NIPI REFERENCE BOOK (BIHAR)

November/2011 ACCESS HEALTH INTERNATIONAL NIPI REFERENCE BOOK (BIHAR) Bihar Ikram Khan, Priya Anant and Prabal Singh

Purpose of this Book This book is a compilation of data from various sources relevant to our work on the Norway India Partnership Initiative (NIPI) Funded project Government contracting for improved health services in Bihar. We have used data from various sources and structured it to serve as a quick reference guide. We have acknowledged the source in most places, but apologise for omissions if any. This resource book would be updated with data once a year and would be available online, meant for others interested in infant health in Bihar. Thanks, Priya Anant, Associate Director ACCESS Health International 2

Contents Chapter-1... 7 1. Healthcare in Bihar... 8 1.1 Introduction... 8 1.2 Health Systems and Structure... 9 1.3 Health Infrastructure... 13 1.4 Human Resources... 14 1.5 State Health Budget Trend... 15 1.6 Important Issues concerning Health in Bihar... 18 1.7 Initiatives... 21 1.8 Recent Reforms in Health... 25 Chapter-2... 27 2. Maternal & Child Healthcare Status in Bihar... 28 2.1 Maternal and Child Health Indicators of Bihar... 28 2.2 Key Achievements in MCH in Bihar... 31 2.3 State Schemes to Improve Maternal and Child Health... 33 Chapter-3... 38 3. Public Private Partnership (PPP)... 39 3.1 Key stakeholders in Healthcare s PPP... 39 3.1.1 Department for International Development (DFID)... 39 3.1.2 Norway- India Partnership Initiative (NIPI)... 40 3.2 PPP Initiatives by Health Department, GoB... 41 3.3 PPP in Rest of India and World on MCH... 45 3.3.1 Chiranjeevi Yojana (CY)... 45 3.3.1 Janani... 47 3.3.2 Child Helpline International... 48 3.3.3 RapidSMS Malawi... 49 3.3.4 Vietnam s Nutritious Food Program... 50 3.3.5 Karra Society for Rural Action... 51 3.3.6 Wired Mothers... 51 Chapter-4... 53 4. District Profile... 54 4.1 Nalanda... 54 4.1.1 Introduction... 54 3

4.1.2 District Health System... 58 4.1.3 Health Infrastructure... 60 4.1.4 Nalanda Facility Survey Findings... 62 4.2 Jehanabad... 67 4.2.1 Introduction... 67 4.2.2 Health System... 70 4.2.3 Health Infrastructure... 72 4.2.4 Jehanabad Facility Survey Findings... 76 4.3 Sheikhpura... 81 4.3.1 Introduction... 81 4.3.2 District health System... 85 4.3.3 Health Infrastructure... 85 4.3.4 Sheikhpura Facility Survey Findings... 87 Chapter-5... 92 5. Maternal and Child Health in NIPI s focus districts... 93 5.1 Maternal Health... 93 5.1.1 Delivery Care... 93 5.1.2. Institutional delivery... 96 5.1.3 Postnatal Care... 100 5.2 Newborn Care... 102 5.2.1 Breastfeeding and Supplementation... 103 5.2.2 Child Morbidity and Treatment... 108 5.2.3 Summary Observation... 110 5.3 Child Immunization... 111 5.3.1 Vaccination coverage... 112 Chapter-6... 116 6. Resource Persons... 117 6.1 List of Resource Person at State Level... 117 6.2 List of Resource person at District Level... 118 6.3 NGOs in Bihar... 121 Works Cited... 126 Appendix-I... 129 4

List of Tables Table 1: Demographic, Socio-economic and Health profile of Bihar State as compared to India... 8 Table 2: Health Provider consulted by Patients for Treatment (%)... 9 Table 3: Infant Mortality Rate (SRS-09)... 9 Table 4: Health Infrastructure of Bihar... 13 Table 5 : Health Institution... 14 Table 6 Public Health Personnel... 15 Table 7 Availability of nursing education programmes in India and Bihar... 15 Table 8 Analysis of Health Budget of Bihar (Rupees in Crore)... 16 Table 9 Allocation by GoI under NRHM to Bihar State (INR in Crore)... 16 Table 10 Public Health Subsidies in Bihar... 17 Table 11 Cost drivers of Department of H& FW and NRHM at State Level (Rs in Crore)... 17 Table 12 New Super Specialty Units in Medical Colleges... 21 Table 13 Trends in Infant Mortality Rate in Bihar and India... 28 Table 14: Infant mortality rate by sex and residence, 2009 (SRS-09)... 28 Table 15 RCH II Goals (Bihar State Report)... 29 Table 16 RCH II Outcomes (Bihar State Report)... 29 Table 17 Maternal and Child health Profile of NIPI focused districts and Bihar State... 29 Table 18: Trends in Child Mortality Rate in Bihar and India... 30 Table 19 Distribution of Women Receiving Pre-Natal Care by Source of Care... 30 Table 20 Stakeholder roles in a Healthcare PPP... 39 Table 21: Nalanda At A Glance (Nalanda DHP, 2010)... 54 Table 22: Comparative Population data (2001 Census) (Nalanda_DHP, 2010)... 55 Table 23: Health Indicator... 58 Table 24: Institutional Delivery in Nalanda district (PHC wise) (Nalanda_DHP, 2010)... 58 Table 25 MCH Indicators in Nalanda district... 59 Table 26: Public Health Care Delivery System: Organisational Structure and Infrastructure... 61 Table 27: Health Infrastructure... 62 Table 28: Statistical Profile (based on 2001 census) (Jehanabad_DHP, 2009)... 68 Table 29: Other Important data :- (Jehanabad_DHP, 2009)... 68 Table 30: Health Indicators... 70 Table 31 MCH Indicators in Jehanabad district... 71 Table 32: Health Infrastructure... 74 Table 33: Final Budget of Jehanabad... 75 Table 34 MCH Indicators in Sheikhpura district... 83 Table 35: Health Infrastructure... 85 Table 36: Human Resource... 86 Table 37: Place of delivery v/s number of living children, NIPI-08... 94 Table 38: Place of delivery v/s economic status of respondents household, NIPI-08... 95 Table 39: Average transportation expenses (in Rupees), NIPI-08... 96 Table 40: Nature of Institutional delivery, NIPI-08... 96 Table 41: Cost incurred in institutional delivery1, NIPI-08... 97 5

Table 42: Problem experienced during delivery by women of different age groups, NIPI-08... 98 Table 43: Reason for home delivery, NIPI-08... 98 Table 44: Reasons behind choosing a specific person to conduct the delivery, NIPI-08... 99 Table 45: Cost incurred in home delivery, NIPI-08... 100 Table 46: Timings of First Post Natal Care, NIPI-08... 101 Table 47: Timing of first neonatal check-up by Districts, NIPI-08... 103 Table 48: Breastfeeding practices, NIPI-08... 104 Table 49: Initiation of breastfeed and gender of child, NIPI-08... 105 Table 50: Feeding of prelacteal liquids, NIPI-08... 106 Table 51: Period of exclusive breastfeeding by background variables, NIPI-08... 107 Table 52: Prevalence of illness in children under study, NIPI-08... 109 Table 53: BCG and Polio 0 coverage by background variables, NIPI-08... 112 Table 54: Child Immunisation Coverage in NIPI Districts, Bihar... 113 Table 55: Immunization coverage all basic vaccines... 114 Table 56: Problems faced by mother/community in vaccinating the child, NIPI-08... 115 List of Figure Figure 1: District Health Society-Organogram... 11 Figure 2 Health Expenditure distribution 2007-08... 18 Figure 3: District Health Administrative Setup (Nalanda_DHP, 2010)... 57 Figure 4 Nalanda District... 59 Figure 5 Jehanabad District... 71 Figure 6: Health Facility in Jehanabad... 73 Figure 7 Sheikhpura District... 83 6

Chapter-1 Healthcare in Bihar 7

1. Healthcare in Bihar 1.1 Introduction Bihar with a population of 104 million is the second most populous state in India, next only to Uttar Pradesh. Despite efforts in the last few decades to stabilize population growth, the state s population continues to grow at a much faster rate (25.07 percent) than the national population (17.6 percent) in terms of decennial growth. The state is densely populated with 880 persons per square kilometer as against the country average of 324. The sex ratio of the state at 916 females per 1000 males is also less favorable than the national average of 940 females per 1000 males. The state has 38 districts divided into 9 administrative divisions. In addition, the state has 101 sub-divisions, 534 community development blocks, 9 urban agglomerations, 130 towns and 37,741 villages. All key health indicators in Bihar are worse than the national average. Increasing fertility, lack of improvement in antenatal care and worsening of under-nourishment amongst children are key areas of concern. In other areas there is improvement, albeit very minimal. Table 1: Demographic, Socio-economic and Health profile of Bihar State as compared to India S. No. Item Bihar India 1 Total population (Census 2011) (in millions) 103.8 1210.19 2 Decadal Growth (Census 2011) (%) 25.07 17.6 3 Crude Birth Rate (SRS 2008) 28.9 22.8 4 Crude Death Rate (SRS 2008) 7.3 7.4 5 Total Fertility Rate (SRS 2007) 3.9 2.6 6 Infant Mortality Rate (SRS, 2009 & AHS 2010-55* 50 11*) 7 Maternal Mortality Ratio (SRS 2007-2009) 261 212 8 Sex Ratio (Census 2011) 916 940 9 Population below Poverty line (%) 42.60 26.10 10 Schedule Caste population (in millions) 13.05 166.64 11 Schedule Tribe population (in millions) 0.76 84.33 12 Female Literacy Rate (Census 2011) (%) 53.33 65.46 Source- (Bihar) Only 34 percent of women in Bihar had three or more antenatal check-ups, with a worsening in urban areas and no improvement in rural areas between National Family Health Survey (NFHS) 2 & 3. During the same period, institutional deliveries rose from 15 percent to 23 percent. Immunization coverage increased from 12 percent to 33 percent and infant mortality fell from 78 to 62 per 1000 live births between NHFS2 (1998-99) and NHFS3 (2005-06). However, the proportion of underweight children below the age of three years increased from 8

54 percent to 58 percent. Polio has not been eradicated and tuberculosis is not well controlled. Approximately 90 percent of the fatal tropical disease Kala-azar in India is in Bihar. Table2: Status of Child health in Bihar and NIPI focused districts NIPI focused State and Districts Bihar Jehanabad Nalanda Sheikhpura Population (census 2011) 103804637 11,24,176 28,72,523 6,34,927 Crude Birth Rate (AHS 2010-11) 26.7 24.9 26.3 28.9 Estimated delivery 2771584 27992 75547 18349 Infant Mortality Rate (AHS 2010-11) 55 53 52 58 Estimated Infant Death 152437 1484 3928 1064 Neonatal Mortality Rate (AHS 2010-11) 35 31 27 31 Estimated Neonatal death 97005 868 2040 569 U5 CMR (AHS 2010-11) 77 67 80 76 Estimated Under-5 child death 213412 1875 6044 1395 Source- Annual Health Survey, 2010-11 Table 2: Infant Mortality Rate (SRS-09) 90 80 70 60 50 40 30 20 10 0 83 77 75 73 71 69 60 61 61 60 58 56 52 11 12 14 15 13 12 12 2003 2004 2005 2006 2007 2008 2009 65 Bihar Orissa Kerala India Source- (SRS 2009) 1.2 Health Systems and Structure The healthcare services organization in the country extends from the national level to the village level. From the total organization structure, we can divide the structure of healthcare system into national, state, district, community, PHC and sub-centre levels. (WHO, 2007) State level - The organization at the state level is under the State Department of Health and Family Welfare in each state headed by a Minister. There is also a Secretariat under the charge of Secretary/Commissioner (Health and Family Welfare) belonging to the cadre of Indian Administrative Service (IAS). By and large, the 9

Percentage NIPI Reference Book-Bihar organizational structure adopted by the state is in conformity with the pattern of the Central Government. The State Directorate of Health Services, as the technical wing, is an attached office of the State Department of Health and Family Welfare and is headed by the Director of Health Services. But regardless of the job title, every program officer under the Director of Health Services deals with one or more subject(s). Every State Directorate has supportive categories comprising of both technical and administrative staff. (WHO, 2007) The area of medical education which was integrated with the Directorate of Health Services at the state, has once again shown a tendency to maintain a separate identity as Directorate of Medical Education and Research. This Directorate is under the charge of Director of Medical Education, who is answerable directly to the Health Secretary/Commissioner of the State. Some states have created the posts of Director (Ayurveda) and Director (Homeopathy). These officers enjoy a larger autonomy in day-to-day work, although sometimes they still fall under the Directorate of Health Services of the state. (WHO, 2007) India: Percentage of Hospitalizations In The Public and Private Sector Among Those Below The Poverty Line, According To State 100% 80% 60% 40% 20% 0% ANDHRA PRADESH BIHAR GUJARAT HARYANA HIMACHAL PRADESH KARNATAKA KERALA MADHYA PRADESH MAHARASHTRA NORTH EAST ORISSA PUNJAB RAJASTHAN TAMIL NADU UTTAR PRADESH States Public Facilities Private Facilities Source: Pearson M, Impact and Expenditure Review, Part II, Policy Issues, DFID 2002 Regional level In the state of Bihar, zonal or regional or divisional set-ups have been created between the State Directorate of Health Services and District Health Administration. Each regional/zonal set-up covers three to five districts and acts 10

under authority delegated by the State Directorate of Health Services. The designation of the officers/in-charge of such regional/zonal organizations differs but they are generally known as Additional/Joint/Deputy Directors of Health Services in different States. (WHO, 2007) District level - In the recent past, states have reorganized their health services structures in order to bring all healthcare programs in a district under unified control. The district level structure of health services is a middle level management organisation and acts as a link between the state and regional structure on one side and the peripheral level structures such as Primary Health Centres (PHCs) and subcentres (SCs) on the other side. It receives information from the state level which is then transmitted to the periphery with required modifications to meet the local needs. Figure 1: District Health Society-Organogram Source- (Kumar, 2009) In doing so, it adopts the functions of a manager and brings out various issues of general, organizational and administrative types in relation to the management of health services. The district officer with the overall control is designated as the Civil Surgeon (CS). These officers are popularly known as CSs and are overall in-charge of the health and family welfare programs in the district. They are responsible for implementing programs according to policies laid down and finalized at higher levels, i.e. the state and Centre. These CSs are assisted by ACMOs and program officers. The number of such officers, their specialization, and status in the cadre of State Civil Medical Services differ from the state to state. Due to this, the span of 11

control and hierarchy of reporting of these program officers vary from state to state. (WHO, 2007) Sub-divisional/Taluka level At the taluka level, healthcare services are rendered through the office of Assistant District Health and Family Welfare Officer (ADHO). Some specialties are made available at the taluka hospital. The ADHO is assisted by Medical Officers of Health, Lady Medical Officers and Medical Officers of General Hospital. These hospitals are being gradually converted into Community Health Centres (CHCs). (WHO, 2007) Community level For a successful primary healthcare program effective referral support is to be provided. For this purpose one Community Health Centre (CHC) has been established for every 80,000 to 1, 20,000 population, and this centre provides the basic specialty services in General Medicine, Paediatrics, Surgery, Obstetrics & Gynaecology. The CHCs are established by upgrading the sub-district/taluka hospitals or some of the block level PHCs or by creating a new centre wherever absolutely needed. PHC level At present there is one PHC covering about 30,000 (20,000 in hilly, desert and difficult terrains) or more population. Many rural dispensaries have been upgraded to create these PHCs. Each PHC has one medical officer, two health assistants one male and one female, health workers and supporting staff. To improve preventive and promotive aspects of healthcare, a post of Community Health Officer (CHO) was proposed to be provided at each new PHC, but most states did not take it up. (WHO, 2007) Sub-centre level The most peripheral health institutional facility is the sub-centre manned by one male and one female multi-purpose health worker. At present, in most places there is one sub-centre for a population of 5,000 (3,000 in hilly and desert areas and in difficult terrain). (WHO, 2007) The 73 rd and 74 th constitutional amendments have given the powers to the local bodies in some states of India. In the process, different states have adopted different stakeholders for the benefit of health services, with the help of community participation, which lays stress on safe drinking water and sanitation at village level. The panchayats are given the power to look after the welfare of the people. (WHO, 2007) 12

1.3 Health Infrastructure Although the state has a fairly extensive network of public health facilities it remains grossly inadequate compared to the Government of India (GoI)/Government of Bihar (GoB) norms. Furthermore, even the existing facilities lack the basic minimum infrastructure needed for their optimal functioning. According to information available with the state directorate, only 23 of the 38 districts in the state have a district hospital. Similarly, of 101 sub-divisional headquarters, only 23 have a sub-divisional hospital. The CHC/ Referral Hospital Network are virtually nonexistent with the state having only 101 CHCs/Referral Hospitals (70 functional). The state has only 398 PHCs that suggest that each PHC covers an average of 2 lakh population as against the norm of 30,000. A similar situation prevails with regard to facilities at the Health Sub-Centre level, where the state has 9140 Health SCs i.e. an average of one Health SC for a population of 9000 as against the norm of 5000. (Madhav, 2010) Table 3: Health Infrastructure of Bihar Item Required In position Shortfall Sub-centre 14959 8858 6101 Primary Health Centre 2489 1641 848 Community Health Centre 622 70 552 Multipurpose worker (Female)/ANM 10499 9127 1372 Health Worker (Male) MPW(M) at Sub Centres 8858 1074 7784 Health Assistant (Female)/LHV at PHCs 1641 479 1162 Health Assistant (Male) at PHCs 1641 634 1007 Doctor at PHCs 1641 1565 76 Obstetricians & Gynaecologists at CHCs 70 21 49 Physicians at CHCs 70 38 32 Paediatricians at CHCs 70 17 53 Total specialists at CHCs 280 104 176 Radiographers 70 15 55 Pharmacist 1711 439 1272 Laboratory Technicians 1711 135 1576 Nurse/Midwife 2131 1425 706 (Source: RHS Bulletin, March 2008, M/O Health & F.W., GOI) (Bihar) Nine out of ten Additional Primary Health Centers (APHC) that work under the Block Primary Health Centre were found closed during the field visit. The Ministry of Health and Family Welfare (MoHFW-GoI) identifies APHC and PHC as PHC in its RHS Bulletin. According to community members, centers are operational once a week only for immunization. (Madhav, 2010) While the services provided by the Block PHC and APHC are primary in nature with specialty services required to be available through the CHC to a population of 100,000 these are not available at block level in Bihar. Furthermore a survey 13

conducted in one district showed that 17 out of 42 APHCs (40 percent) are without a Medical Officer (MO). (Madhav, 2010) APHC provides only weekly consultation and immunization. Maternal and Child healthcare, which also includes family planning, has emerged as the main function of PHCs as no deliveries have been carried out at the APHCs and SCs. Only normal deliveries are conducted at PHCs with complicated cases being referred for further treatment. Hospitals with lady doctors (6 percent) are in a better position to provide services of internal examination and other gynecological treatments. (Madhav, 2010) In Bihar, while Additional PHCs continue to exist on paper, many centres are derelict and abandoned sites, while others stand devoid of all human resources. These human resources have been diverted to upgraded PHCs that are on par with CHCs in other states. There are yet other workers who have been contracted out on a public-private partnership (PPP) basis (Ref-13). Similarly, 20 percent of SCs in Bihar were found to be functioning on an ad hoc basis out of a primary school building or a room in a construction site, with the auxiliary nurse midwife operating out of here only on immunization days. (Gill, 2009) The other health institutions in the state are given below: Table 4 : Health Institution Health Institution Number Medical College 8 District Hospitals 25 Referral Hospitals 70 City Family Welfare Centre 12 Rural Dispensaries 366 Ayurvedic Hospitals 11 Ayurvedic Dispensaries 311 Unani Hospitals 4 Unani Dispensaries 144 Homeopathic Hospitals 11 Homeopathic Dispensary 179 Source- (Bihar) 1.4 Human Resources Due to inadequate physical infrastructure, districts face acute shortage in health personnel as well. A large number of posts of Medical Officers and frontline health workers remain vacant. In the case of frontline health workers such as Auxiliary Nurse Midwife (ANM), 14

