12. JSY payments. ASHAs report difficulties with helping women receive their JSY checks (and therefore get their own payment) if the women do not have the necessary documentation to get a bank account, as all JSY payments are done through account transfers. This was particularly a problem in Pakyong PHC where there is a high population of migrant workers who often lack necessary documentation, like an ID card. Hospitals should be able to have the flexibility to give JSY payments by cash or check to such patients. 13. Sanitation. Much work needs to be done to ensure all toilets in all facilities are in good working condition, cleaned regularly and rules regarding men and women s toilets are upheld as per IPHS norms.

Findings 1. District Hospital The toilets on the ground floor were in complete disrepair and were very filthy. Hospital Administrator Upon arriving at the District Hospital (DH), the activists first spoke with an administrator: Blood Bank - The administrator told them that there is currently no blood bank at the hospital, but it will hopefully be completed by the end of May 2014. The hospital has written the proposal and apparently the funding has been approved. Referrals - The DH gets only about 2-3 referrals a month from the PHCs that come under it. This is because most patients choose to go straight from the PHC to STNM Hospital as they believe it offers better care than at the DH. They themselves do 7-8 referrals a month to STNM MMR and IMR - There were 2 maternal deaths in the last year, for which audits were completed. He did not have details on these audits or where we could get copies of them, but recommended we ask the gynaecologist. There were 13 infant mortalities in the last year, for which he recommended we speak to the paediatrician. Staffing - There are currently 9 doctors, of which 3 are specialists a gynaecologist, paediatrician and dental surgeon. They are still trying to fill some positions for more doctors. There are 10 nurses. There are 84 ASHAs under this hospital. Most of the

deliveries come through the ASHAs. JSY payments happen for all institutional deliveries and are made directly through the patient s bank account. Infrastructure - They have a generator so there are no problems with electricity. However internet is a big problem for them to complete their reporting and administration work. DOTS Programme Staff There are currently about 60 TB patients registered in this area. There are new strict rules about ensuring that all cases are registered, so they are quite sure these are all the cases. Often the ASHAs or anganwadi workers are helpful in referring TB patients to them. However, they have a small problem with alcoholic patients who often discontinue their drug regime because they do not want to give up alcohol, which cannot be taken with the medication. Senior Hospital Administrator This senior administrator was kind enough to speak with us and give us their honest perspective on the functioning of the hospital: Roads and Transportation This, compounded with the fact they are situated in an earthquake-prone area, is the biggest challenge they face. The hospital has 2 ambulances, which are only used for transporting patients to Gangtok. They normally make 3-4 journeys a day. The PHCs each have one ambulance that brings patients to the DH or Gangtok. It is quite rare that the PHCs send patients to the DH (1-2 times in a month). Mostly they are sent to Gangtok. Presently transport is working fine but sometimes they are not able to cope with demand. Many patients pay for private transportation. After the earthquake villagers had to walk to reach healthcare facilities. Even if it tried, the ambulance was unable to reach them. Currently there is still no vehicle available to transport patients or women in labour from their villages in an emergency to any health facility. Sometimes patients are even carried by hand. Referrals - Previously almost all patients would want to be transferred directly to Gangtok, however since November 2013 when they employed a gynaecologist and paediatrician many more stay. Before they were making over 200 referrals a month. Already this month they have done 32 referrals, and there are still 10 days of May left. ASHAs - To improve access to healthcare they have focused on training ASHAs. The hospital holds monthly trainings to improve ASHAs skills. They are trained to recognize complicated cases and make an effort to reach the most remote places. Often if an ASHA is going to a particularly far off place she will send messages a few