Male Health Workers (MHW), staff nurses and Anganwadi Worker (AWW) the situation is almost similar or even worse. Table 5 Public Health Personnel Category IPHS Standard Required Sanctioned Existing Gap Medical 1 Per 10000 9500 5124 3860 516 Officers Population ANM 1 Per 2500 Population 38500 11294 10055 17151 Source- (Status, 2009) The state of Bihar requires 5488 ANMs, 1157 Lady Health Visitors (LHVs), 70 Public Health Nurses (PHNs), 76 District Public Health Nursing Officers (DPHNOs), 13818 Staff Nurses, 383 Head Nurses, 114 Assistant Matrons, 48 Matrons and 147 teachers excluding the additional personnel required for additional SHCs, PHCs and CHCs to be established based on the norms for population in 2008. (Nursing in Bihar, 2010) Table 6 Availability of nursing education programmes in India and Bihar ANM training or MPHW(F) training Institutes -18 months after 10th class General Nursing and Midwifery(GNM) Training Institute for three years after 12th class or intermediate B.Sc. Nursing colleges for four years after 12th class with science Post basic B.Sc. Nursing college for two year for staff nurses with GNM diploma M.Sc. (N) College for 2 years after completion of B.Sc. nursing Source- (Nursing in Bihar, 2010) India Bihar % 487 27 5.5 1805 11 0.6 1069 Nil Nil 129 Nil Nil 153 Nil Nil 1.5 State Health Budget Trend The health budget of the Department of Health and Family Welfare has increased from INR 709.31 crore to INR 1331.57 crore from year 2004-05 to year 2007-08. The growth of the budget has been the highest in 2006-07 at 51.09 percent from the previous year but it declined to 8.41 percent in 2007-08. There was a sharp increase and then a decrease in the growth rate of the budget. This sharp increase in budget estimate could be due to the fact that year 2006-07 was the first year in which the new government in the state presented the budget. (Bihar DET Report, Apr,2010) 15

Table 7 Analysis of Health Budget of Bihar (Rupees in Crore) Particulars 2004-05 2005-06 2006-07 2007-08 Total Health Budget 709.31 812.94 1228.29 1331.57 Trend of Growth Rate 14.61 51.09 8.41 Total Expenditure budget 28350.46 32227.9 35483.7 36571.55 Percentage of State Health Budget 2.5 2.52 3.46 3.64 to Total State Expenditure Budget Source Study of State Finances RBI There is an increase in the state health budget from 2.50 percent to 3.64 percent in the total state budget showing a constant increasing trend from 2004-05 to 2007-08. The average percentage of state health budget to total state budget was 3.03 percent over the period of four years under consideration of this review. (Bihar DET Report, Apr,2010) Budget Allocation to Bihar under NRHM The budget allocation to Bihar under NRHM has increased continuously from INR 398.22 crores in 2005-06 to INR 695.26 crores in 2007-08. The total allocation to the state under NRHM during this period has been INR 2373.39 crores (Bihar DET Report, Apr,2010) The budget allocation increase by 50.47 percent in 2006-07 was the highest year-onyear increase. This could be due to the fact that 2006-07 was the first year of NRHM. (Bihar DET Report, Apr,2010) Table 8 Allocation by GoI under NRHM to Bihar State (INR in Crore) Head 2005-06 2006-07 2007-08 2008-09 Grand Total Total Allocation under NRHM 398.22 599.21 680.7 695.26 2373.39 RCH Flexipool 123.72 174.32 127.76 213.84 639.64 NRHM Flexipool 0 146.62 256.31 186.28 589.21 National Disease Control Programme 65.68 51.69 55.14 66.91 239.42 Source- Website of MOHFW/NRHM RCH Flexipool shows a trend of more allocation in the years of 2005-06 to 2006-07. Later in 2007-08 NRHM Flexipool got more allocation but in 2008-09 RCH Flexipool again received more allocation. The National Disease Control Program has got in the range of 10 percent in all the years and the budget allocation decreased from 2005-06 (Bihar DET Report, Apr,2010) 16

Table 9 Public Health Subsidies in Bihar Share of Public Subsidies by Quintiles (%) 1 2 3 4 5 Ratio I/V (%) Share of Public Subsidies by Items (%) Rural Short Hospitalization 3.9 15.9 28.5 21.3 30.4 7.8 35.4 Hospitalization 3.5 11.4 21 23.4 40.8 11.7 51.3 PHC & Others 7.2 9.6 23.6 26.2 33.4 4.6 5.2 Immunization 19.8 22 19.6 19.3 19.3 1 8.1 Total 5.1 13.7 23.7 22.5 35 6.8 100 Urban Short Hospitalization 5.7 20.1 31.9 22.8 19.5 3.4 33.3 Hospitalization 3 10.8 21.6 50 14.5 4.8 63.1 PHC & Others 24.3 12.1 20 12.9 30.7 1.3 2.1 Immunization 25.7 20 18.8 14.9 13.9 0.5 1.5 Total 4.7 18.8 25 39.7 16.5 3.5 100 Source- (Srivastava, 2003) Table 10 Cost drivers of Department of H& FW and NRHM at State Level (Rs in Crore) Budget Head Expenditure incurred % of Total during FY 2007-08 Expenditure Rural Health Services-Allopathy 544.88 41.05 Urban health Services -Allopathy 293.47 22.11 RCH Flexipool- NRHM 174.97 13.18 Rural family welfare services 128.2 9.66 Medical Education, Training and Research 106.14 8 Public Health 29.66 2.23 NRHM Flexipool 12.18 0.92 Direction and Administration 10.1 0.76 National Disease Control Programme 8.53 0.64 Rural Health Services- Other Systems of 6.43 0.48 medicine Urban health Services -Other system of 6.17 0.47 medicine Training 4.18 0.31 Maternity and child health 1.48 0.11 Urban family welfare services 0.81 0.06 Research and Evaluation 0.04 0 Grand Total 1327.24 Source- State Health Society, Bihar 17

Figure 2 Health Expenditure distribution 2007-08 Direction and Administration 1% Medical Education, Training and Research 9% Public Health 3% Rural family welfare services 11% Urban health Services -Other system of medicine 1% H.E. Composition 07-08 Rural Health Services- Other Systems of medicine 1% Urban health Services -Allopathy 26% Rural Health Services-Allopathy 48% Source: Finance Accounts 2004-05 to 2007-08 1.6 Important Issues concerning Health in Bihar Health is a complex sector with deep cross linkages across other social sectors like nutrition, literacy, poverty, women and child development, panchayati raj, etc. Interventions under NRHM need to be catalyzed by parallel actions in these sectors. Health is still not a high priority area and as such needs to be brought under the prime focus, particularly at the state level. For successful planning and implementation of the Mission activities, it is extremely important that there is an assured availability of incremental outlay. It is also necessary that the outlay is made known to the state in time so that these could be factored while preparing the annual plan. The state also needs to hike its health budget very significantly in order to meet the target of 2-3 percent of the GDP. (Jha, 2007) Panchyat Raj Institutions have a very crucial role to play in the entire process. It is, therefore, imperative that sufficient powers are delegated to them that enable them to lead the process. The shortage of manpower particularly doctors and paramedical staff willing to work in the rural areas is expected be a serious challenge. Operationalization of all the healthcare 18

facilities in the light of manpower constraints would be a major challenge for the state. (Jha, 2007) Substantial Gaps in PHC Infrastructure: In Bihar, there is an acute shortage of CHCs, PHCs and SCs. The state has a shortage of 1210 SCs, 13 PHCs, and 389 CHCs. Besides, out of a total of 38 district hospitals, only 24 are currently functional. (Jha, 2007) Shortage of Manpower, Drugs and Equipments Necessary for Primary Healthcare There is also a shortage of essential requirements in terms of manpower, equipment, drugs and consumables in the primary healthcare institutions. Moreover, there are no specialists at the CHCs. There is a shortage of 3376 MOs and 19945 ANMs. The percentage of PHCs having adequate equipment stands at only 6.2 percent compared to the national figure of 41.3 percent. There is inadequate and erratic availability of essential drug supplies, ORS packets, weighing scales, etc. There is also a very acute shortage of gynaecologists and obstetricians to provide maternal health services in the peripheral areas of the state. (Jha, 2007) Lack of Training Facilities The status of training facilities in the state (both in terms of infrastructure and human resources) remains far from satisfactory at all levels. At the state level, there is only one training institute {the State Institute of Health and Family Welfare (SIHFW)} that imparts training to health personnel. The SIHFW is facing a severe shortage of faculty and related facilities. At the regional level too there is an acute shortage of good training centres. (Jha, 2007) Very High Fertility Rate The total fertility rate in the state is second highest in the country (4.2 compared to the national figure of 3.0). The birth rate is also second highest in the State (30.4 compared to the national figure of 23.8). Besides, birth order 3 + is 54.4 percent compared to the national figure of 42 percent. Approximately 51.5 percent of the girls get married below the age of 18 years as compared to the national figure of 28 percent. The percentage of couples practicing any method of contraception is only 34 percent against the national figure of 53.9 percent. (Jha, 2007) 19

Low Institutional Deliveries and High Level of Maternal Death The Maternal Mortality Ratio (MMR) in Bihar (371 per 100,000 live births) is the 4th highest in the country. The high level of MMR can be attributed to low level of institutional deliveries (23.2 percent compared to national figure of 41 percent), high level of anaemia among women (63.4 percent compared to national figure of 51.8 percent), low provision of iron and folic acid tablets to antenatal cases (8.1 percent compared to national figure of 20.4 percent), and low level of complete antenatal coverage (5.4 percent compared to national figure of 16.4 percent). (Jha, 2007) Undernutrition in Children and Women Bihar is a state with lowest per capita income and a very high level of poverty. Diet surveys carried out by the Department of Women & Child Development indicate that the state ranks very low in terms of dietary intake (not more than 2000 calories). Undernutrition is very high in the state, because of low dietary intake, high morbidity and also closely spaced pregnancies. Approximately 39.3 percent of women are undernourished (BMI of less than 18.5 kg/m2). The state has very low overweight and obesity rates in women. The percentage of women with chronic energy deficiency is also higher (39.3 percent) compared to the national figure of 35.8 percent. (Jha, 2007) On assessment of weight-for-age in the state, 54.4 percent of children under the age of three years have been found to be underweight in comparison to the national figure of 47 percent. Assessments of height-for-age about 53.7 percent of the children have been found to be stunted in comparison to the national figure of 45.5 percent. The number of infants receiving semi-solid foods at the age of six months is much lower than the national level and as a result under-nutrition rate in children is much higher than the national level. About 54.4 percent children are underweight and 81 percent are anaemic. (Jha, 2007) Very Low Coverage of Full Immunization The coverage of routine immunizations and Pulse Polio is low. As per 2001 census, full immunization in the state was only 11 percent against the national average of 54 percent. As a result, a large number of polio cases are still reported in the state. Coverage of Vitamin-A dose (10 percent) is also very low in the state. With improvement in the immunization services in the state, the coverage of immunization is at present 33 percent (NFHS 3). (Jha, 2007) 20

Low Level of Female Literacy Low female literacy rate in the state, particularly in rural areas, is one of the major reasons for poor health conditions in the state. According to the 2001 census, female literacy rate in the state is 33.57 percent against the national average of 54.28 percent. Due to illiteracy, there is a lack of awareness among women about antenatal, intranatal and postnatal care, especially in rural areas. (Jha, 2007) Poor Status of Family Planning Programs Key indicators related to Maternal and Child Health (MCH) and Family Planning clearly show the poor health status in Bihar. Roughly 51.5 percent of the girls in the state get married below the age of 18 years compared to the national figure of 28 percent. The proportion of couples practicing any method of contraception is 34 percent against the national figure of 53.9 percent. Some of the reasons affecting the implementation of the Family Planning program in the state are: lack of health facilities, both in terms of physical infrastructure and skilled human resources to deliver quality family planning services, evidently low exposure to mass media in Bihar, leading to lower exposure of family planning messages in the community, particularly among rural and socioeconomically disadvantaged groups. The program has also failed in being able to take effective measures to increase the median age at marriage and first childbirth, etc. (Jha, 2007) 1.7 Initiatives 1 A. Three New Medical College & Hospitals proposed by Government of Bihar in Pawapuri, Bettiah, and Madhepura districts of Bihar. B. Super Specialty Units in Medical Colleges: Table 11 New Super Specialty Units in Medical Colleges DMCH, Darbhanga SKMCH, Muzzafarpur JLMNCH, Bhagalpur PMCH, Patna ANMMCH, Gaya Neurosurgery & Cardiology Neurosurgery & Cardiology Neurosurgery & Cardiology Nephrology, Cardiothoracic Surgery, Gastroenterology, Endocrinology and Laparoscopic Surgery Neurosurgery & Cardiology 1 State health Society- Bihar(http://statehealthsocietybihar.org/new-proposed-initiatives.html) 21

C. Super Specialty Hospitals - Lok Nayak Jai Prakash Narayan Hospital (Ortho) - Rajendra Nagar Hospital (Eye) - Gardiner Road Hospital (Haemophilia) - Guru Govind Singh Hospital (Maternal & Child) D. Ultra-Modern Diagnostic Centres: In the State, Ultra-Modern diagnostic centres include nine Regional Diagnostic Centres and six Medical College Hospitals that have been set up. - Contracts have been awarded to two agencies to operate, maintain and report 24-hours centres. - Facilities to be provided - Pathology- Biochemistry, Radiology Digital X- ray, USG, CT Scan, MRI, ECG, and Mammography. - The agency will provide required staff, equipment, machine, logistics and consumables. - The agency will ensure installation, maintenance and operation of equipment with provision of expert technical staff round the clock. - Regional Diagnostic Centres will be handed over to the agency. - The agency will share a fixed percentage of gross revenue with the government. - There is no cost on the government. Rather, the government will receive money out of it. - The agency will charge rates for diagnostic services from the patients as applicable at AIIMS, New Delhi. E. Modular OT - To ensure proper upkeep and maintenance of OT equipment it has been decided to outsource OT equipment to private agencies. - Modular O.T. equipment will be provided in six Government Medical College Hospitals of Bihar on a rental basis. - The OT equipment will also be provided on a rental basis to the 25 District Hospitals. F. Mahadalit Healthcare - The government of Bihar has initiated healthcare services to the people living in the Mahadalit Tolas who are considered to be the poorest of poor in the state. 22

- A survey is to be conducted to identify these Mahadalit Tolas. - Health camps will be organized in the identified Mahadalit Tolas. G. Developing four districts as models (Padmanabhan, 2009) - Jehanabad, Gaya, Vaishali and Nalanda districts - Develop all facilities in these districts as models - Improve patient amenities to IPHS standards and also make them women friendly. - Capacity building of health functionaries to deliver quality healthcare. - Mobile nurse trainers to give hands-on training to the nurses and ANMs on various protocols. - Visits to these facilities by the health functionaries of other districts. I. Drug testing:- Four laboratories accredited by the National Accreditation Board for Testing and Calibration Laboratory have been selected for testing of the quality of drugs supply to government health facilities. The drug controller will randomly take & collect samples from the drug depots. The collected samples will be sent to the laboratories. So far samples of 46 drugs have been sent for quality testing. H. Biomedical Waste Management:- Hospital Waste Treatment and Disposal Services, in all health facilities right from Medical Colleges to the PHCs. Common biomedical waste treatment facility established for Patna Division through a Private Firm. In the remaining 7 divisions private sector partnership is being approved through tender. In Muzzafarpur M/s Semb Ramky has been contracted to set up treatment plant in PPP mode. The agency will collect biomedical waste generated in the health facilities from 15 districts. In Gaya and Bhagalpur M/s Synergy is to set up treatment plants for the collection, treatment and disposal of biomedical waste generated in 15 districts. The agency is to provide training to all the health service providers. 23

J. Yoga The state government has initiated yoga camps for patients as an alternate method for treatment. Yoga instructors are being selected to organize Yoga Camps in the District & Sub-Divisional Hospitals. Yoga Camps are being organized continuously for six months. Every Yoga instructor is paid INR 10,000 per month. K. School Health The government of Bihar has initiated health camps in all the Middle Schools for regular health checkups of the students. Each student will be issued a health card on completion of the check-up. Private agencies/ngos/institutions are being selected for conducting health check-ups in schools. All the 9 Division Health Quarters were provided INR.1.00 Cr. for the year 2007-08. L. Rashtriya Swasthya Bima Yojana in Bihar, A medical insurance of INR 30,000 would be available to every family living below poverty line (BPL) against a card worth INR 30. Jagrugta Rath is equipped with necessary information for families living below poverty line. Information would also be available to experts who are present to help the families. (Bhelari, 2011) The card provides health coverage of INR 30,000 for five members of a BPL family every year. The cardholder and his family can visit government and private hospitals in their district to avail treatment. The cost of medicines from one day prior to the admission in the hospital to one day after the discharge, would be covered by the scheme. (Bhelari, 2011) The coverage under Rashtriya Swasthya Bima Yojana is provided in association with Royal Sundaram Insurance Company. The minister and the principal secretary termed the scheme as a hassle-free health insurance scheme. The card owner would just need to carry the card to the network of 24

hospitals and the expenses for the treatment would be taken care of and the amount deducted from the card. (Bhelari, 2011) This project would cater to five members of every BPL family. The process of making the cards has already been initiated in various places in all the districts and thousands of families have already got the card against a fee of INR 30. (Bhelari, 2011) Under the scheme, health smart cards would be distributed among BPL families. This is a special initiative by the central and the Bihar governments. (Bhelari, 2011) 1.8 Recent Reforms in Health The health department s goal for 2006 was to provide quality and affordable healthcare 24 hours a day at the block level. The year was also declared Routine Immunization Year by the Chief Minister and remarkable progress was made, increasing the rate of immunization from 12 percent to 33 percent in 12 months. (TOR_Bihar_DFID, 2008) The government has taken radical measures such as: improved staffing at block PHCs by relocating from lower level facilities and contracting of 800 general doctors and 400 specialists; improved attendance of doctors by installing telephones in PHCs and contracting a call centre to monitor their presence. There is zero tolerance of absenteeism and doctors have been fired for non-attendance. Essential drug lists have been agreed for each type of facility, drug suppliers and rates have been agreed centrally with orders and payment decentralized to district levels. There is close monitoring of stocks. As a result of the presence of both doctors and drugs at the facilities, out-patient attendance has shot up in the past year, from less than 30 to an estimated over 2000 per month. (TOR_Bihar_DFID, 2008) Public Private Partnerships (PPPs) have been developed for laboratory diagnostics, radiology (X rays), mobile medical services and hospital maintenance. Some PHCs have also been contracted out to NGOs though the experience on this is considered to be mixed. (TOR_Bihar_DFID, 2008) 25