days before and call all patients to one particular place. Last month there was a training in a nearby PHC which the NRHM Director Sikkim attended he takes ASHAs very seriously. There are 27 ASHAs under this DH area alone, they are the backbone of the system. We are so grateful to our ASHAs go see for your own eyes how difficult it is to do the work they do. Even our doctors they are almost all ladies in Sikkim, and to be living in some of the remote PHCs is very difficult for them but they work hard. Mobile Medical Unit The MMU used to be sent out to a different place at least every day. However, since the earthquake many of the roads are very destroyed and this MMU bus can t pass them. It has a lot of equipment including a sonogram, x-ray equipment, etc., but is currently not being utilized. For now visits are made in a normal vehicle with 1-2 doctors, a nurse and pharmacist. Blood Bank / Operating Theatre - They have already started work on the blood bank, it should be completed in the next month. They are also starting construction of the operating theatre, which should be ready in the next 3 months. Once these two are complete they will need to make even fewer referrals. Staffing - They still need to hire one more specialists, though they didn t specify which posts. Right now every Friday the following specialists come from Gangtok for the day: A&T, ophthalmologist, psychologist, and others. This is one of the biggest challenges they face maintaining sufficient numbers of staff. Trauma Centre Speaking honestly with us, the administrator told us the thing the hospital actually needs most is a trauma centre. Road accidents is the biggest health problem they have to deal with, especially because of the bad road conditions described above; for six months of the year there are heavy rains and landslides. This is a health problem that also affects tourists greatly. Yet, they don t even have a trauma centre or a resident orthopaedic. Often casualties die on their way to STNM. Every year for the last few years they have sent a proposal for a trauma centre but they get no response. They generally get between 5-10 trauma cases a month. Paediatrician Importance of specialists in remote areas The paediatrician told us it feels good to be posted at the DH. This is especially because there are some patients that are too poor to be able to travel to Gangtok, so it is important that they are able to see a doctor locally. Roads and Transportation - The main challenge they have seen their patients face is the road conditions. Many of them live far away and it is difficult for them to reach the hospital in time. Also, when they do make it to the hospital, they have to leave by 2:30pm or they will not find a vehicle to take them back to their village so she cannot keep them for observation. Often because of the distance, parents do not bring their children back for follow-up appointments and instead show them to local

doctors or witchdoctors, which can be dangerous. They only make the long journey when it seems really serious, and by that time it is often too late. Lab facilities - They are also lacking good lab facilities. There is a basic lab here, but there is no pathologist, which creates problems. It takes too long to send samples to Gangtok and wait for results so they end up referring such cases. If it looks like the results will take time they usually recommend that the patients stay in Gangtok to wait for the results and see what follow-up care will be needed, but that is also expensive for patients. Infant Mortality - The main cause of infant mortality in this area is acute respiratory infections. Unfortunately they are also lacking ECG equipment, so many new-borns go undiagnosed. Staffing One of the biggest problems they face is that they are very understaffed, especially when it comes to nurses. Pharmacist Sometimes they face shortages with medicines, especially anti-hypertension drugs and antacids. Gynaecologist The AYUSH doctor was helping the gynaecologist with her consultations when we walked in. We, and a long line of patients, had been waiting several hours to meet her. It appears she is a busy woman and her services are highly in demand. The AYUSH doctor told us the biggest ailments she treats are hypertension, gastritis and diabetes. We were present while the gynaecologist was handling one consultation. She was discussing with the patient, and asked her who her ASHA is, supplying a few names of the ASHAs who work in the patient s area. She clearly knows the ASHAs well, and works closely with them. Maternal complications - The main causes of maternal complications are anaemia, which is quite common amongst women, and PI hypertension. Blood / OT - Most complications she refers to STNM because they do not have any blood facility or an OT. She knows that the OT and blood bank are in the process of being set up but doesn t know when they will be completed. They really need to be able to do blood transfusions to save lives. Staffing - The other main challenge is a big lack of nurses.

Maternal deaths - Of the two maternal deaths that took place in the last year, one was caused by atonic post-partum haemorrhage. The other was referred to STNM and she doesn t know the details. Contraception - Awareness of contraception is extremely high, although only about 60% of women use modern contraceptives. Most use injections. They don t do sterilizations at the DH. These are available at STNM, but the frequency is quite low. Medical termination of pregnancy Previously these used to happen more, about 7 a month, however now due to personal problems she is not performing them so there are fewer, despite the fact this is a guaranteed service under the NRHM. Patient in maternity ward This patient had just had a miscarriage. She was in her village and bleeding, so she came to the hospital. They did an ultrasound and the doctor told her she has lost the baby, so now she is waiting for it to be flushed out. She doesn t know the cause yet. Transport - It was very difficult for her to get here, transportation in this area is not easy. Challenges facing migrants - She does not know who the ASHA in her area is, and had not seen any, because she just moved here from West Sikkim.

2. Primary Health Centre Administrator The hospital is open from 10-2, or until the last patients of the day are finished. After that the doctor and two nurses live on site and all the locals know their numbers or how to find their homes so they are always on call. They usually have about 20-30 patients a day. Currently there aren t any inpatients. Referrals and Transportation - They do several referrals to STNM a week. They have one ambulance, which makes these trips, which are almost always to Gangtok. Patients usually get to the PHC by taxi or walking. The SCs rarely refer patients to them but send the patients straight to the DH, or, more likely, Gangtok. Staffing - There are 2 doctors, but one is currently on maternity leave, altogether they have about 20 staff. This includes 3 nurses, 2 compounders, drivers, etc. Electricity The biggest problem they face is power cuts. They have a back up invertor, but whenever it rains which is very often there is no electricity. When the team visited, the facility did not have power. Medical Officer The doctor has been working here for 4-5 months. They usually have about 5-8 deliveries a month. Referrals - They do about 2 referrals a week. These referrals are almost always trauma cases or deliveries. They always send them to Gangtok since Mangan doesn t have the facilities to handle these cases. Equipment The facility requires, an x-ray, a minor OT, a generator, and an autoclave. They usually have oxygen cylinders. At this very moment they need to get them replaced, but they are always available on a monthly basis. Another problem they face is with maintenance of equipment. This is a very slow process and often they find nothing happens. All the equipment is there, and much of it is good, but unusable. This equipment is extremely important, especially for many trauma cases. For example, because there is no x-ray they have to send patients to the DH. Electricity - Electricity is a big problem. They used to have a generator but it broke a year ago. They made an application for it to be fixed and at some point someone came to look at it, but nothing has happened. They complained that these things always take a long time, if they happen at all.

Contraception - Most women use Mala or Mala-D for contraception. IUDs are less popular, although they are available at the PHC. No MTP is available, for that they have to go to the DH (the same one where we just heard that it is no longer available). However, people often take illegal medication to try and induce abortions, which causes problems. This happens because many people are hesitant to ask for an abortion and drugs are very easy to get. She gets at least 2 cases of complications from abortions a month, so it is quite common. They have wondered if it is due to a problem in their family planning programme. People often also appear to be quite shy about telling ASHAs they have conceived and don t feel comfortable to discuss these issues openly. Maternal and infant deaths - In January there was one maternal death at an SC under this PHC. It was a home delivery, and there was a uterine inversion. Luckily, home deliveries are much fewer these days. There was also one infant death in the last few months. He was born with a low birth weight, they referred the family to Gangtok, where he was treated, and then discharged but then unexpectedly died after being discharged. Staffing - NRHM has really strengthened the PHCs and SCs in the last few years. The main thing lacking now is staffing there is only one Assistant Nurse Midwife here and one Medical Officer (MO). The other MO is on maternity leave and there is no sub. So whenever the MO has to go somewhere the station is empty.

3. Pakyong Primary Health Centre Nurse There are three Medical Officers 1 dental surgeon, 1 chief medical officer, 1 general MO, 12 nurses (which amounts to more nurses than the DH above). They see 100-200 patients a day, and have about 5-15 deliveries a month. They have one ambulance, which they use for referrals to Manipal or Gangtok, about 2-4 a day. In violation of NRHM service guarantees, they only do emergency MTPs if someone comes in with an incomplete abortion. Otherwise they refer the patients to STNM. ASHA The Reproductive and Child Health Centre at Pakyong is large, spacious and well equipped. The airport company recently donated it as part of its local CSR efforts. They don t actually do many deliveries here in Pakyong because many women prefer to go to STNM of their own accord since it is so close. In addition, all first deliveries are referred to STNM, as well as any complications. The few deliveries that take place in Pakyong are mostly with poor women from nearby villages who are unable to make it to Gangtok. The ASHA has been working in the area since 2007. Up until 2011 she was doing it as social work. Since then ASHAs have started to be paid by the state on a commission basis. She is also an ASHA facilitator for trainings and has 10 ASHAs working under her. She says support for ASHAs in Sikkim is very good there are lots of trainings, they have fully stocked kits that are easy to replenish. There are 37 ASHAs in the Pakyong area, all doing good work. Almost all births are institutional. There have been no maternal deaths in the last year. JSY Payments - With JSY they have a big problem with bank accounts. Many mothers are from outside Sikkim and don t have an ID card. Therefore it is not possible for them to get a bank account. So they don t receive JSY money, and neither do the ASHAs. In general ASHAs face problems with any patients who do not have sufficient documentation. Roads and Transportation - The biggest problem they face with maternal complications is that there are so many remote villages that are hard to reach. This is especially true during the monsoon season when many roads become unpassable. Sometimes ASHAs are forced to do emergency home deliveries, which they are trained to do. But they don t like doing that, it is difficult without support and equipment and it is often not clean. Thankfully so far, in the time that she has been an ASHA she has never had to deal with any complications.