Undernutrition in children below the age of three years has increased from 54 percent to 58 percent between NFHS 2 and NFHS 3. The Social Welfare Department (SWD) has responded to the Supreme Court order for universalisation of ICDS services and subsequently 8000 Anganwadi Centres (AWC) has been sanctioned. The selection of Anganwadi Workers (AWWs) has been decentralized to Panchayati Raj Institutions (PRIs), and money for local procurement and distribution of food for the AWCs is now in the hands of the village mothers committees. Some foods fortified with micronutrients are available. There is a huge challenge to universalize access to Integrated Child Development Scheme (ICDS), and to ensure that the services reach children under the age of three years who are at greatest risk from under nutrition. (TOR_Bihar_DFID, 2008) There are ambitious plans for a Management Information System (MIS) with a longitudinal system of recording every child s nutritional status monthly. There is a massive infrastructure shortfall, and the department has taken a loan from National Bank for Agriculture and Rural Development (NABARD) for this purpose. There is a huge need for AWW training. The Health and Social Welfare departments meet in the State Health Task Force chaired by the Chief Minister. (TOR_Bihar_DFID, 2008) The Department of Public Health Engineering has embarked on an ambitious policy reform and operational plan to address access to water and sanitation. This includes the provision of toilets for all Anganwadi centres and total sanitation campaign across the state (funded by GoI). The department is also making efforts to mitigate the chemical contamination of well water (arsenic, fluoride, iron) especially in eastern Bihar, and exploration of the use of abundant river water to replace contaminated well water. There is an understanding and commitment to convergence at the village level as well as between the Department of Health, Social Welfare and Public Health Engineering. (TOR_Bihar_DFID, 2008) 26

Chapter-2 Maternal & Child Healthcare in Bihar 27

2. Maternal & Child Healthcare Status in Bihar 2.1 Maternal and Child Health Indicators of Bihar The total fertility rate of the state is 3.9. The IMR is 52 and MMR is 312 (SRS 2004-2006) both of which are higher than the national average. The sex ratio in the State is 919 females for every one thousand males (as compared to 933 females for every one thousand males in the country). Comparative figures of major health and demographic indicators are as follows: (Bihar) In 1998-99, the IMR was 78 per 1000 live births in Bihar compared to 68 for all India (NFHS-2). According to the latest NFHS-3 (2005-06) the figure for Bihar is 62 per 1000 live births. SRS 2009 estimates the IMR of Bihar to be 52 per 1000 live births. (Bihar_NIPI, 2009) Table 12 Trends in Infant Mortality Rate in Bihar and India Source/Year Infant Mortality Rate Bihar India NFHS 2 ( 1998-99 ) 78 68 NFHS 3 ( 2005-06) 62 57 SRS 2000 62 71 SRS 2003 60 60 SRS 2006 61 57 SRS 2009 52 50 NRHM Goal by 2010 45 Source: NFHS 2 and 3, SRS Bulletin (1997), SRS (2000, 2003, 2006) India/States/ Union Territories Table 13: Infant mortality rate by sex and residence, 2009 (SRS-09) Total Rural Urban Total Male Female Total Male Female Total Male Female India 50 49 52 55 54 56 34 32 35 Bihar 52 52 52 53 53 53 40 39 41 Kerala 12 10 13 12 10 14 11 10 11 Source- (SRS 2009) 28

Comparative figures of major health and demographic indicators are as follows: (Bihar) Table: Status of Child health in Bihar and NIPI focused districts NIPI focused State and Districts Bihar Jehanabad Nalanda Sheikhpura Population (census 2011) 103804637 11,24,176 28,72,523 6,34,927 Crude Birth Rate (AHS 2010-11) 26.7 24.9 26.3 28.9 Estimated delivery 2771584 27992 75547 18349 Infant Mortality Rate (AHS 2010-11) 55 53 52 58 Estimated Infant Death 152437 1484 3928 1064 Neonatal Mortality Rate (AHS 2010-11) 35 31 27 31 Estimated Neonatal death 97005 868 2040 569 U5 CMR (AHS 2010-11) 77 67 80 76 Estimated Under-5 child death 213412 1875 6044 1395 Source- Annual Health Survey, 2010-11 Table 14 RCH II Goals (Bihar State Report) BIHAR INDIA INDICATOR RCH II/ NRHM Trend (year & source) Current status (2012) goal Maternal Mortality Ratio 312 (SRS 04-371 (SRS 01-03) (MMR) 06) 254 (SRS 04-06) <100 Infant Mortality Rate (IMR) 60 (SRS 2003) 58 (SRS 2007) 55 (SRS 2007) <30 Total Fertility Rate (TFR) 4.2 (SRS 2003) 3.9 (SRS 2007) 2.7 (SRS 2007) 2.1 S. No. RCH OUTCOME INDICATOR Table 15 RCH II Outcomes (Bihar State Report) DLHS 2 (2002 04) Bihar DLHS 3 (2007 08) DLHS 2 (2002 04) India DLHS 3 (2007 08) 1 Mothers who received 3 or more antenatal care checkups (%) 16 26.4 50.4 51 2 Mothers who had full antenatal check-up (%) 4.3 3.9 16.5 19.1 3 Institutional deliveries (%) 18.8 27.7 40.9 47 4 Children 12-23 months age fully immunised (%) 20.7 41.4 45.9 54.1 5 Children age 6-35 months exclusively breastfed for at least 6 months (%) 6 11.8 22.7 24.9 6 Children with diarrhoea in the last 2 weeks who received ORS (%) 13.4 22 30.3 33.7 7 Use of any modern contraceptive method (%) 24.5 28.4 45.2 47.3 8 Total unmet need for family planning - both spacing methods and terminal methods (%) 38.3 37.2 21.4 21.5 Table 16 Maternal and Child health Profile of NIPI focused districts and Bihar State Key Indicator Bihar Nalanda Jehanabad Sheikhpura 3+ ANC visit 26.4 15 20 23 ANC At least 1 TT injection 58.4 50 54.5 83.5 Received 100+ IFA 9.3 5.5 6.9 5.7 Child DPT (all 3) 54.2 65.1 55.1 49.2 29

Immunization Measles 49.9 69.1 63.9 49.3 Full 41.4 54.2 47.2 38.3 Delivery Characteristics Institutional Births 27.7 39.3 42.5 41.6 Source: DLHS-3, 2007-08 Under 5 mortality rate (U5MR) in Bihar as per NFHS-3 is 848 per 10000 live births, one of the highest in India. (Bihar_NIPI, 2009) Table 17: Trends in Child Mortality Rate in Bihar and India Under 5 Mortality Rate Source/Year Bihar India NFHS 2 ( 1998-99 ) 105.1 95 NFHS 3 ( 2005-06) 84.8 75 SRS 2000 SRS 2003 SRS 2006 NRHM Goal by 2010 < 50 < 50 Direct estimates of infant and child mortality indicators at district level are not available, though estimates using census data on children ever born and children surviving are available but are inconsistent and not reliable. Hence this data is not presented in this report. The District Level Household Survey (DLHS 2002-03) does not provide district level infant and child mortality estimates. Thus no reliable estimate of infant and child mortality is available at the district level. (Bihar_NIPI, 2009) Table 18 Distribution of Women Receiving Pre-Natal Care by Source of Care Govt Pvt. NGO Quintiles ANM/BHW Others Total Doctor Doctor Doctor 1 23.5 17.7 44.1 2.9 11.8 100 2 20 28 40 8 4 100 3 21.2 15.2 45.5 15.2 3 100 4 7.5 25 57.5 5 5 100 5 7.7 20.5 64.1 2.6 5.1 100 Total 15.2 21.1 51.5 6.4 5.9 100 Source- (Srivastava, 2003) 30

2.2 Key Achievements in MCH in Bihar Maternal Health, including Janani Suraksha Yojana (JSY) (Bihar State Report) Number of JSY beneficiaries in the state increased sharply from 0.90 lakh in 06-07 to 8.38 lakh in 07-08 and 10.51 lakh in 08-09. Training on Life Saving Anaesthesia Skills (LSAS): Six medical colleges have been identified for the purpose, 14 master trainers and 74 MBBS doctors have been trained in LSAS against a target of 76. Training in comprehensive Emergency Obstetric Care (EmOC): Patna Medical College has been strengthened as a training site, eight master trainers and 40 MBBS doctors have been trained in EmOC against a target of 76. Skilled Birth Attendant training (SBA): 20 districts have been identified, 150 district level master trainers and 592 SNs/ ANMs have been trained as SBAs, against a target of 2895. Outsourcing of blood banks in public private partnership model has been initiated in 4 districts and MoU has been signed in 17 districts. Emergency referral service has been initiated in Patna municipal and sub urban area. While the number of institutional deliveries under JSY has increased to 10.51 lakhs in 08-09, Bihar is yet to adequately gear up facilities to meet the load: (Bihar State Report) The state has operationalized 533 PHCs that operate 24x7 so far against the target of 821 PHCs by 2010. While monthly NRHM reports submitted by the state reports all the planned (76) FRUs as Functional - there are only 3 FRUs that fulfil all the three critical criteria of functionality (as reported during a recent review). A large number of FRUs do not provide the stipulated range of services due to lack of access to blood storage facilities and lack of specialist staff. A rapid assessment of functionality of FRUs and 24x7 PHCs was carried out in the state through GoI/ Development Partner support. There is no indication that District CMOs & District Program Managers are utilising facility survey 31

findings for comprehensive planning of operationalization of FRU and PHCs, including linking the same with EmOC and LSAS trainings, placing anaesthetic drugs, SBA drugs, operationalizing OTs, and establishing Blood Banks/ Blood Storage facilities at FRUs. There is irrational selection and placement of trained staff with the result that the existing staff is not used appropriately. Further, LSAS and EmOC trained doctors are yet to be posted at FRUs. SBA training was initiated but stopped due to the floods. Now there is a need to immediately begin the training with plans for scaling-up and monitoring the quality of the training. SIHFW was instructed by the State Health Society (SHS) for monitoring but the quality of the training is not yet maintained, post training supervision is weak, and basic protocols in labour room during delivery are not followed. State and District Level Quality Cell are yet to be created for monitoring the skilled based training. Evaluation of the trainees needs to be done at the site of posting/ service provision. Referral transport services need to be strengthened and systematically rolled out. Child Health: (Bihar State Report) Integrated Management of Neonatal and Childhood Illness (IMNCI) is ongoing in 23 (out of 38) districts of the state. Six SNCUs are functional in the state and are to be replicated in 23 districts in year 2009-10. IMNCI trained ANMs run sub centre clinics on Thursday in few districts, which is to be extended to all districts by 2009-10. The state is considering the option of decentralised hiring of doctors through Rogi Kalyan Samitis (RKSs) at facilities, for running the clinics once a month Neonatal mortality rate or NMR (deaths of newborns within 4 weeks of life per 1000 live births) at 31 (SRS 2007) accounts for 53 percent of the IMR, while early NMR 32

(newborn deaths within one week of life per 1000 live births) at 27 (SRS 2007) accounts for 87 percent of the NMR. An evaluation of Janani Suraksha Yojana in the state in December 2008 highlighted that only 11 percent of the beneficiaries surveyed stayed for at least two days in the health facility after delivery. With the huge off take in JSY in the state (10.51 lakh beneficiaries in 2008-09), this is clearly a missed opportunity to address early neonatal mortality. (Bihar State Report) Other Initiatives (Bihar State Report) Outsourcing of Additional PHCs: 46 APHCs have been handed over to 12 NGOs covering nine districts. Six GNM and 21 ANM schools have been made functional in the current year. The state has also developed an online system to monitor service delivery and logistics availability at the PHCs. Immunization (Bihar State Report) As per the various evaluated surveys the immunization coverage shows an improving trend with full immunization increasing to 41.4 percent in 2007-08 (DLHS 3) The state initiative of Muskaan is apparently showing good results including immunization coverage. There has been very good progress in immunization training of the health workers (11478/12675) District level committees to monitor Adverse Effects Following Immunisation are constituted in 25 out of the total 38 districts. 90 percent of these committee members are trained. 2.3 State Schemes to Improve Maternal and Child Health Ongoing health related programs in Bihar In order to improve the implementation of several child and related maternal health activities, certain programs are ongoing currently such as of Janani Evam Bal Suraksha Yojana, Reproductive and Child Health Care Services, Anaemia Control Program, Vitamin A 33

Supplementation Program, NRHM, Routine Immunization & Pulse Polio, Mamta and IMNCI program. (Bihar_NIPI, 2009) Janani Evam Bal Suraksha Yojana: Janani Evam Bal Suraksha Yojana under the overall umbrella of the National Rural Health Mission integrates the benefit of cash assistance with institutional care during delivery, coupled with antenatal care and immediate post-partum care. This is to reduce maternal as well as infant mortality. Under this scheme, pregnant women from BPL families in rural areas will receive INR 1400 and those in urban areas will receive INR 1000. This is to encourage registration with a clinic and go to a government or private hospital for delivery. The scheme has been implemented in the state since July 1, 2006 and so far 3.5 lakh registrations and 89839 deliveries have taken place. To include the private nursing homes in this scheme, so far 53 private nursing homes have been accredited. This can be considered a good progress in the program. (Jha, 2007) Reproductive and Child Healthcare (RCH) Services These services basically include three major packages. The first package is for mothers, which includes early registration, antenatal care, institutional deliveries and deliveries by SBAs, home-based postnatal care and increased facilities for MTP. The second package is for newborns which includes skilled care at birth, IMNCI for common childhood illness and immunization. Other services include increased choice and availability of family planning services, gender sensitization and gender equality, and prevention and management of RTIs & STIs etc. (Jha, 2007) Anaemia Control Program Decrease in the haemoglobin level which affects the oxygen carrying capacity of blood is known as anaemia. Under this program, pregnant and lactating mothers are given IFA (Iron and Folic acid) tablets to prevent anaemia during pregnancy. Therefore, IFA tablets are distributed to all the pregnant and lactating mothers through Anganwadi Centres. (Jha, 2007) Vitamin A Supplementation Program 34

Government of Bihar and State Health Society have been successful in the implementation of the Vitamin A supplementation Program for pre-school children. It has, therefore, been decided to undertake the same for the children between the age group of nine months to five years in all the 38 districts of the state, following the biannual fixed day strategy linked with Routine Immunization. Children between nine months and five years of age would be covered with six monthly doses of Vitamin A syrup. The state has been conducting catch-up rounds of Vitamin- A and has got exceptional success in it as its coverage soared to 95 percent. As a long term strategy, diet management has been included in all training and communication materials. (Jha, 2007) Routine Immunization & Pulse Polio The year 2006 was declared Routine Immunization year by the State Government. The efforts of the year have yielded results, as the dismal figure of 11% complete immunization has improved to 34 percent and the projected figure by the end of this year (2007) is 60-70 percent. Polio rounds are also being taken up regularly. The target of the State Government is that by year 2010, all the districts in Bihar would provide timely and safe immunization with all antigens (plus 2 dosages of Vitamin A ) to all children between 12-23 months (100 percent coverage) and all pregnant women with 2 doses of TT (100 percent coverage). Under the Intensive Pulse Polio Immunization, micro plans including area maps are available and special emphasis has been given on Information, Education and Communication (IEC) and social mobilization. (Jha, 2007) National Rural Health Mission (NRHM) Bihar is a focused state. It has as its key components provision of a female health activist in each village (in case of focus State); a village health plan prepared through a local team headed by the Health & Sanitation Committee of the Panchayat; strengthening of the rural hospital for effective curative care made measurable and accountable to the community through Indian Public Health Standards (IPHS); integration of vertical health & family welfare programs for optimal utilization of funds and infrastructure and strengthening delivery of primary healthcare. It seeks to revitalize local health traditions and mainstream AYUSH into the public health system. It aims at effective integration of health concerns with determinants of health 35

like sanitation & hygiene, nutrition and safe drinking water through a District Plan for health. (Jha, 2007) The state has set up institutional arrangements to implement the activities under the NRHM. If NRHM is implemented effectively, it is expected that the state may have indicators like other better performing states. (Jha, 2007) Mamta Mamta Scheme is an ambitious project aimed at improving the condition of mothers and newborns in Bihar. Under this scheme, trained midwives would be posted at hospitals and sub-divisional health centres to take care of mothers and their newborn babies. The midwives will be paid INR 75 for taking care of a mother and her newborn. The scheme is expected to attract pregnant women, particularly in rural areas, to opt for institutional delivery. Besides, the scheme aims to raise awareness about breast feeding, immunisation and encourage mothers to adopt family planning methods. The state government and different executing agencies under the National Rural Health Mission (NRHM) are funding the scheme. (Mamta, 2008) Home Based Neonatal Care (HBNC) In the continuum of care, home-based care for the newborn is recognized as a weak link. The NIPI focus states now recognize that if a difference is to be made in neonatal and child health, it is important to address and affect what happens in the home. Since the NRHM already has provided for a voluntary grass root worker, the ASHA, State Health Societies of the focus states have chosen to build on her presence and competency to create a structured follow-up system for both the mother and the newborn. The intervention: The intervention consists of three parts. (CHPNC, 2009) o A special training module (2+5 days) on home-based newborn care. o An incentive to the ASHA for completion of the PNC check-up routine o A referral fund to ensure that sick newborns and mothers can be referred to a facility with proper care available Under this scheme the ASHA is to visit the home of the beneficiary six times within the first twenty eight days of birth. The first visit will be during the last phase of the 36

pregnancy (eight month). This will be in addition to the already established antenatal care that is provided within NRHM, and the main purpose of the first visit is to motivate the mother for an institutional birth, make sure she is aware of JSY and to identify any risk factors that the mother may have, indicating that the birth should take place at a even higher level facility. After the birth, the ASHA will visit the home on day 1 (in case of home delivery), 3, 7, 15, and 28. In the state of Rajasthan there is an additional visit at day 42. (CHPNC, 2009) The ASHA will fill a Postnatal Check-up card (PNC-card) during the visit, which is to be submitted for validation and payment after the total check-up has been completed. In addition to basic information such as birth and weight, the card will also provide information about morbidity and mortality, referrals, immunization, breastfeeding status etc. (CHPNC, 2009) 37

Chapter-3 Public Private Partnership 38

3. Public Private Partnership (PPP) 3.1 Key stakeholders in Healthcare s PPP There are five key stakeholders in any healthcare service system as shown below. Implementing a healthcare PPP will have an impact on all these stakeholders and the PPP itself can be structured along any of the roles where private sector participation is applicable. (PPP in Healthcare_CII) Table 19 Stakeholder roles in a Healthcare PPP Provider Payer Beneficiary Regulator IT Infrastructure Participant Type Public or Private Public or Private Neutral Public Public or Private Source- (PPP in Healthcare_CII) Role Description Entity providing the core services of designing, building and operation of healthcare units. Entity or person paying for the service rendered to the end user. Outof-pocket expenses where the end-user pays for himself/herself still forms a large part of this segment in India. Formal sector consists of insurance players both in public and private sectors where the end-user comes under medical cover. End-user or the ultimate recipient of the healthcare service. Currently impacted by high costs as percentage of income and significant vagaries in quality of service across the country An apex body governing the formal healthcare market in the system. The role of a central regulator will be key to monitor the expansion and sustainability of a scalable PPP model Resource, expertise and management provider for connectivity and sharing of data on patients, specific medical cases, diagnoses and treatment techniques is an area of development that can bridge the quality and accessibility gap across regions in the country. 3.1.1 Department for International Development (DFID) DFID has approved the Bihar health sector reform program Sector Wide Approach to Strengthening Health (SWASTH) recently with a budget of GBP 145 million. This will be one of the largest and most integrated health programs of DFID where it will be working with three departments simultaneously. The Bihar TAST team is all geared up to take on the challenge of implementation and to improve services through sector reforms in one of the poorest states of India. (Medha Soni, 2010) 39

3.1.2 Norway- India Partnership Initiative (NIPI) The Norway- India Partnership Initiative is an outcome of a commitment by the Hon able Prime Minister of Norway and the Hon able Prime Minister of India, focusing on the issue of reducing child mortality and improving child health to attain the Millennium Development Goal 4 by the year 2015. Norway has contributed USD 80 million over five years for this purpose to the five states of Orissa, Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh. These States together constitute 40 percent of India s population and contribute almost 60 percent of child deaths in India. The NIPI activities are for five years (2007-2012) and corresponds with the duration of the NRHM. (NIPI_GoO) The activities under NIPI are put into operation through UN organizations like UNICEF, WHO and United Nation s Office for Project Services (UNOPS). While UNOPS is a local fund agency and operates through the NIPI Secretariat, UNICEF and WHO have a grant of USD 20 million and 10 million each respectively for program implementation in the five focused states. Many of the recent initiatives of UNICEF in child health sector in Bihar are funded by NIPI. (NIPI_GoO) Aims & Objectives With sustained effort by the Government of Bihar, child health indicators have shown improvement, but extra efforts are needed to achieve the MDG 4. (NIPI_GoO) NIPI aims at accelerating the child health interventions: 1. Based on block, district, region and state specific situations. 2. Through partnership and collaborative arrangements with professional organizations, NGOs, local elected bodies and administration within the state. 3. Aimed at making child health visible through catalytic input and create a mechanism that will ensure sustainability under NRHM processes. Core Interventions The core interventions of NIPI are: Capacity building of frontline workers in home-based newborn and child care and community mobilization. Institutional strengthening at block and district level to meet the expanding requirements related to quality child and related maternal health service delivery. (NIPI_GoO) Complimenting these, NIPI will support the state and national governments in developing and optimizing a Management Information System on child health and related maternal health. The 40

Partnership is deeply committed to equity-driven, gender-sensitive, and pro-poor principles approach and it would endeavour to draw upon and enhance the strong equity rubric of the NRHM. (NIPI_GoO) Institutional Mechanism The institutional mechanism of NIPI is led by a Joint Steering Committee with Secretary, Health and Family Welfare, Government of India as Chairperson and the Norway Ambassador to India as the Co-Chair. Additionally, there are representatives of Government of India, Government of Norway, WHO, UNICEF and the NIPI focus States. At the state level, activities under NIPI will be implemented by the Bihar government. 3.2 PPP Initiatives by Health Department, GoB Private Specialists (Status, 2009) - From District Hospitals to PHC - Provision of Private specialists in Ophthalmology, ENT, Orthopaedics, Paediatrics, Gynac. and Surgery - The doctors are to be paid INR.500 per day. - Renowned doctors being contacted - Total number of doctors empanelled is 217 (Source : Data Centre) Mobile Medical Units (Status, 2009) (MMU) - Scheme of 1 MMU per district launched on July 13 2009 - Total Functional MMUs in Bihar till date:- 12 - Rest to start operations from November end onwards - Staff per MMU includes Specialist Doctor, Nurse, X-ray Technician, Lab. Attendant, Para Medic/ Pharmacist cum Van Supervisor, OT Assistant and Driver. - Services per MMU Free OPD, Free Drugs, Gynac/ANC clinic, Eye check up, ENT check up, HIV testing, Pathology, Radiological tests, IEC, Medical camps etc. - Budget Sanctioned in FY 09-10 is INR16.56 cr. - Rent Per Month INR 4.68 lakhs for one MMU Dial 108 (Status, 2009) - Pilot in Patna city through PPP - In operation from June 3, 2009-2 kinds of Ambulances Five Advanced Life Support and five Basic Life Support 41

- Basic facilities Drugs, Oxygen, Heart monitor, ventilator and other supportive medical system - Patient fees- INR300. Very poor patients would receive treatment at lower rates or for free. - 15-20 minutes service availability - GPS fitted - Total number of calls 3509 (June 09 to Oct 09) Diagnostic Services (Status, 2009) - Free Services to all Patients at the PPP operational centres from PHC to DH - Free Services to all BPL Patients at the PPP operational centres in the MCH Pathology Services (Status, 2009) In the government hospitals pathology services to the needy patients were not provided efficiently due to paucity of lab technicians and irregular supplies of reagents required for pathological tests. The state decided to outsource pathological services to reputed private labs in order to improve them in the government hospitals. Two agencies have been selected through a tender process. The agencies have set up labs at the District Hospitals and sample collection centres at the health facilities below district levels. In the state 407 centres are operational. More than 4 lakhs tests have been conducted in the last two years. (PPP_BSHS) - Private sector provider operates, maintains and reports through 24-hours Diagnostic centres - Coverage : 25 District Hospitals, 23 Sub-Divisional Hospitals, 76 Referral Hospitals and 398 PHCs of Bihar - 19 districts each divided among two agencies for Pathology - Agency pays nominal monthly rent for space in DH & SDH - District Hospitals have Labs - Collection Centres at PHCs - Reports within 24 hours - Number of Tests conducted 5.58 lakhs (Mar 06-Apr 09) - Services started in 407 Radiology Facilities (Status, 2009) The state had decided to outsource radiology services in all the government health facilities. About 151 radiology centres have been operationalized. These centres have 42

provided X-ray services to 3.53 lakhs patients in the last two years. Ultrasound Facilities in the District Hospitals and Sub-divisional Hospital are also being provided. (PPP_BSHS) - 38 districts given to one agency to operate, maintain and generate x-ray films - Functional units 134 - Space provided against nominal rent - No investment by Government - Government doctor reports on films - Reports within 24 hours - Functions under the overall supervision of the Hospital Management Society (RKS) of the respective Hospital. - Functions under the operational control of District Health Society - Number of Tests conducted 3.71 lakhs (July 06 to Apr 09) - Services started in 91 centres Hospital Maintenance Services (Status, 2009) The support services for the cleanliness of the hospital s wards and the premises were not up to the mark and the washing of the bed sheets, linen and other apparel were not proper due to paucity of adequate numbers of sweepers and washer men. Due to recurrent powercuts the maintenance of the cold chain of the vaccines was also not proper. Similarly the diet given to the in-patients was not satisfactory. In order to improve the support services in the hospitals the state decided to outsource these services to private agencies and NGOs through a tender process. The following support services have been outsourced: (PPP_BSHS) - Maintenance of Hospital Premises. - Generator Facility. - Cleanliness of Hospitals. - Laundry - Diet for in-patients - Centralized rate contract finalized and each district was given three parties to choose from. All 38 districts have already started using these services Outsourced Services Quality issues (Padmanabhan, 2009) - 21 contracts were signed by SHS, Bihar with private agencies. - A checklist developed to monitor the quality of services - Registers and checklists have also been prescribed for outsourced agencies to prevent false claims Maternal & Child health Improvement (Padmanabhan, 2009) 43

- APHCs to be made functional with paramedical model - One CEmONC for each district - VHSCs to be formed - Use of HSC untied funds - Community monitoring system - Use of trained anaesthetists by reorientation - Rational distribution of human resources - Encourage the use of self improvement NRHM quality manual by the health facilities in the state by conduct of regional workshops - Fast tracking ASHA training program Generic Drug Shops For making drugs available at comparatively cheaper rates to the patients, an initiative has been taken to set up generic drug shops. Three generic drug shops are being set up in each of the six Medical College Hospitals; two in each of the 38 District Hospitals and two in other hospitals. (PPP_BSHS) Funds have been sent to 23 DHSs for the construction of drug stores. Five drug stores have been constructed. (PPP_BSHS) Data Centre: At State & District level:- From the state level monitoring is done through the State Data Centre on a daily basis through telephones. Detailed reports are being posted on the SHSB website. An option to receive public feedback has been provided on the website www.statehealthsocietybihar.org. (PPP_BSHS) Blood Storage Units: To ensure provision of quality blood to the needy patients, blood storage units are being set up in 76 FRUs of the state through the PPP model. While 21 units have been operationalized by the Bihar AIDS Control Society, the remaining 55 units are in the process of operationalization in PPP model. (PPP_BSHS) APHC Outsourcing: It has been decided to provide 24 x 7 hours services at PHCs. To enable this service all available staff has been deployed to the PHCs. The APHCs have been outsourced to private agencies to provide proper OPD services, routine immunization and ANC. 44

Presently about 44 APHCs have been outsourced while outsourcing of the remaining APHCs is in process. (PPP_BSHS) Drug Availability (PPP_BSHS) Rate Contract for procurement of drugs has been finalized at the state level and the finalized rates have been provided to the districts. The list of free drugs has been expanded to incorporate 33 OPD and 37 IPD medicines in other hospitals. 107 IPD drugs in each hospital of every district. In-patient treatments to be free in all District Hospitals Doctors instructed to prescribe only generic drugs to patients. Monitoring & Evaluation: (PPP_BSHS) At the state level monitoring is done through the State Data Centre on a daily basis. Detailed reports are being posted on the SHSB website. Officials of the Department visit the health facilities to monitor activities there. DMUs have been instructed to adopt PHCs to ensure better performance. Evaluation of Free Drug Distribution Scheme & JBSY is being done through third party. Performance-based ranking of districts is being undertaken on select health indicators. 3.3 PPP in Rest of India and World on MCH 3.3.1 Chiranjeevi Yojana (CY) CY was created to significantly reduce maternal and infant mortality by harnessing the existing private sector and encouraging it to provide delivery and emergency obstetric care at no cost to families living below the poverty line. Under the scheme the government contracts private providers that volunteer to render their services by signing a Memorandum of Understanding with the district government. In return, they receive an advance payment to commence services and are compensated at about USD 4,500 per 100 deliveries (normal, caesarean, or with other complications). Any qualified private provider with basic facilities, 45

such as labour and operating rooms, and access to blood bank and anaesthetists can enroll in the program after a thorough orientation. CY beneficiaries are enrolled through their family health workers. The scheme uses the existing cards issued to families living below the poverty line by the rural development department of the state government to access services. In the first six months since the launch of the scheme, each provider performed an average of 116 deliveries. The institutional delivery rate has increased from 54.7 percent to more than 81 percent in 2005 06. CY s long-term goal is to achieve an institutional delivery rate of 95 percent by 2012. (CHMI, 2011) Key program components include: Benefits Package. CY uses demand-side financing to provide families living below the poverty line with access to a comprehensive benefits package that covers both direct and indirect costs, including free delivery (with no condition exclusions), free medicines after delivery, and transport reimbursement. In addition, it offers support to the attendant in exchange for lost wages. The payment method and formula encourage providers to reach a certain volume of work, avoid complicated transaction costs, and create a disincentive for unnecessary Caesarean section surgeries. The provider compensation package is designed to account for all potential complications during delivery (estimated at 15 percent of cases). (CHMI, 2011) Contract Management. CY s district management authorities require participating doctors to maintain a case file for each patient they serve. Weekly records of the deliveries conducted by the providers are submitted to local authorities and the block (sub-district) health officer, who regularly visits beneficiaries to monitor service quality and address grievances. Payment to providers is also made through block health officers based on instructions from district authorities. All districts send a monthly report to state authorities for review and feedback. (CHMI, 2011) District Management Capacity. CY employs a decentralized management model that engages health officials at four government levels (state, district, block, and village) as facilitators and organizers of health services. To implement the scheme state-wide, officials at various levels play interlinked and overlapping roles. These roles are divided into state level (state-wide planning, implementation, and monitoring of the scheme), district level (district wide implementation, provider enrolment and orientation, provider compensation, and report collection), block level (registration of beneficiaries, bill collection from providers, and overall supervision), and village level (motivating expectant mothers to use institutional delivery and facilitating their visit). (CHMI, 2011) 46

3.3.1 Janani Janani started a social marketing and social franchise program that uses India's large private health sector network of practitioner and facilities to provide safe and low-cost options for family planning, health, and reproductive health services in rural areas. (CHMI, 2011) The conventional social marketing infrastructure of shops (more than 31,000 in number) and stockists sells products (such as contraceptives) in urban and semi-urban areas and replenishes supplies to rural health franchisee centres and franchisee medical clinics. This is complemented by a social franchisee program through which doctors in rural areas provide low-cost clinic-based services. The social franchise has a network of rural health practitioners who work in partnership with a female family member. She serves as the conduit between the clinics and rural communities. After receiving Janani training, rural practitioners are franchised as Titli (Butterfly) Centres, and they sell nonclinical products and over-the-counter pregnancy tests. Clients needing clinical services are counselled and referred to the nearby Surya Clinic, which earns the Titli Centres a commission. Under the private-public partnership of the NRHM the government has accredited 15 of Janani s Surya Clinics as authorized sterilization centres, which the government reimburses USD 35 to the clinic for each sterilization. The plan is to set up 40 free clinics at the district headquarter town by the end of December 2009. More than 40,000 trained networked rural providers are monitored by project field teams set up by entrepreneurs, and the 620 franchisee medical clinics are supervised by Janani. (CHMI, 2011) Key program components include: Social marketing for the underserved. The conventional social marketing franchise uses shopkeepers (mostly in urban centres) to deliver primarily nonclinical products such as condoms and oral contraceptives. In contrast, Janani s model focuses on expanding service delivery from urban to rural areas, integrating a strong clinical component and catering to the poorest segments of the population. (CHMI, 2011) Profitable franchisee product bundle. The rural health providers find the franchise profitable and worth belonging to because of a broad mix of income-generating services including the sale of non-clinical products, charges for over-the-counter diagnostic tests, and commissions for referring clients needing clinical services to the Surya clinics. (CHMI, 2011) 47

Formalizing the private sector. Janani has played an important role in bringing rural providers and private doctors into a formal operational framework. The Surya health promoters in the network receive training in non-clinical skills to function as the first point-of-contact in the villages, while the surgical skills of doctors in the Surya clinics are upgraded to provide quality family planning services and comprehensive abortion care services. This has effectively complemented the network of shops that have long worked with the well organized private sector. (CHMI, 2011) Fostering community-level ownership. Janani seeks to transform participants into stakeholders at both the rural and urban levels. About half of Janani s budget is for communication and education campaigns, a critical component of which is empowering clients about quality services so they can maintain pressure on providers for good-quality care. To complement this, Surya health promoters are selected from within communities. (CHMI, 2011) 3.3.2 Child Helpline International Child Helpline International (CHI) facilitates the establishment of helpline services in countries were these facilities and services do not exist and helps scale-up helpline services that work primarily on a district level. In developing nations where state mechanisms are unable to reach children in crisis, it has been seen that helpline services provide an efficient link between children and the system. (CHMI, 2011) Additionally, CHI also concentrates its efforts on advocacy and child participation. CHI hopes to bring the issues and concerns of children from around the world to the attention of policy makers in all corners of the world, ensuring children have a voice and that their voices are heard. (CHMI, 2011) Objectives: To place children on the global telecom agenda To pass a resolution in International Telecommunication Union (ITU) which makes helpline services a global strategy in reaching out to children To allocate funding for bridging the digital divide and ensure that children, especially the marginalised child, have access to telecom In 2004, 11.5 million calls were received at child help lines across the globe. By establishing and scaling-up helpline services, CHI endeavours to bring these services to as many children, especially the most marginalised, as possible. (CHMI, 2011) 48

In May 2004, the helpline was officially launched in Vietnam. The helpline is a partnership between Plan Vietnam and the Committee on Population, Children and Families (VNCPFC). The helpline operates in Hanoi and is now looking to expand to other cities in Vietnam. The helpline has a free number (1800 1567) which is active from 7a.m. to 9p.m. daily and has, since its inception, received around 12,000 calls. The helpline number can be directly called from anywhere in Vietnam, so it is very easy to reach. A large number of phone calls have been received for advice on domestic violence, child sexual abuse, abandoned children and child accident etc. (CHMI, 2011) The helpline has also started on-line counselling services relating to reproductive health, children s rights and psychology as an addition to the telephone service already provided. In addition, two centres for the protection of children have been operational in Ho Chi Minh (in the south) and Da Nang city (in central Vietnam) to make the helpline more efficient. (CHMI, 2011) 3.3.3 RapidSMS Malawi RapidSMS works to address serious constraints within Malawi's National Integrated Nutrition and Food Security Surveillance (INFSS) System, which faces slow data transmission, incomplete and poor quality data sets, high operational costs and low levels of stakeholder ownership. (CHMI, 2011) RapidSMS allows health workers to enter a child s data, and through an innovative feedback loop system, it instantly alerts field monitors of their patients nutritional status. Automated basic diagnostic tests are now identifying more children with moderate malnutrition who were previously falling through the cracks. This system also increases local ownership of the larger surveillance program through two-way information exchange. Operational costs for the RapidSMS system are significantly less than the current data collection system. (CHMI, 2011) The Government of Malawi, pleased by the results of the pilot, plans on scaling RapidSMS up nationally later in 2010. They are also interested in expanding this to a country wide campaign to register child births, as well as deploying RapidSMS in other sectors, including education and HIV/AIDS. (CHMI, 2011) 49

3.3.4 Vietnam s Nutritious Food Program The goal of the project is to reduce the incidence and severity of malnutrition among lowincome, vulnerable, and primarily rural children by expanding access to improve feeding practices, including giving fortified complementary foods to children 6-24 months of age. Based on an alliance between the government, food producers, and non-government organizations (NGOs), the project has enabled the National Institute of Nutrition (NIN) to further develop an innovative model for increasing production capacity by expanding sales, reducing unit costs, and lowering the price to consumers, thereby improving the prospects for sustainability. (CHMI, 2011) Specific objectives are to: (i) expand localized, commercial production of a fortified, low-cost complementary food; (ii) develop and expand the system of community-based complementary food sales, distribution, and enhanced nutrition education; (iii) address barriers to accessing complementary food among the most poor and vulnerable; and (iv) address policy development and advocacy for long-term support for fortified complementary food (as part of a range of options that should be available for addressing malnutrition). (CHMI, 2011) The expected outcome of the project is increased access of approximately 325,000 poor children to fortified complementary food. Over 3 years, the project has worked to open community-based channels for distribution, marketing, and nutrition education in 6 provinces and 60 districts. (CHMI, 2011) Vietnam s Country Investment Plan (CIP) for food fortification prepared under the Asian Development Bank s regional Technical Assistance project outlines a 10-year expansion of this model to reach 25 percent of vulnerable infants between six to 24-months on a national basis. This project is a strategic first step in the expansion, with a focus on developing strategies for scaling up and sustainability as well as ensuring that the product and project benefits reach the poorest and most vulnerable. The new mechanisms for financial sustainability have been adopted actively by using the strengths of public private partnership. (CHMI, 2011) 50

3.3.5 Karra Society for Rural Action The Karra Society for Rural Action, in partnership with the Government of Jharkhand and district healthcare facilities, established a referral network in six blocks of Kunti District in Jharkhand. (CHMI, 2011) To address this issue, the Karra Society initiated the establishment of quality referral services for obstetric and infant healthcare facilities in 320 villages of six blocks in the Kunti district. The project's objective is to create a pool of village health volunteers with awareness on reproductive and child health, increase the incidence of safe births by facilitating institutional deliveries, and encourage community ownership by establishing a call centre in each block for instant access to referrals. (CHMI, 2011) To help this initiative achieve its goals, the Society has engaged in community mobilization for health by strengthening Self Help Groups (SHGs), creating a health fund to be used in case of emergencies, establishing a call centre available 24 hours a day, seven days a week in each block, and providing transport vehicles for all villages in the network to facilitate quick referrals. Furthermore, training is conducted for TBAs, SHGs and Sahiyyas (individuals who educate pregnant women in rural areas). Awareness sessions are also conducted for future mothers on proper precautions to be taken during pregnancy. (CHMI, 2011) As the program helps deliver government maternal and child health programs, the government has decided to partner with the Karra Society and UNICEF to support the design and development of this model. In 2009, about 1354 patients utilized the Society's services and 769 were referred to higher levels of care. (CHMI, 2011) The model appears to be able to successfully control maternal and infant deaths in the region, documenting about two maternal and 12 neonatal deaths since it began operations. (CHMI, 2011) 3.3.6 Wired Mothers The study aims to examine the beneficial impact of mobile phones for healthcare on maternal and neonatal morbidity and mortality, and to seek innovative ways to ensure access to skilled attendance at delivery through an intervention called "wired mothers". Wired mothers are pregnant women linked to a Primary Healthcare Unit through mobile phones receiving standard SMS reminders for care appointments and who can call the primary provider in case of acute or non acute problems. The study also looks at the health system's response in 51

relation to obstetric emergencies when using mobile phones thereby strengthening communication between the different levels from TBA to referral hospital. (CHMI, 2011) Specific objectives To study the attendance of wired and non-wired women at routine primary healthcare appointments. To study the level of facility-based deliveries amongst wired and non-wired women. To study morbidity amongst wired and non-wired women. To study the quality of services provided to wired and non-wired women. To study neonatal morbidity and mortality amongst children delivered by wired and non-wired mothers. The project was initiated in January 2009 and completed in December 2010 52