Migrant patients - Another big problem that they face in the maternal and child health ward is inconsistency with patients attending the PHC. The reason they cited for this is the high number of migrant workers and their families who have moved to Pakyong in recent years to work on the airport. Many of them may come to the PHC for the first time in their last trimester, so all their check ups are late. Or, they may unexpectedly return back to their homes, not receiving all their check ups. The same is true for vaccinations for their children. Many families have gone back before their children have received their full immunization course. Doctor from DH Travelling from the Pakyong PHC, the activists met a doctor employed at a different DH who reported the following: Equipment - There is lots of expensive equipment at the hospital that is completely unused because one part might have been forgotten when the equipment was originally delivered, it might be lost now, or some part might be broken. Despite multiple inquiries for repair by doctors, they get little response and progress is very slow. Fuel and Transportation - While they do have an ambulance, often they do not have any money for fuel for the vehicle. As a doctor who cares deeply about the lives of her patients she believes the ambulance must continue its operations and for over a year paid for fuel for the ambulance out of her own pockets, and is still awaiting reimbursement. Often not all patients are able to get the ambulance services they need since there are only three. Therefore they have to decide who gets to use the ambulance by balancing economic ability to pay with urgency of the patient s condition. The remaining patients have to use private transportation.

4. STNM Hospital Gangtok Maternity Ward When we walked into the maternity ward at STNM Hospital it was 8:00pm. The corridor was filled with patients who had put down bedding ready to spend the night on the floor. We spoke to one woman who was lying on the floor who said she was bleeding and the doctor had asked her to stay, she didn t know what the problem was yet. She was waiting until she would be able to see the doctor the next day. She was in a lot of pain. Because it was so late we were unable to speak with any doctors, however we were able to speak to a room of nurses and nurse interns and several patients. The hospital has more than 10 deliveries a day, and up to 5 caesarean sections. Despite efforts to build new toilets outside for visitors, the toilets in the ward are still being used to male and female visitors, as well as to wash clothes and utensils in. There are signs that say, Women Only that are being completely disregarded. There needs to be someone there to enforce these rules to prevent the toilets from descending into the unhygienic state that we found them in.

Woman from North Sikkim The ASHA in her village was very good and she got all the necessary antenatal check-ups and 3 injections. Lack of trust in District Hospital - She didn t go to the District Hospital because she doesn t feel comfortable with the quality of care there. She feels safer to come to STNM. Paying for medicines - All of the medicines she has needed since she was pregnant including since she arrived at the hospital now she has had to pay for, except the calcium and iron pills. Couple from Tadong Shortage of pills - She came to STNM for all her ANCs, all medication was meant to be free. However, in the middle they ran out of iron and calcium pills and so she had to buy them herself from a chemist at her own cost. Woman from Pakyong She went to Pakyong PHC but her baby was facing the wrong direction, so they referred her here. The ASHAs were good and helped her to get to STNM and get medicines. Long waits for beds and to see doctor - She arrived her at 10am, and got a bed at 4pm. She saw a doctor finally at 7pm. She is still in labour. Woman from Laksam (West Sikkim) She first went to the small dispensary in Laksam where they gave her all the necessary injections during her pregnancy and the ASHA was very helpful. It is half an hour from where she lives to Geyzing DH, where she was referred for one of her antenatal check ups. They detected that there is water in her baby s brain so they referred her to Gangtok. Lack of beds - She and her husband arrived in Gangtok on May 2 nd, but there were no beds so they had to stay in a hotel for a night. They were admitted on May 3 rd and have been there since (May 21 st ). Her baby was born on the 16 th, and is currently in ICU. They are waiting for the baby to be discharged and then they will return to Laksem. Nurses Equipment - Biggest thing they need is a ventilator in the neonates ICU. There is also only one incubator. The ICU is overall not well equipped, so if the condition is serious or more than one baby needs an incubator then it is referred to Manipal. When we asked if they have enough equipment, they joked, Whatever was there when the Chogyal left, that s all we have, continuing to say that there are many shortages and a lot of equipment is quite old. For example, they don t have a baby suction, which is very important and right now they have to do it by hand.

Referrals - Even here referrals are made, any truly serious cases are referred to Manipal, but at the patient s own cost. Patients come from all districts, some come themselves and many are referred by the District Hospitals. Normally the staff at the district hospitals doesn t refer them straight away, but the patients request strongly to be referred directly upon arrival. Staffing - They are extremely understaffed with nurses. Especially for the evening and night shift when there are only two nurses for all the patients, and one doctor is on call. There are 6 doctors. Beds - Beds is also a big problem with a huge shortage. Sometimes there are patients lying on the floor stretching all the way out to the main gate. Patients are also discharged far too soon after delivery, even 2 hours afterwards in order to free up the beds. Maternal deaths - They have very few maternal deaths, though they were unable to give an exact number, but they said the major causes were lack of follow-up of ANCs, and eclampsia.

Sub Centres List of Necessary Equipment according to IPHS

Primary Health Centres

District Hospitals