Chapter-4 NIPI Focus Districts Profile 53

4. District Profile 4.1 Nalanda 4.1.1 Introduction Nalanda is one of the important districts of Bihar with an area of 2367 sq.km and a population of over two million. Bihar Sharif is the district headquarters and the district is flanked by two important rivers namely Phalgu and Mohane. The decadal growth rate for the year 1991-01 was estimated at 18.6 percent, the lowest for all the states of Bihar. The sexratio of the district is recorded at 915 females per 1000 male population. The percentage of SC & ST population stands at 19.4 percent and 0.02 percent respectively, which is much lower than other districts of Bihar. A marked disparity was noted between male and female literacy rates, at only 39.6 percent for males compared to 66.9 percent for females. (Bihar_NIPI, 2009) The modern district of Nalanda with HQ Bihar Sharif was established on November 9, 1972. Earlier it was Bihar Sharif sub-division of Patna district. (Nalanda_DHP, 2010) Table 20: Nalanda At A Glance (Nalanda DHP, 2010) AREA ( Sq. Kms) 2367 Sq Km Population(Census 2001) Total 2370528 Males 1238599 (52.24%) Females 1131929 (47.75%) Rural Population Total 2014948 Males 1052608 (52.23%) Females 962340 (47.76%) Urban Population Total 355580 Males 184094 (51.77%) Females 171531 (48.23%) Population Of Scheduled Castes 473786 (19.98%) Population Of Scheduled Tribes 970 Density Of Population 1007 Sex Ratio 915 54

Table 21: Comparative Population data (2001 Census) (Nalanda_DHP, 2010) Basic Data India Bihar Nalanda Population 1027015200 828787 2370528 Density 324 880 1007 Sex- Ratio 933 921 915 Literacy (%) Total 65.38 47.53 53.64 Male 75.85 60.32 66.44 Female 54.16 33.57 38.58 Demographic Indicators Nalanda Bihar Density 1007 880 Decadal Growth rate (1991-2000) 18.64% 28.43% Population 2370528 8,28,78,796 Male 1238599 43243795 Female 1131929 39754714 0-6 years 461240 16806063 0-6 years - male 237527 8652705 0-6 years female 223713 8153358 SC 19.90% 15.72% ST 0.04% 0.91% BPL 58.80% 42.60% Sex Ratio 915 921 Early age of marriage 59.60% 51.50% Literacy 53.64% 47.53% Male literacy 66.44% 60.32% Female literacy 38.58% 33.57% Crude birth rate 31.20% 29.90% Infant Mortality rate Total Fertility Rate (Nalanda_DHP, 2010) 62 60 4.2 4.3 These tables show the demographic scenario of Nalanda district. According to Census of India 2001: (Nalanda_DHP, 2010) The size of population of Nalanda district is above 2370528 comprising 2.86 percent of the population of Bihar state in 2.51 percent of the state s area. Very high density of population (1007) which is still rising Decadal population growth rate of 18.6 percent as against 28.43percent of the state as whole. Thus the decadal growth rate of the district is lowest than that of 55

the state. Sex ratio of the population is 915 females per thousand males which is less than the sex ratio of the state. It is difficult to interpret the deficit of 85 females per thousand males in the district despite outward migration, predominantly of males in the working ages. A possible explanation seems to be that over the years male population has benefited more from the epidemiological transition than the female population. Only 15 percent of the population resides in the urban area, and the rest lives in the rural areas. General Information Agriculture Industry Nalanda Paddy, Wheat, Potato, Onion, Vegetables Handloom. Weaving Ordinance Factory(Under Construction), Railway Coach Maintenance Factory (Under Construction) Bihar Paddy, Wheat, Jute, Maize, Oil Seeds, Sugarcane, Barley etc. Oil refinery, Fertilizer factories, Cotton spinning mills, sugar mills Prone to flood Yes Yes (Nalanda_DHP, 2010) Based on these statistics one can say that Nalanda district lacks urbanization and industrialization. As far as industrialisation is concerned the situation is expected to improve on completion of the two projects mentioned above. Population density of this district is 1007 per sq. km. which is also high in comparison to the state density. Decadal population growth is lowest in this district in Bihar, which is a positive sign. (Nalanda_DHP, 2010) Government Administrative Set-up The district comprises three sub divisions and 20 blocks. There are also 1084 revenue villages and 249 gram panchayats. Traditionally the district was divided into 12 C.D. blocks but eight more blocks were created during last decade. The newly elected Panchayati Raj is enthusiastic in playing an important role (Nalanda_DHP, 2010) 56

Figure 3: District Health Administrative Setup (Nalanda_DHP, 2010) General Indicators Nalanda (HQ - Bihar Sharif) Bihar Subdivisions 3 9 divisions, 101 subdivisions Blocks 20 534 Towns 3 No. of Municipalities Gram Panchayats 249 8471 Revenue Circles 20 Villages 1084 45,103 Source: (Nalanda_DHP, 2010) 1 57

4.1.2 District Health System In a study of 593 districts of the country (Jansankhya Sthirata Kosh", www.jsk.gov.in) in terms of overall rank in health it was found that Nalanda district ranks 509 though on the basis of under-five mortality it ranked 328. Filaria, Malaria, Kala-azar, skin diseases, and Tuberculosis are some of the most common diseases in Nalanda district. Hepatitis, Diarrhoea, Typhoid, Blindness and Leprosy are other high prevalence diseases. (Nalanda_DHP, 2010) Table 22: Health Indicator Indicator Nalanda Bihar India CBR 32 31 1.4 CDR N.A 8.1 6 IMR 60/1000 61 58 MMR 452/100000 371 301 TFR 4.3 4 2.68 CPR 21.5 Complete Immunization 38% 32.8 Sources: DLHS3, NFHS3, SRS2007 (Nalanda_DHP, 2010) S. No. Name of PHC Table 23: Institutional Delivery in Nalanda district (PHC wise) (Nalanda_DHP, 2010) April May June July August Sep. Oct. Nov. Dec. Jan. 1 Asthawan 123 138 92 151 221 207 229 208 185 47 2 Giriyak 92 78 76 123 146 162 159 160 149 92 3 Rajgir 132 231 237 297 300 201 408 325 352 37 4 Harnaut 150 124 122 139 236 274 280 234 240 249 5 Sarmera 44 25 37 37 48 82 126 89 110 61 6 Noorsarai 101 117 124 180 199 253 318 230 214 150 7 Rahui 95 106 106 124 129 199 213 186 147 107 8 Hilsa_PHC 0 0 0 0 0 0 0 0 0 0 9 Hilsa_Sub 139 146 126 193 277 275 318 214 236 51 10 Chandi 96 118 115 166 292 356 392 289 249 203 11 Ekangarsarai 95 148 140 201 240 248 257 212 214 235 12 Islampur 48 32 52 39 65 107 101 76 79 83 13 Sadar_PHC 0 0 0 0 0 0 0 0 0 0 14 Sadar Hospital 1135 762 853 1141 1797 1656 1398 1058 1534 690 15 Urban Health Centre 0 0 0 0 0 0 0 18 40 35 Total 2250 2025 2080 2791 3950 4020 4199 3299 3749 2040 58

Figure 4 Nalanda District Table 24 MCH Indicators in Nalanda district INDICATORS DLHS-2 (2002-04) DLHS-3 (2007-08) NIPI BASELINE (2008-09) MATERNAL HEALTH Total Rural Total Rural Total Rural Mothers registered in the first trimester when they were pregnant with last live birth/still birth (%) Mothers who had at least 3 antenatal care visits during the last pregnancy (%) Mothers who got at least one TT injection when they were pregnant with their last live birth / still birth (%) - - 25 22.1 42.7 37.40% 14 13.1 25.2 22.2 38.5 36.6 29.7 27.9 50 47.2 95.3 95.3 Institutional births (%) 27.3 23.4 39.3 34.5 58.6 57.7 Delivery at home assisted by a doctor/nurse /LHV/ANM (%) Mothers who received postnatal care within 48 hours of delivery of their last child (%) CHILD IMMUNIZATION AND VITAMIN A SUPPLEMENTATION 7.5 8.3 7 6.2 20.6 17.9 - - 27.9 24.2 45.5 42.9 59

Children (12-23 months) fully immunized (BCG, 3 doses each of DPT, and Polio and Measles) (%) Children (12-23 months) who have received BCG (%) Children (12-23 months) who have received 3 doses of Polio Vaccine (%) Children (12-23 months) who have received 3 doses of DPT Vaccine (%) Children (12-23 months) who have received Measles Vaccine (%) Children (9-35 months) who have received at least one dose of Vitamin A (%) Children (above 21 months) who have received three doses of Vitamin A (%) TREATMENT OF CHILDHOOD DISEASES (Children under 3 years, based on last two surviving children) Children with Diarrhoea in the last two weeks who received ORS (%) Children with Diarrhoea in the last two weeks who were given treatment (%) Children with acute respiratory infection/fever in the last two weeks who were given treatment (%) Children who were examined within 24 hours of birth (based on last live birth) (%) Children who were examined within 10 days of birth (based on last live birth) (%) CHILD FEEDING PRACTICES (Children under 3 years) Children breastfed within one hour of birth (%) Children (age 6 months above) exclusively breastfed (%) Children (6-24 months) who received solid or semisolid food and still being breastfed (%). 19 19.8 54.2 53.2 48 48.9 46.4 46.4 88 88.6 97.3 96.9 30.7 29.9 62.8 62.4 73.8 73.8 35.1 28.9 65.1 64.5 71.9 72.9 25.5 25 69.1 69.2 66.8 68 - - 59.4 58.5 41 43.1 - - 10.4 11.5 13.1 13.5 0 0 45.3 46.2 44.6 42.6 9.4 0 86.6 86.1 76.4 77.3 - - 80.9 79.5 82.5 86.4 - - 28 25.4 9.1 8.3 - - 28 25 15.80% 14.10% - - 30.2 31.6 8.5 8.9 - - 20.7 20.9 22.5 17.6 - - 87 87.8 51.5 50.9 Source- (Bihar_NIPI, 2009) 4.1.3 Health Infrastructure The District Head Quarter Hospital at Bihar-Sharif together with two referral hospitals, twenty block PHCs, and 25 APHCs caters to the healthcare needs of the people. There is also one blood bank and a total of 141 doctors in districts. 60

Table 25: Public Health Care Delivery System: Organisational Structure and Infrastructure 61

Table 26: Health Infrastructure S.No. Type of Institutions Number 1 District Hospital 01 120 2 Referral 02 60 3 Block PHCs 20 72 4 APHCs 25 0 5 Sub-centres 305 0 6 Ayurvedic Dispensaries 00 N.A 7 Anganwadi Centres 2246 N.A 8 Others (Pvt. Facility accredited) 04 N.A 9 Blood Bank 01 10 No. of ANMs 650 N.A. 11 No. of Doctors 141 N.A. (Nalanda_DHP, 2010) Total No. of Beds* 4.1.4 Nalanda Facility Survey Findings The study done by A N Sinha Institute of Social Sciences for Access Health International in Sep. 2010 was an attempt to provide insights into the infrastructure available and current capacity of both governments, corporate and private health services providers of Nalanda district in neonatal and infant care. Number of deliveries conducted in the health facility People prefer government hospitals for delivery due to the facilities that are available and at no extra cost. Usually a patient in a private hospital incurs an expenditure of about INR 2500 to INR 3000 for a normal delivery. On the other hand in a government hospital, the beneficiary receives INR 1400 under the JBSY scheme. As a result while on an average only 62 deliveries take place in private hospitals, there are about 260 that take place in a government hospital in a month in Nalanda district (Ratan, 2010) 62

Average number of deliveries per month Private Nursing Home/ Private Hospital Govt. Hospital 62 260 Neonate Outpatients attended 92 neonates consult the doctor in private hospitals and 80 neonates come to government hospitals each month. (Ratan, 2010) Average number of Neonates (OPD) per month Private Nursing Home/ Private Hospital Govt. Hospital 92 80 Infant Outpatientss attended 249 Infants come across to consult the doctor in private hospital and 299 infants come across to the government hospital. (Ratan, 2010) Average number of Infants (OPD) per month Private Nursing Home/ Private Hospital Govt. Hospital 249 299 Consultation Charges for outpatients INR 61 is the average charge for consultation in a private hospital while in the government hospital only INR 1or 2 is charged from the outpatient towards registration. (Ratan, 2010) Average charge for OPD Consultation (INR) Private Nursing Home/ Private Hospital 61 Govt. Hospital 1-2 (Only Registration Charges) Distance covered by patients Generally 0-1 year old patients travel about 25 kms to consult the doctor in a private nursing home or private hospital. At the same time patients visiting a government hospital travel a distance of18 kms for a consultation with the doctor there. (Ratan, 2010) 63

Distance travelled by 0-1 year old Patient to consult the doctor Private Nursing Home/ Private Hospital Govt. Hospital 25 Kms. 18 Kms. Common Ailments of outpatients below the age of one year Fever, vomiting, diarrhoea, pneumonia, RTI/ARI, cold and cough, loose motions and jaundice where found in patients at both private and government hospitals while cases of gastroenteritis, rickets, LBW, paralysis, meningitis and malnutrition have been seen in private hospitals only. (Ratan, 2010) Common Ailments Private nursing home/ Private hospital Govt. hospital Fever Paralysis X Meningitis X Jaundice Loose Motion Cold and Cough Diarrhoea Pneumonia RTI/ ARI Gastroenteritis x Rickets X Vomiting LBW X Malnutrition x Number of Neonate In-patients Private hospitals for child care in Nalanda is in far better conditions and more in number than in the other 2 NIPI focused districts. Government hospitals also manage neonate s complications to some extent. So the average number of neonate in-patients in private and public hospital remains almost the same i.e. 28 and 29 respectively per month. (Ratan, 2010) Number of Neonates (IPD) per month Private Nursing Home/ Private Hospital Govt. Hospital 28 29 64

Common Complications of Neonate In-patients Common complications like birth asphyxia, jaundice, hypothermia and sepsis & RTI / ARI are found in the in-patients of private as well as government hospitals while LBW PEM, gastroenteritis & meningitis are found in the in-patients of private hospitals only. (Ratan, 2010) Name of common neonatal complications of inpatient Private nursing home/ Private hospital Govt. hospital Birth Asphyxia Jaundice Hypothermia Sepsis RTI / ARI LBW X PEM X Gastroenteritis X Meningitis X Duration of stay of neonate In-patients in hospital Government hospitals are not well equipped to handle complications. Only Hilsa subdivision and Sadar hospital manage the complication among neonates at some extent. So the average length of stay of neonates in a government hospital is about 24 hours to 2 days in case of complications. On the other hand, private hospitals have proper facilities and equipment to manage the neonatal complications. So the average length of stay of neonate in-patients is about 2 to 10 days in Nalanda private hospital. (Ratan, 2010) Duration of Stay of Neonates (IPD) Private Nursing Home/ Private Hospital Govt. Hospital 2-10 Days 24 Hour-2 Days Hospitalisation cost of Neonate In-patients The Average expenditure in the hospital that includes the bill and medicine are INR 650 and INR 400 per day respectively while diagnostics costs are above INR 500 per patient in private hospital of this district. (Ratan, 2010) 65

Hospitalisation cost of Neonates in inpatient in private hospital Terms of expenses Average Amount (INR/day) Hospital Bill 650 Medicine cost 400 Diagnostics cost 500 Number of neonatal in-patients between 29 days and 12 months The number of neonatal in-patients is 26 in private hospitals as against 75 in government hospitals. This is so because complications or common illness of infants are managed very well in government hospitals and at no cost. On the other hand the treatment and hospital bills in a private hospital are unaffordable by poor people. This results in the government hospitals having more patients of this age than private hospitals. (Ratan, 2010) Number of Neonatal in-patients between 29 days and 12-Months per month Private Nursing Home/ Private Hospital Govt. Hospital 26 75 Common complication of 29 days-12 months old children inpatients Complications in neonates between 29 days and 12 months include diarrhoea, pneumonia, loose motion, RTI / ARI meningitis, and cold & cough. Fever was found in patients of both private and government hospitals while cases of jaundice gastroenteritis, malnutrition and rickets were found in private hospitals only and cases of hypothermia was found in government hospital only. (Ratan, 2010) Name of common complication in 29 days - 12 months old children out patients. Private Hospital/Nursing Home Govt. Hospital Diarrhoea Jaundice Pneumonia Loose Motion RTI / ARI Mengitis X Gastroenteritis Cold & Cough X 66

Malnutrition Fever X Bronchitis X Hypothermia X Rickets X Duration of stay of neonatal in-patients between the age of 29 days and 12 months It is observed that 29 days 12 month old neonatal in-patients stay between 12 hours to 3 days generally in both private and government Hospitals. Some critical neonatal patients have stayed up to 16 days in some private hospital. (Ratan, 2010) Length of stay (LoS) of 29 days 12 Months old children (IPD) per month Minimum LoS Maximum LoS 12 Hours 3 Days Hospitalisation costs of 29 days 12 month old neonatal in-patients in private hospital The average hospital bill in a private hospital is INR 100-500 per day while INR 100-500 is spent on medicines and INR 150-500 on diagnostics for the in-patient. (Ratan, 2010) Hospitalisation cost for 29 days-12 month old neonatal in-patient in private hospital Terms of expenses Average Amount (INR/day) Hospital Bill 100-150 Medicine cost 100-500 Diagnostics cost 150-500 4.2 Jehanabad 4.2.1 Introduction Jehanabad is located at the confluence of two small rivers called Dardha and Yamunaiya. It is the heartland of Magadh and the local dialect is called Magahi. The area is developing now and the services sector is gaining ground in the district. Jehanabad town is the administrative headquarter of this district. This district is a part of Magadh division and is only 45 km from Patna, the state capital. The decadal growth rate for the year 1991-01 was estimated to be 67

28.6 percent, which is more or less the same as the state growth rate. The sex-ratio of the district is recorded at 928 females per 1000 male population. The percentage of SC & ST population stands at 18.4 percent and 0.02 percent respectively, which is much lower than other districts of Bihar. A marked disparity is noted between male and female literacy rates, the latter being only 40.1 percent compared to the former (70.9 percent). (Bihar_NIPI, 2009) Sl. No. Table 27: Statistical Profile (based on 2001 census) (Jehanabad_DHP, 2009) Population Male Female Total 1. Bihar 43153964 39724832 82878796 2. Jehanabad 480518 443959 924477 3. Rural Population 420777 391807 812584 4. Urban Population 59741 52152 111893 5. Literacy rate 70.29% 40.43% 55.91% 6. Rural 69.03% 37.94% 53.99% 7. Urban 78.83% 58.62% 68.42% History: Description of Jehanabad and its history is found in the famous book "AINA-E- AKBARY" wrote by Abul Fazal. The book states that in the 17th century Jehanabad was badly affected by famine and people were dying of hunger. Moghul emperor Aurangzeb, in whose times the book was re-written established a "Mandi" for relief of the people and named it JEHANABAD. (Aggrawal, 2010) Jehanabad district was carved out of the old GAYA district on August 1, 1986. Earlier it was a subdivision of Gaya since 1872. It is situated 56 km to the south of the state headquarters, Patna and 47 km to the north of Gaya by road and is well connected to both the stations via an electrified rail-route as well. In the year 2001, the district of Arwal was created out of the district of Jehanabad. (Aggrawal, 2010) Table 28: Other Important data :- (Jehanabad_DHP, 2009) 1. Area (in Sq. km.) 941.4 sq.km 2. Decadal growth rate 28.64% (1991 to 2001) 3. Population Density 963 PPSK (Person per sq.km) 4. Sex Ratio 928 (per 1000 male) 5. Villages Populate - 562 Uninhabited - 43 Total - 605 68

6. Town 02 7. Municipality 02 8. Rural Families 144199 9. SC Population 124856 10. Cultivator 1.40 Lacs 11. Small and Marginal Farmers 92138 12. Agriculture Labours 1.78 Lacs 13 Skilled labours/ artisan 7967 14. House hold Cortege Workers 12661 15. Other Workers 59716 16. Net Area under Cultivation 78000 Hec. 17. Gross Cropped Area 260735.46 acr. 18. Net Irrigated Area 66450 Hec. 19. Area under Forest 1030 Hec. (0.41%) 20. Water Area Fishery 1176..46 Hec. 21. Total Cattle 2.04 Lacs (1982) Geography: The district covers 941.4 sq. km. of geographical area in South Bihar. The town of Jehanabad, which is the HQ of the district, is situated at the confluence of rivers Dardha and Jamuna. Lying between 25-0 to 25-15 degree north latitude and 84-13 to 85-15 degree eastern longitudes, the district is bounded by districts of Patna in the north, Gaya in the south, Nalanda in the east and Arwal in the west. (Aggrawal, 2010) Administration: There is one subdivision - Jehanabad and seven blocks in the district - Jehanabad, Kako, Makhdumpur, Ghosi, Ratni Faridpur, Hulasganj and Modanganj. There are 93 Gram Panchayats, seven Panchayat Samities and one Zila Parishad in this district. One Nagar Panchayat is at Makhdumpur and one Nagar Parishad at Jehanabad, M.P. constituency - 01, MLA constituency - 3 (Jehanabad_DHP, 2009) Socio-Economic: The relatively small sized district is a cauldron of conflict as far as the socioeconomic situation is concerned. There were extreme caste tensions (with an economic bearing) prevailing in the whole Magadha area (old Gaya district - now broken into 5 districts of Gaya, Aurangabad, Nawada, Jehanabad and Arwal) and they were manifested in their worst forms in this district. Thus this place has been badly affected by Naxalism (PWG, MCC, ML (Lib) etc.) and has seen the emergence of rival outfits such as Ranvir Sena. As a result this district has witnessed a horrifying spate of large scale carnages in the past which has resulted in the killing of hundreds of innocent people. Nonhi-Nagwan, Parasbigha, 69

Khagari-Damuha, Laxmanpur-Baathe, Rampur-Chauram, Senari, Shankarbigha and Narainpur - there are numerous villages where big massacres have occurred. (Aggrawal, 2010) 4.2.2 Health System Janani Suraksha Yojana (JSY): JSY is the prime strategy in the NRHM with the objective to increase the institutional deliveries so that the reduction in MMR objective is achieved. The scheme comprises of payments to the beneficiary and ASHA for food, transportation and motivation. During the current year the performance and outcome of JSY has been quite encouraging. This scheme has significantly increased the incidence of institutional deliveries in the district and the same time, it has also increased the public s faith in public health facilities. The district had achieved 120 percent of JSY s target. In the year 2009-10 a total of 20520 deliveries were carried out in all PHCs. For the F.Y.2010-11 the district has proposed 18550 deliveries to improve institutional deliveries in rural areas. (Aggrawal, 2010) JSY payments were up-to-date in almost all the facilities that were visited. But in few facilities the payment has not been made due to unreleased funds. All the beneficiaries were issued cheques at the time of discharge. (Aggrawal, 2010) Table 29: Health Indicators Indicator Jehanabad Bihar India CBR 28.6 29.2 23.8 CDR 8.1 8.1 6 IMR 62 61 58 MMR 371 371 301 TFR 4.6 4 2.68 CPR 33 34.1 56.3 Complete Immunization 47.2 32.8 44 Sources: DLHS3, NFHS3, SRS2007 (Jehanabad_DHP, 2009) 70

Figure 5 Jehanabad District Table 30 MCH Indicators in Jehanabad district INDICATORS NIPI DLHS-2 (2002 DLHS-3 (2007 - BASELINE - 04) 08) (2008-09) MATERNAL HEALTH Total Rural Total Rural Total Rural Mothers registered in the first trimester when they were pregnant with last live - - 26.7 27 36 35.60% birth/still birth (%) Mothers who had at least 3 Antenatal care visits during the last pregnancy (%) 18.7 18.3 30.6 31.2 39.6 39.2 Mothers who got at least one TT injection when they were pregnant with their last live birth / still birth (%) 30 29.3 54.5 54.4 98.6* 98.5 Institutional births (%) 31.4 30.2 42.5 43 66.1 66.2 Delivery at home assisted by a doctor/nurse /LHV/ANM (%) Mothers who received post natal care within 48 hours of delivery of their last child (%) CHILD IMMUNIZATION AND VITAMIN A SUPPLEMENTATION Children (12-23 months) fully immunized (BCG, 3 doses each of DPT, and Polio and Measles) (%) Children (12-23 months) who have received BCG (%) 11.9 12 10.6 10.3 31.6 30.4 - - 31 31.5 39 39 14.1 14 47.2 46.3 51 50.7 36.8 36.8 85.4 87.2 98.7 98.6 71

Children (12-23 months) who have received 3 doses of Polio Vaccine (%) Children (12-23 months) who have received 3 doses of DPT Vaccine (%) Children (12-23 months) who have received Measles Vaccine (%) Children (9-35 months) who have received at least one dose of Vitamin A (%) Children (above 21 months) who have received three doses of Vitamin A (%) TREATMENT OF CHILDHOOD DISEASES (Children under 3 years, based on last two surviving children) Children with Diarrhoea in the last two weeks who received ORS (%) Children with Diarrhoea in the last two weeks who were given treatment (%) Children with acute respiratory infection/fever in the last two weeks who were given treatment (%) Children had check-up within 24 hours after delivery (based on last live birth) (%) Children had check-up within 10 days after delivery (based on last live birth) (%) CHILD FEEDING PRACTICES (Children under 3 years) Children breastfed within one hour of birth (%) Children (age 6 months above) exclusively breastfed (%) Children (6-24 months) who received solid or semisolid food and still being breastfed (%). 21.5 21.3 48.7 49.9 73.1 72.9 26.1 27.2 55.1 56.4 71.1 71.5 19.4 19.9 63.9 65 63.6 63.5 - - 66 66.9 41.2 41 - - 9.2 9.9 13.7 15.6 0 0 13.6 13.4 34.8 34.8 100 100 74.7 77.7 56.5 56.5 - - 72.6 72.5 77.1 76.5 - - 29.8 30 10.4 10.7 - - 31 31.8 17.2 17.7 - - 18.6 19.1 20.2 20.5 - - 10.9 11.4 28.4 25.7 - - 84.5 84 41.4 39.7 4.2.3 Health Infrastructure There are 120 Health Sub Centers (HSCs) in the district, of which only 81 HSCs are functional. However most of them do not have their own building with adequate facilities. Most facilities also face a shortage of staff due to which they were unable to provide the services. In some FRUs, BPHCs and APHCs C-section was not conducted due to lack of specialists. (Aggrawal, 2010) A total of 52 of the 80 HSCs are being run without their own buildings in private accommodations which are unfit for an HSC, to say the least. (Jehanabad_NIC) 72

Figure 6: Health Facility in Jehanabad Source: (Aggrawal, 2010) 73

Type of Hospital Table 31: Health Infrastructure No. of Hospital No. of Beds No. of Doctors Sanctioned No. of Doctors working Sadar Hospital 1 95 13 13 Referral Hospital 2 60 09 4 Block P.H.C 07 24 25 11 Adi. P.H.C 28 168 56 33 Health Sub Centre 81 - - - (Jehanabad_NIC) Month's OPD Inpatients Name of DISTRICT : Jehanabad (Jehanabad_DHP, 2009) No. of Delivery Referred Case No of Emergency Immunization Mother Child Pulse Polio 7810 198 204 0 742 797 2995 0.00% May-05 8984 172 179 0 390 1233 6121 0.00% Jun-05 9905 193 162 0 408 804 3417 0.00% Jul-05 11273 186 215 0 544 816 3298 0.00% Aug-05 11957 425 305 0 807 794 3557 0.00% Sep-05 12156 221 304 0 482 810 3806 0.00% Oct-05 10856 214 260 0 496 758 3703 0.00% Nov-05 10379 203 244 0 420 791 4334 0.00% Dec-05 10363 286 159 0 511 788 4982 0.00% Jan-06 9137 402 182 0 616 609 3947 0.00% Feb-06 8893 669 159 0 731 735 5556 0.00% Mar-06 9054 349 148 0 731 858 5741 0.00% TOTAL'05-06 120767 3518 2521 0 6878 9793 51457 Apr-06 8067 190 151 0 623 944 5638 0.00% May-06 9632 203 181 0 946 1141 5562 0.00% Jun-06 10677 242 189 0 1071 1182 5220 0.00% Jul-06 20048 331 269 0 1704 1484 5140 0.00% Aug-06 22603 445 281 0 1347 1294 4917 0.00% Sep-06 24237 386 327 0 1216 806 4863 0.00% Oct-06 21345 356 303 0 1246 675 4620 0.00% Nov-06 18749 484 306 0 965 900 6867 0.00% Dec-06 17370 457 301 0 988 1295 16819 0.00% Jan-07 15910 521 265 0 1070 995 11101 0.00% Feb-07 16955 808 230 0 789 1271 13445 0.00% Mar-07 19704 634 251 0 1223 1466 10093 0.00% 74

TOTAL'06-07 205297 5057 3054 0 13188 13453 94285 21738 335 299 35 1278 1993 13247 1.50% May-07 24349 653 465 158 1737 1883 6375 0.92% Jun-07 28739 1133 508 233 1559 4046 14052 0.00% Jul-07 38093 1403 715 235 1723 3966 10872 1.26% Aug-07 40130 2055 1171 221 2283 4502 15340 1.21% Sep-07 38828 2768 1551 210 2126 3807 17183 1.00% Oct-07 40869 3389 1967 168 2690 3168 17838 1.00% Nov-07 38505 3512 1932 154 2336 2711 17628 0.00% Dec-07 33522 3587 1711 156 2112 2497 17082 0.91% Jan-08 35443 3495 1399 107 1990 2572 18572 0.99% Feb-08 33193 3015 1202 94 1852 2889 21955 1.13% Mar-08 29771 3240 1065 148 2030 2743 19330 1.33% TOTAL '07-08 403180 28585 13985 1919 23716 36777 189474 Apr-08 26667 2818 900 153 2206 1452 16298 1.13% May-08 35413 3014 864 164 2391 2470 17900 0.00% Jun-08 36989 2626 864 149 2284 4173 14901 0.95% Jul-08 43654 3417 1200 157 2594 4209 13055 1.04% Aug-08 48658 4568 1691 240 3001 4955 11801 1.04% Sep-08 54762 5114 2131 193 3171 3889 12358 0.81% Oct-08 43669 5857 2563 185 3315 3064 17165 0.81% Nov-08 41295 5108 2343 169 2799 2732 15922 0.78% Dec-08 41527 5401 2232 156 2671 2848 17712 1.14% TOTAL '08-09 372634 37923 14788 1566 24432 29792 137112 Total 1101878 75083 34348 3485 68214 89815 472328 (Jehanabad_DHP, 2009) Table 32: Final Budget of Jehanabad Sl. Budget % Total Budget No 1 Head TB 0.44% 962000 2 Kala azar 2.43% 5366460 3 Leprosy 0.56% 1245000 4 Filariasis 0.22% 496000 5 Blindness 1.55% 3424000 6 Child Health 3.90% 8603648 7 Maternal Health 70.51% 155552750 8 Family Planning 17.45% 38494000 9 Institution 2.93% 6453000 Strengthening Total 220596858 (Jehanabad_DHP, 2009) 75

4.2.4 Jehanabad Facility Survey Findings The study done by A N Sinha Institute of Social Sciences for Access Health International in September 2010 was an attempt to provide insights into the infrastructure available and current capacity of both Governments, corporate and private health services providers of Jehanabad district in neonatal and infant care. Number of deliveries conducted in the health facility People prefer government hospitals to private hospitals or nursing homes due to the Janani Bal Suraksha Yojana (JBSY). The average number of deliveries per month is 275 in government hospitals while only 16 deliveries occur in private nursing homes or private hospitals. (Ratan, 2010) Average number of deliveries per month Private Nursing Home/ Private Hospital Govt. Hospital 16 275 Neonate Outpatients attended There are more neonate consultations (about 83/ month) in private nursing home as against only 17 neonates consult the doctor at the government hospital during an illness. (Ratan, 2010) Average number of Neonates Attended (OPD) per month Private Nursing Home/ Private Hospital Govt. Hospital 83 17 Infant Outpatients attended 180 infants consult the doctor at a private nursing home per month while 102 infants consult the doctor at the government hospital every month for the treatment of their illness. (Ratan, 2010) Average number of infants Attended (OPD) per month Private Nursing Home/ Private Hospital Govt. Hospital 180 102 76

Consultation Charges for Outpatients Private nursing homes charge an average of INR 55 for an outpatient consultation for 15 days to one month. On the other hand, government hospitals charge a nominal fee of INR 1 or 2 towards registration for an outpatient consultation in which medicines, diagnosis and treatment are provided. (Ratan, 2010) Normal Charges for Outpatient Consultation (INR) Private Nursing Home/ Private Hospital 55 Govt. Hospital 1-2 (Only Registration Charges) Distance covered by patients Generally 0-1 year old patients travel about 35 kms to consult the doctor in a private nursing home or private hospital. Patients seeking treatment in a government hospital travel a distance of 13 kms to consult the doctor there. (Ratan, 2010) Distance travelled by 0-1 year old patient to consult the doctor Private Nursing Home/ Private Hospital Govt. Hospital 35 Kms. 13 Kms. Common ailments of below one year old out patient Fever, meningitis, jaundice, loose motion, sepsis, cold and cough, diarrhoea, dehydration, pneumonia, RTI / ARI, bronchitis etc. are some of the common ailments in 0-1 year old outpatients who go to a private hospital for treatment. On the other hand fever, loose Motion, cold & cough, diarrhoea, pneumonia, RTI and bronchitis, etc. are found in out-patients who get treated at the government hospital. (Ratan, 2010) Common Ailments Private nursing home/ Private hospital Govt. hospital Fever Paralysis X Meningitis X Jaundice X 77

Loose Motion Sepsis X Cold and Cough Diarrhoea Dehydration X Pneumonia RTI/ ARI Bronchitis X Number of Neonate in-patients It is found that average number of neonates who are provided in-patient treatment for complications at birth is 83 per month at private hospitals/ nursing homes and 18 at the government hospital in Jehanabad district. (Ratan, 2010) Number of Neonates inpatient per month Private Nursing Home/ Private Hospital Govt. Hospital 83 18 Common complications of Neonate In-patients Common neonatal complications seen in in-patients are birth asphyxia, jaundice, hypothermia and sepsis. Neonate in-patients in government hospitals are seen with complications of RTI, LBW, meningitis and diarrhoea. (Ratan, 2010) Name of common neonatal complications of Inpatient Private nursing home/ Private hospital Govt. hospital Birth Asphyxia Jaundice Hypothermia Sepsis RTI X LBW X Meningitis X Diarrhoea X Blood Exchange X 78

Duration of stay of Neonate In-patients Due to the lack of facilities in government hospitals to treat complications, neonate inpatients generally stay only for one or two days. However there are some private hospitals in this district that have paediatricians and equipment and therefore allow neonate in-patients to stay for about three to seven days. (Ratan, 2010) Length of stay of neonates inpatient Private Nursing Home/ Private Hospital Govt. Hospital 3-7 days 24 hrs-2 days Hospitalisation Cost of Neonate In-patients The hospital bill and medicine cost for neonate in-patients amounts to INR 500 and INR 270 per day respectively and diagnostics costs above INR 250 (Ratan, 2010) Hospitalisation cost of neonate in-patient in private hospital Terms of expenses Average Amount (INR./day) Hospital Bill 500 Medicine cost 270 Diagnostics cost 250 Number of 29 days 12 months old in-patients The number of in-patients in the age group of 29 to 12 months old neonate in-patients at 68 is about 3 times more in the government hospital than the 23 patients who visit private hospitals. (Ratan, 2010) Number of 29 days-12 month inpatient per month Private Nursing Home/ Private Hospital Govt. Hospital 23 68 Common complication of 29 days-12 months old children inpatients The common complications among neonate in-patients 29 days 12 months old are diarrhoea, hypothermia, jaundice, pneumonia, loose motion, fever, cold & cough, RTI in both private & government hospitals while the cases of LBW, paralysis and snake biting are seen only in private hospitals. (Ratan, 2010) 79

Name of common complication in 29 days - 12 months old children out patients. Private Hospital Nursing Home Govt. Hospital Diarrhoea Hypothermia X Jaundice Pneumonia Loose Motion Cold & Cough RTI Dehydration X LBW X Paralysis X Snake Biting X Duration of stay of neonate in-patients of the age group 29 days 12 months It is observed those 29 days 12 month old neonate in-patients stay for 12 hours to 5 days in private hospitals or in government hospital. The duration of the stay usually depends upon the condition and complication of patient. (Ratan, 2010) Duration of stay of 29 days-12 month inpatient Private Nursing Home/ Private Hospital Govt. Hospital 12 hours 5 days 5.16 Hospitalisation Costs for Infant in-patients in Private Hospital. The daily expenses for care of infant in-patients at a private hospital or nursing home is approximately INR 100-150 while INR 300 is spent on medicine and INR 185 on diagnostics (Ratan, 2010) Hospitalisation cost of Infant in-patients in private hospital Terms of expenses Average Amount (INR /day) Hospital Bill 100-150 Medicine cost 300 Diagnostics cost 185 80

4.3 Sheikhpura 4.3.1 Introduction Sheikhpura district is spread over an area of 689 sq.km. Its headquarters is Sheikhpura. The district is divided into six blocks namely Ariari, Sheikhpura, Barbigha, Ghatkusumbo, Chebara and Shekhopur Sarai. Paddy, wheat and lentils are the main crops. The Ganges, Mohane, Harohar and Kiul are the important rivers that pass through the districts. The population of the district is a little over five lakhs, with a decadal growth rate for the year 1991-01 being 25.0 percent. The sex-ratio of the district is recorded at 920 females per 1000 male population. The percentage of SC & ST population stands at 19.7 percent and 0.04 percent respectively, which is much less compared to the other districts of Bihar. A marked disparity is noted between male and female literacy rates, the latter being only 34.1 percent compared to the former (62.6 percent). (Bihar_NIPI, 2009) Social: (Sheikhpura_DHP, 2009) Sheikhpura district has a strong hold of tradition with a high value placed on joint family, kinship, caste and community. The villages of Sheikhpura have old social hierarchies and caste equations still shape the local development. The society is feudal and caste ridden. 17.84 percent of the population belongs to SC and 0.1 percent to ST. There are at least 9 percent villages where the SC population is more than 40percent. Some of the most backward communities are Mushahar, Turha, Mallah and Dome. Area (Hectares) 77705 Population 2009 (Projected Figure) Total 622177 Males 324054 Females 298126 Population of SC 111003 Population of ST 37 Population Density 762 Sex Ratio 920 (Sheikhpura_DHP, 2009) Demographic scenario of Sheikhpura district (According to Census of India 2001): (Sheikhpura_DHP, 2009) 81

The size of population of Sheikhpura district is above 622177, comprising 0.75 percent population of Bihar (Sheikhpura_DHP, 2009) The density of population is (762) which is still rising (Sheikhpura_DHP, 2009) Decadal population growth rate of 26.39 percent as against 28.43 percent of the state as a whole. Thus the decadal growth rate of the district is slightly less than that of the state. (Sheikhpura_DHP, 2009) The sex ratio of the population is 920 females per thousand males which is almost same as the sex ratio of the state. It is difficult to interpret the deficit of 80 females per thousand males in the district despite outward migration, predominantly of males in the working ages. A plausible explanation seems to be that over the years male population has benefited more from the epidemiological transition than the female population. (Sheikhpura_DHP, 2009) Basic Data India Bihar Sheikhpura Population 1027015247 82878796 525137 Density 324 880 762 Sex Ratio 933 921 920 Literacy (%) Total 68.38 47.53 49.01 Male 75.85 60.32 66.16 Female 54.16 33.57 33.84 (Sheikhpura_DHP, 2009) Economic: (Sheikhpura_DHP, 2009) The main occupation of the people of Sheikhpura is labour work in crushers (stone works), agriculture, fisheries and daily wage labour. Almost 20 percent of the youth population migrates to the metropolitan cities like Kolkata, Mumbai, and Delhi etc. in search of jobs. The main crops are wheat, paddy, pulses, and o oilseeds. Villages Total 310 Uninhabited 52 Inhabited 258 Gram Panchayat 54 Nagar Panchayat 2 Towns 2 82

Blocks 6 Revenue Circles 6 Sub-Division 1 Police Station 9 Police Outposts 2 M.L.A. Constituency 2 (Sheikhpura_NIC) Based on these statistics one can say that Sheikhpura district lacks urbanization and industrialization. As elsewhere in Bihar, Sheikhpura suffers from lack of infrastructure facilities, lack of connectivity, and lack of social development and most people depend on small-size agricultural land. (Sheikhpura_DHP, 2009) Figure 7 Sheikhpura District (Sheikhpura_DHP, 2009) Table 33 MCH Indicators in Sheikhpura district INDICATORS NIPI DLHS-2 (2002 DLHS-3 (2007 - BASELINE - 04) 08) (2008-09) MATERNAL HEALTH Total Rural Total Rural Total Rural Mothers registered in the first trimester when they were pregnant with last live - - 42.9 43.4 51.3 48.6 birth/still birth (%) Mothers who had at least 3 Antenatal care visits during the last pregnancy (%) 22.2 21.1 43.2 43.4 40.7 39.5 83

Mothers who got at least one TT injection when they were pregnant with their last live birth / still birth (%) 33.2 31.9 83.5 84.2 98.5 98.4 Institutional births (%) 21.2 18.8 41.6 41.3 60.5 59.3 Delivery at home assisted by a doctor/nurse /LHV/ANM (%) Mothers who received post natal care within 48 hours of delivery of their last child (%) CHILD IMMUNIZATION AND VITAMIN A SUPPLEMENTATION Children (12-23 months) fully immunized (BCG, 3 doses each of DPT, and Polio and Measles) (%) Children (12-23 months) who have received BCG (%) Children (12-23 months) who have received 3 doses of Polio Vaccine (%) Children (12-23 months) who have received 3 doses of DPT Vaccine (%) Children (12-23 months) who have received Measles Vaccine (%) Children (9-35 months) who have received at least one dose of Vitamin A (%) Children (above 21 months) who have received three doses of Vitamin A (%) TREATMENT OF CHILDHOOD DISEASES (Children under 3 years, based on last two surviving children) Children with Diarrhoea in the last two weeks who received ORS (%) Children with Diarrhoea in the last two weeks who were given treatment (%) Children with Acute Respiratory Infection/fever in the last two weeks who were given treatment (%) Children had check-up within 24 hours after delivery (based on last live birth) (%) Children had check-up within 10 days after delivery (based on last live birth) (%) CHILD FEEDING PRACTICES (Children under 3 years) Children breastfed within one hour of birth (%) Children (age 6 months above) exclusively breastfed (%) Children (6-24 months) who received solid or semisolid food and still being breastfed (%). 9.2 7.8 5 4.2 8.2 7.8 - - 44.1 45 36.8 28.8 19.1 20 38.3 41.3 55.6 55.4 50 50 74.5 73.2 95.1 95.1 25.5 27.4 48.3 49.8 70.2 69.6 26.7 31.3 49.2 50.9 72.9 72.8 27.4 30.2 49.3 50.7 67.6 65.8 - - 49.3 51 42.7 41.3 - - 8 9.2 19.2 14.7 67.4 61.7 24.5 25.8 25.9 25.8 79.1 75.4 80.2 82.9 76.3 83.1 - - 76.2 77.5 93.1 93 - - 39.4 40.2 18.1 17.2 - - 41.3 42.3 24.4 23.7 - - 10.5 11.5 10.6 11.4 - - 12.5 12.9 29.9 26.8 - - 82.5 82.5 58.4 57.5 84

4.3.2 District health System Government Administrative Set-up There is one sub division and six blocks in the district. The district has 19 police stations and 54 gram panchayats. There are two railway police stations in Sheikhpura. Traditionally the district was divided into three blocks but three more blocks were created during the last decade. A few of the newly created blocks are still in the formation process. The newly elected Panchayati Raj is enthusiastic to play important role in the district. (Sheikhpura_DHP, 2009) 4.3.3 Health Infrastructure Table 34: Health Infrastructure 85

Institution Number District Hospital 1 Referral Hospital 1 Primary Health Centre 6 Additional Primary Health Centre 17 Health Sub Centre 85 Blood Bank 02 (in Process) (Sheikhpura_DHP, 2009) (Sheikhpura_DHP, 2009) Table 35: Human Resource Allopathic Doctor 86

Regular Contractual 33 17 Regular Lady Doctor Contractual 3 1 Regular Pharmacist Contractual 8 2 Regular Lab Technician Contractual 2 3 Regular Health Educator Contractual 13 0 Regular ANM Contractual 111 65 Regular Staff Nurse Contractual 4 27 Regular Health Worker (Male) Contractual 1 0 (Sheikhpura_DHP, 2009) 4.3.4 Sheikhpura Facility Survey Findings The study done by A N Sinha Institute of Social Sciences for Access Health International in September 2010 was an attempt to provide insights into the infrastructure available and current capacity of both Governments, corporate and private health service providers of Shiekhpura district in neonates and infant care. Number of Deliveries On an average 60 deliveries are performed in private hospitals and 290 in government hospitals. (Ratan, 2010) Average numbers of Deliveries 87

Private Nursing Home/ Private Hospital Govt. Hospital 60 290 Average Number of Neonates/ Outpatient Attended Common people mostly preferred the government hospital for institutional deliveries primarily because of the government JBSY scheme. JBSY provides medical treatment and medicines free of cost. However the first choice for treating a neonate is a private hospital or nursing home as against a government hospital. (Ratan, 2010) Average number of Neonate Outpatients attended Private Nursing Home/ Private Hospital Govt. Hospital 91 60 Outpatient child (Infant attended) An average 260 infant outpatients visit private hospitals or nursing homes for treatment in a month while only 180 outpatients visit a government hospital for treatment. (Ratan, 2010) Average numbers of Infants Outpatient attended Private Nursing Home/ Private Hospital Govt. Hospital 260 180 Consultation Charges for Outpatients The minimum charge for outpatient consultation in a private hospital or nursing home is INR 40 with a maximum of INR 100. Three visits are covered in one consultation charge. Most nursing homes and private hospitals provide one month of consultation free. However one doctor charged once every 15 days while another doctor charged for each visit. (Ratan, 2010) Normal charge of Outpatient Consultation (INR) Private Nursing Home/ Private Hospital Govt. Hospital 76 1.25 Distance covered by patient 88

A patient travels a distance of 23 kms to go to a private nursing home or hospital. However the distance covered to visit a general hospital is a little less than 18 kms. (Ratan, 2010) Distance Travelled by Out Patients Private Nursing Home/ Private Hospital Govt. Hospital 23 Km. 18 Km. Common neonatal ailments Jaundice, cough & cold, feeding problem, loose motion, pneumonia, fever, diarrhoea, RTI, sepsis and hypothermia are some of the common neonatal ailments in Sheikhpura district. (Ratan, 2010) In-patient care of neonates Average neonates inpatients care Private Nursing Home/ Private Hospital Govt. Hospital 120 53 Neonatal Complications Different kinds of neonatal complications are found like no crying by the neonate, sepsis, birth asphyxia, dehydration, meningitis, hypothermia, Pneumonia, RTI, fever, loose motion and jaundice. (Ratan, 2010) Duration of stay of Neonate In-patients Neonate in-patient care in a private hospital can involve a duration of 2-7 days in a private hospital while in a government hospital the maximum length of stay is about 5 days. (Ratan, 2010) Length of Stay Private Nursing Home/ Private Hospital Govt. Hospital 2-7 days 1-5 days Hospitalization cost of neonates 89

Neonate hospitalization costs an average of INR 200 per day in a private hospital or nursing home. Sometimes the cost may even go up to INR 525 for a patient. On the other hand it is free of cost in government hospitals. (Ratan, 2010) Average Hospitalization cost Private Nursing Home/ Private Hospital Govt. Hospital 200 Free Number of 29 days to 12months old neonates in in-patient care An average of 132 neonate patients from different parts of the district visit private nursing homes and hospitals and 160 patients visit government hospitals. (Ratan, 2010) Average 29 days-12 months old children inpatient care Private Nursing Home/ Private Hospital Govt. Hospital 132 160 Common Complications (29 days to 12 months) Some of the common complications experienced by neonates of the age group of 29 days to one year are diarrhoea, jaundice, pneumonia, vomiting, sepsis, dehydration, fever, cold and cough and hypothermia of children. They usually get treated at a private nursing home or hospital. Neonate patients who visit government hospitals usually experience complications such as pneumonia, jaundice, LBW, fever, cough and cold and RTI. (Ratan, 2010) Private Nursing Home/ Private Hospital Common complications Diarrhoea, Jaundice. Pneumonia, Vomiting, Sepsis, Dehydration, Fever, Cold &Cough and Hypothermia Govt. Hospital Jaundice. Pneumonia, Vomiting, Fever, Cold &Cough and Low Birth Weight Duration of stay (29 days to one year old children) Neonate infants of the age 29 days to one year may stay for 1-7 days in private hospitals or nursing homes. Neonates who visit government hospitals stay for 1-5 days for the same condition. (Ratan, 2010) 90

Length of stay( 29 days-12 months old children) Private Nursing Home/ Private Hospital Govt. Hospital 1-7 days 1-5 Days Hospitalization cost (29 days to one year old children) The daily average hospitalization cost for a neonate inpatient at a private hospital or nursing home is INR 580. On the other hand it is free of cost for a neonate in patient at a government hospital. This also includes treatment, diagnostics and medicines that are provided by the hospital. (Ratan, 2010) Average Hospitalization cost (INR) Private Nursing Home/ Private Hospital Govt. Hospital 580 Free 91

Chapter-5 Maternal & Child health in NIPI s focus Districts 92

5. Maternal and Child Health in NIPI s focus districts In this section, the data was collected for NIPI Baseline Report of Bihar from the three NIPI focus Districts; Nalanda, Sheikhpura and Jehanabad and relevant information from the state level. The districts were selected by NIPI in consultation with the state NRHM for implementation of the interventions. (Bihar_NIPI, 2009) 5.1 Maternal Health Maternal healthcare is a concept that encompasses family planning, pre-conception, prenatal, and postnatal care. The goal of pre-conception care includes providing education, health promotion, screening and interventions for women of reproductive age to reduce risk factors that might affect future pregnancies. Antenatal care is the comprehensive care that women receive and provide for themselves throughout their pregnancy. Women who begin prenatal care early in their pregnancies have better birth outcomes than women who receive little or no care during their pregnancies. Postnatal care issues include recovery from childbirth, concerns about newborn care, nutrition, breastfeeding, and family planning. (Bihar_NIPI, 2009) 5.1.1 Delivery Care One of the important thrusts of the program is to encourage deliveries under proper hygienic conditions (delivering under clean conditions, washing hands with disinfectant before delivery, etc.) and under the supervision of qualified/ experience health professionals. For each live/still birth during two years preceding the survey, we had asked the women on the place of delivery, who assisted during the deliveries in case of home deliveries, characteristics of delivery and any problems that may have occurred during the delivery process. This section provides the details. (Bihar_NIPI, 2009) According to NFHS reports, the percentage of women who have delivered in a health facility has steadily increased in Bihar and overall in India. In Bihar, institutional deliveries were only 14.8 percent in 1998-99 (NFHS 2), which has increased by nine 93

percent in 2005-06 (NFHS3). Assistance of trained health personnel during delivery is critical for maternal and child survival. A steady increase was also noted in the number of pregnancies assisted by health personnel in both Bihar and India. When compared to the all-india statistics, Bihar is still lagging behind in terms of both institutional delivery and births assisted by health personnel. (Figure 4.3) (Bihar_NIPI, 2009) A recent DLHS3 reported institutional deliveries at 27.7 percent while NIPI Phase II survey also clearly indicates that the trend has increased to nearly 40 percent of all deliveries, which took place in government hospitals (61.6 percent in institutions), while only 38.4 percent took place at home. (Bihar_NIPI, 2009) Influence of background characteristics choice of place of delivery The following section explores the relationship between the place of last delivery and critical background variables, viz. age of respondent, her education level, child s birth order and standard of living level of her household based on Asset Ownership Index. (Bihar_NIPI, 2009) Nearly 40 percent women reported the place of delivery as a government health facility while 21.4 percent women visited private health facility for delivery. Of the total home deliveries, 23.6 percent took place at the in-laws home, 11.9 percent in p arental home and nearly 2.5 percent took place in others homes. The preferences of health facility for the delivery by the mothers do not have any relation with the age of mothers. (Bihar_NIPI, 2009) Table 36: Place of delivery v/s number of living children, NIPI-08 Institutional Home Total All Govt Other Other Birth NGO Private In-laws Parental Births Hospital places Order N % N % N % N % N % N % N % N % 1-2 755 39.2 2 0.1 552 28.7 348 18.1 226 11.7 36 1.9 9 0.5 1927 100 3-4 534 41.5 3 0.2 202 15.7 340 26.4 166 12.9 39 3 3 0.2 1287 100 5+ 253 40.3 0 0 68 10.9 218 34.9 64 10.2 21 3.4 3 0.5 626 100 Total 1540 40.1 5 0.1 822 21.4 906 23.6 456 11.9 96 2.5 15 0.4 3840 100 94

Data shows that deliveries in health facilities and at home do not have any relation with the education of the mothers while the preference for private institutional delivery also increases with the education of the pregnant mother. (Bihar_NIPI, 2009) The hypothesis that younger women having their first child would rather have a risk-free institutional delivery rather than have it at home while more experienced women with children can afford to think otherwise is more or less validated in the above table. Institutional deliveries come down from 67 percent for women with 1-2 live children to 55.4 percent for those who had more than two children. (Bihar_NIPI, 2009) Table 37: Place of delivery v/s economic status of respondents household, NIPI-08 Institutional Home Total Wealth Index Delivery at Govt place(public) NGO Private In-laws Parental Home Others Other All Births N % N % N % N % N % N % N % N % Lowest 841 41 1 0 307 15.1 562 27.6 262 13 55 2.7 6 0.3 2034 100 Second 243 44 1 0.2 104 18.7 116 20.9 67 12 18 3.2 6 1.1 555 100 Third 172 38 0 0 124 27.3 94 20.7 51 11 11 2.4 2 0.4 454 100 Fourth 150 36 1 0.2 131 31.5 81 19.5 47 11 5 1.2 1 0.2 416 100 Highest 134 35 2 0.5 156 40.9 53 13.9 29 7.6 7 1.8 0 0 381 100 Total 1540 40 5 0.1 822 21.4 906 23.6 456 12 96 2.5 15 0.4 3840 100 The generic trend was that women with lower economic profile tended to favour having deliveries at government facilities as against those who belonged to wealthier households and could afford private treatment. (Bihar_NIPI, 2009) Arrangement and cost of transport In more than 70 percent cases, family members, relatives and friends made the arrangement for transport. Husbands also played an important role in arranging transport particularly in urban areas for delivery. A significant number of ASHA s 95

made arrangement for transport in rural areas of Sheikhpura (18.3 percent), and Jehanabad (8.4 percent). On an average, the cost of transport worked out to be as follows: (Bihar_NIPI, 2009) Table 38: Average transportation expenses (in Rupees), NIPI-08 Jehanabad Nalanda Sheikhpura Total Rural Urban Total Rural Urban Total Rural Urban Total Rural Urban Total N N N N N N N N N N N N N 789 44 833 648 117 765 635 134 769 2072 295 2367 Mean 213 171 207 187 155 173 250 186 235 217 169 206 On an average, the cost incurred on transportation is less than INR 300 in all the districts. In urban areas average cost of transportation varies from INR 155 to INR 186 while in rural areas it varies from INR187 to INR 250 in the study districts. (Bihar_NIPI, 2009) 5.1.2. Institutional delivery Who conducted the delivery Governmen t Doctor Private Doctor This section elaborates on issues dealing with the nature of delivery and attending service provider, incurred costs, health problems/complications experienced during delivery, nature of advice received post delivery and from whom, and finally, opinion on quality of service and facility standards. (Bihar_NIPI, 2009) Rura l Table 39: Nature of Institutional delivery, NIPI-08 Jehanabad Nalanda Sheikhpura BIHAR Urba Tota Rura Urba Tota Rura Urba Tota Rura Urba n l l n l l n l l n % % N % % N % % N % % N 15.6 17.6 15.2 13.6 13.9 14.1 15.9 15 15.7 15.1 15.2 15 Assisted 7.7 6.5 7.6 4.5 8.2 5.2 3.3 4.3 3.3 5.4 6.5 5.4 Total 789 44 833 648 117 765 635 134 769 2,07 295 2,36 2 7 96 Total 23.2 27.5 24 17.4 19.7 18.7 11.8 15.5 12.5 17.9 20.4 18.5 ANM 60.8 54.2 60.4 68.5 65.6 66.7 71.8 69.5 71.4 66.6 63.9 66 Other 0.4 0.7 0.4 0.5 0.8 0.5 0.5 0 0.4 0.4 0.5 0.4 Type of Delivery Normal 79.7 76.5 79.5 85.6 81.1 84.2 89.6 83.4 88.3 84.6 80.7 83.9 Caesarean 12.5 17 13 9.9 10.7 10.6 7.1 12.3 8.5 10 12.8 10.7

The above table clearly shows that the person actually performing the delivery was primarily an ANM (66 percent) followed by private doctor (18.5 percent) and government doctor (15 percent). The trend is similar across the districts and locality. While most deliveries were normal, incidence of caesarean deliveries was more in urban areas. Around 5 percent of the deliveries across both urban and rural areas were assisted deliveries. (Bihar_NIPI, 2009) Table 40: Cost incurred in institutional delivery1, NIPI-08 Rupees Jehanabad Nalanda Sheikhpura BIHAR Rural Urban Total Rural Urban Total Rural Urban Total Rural Urban Total % % % % % % % % % % % % <500 12.2 6.8 11.9 12.8 10.3 12.4 18.9 19.4 19 14.4 13.9 14.4 500-45.4 54.5 45.9 47.1 37.6 45.6 50.2 40.3 48.5 47.4 41.4 46.6 1000 1001-9 6.8 8.9 8.2 1.7 7.2 6.5 4.5 6.1 8 3.7 7.4 1500 1501-12 11.4 12 10 22.2 11.9 10.1 8.2 9.8 10.8 14.2 11.2 2000 2001-3.2 0 3 3.1 3.4 3.1 1.7 1.5 1.7 2.7 2 2.6 2500 2501-2.9 9.1 3.2 2.9 5.1 3.3 2 6.7 2.9 2.7 6.4 3.1 3000 3001-2.4 2.3 2.4 1.9 3.4 2.1 2.2 4.5 2.6 2.2 3.7 2.4 4000 4001-3 2.3 3 2.9 5.1 3.3 2 2.2 2.1 2.7 3.4 2.8 5000 5001 + 9.9 6.8 9.7 11.1 11.1 11.1 6.3 12.7 7.4 9.2 11.2 9.4 Total 789 44 833 648 117 765 635 134 769 2072 295 2367 The survey also attempted to understand the cost incurred on institutional delivery including transportation cost. More than half (52.6 percent) of the mothers spent less than INR 500 on institutional delivery; another 42 percent mothers spent INR 501 to 1000 and 5 percent mothers spent INR 1001-1500 on institutional delivery. The data reveals that delivery expenses in rural areas are more than in urban areas. (Bihar_NIPI, 2009) Premature labour was one of the major problems experienced by almost 60 percent of the women respondents who faced problems. This is consistent across all age groups. Prolonged labour was another problem faced by a third of the respondents across all age groups. (Bihar_NIPI, 2009) 97

Table 41: Problem experienced during delivery by women of different age groups, NIPI-08 Institutional Delivery 15-19- 18 22-21 26-25 31-30 41-40 49 Premature labour Excessive bleeding Prolonged labour Obstructe d labour Breech presentation Other Total N % N % N % N % N % N % N 56 69.1 11 13.6 31 38.3 10 12.3 3 3.7 2 2.5 81 262 57.8 56 12.4 176 38.9 95 21 22 4.9 25 5.5 453 478 57 89 10.6 320 38.1 169 20.1 42 5 39 4.6 839 425 62.1 64 9.4 233 34.1 124 18.1 47 6.9 25 3.7 684 163 56.4 26 9 86 29.8 48 16.6 8 2.8 10 3.5 289 13 61.9 2 9.5 7 33.3 4 19 0 0 0 0 21 Home Delivery This section deals with the details of home delivery cases, including reasons behind choosing to have the baby delivered at home and not in an institution, the actual place where the delivery took place and whether it was influenced by the background of the pregnant mother-to-be, the person who actually conducted the delivery and finally, why this person was chosen to begin with. (Bihar_NIPI, 2009) Table 42: Reason for home delivery, NIPI-08 Reason (multiple response) Costs too much Facility not open Too far/ No transportation Don't trust facility/poor quality service No one to accompany Did not get time/no time No female provider at facility Rura l Jehanabad Nalanda Sheikhpura BIHAR Urba n Tota l Rura l Urba n Tota l Rura l Urba n Tota l Rura l Urba n % % % % % % % % % % % % 15.5 9.7 14.8 19.6 16.2 18.9 18.7 18.1 18.5 18 14.8 17.6 2.2 2.2 2.1 4.1 2 3.7 6 8.4 6.4 4.1 3.7 4.2 11.5 6.5 10.8 25.8 17.6 23.2 18.9 8.4 17.5 19.1 12 17.6 3 1.1 2.8 2.3 10.1 4.7 3.7 6 4.2 3 6.5 4 19.7 20.4 19.3 26 21.6 24.7 15.2 14.5 14.9 20.5 19.4 19.8 32.7 37.6 32.5 28.1 24.3 27.3 32.8 26.5 31.1 31.1 28.7 30.1 1 2.2 0.9 0.9 0.7 0.9 0.9 2.4 1.2 0.9 1.5 1 Tota l 98

Husband/famil y did not allow 12.7 14 13.2 7.9 8.1 8.4 5.8 6 6 8.7 9.3 9 Not necessary 25.9 20.4 25.9 24.9 24.3 25.6 28.9 36.1 30.5 26.6 26.2 27.4 Not customary 4.7 2.2 4.5 3 5.4 3.4 5.5 7.2 6 4.4 4.9 4.6 Other 7.7 15.1 7.8 4.3 4.1 3.9 6.9 8.4 6.8 6.2 8.3 6 Total 401 401 425 401 401 535 401 401 498 401 401 145 8 Out of 3843 women interviewed in three districts, 1458 (39 percent) women delivered at home. In Nalanda, 41 percent mothers delivered at home followed by 39 percent in Sheikhpura and 34 percent in Jehanabad. (Bihar_NIPI, 2009) As mentioned above, nearly two-fifth of the total surveyed women delivered at home. They were also asked the reasons why they did not deliver in the health facility. 30 percent women mentioned they did not have time to go to health facility, 27 percent felt that delivery in an institution is not necessary, 18 percent women cited non-availability of transportation facility and another 20 percent reported nobody was there to accompany them for delivery as the main reason for their deliveries at home. The most important reason emerging in all the districts for not going to a health facility for delivery is the lack of time. Q ualitative discussions have inferred that people generally did not prefer to go to health facility if there was no serious problem or any complication to the pregnant woman. Non availability of transportation also emerged as an important reason during the qualitative discussions. (Bihar_NIPI, 2009) Delivery Specification Table 43: Reasons behind choosing a specific person to conduct the delivery, NIPI-08 Jehanabad Nalanda Sheikhpura BIHAR R U T R U T R U T R U T % % % % % % % % % % % % Why did you choose the person to conduct delivery? Past experience 28.9 20.4 28.9 21.1 23.6 22.1 58.7 48.2 58 36 29 36.4 Economical 13 11.8 12.2 15.1 4.7 13.6 0.9 2.4 1 9.7 6.2 8.9 Safe delivery 33.2 32.3 33.2 38.6 43.9 40 17.6 16.9 17.5 29.9 33.6 30.3 Reliability 9.7 10.8 9.2 4.5 4.7 4.9 8.8 14.5 8.8 7.5 9 7.5 Behaviour of the service 1.5 6.5 2.4 14.9 17.6 14 2.3 2 6.6 9.9 6.5 provider Recommended 10 11.8 10.4 4.5 3.4 4.1 9.7 16.9 10.7 7.9 9.3 8.2 Other 3.7 6.5 3.8 1.3 2 1.3 2.1 1.2 2 2.3 3.1 2.3 Total 401 24 425 469 66 535 433 65 498 1303 155 1458 99

The reason for choosing a particular person to conduct delivery at home was also asked. The two most important criteria for selection of the individual was her past experience (36 percent) and past record of conducting safe deliveries (30 percent). T h e Person being economical (9 percent) and recommended by somebody (8 percent) were the other reasons expressed for choosing the person to conduct home delivery. (Table 4.32) (Bihar_NIPI, 2009) Amount (in INR.) Table 44: Cost incurred in home delivery, NIPI-08 Jehanabad Nalanda Sheikhpura BIHAR R U T R U T R U T R U T % % % % % % % % % % % % < 500 39.3 40.7 37.9 36.1 32.2 35.6 55.2 57.5 55.1 43.6 41.1 43 500-1000 52.7 49.4 53.3 54.9 58.7 55.2 32.9 31.3 32.7 46.7 49 46.8 1001-1500 4 4.9 4.5 3.5 1.4 3.1 2.4 5 2.9 3.3 3.3 3.4 1501-2000 2.8 3.7 2.9 3.5 4.2 3.8 6.2 5 6.2 4.2 4.3 4.4 2001-2500 0.3 1.2 0.5 0.7 1.4 0.8 1.2 1 0.7 1 0.8 > 2500 0.9 0.8 1.3 2.1 1.5 2.1 1.3 2.1 1.5 1.3 1.5 Total 351 24 375 457 65 522 420 63 483 1228 152 1380 So far as the amount spent on home deliveries are concerned, 43 percent spent less than INR500 and another 47 percent spent between INR500 1000. In Sheikhpura, expenditure on most of the home deliveries (55 percent) was less than INR500 while in Jehanabad and Nalanda; it was between INR500- to INR1000 in more than 50 percent cases. (Bihar_NIPI, 2009) 5.1.3 Postnatal Care The health of a mother and newborn child depends not only on the healthcare she receives during her pregnancy and delivery, but also on the care she and the infant receive during the first few weeks after delivery. Postnatal care check-ups soon after the delivery are particularly important for births that take place in non-institutional settings. (Bihar_NIPI, 2009) A large proportion of maternal and neonatal deaths occur during the first 48 hours after delivery. Hence safe motherhood programs have increasingly emphasized the importance of postnatal care, recommending that all women receive a check 100

up within the first two days of delivery. The World Health Organisation (WHO) recognizes several crucial moments when contact with the health system/informed caregiver could be instrumental in identifying and responding to needs and complications (WHO, 1998). It is most important to have the first postnatal checkup within a few hours of delivery. Another important time for a postnatal check-up is six weeks (42 days) after the delivery. By this time, a woman s body should generally have returned to its per-pregnancy state. To assess the extent of postnatal care check-ups, women were asked whether any health personnel checked on her health since her last delivery. (Bihar_NIPI, 2009) Table 45: Timings of First Post Natal Care, NIPI-08 District Jehanabad Nalanda Sheikhpura All Districts Rural Urban Total Rural Urban Total Rural Urban Total Rural Urban Total % % % % % % % % % % % % <4 Hrs 0.2 0.2 0.4 0.3 0.2 0 0.2 4-23 0.6 0.5 0.3 0.3 0.3 1 1.8 1.1 0.6 0.6 0.7 Hrs 1-2 1.9 1.8 0.8 0.5 0.8 1.5 4.6 2 1.4 1.6 1.5 days 3-41 1.6 1.5 0.3 0.3 0.2 1.8 1.1 1.7 1.2 0.4 1.1 Days >41 0.1 0.1 0 0 0 days DK/CS 0.6 0.4 0.5 0.5 0.5 0.5 0.4 0.5 0.1 0.5 No Checkup 95.1 99.6 95.4 98.1 99 98.3 94.9 92.5 94.5 96 97.2 96.1 Total 1,192 68 1,260 1,124 184 1,308 1,072 200 1,272 3,388 452 3,840 A majority of women (96 percent) did not receive any postnatal check-up after their most recent birth within two months of delivery. Only 4 percent of women received a health check-up within two months of delivery. (Bihar_NIPI, 2009) Among the small number of mothers who received postnatal care, ANM/Nurse/ Midwife checked 57 percent mothers and doctors checked 33 percent mothers. About one third (31 percent) of mothers attended a PHC for postnatal check up followed by 21 percent mothers who visited a private hospital/clinic and 20 percent who visited a government hospital. Around 15 percent mothers received post partum care at home. (Bihar_NIPI, 2009) 101

Out of the total women who received PNC, 14 percent received PNC in the government hospital, 27 percent in PHC and 18 percent received PNC at a private hospital but they all delivered in the same health facilities. About 4 percent women delivered in a private health facility but they received PNC in government hospital. Another three percent women received first prenatal check-up in a PHC while they delivered in a private hospital. In most of the cases women received PNC at the same place where they delivered. There were some women who received PNC at a government facility but delivered in private health institution, while a negligible number of women received PNC in a private health facility after delivering in a government institution. (Table in Annexure) (Bihar_NIPI, 2009) 5.2 Newborn Care The majority of newborn problems are specific to the perinatal period. They result not only in deaths but also high morbidit y and disability. These problems are the result of poor maternal health, inadequate care during pregnancy, inappropriate management and poor hygiene during delivery, lack of newborn care and discriminatory care. Death among newborn infants is so frequent that it is accepted as routine by many families and community members. If a mother dies during childbirth, her baby has smaller chance of survival. However if the baby survives he/she is at high risk for neglect, malnutrition and morbidity. Keeping this in view, the government has launched a nationwide program for the care of pregnant women and newborns. (Bihar_NIPI, 2009) The first check of the baby after delivery is very crucial for overall assessment, exclusive breastfeeding and appropriate care. The study has collected information regarding first health check-up, contact with care provider within ten days of birth and vaccination within one month of birth for all babies either delivered at hospital or home. (Bihar_NIPI, 2009) The first health check-up of babies that took place within ten days of birth was reported to be very low in Bihar. Nearly four-fifth (81 percent) of babies did not have contact with any 102

health worker within the first 10 days of birth. Only 11 percent of babies had contact with any health worker within the first 24 hours of birth. About 19 percent of babies had contact with a health worker within the first 10 days after birth. The variation in these figures across the three study districts was minimal. There was minimal variation between rural and urban areas in this practice except for the urban area of Jehanabad district where little more than 90 percent babies were not checked. (Table 5.3 & 5.4) (Bihar_NIPI, 2009) Table 46: Timing of first neonatal check-up by Districts, NIPI-08 JEHANABAD NALANDA SHEIKHPURA RURAL URBAN RURAL URBAN RURAL URBAN N % N % N % N % N % N % <6 Hrs 114 9.5 8 3.2 82 7.3 46 11.7 169 15.8 57 21 6-23 Hrs 14 1.2 2 0.8 11 1 6 1.5 15 1.4 3 1.1 1-2 Days 57 4.8 2 0.8 28 2.5 8 2 43 4 10 3.7 3-4 Day 19 1.6 2 0.8 15 1.3 14 3.6 11 1 5 1.8 5-6 Days 2 0.2 5 0.4 5 0.5 1 0.4 Week or 5 0.4 1 0.4 18 1.6 6 1.5 11 1 more No Checkup 984 82.3 233 94 965 85.9 314 79.7 818 76.3 195 72 Total 1195 100 248 100 1124 100 394 100 1072 100 271 100 Sheikhpura district of Bihar proved to be the best performer among all the surveyed districts where 28 percent neonates received check-up in urban areas while 24 percent in rural areas. At the same time in other districts its ranges between 6-20 percent. (Bihar_NIPI, 2009) 5.2.1 Breastfeeding and Supplementation Breastfeeding is one of the main pillars of newborn care. Educating mothers on correct breast-feeding practices and child nutrition is a very important component of newborn care. In this survey, we explored breastfeeding practices among the eligible women, the attitude and practice of feeding pre-lacteal liquids, the period of exclusive breastfeeding and introduction of supplementary feeding. (Bihar_NIPI, 2009) 103

Initiation of breastfeeding immediately after birth is beneficial to both the infant as well as the mother. More than 96 percent of women in Bihar had breastfed their children. Little more than half of the mothers received help from somebody in initiation of breastfeeding. A comparison on breastfeeding between rural and urban women showed that rural women had received help in initiation of breastfeeding as compared to urban women. (Bihar_NIPI, 2009) Ever breastfed Table 47: Breastfeeding practices, NIPI-08 JEHANABAD NALANDA SHEKIPURA RURAL URBAN RURAL URBAN RURAL URBAN N % N % N % N % N % N % Yes 1158 96.9 243 98 1070 95.2 384 97.5 1029 96 262 96.7 No 37 3.1 5 2 54 4.8 10 2.5 43 4 9 3.3 1195 100 248 100 1124 100 394 100 1072 100 271 100 Anybody helped in initiating the breast feeding Yes 720 62.2 131 53.9 605 56.5 174 45.3 437 42.5 79 30.2 No 438 37.8 112 46.1 465 43.5 210 54.7 592 57.5 183 69.8 1158 100 243 100 1070 100 384 100 1029 100 262 100 Sources helped in initiating breastfeed Government 14 1.9 1 0.8 9 1.5 4 2.3 7 1.6 2 2.5 Doctor Private Doctor 51 7.1 17 13 40 6.6 12 6.9 35 8 8 10.1 Nurse 77 10.7 13 9.9 81 13.4 19 10.9 67 15.3 16 20.3 ANM/ASHA/LHV 67 9.3 7 5.3 98 16.2 22 12.6 42 9.6 7 8.9 Dai 62 8.6 19 14.5 47 7.8 14 8 49 11.2 9 11.4 Mother/ Mother-inlaw 341 47.4 52 39.7 204 33.7 71 40.8 182 41.6 27 34.2 Friends/Relatives 104 14.4 22 16.8 126 20.8 32 18.4 52 11.9 10 12.7 Others 4 0.6 3 0.7 720 100 131 100 605 100 174 100 437 100 79 100 Around two-third of mothers received support from untrained persons like mother, mother-in-law and friends. Little more than one tenth of the mothers received support from a nurse and similar proportion received it from an ANM/ASHA. The role of government doctors in the initiation of breastfeeding was found to be negligible with only two percent mothers having received help from them. A rural -urban analysis of the district showed almost similar results as that of the state. (Table 48) (Bihar_NIPI, 2009) 104

Eligible mothers from the survey stated that initiation of breastfeeding practices has taken place within one hour of delivery and before completion of three days from delivery. Around 13 percent women started breastfeeding the child within one hour of delivery. (Bihar_NIPI, 2009) In Bihar around 61 percent of women have delivered in health institutions. At these health institutions the doctor/nurse/anm attending to the delivery is expected to advice women on initiation of breastfeeding soon after birth. However, in Bihar the percentage of women who initiated breastfeeding within one hour of childbirth is substantially less than the proportion of institutional deliveries, suggesting that even in health institutions also early initiation of breastfeeding was not ensured. (Bihar_NIPI, 2009) An in-depth interview with ANMs, ASHAs and Anganwadi Workers revealed that the customary practices for breastfeeding is prominent in the region but varies from village to village. Although some of the ANMs revealed that they counsel women on breastfeeding practices most of them were unable to do so due to lack of time. ASHAs are more close to mothers than any other health workers in rural areas and they counsel them on breastfeeding practices like give mother s first milk to the child, exclusive breast feeding up to six months, how the mother s milk enhances the immunity of the child etc. However a change in customary system will take some time. (Bihar_NIPI, 2009) There is no significant difference or impact of the gender of child on initiation of breastfeeding. (Bihar_NIPI, 2009) Table 48: Initiation of breastfeed and gender of child, NIPI-08 Gender of child Immediately within an hour of birth Same day after an hour of birth 1-3 days After 3 days % % % % Boy 11.9 35.9 45.2 6.2 Girl 14.3 34.4 44.3 5.8 105

Exclusively breastfeed Milk (other than breast milk) Table 49: Feeding of prelacteal liquids, NIPI-08 JEHANABAD NALANDA SHEIKHPURA All Districts Rural Urban Rural Urban Rural Urban Rural Urban N % N % N % N % N % N % N % N % 13 2.3 3 3.2 16 3.3 5 2.6 15 2.6 2 1.1 44 2.7 10 2.2 368 65.5 54 58 349 72.7 135 69.2 458 79.7 148 85.1 1175 72.7 337 73 Plain water 78 13.9 5 5.4 30 6.3 12 6.2 19 3.3 9 5.2 127 7.9 26 5.6 Sugar or glucose water Sugar-saltwater solution 58 10.3 10 11 45 9.4 37 19 20 3.5 9 5.2 123 7.6 56 12 2 0.4 2 2.2 2 0.4 1 0.2 5 0.3 2 0.4 Fruit juice 2 0.4 1 1.1 16 3.3 18 1.1 1 0.2 Infant 1 0.2 1 0.1 formula Tea 3 0.5 1 1.1 2 0.3 1 0.6 5 0.3 2 0.4 Honey 3 0.5 4 4.3 10 1.7 1 0.6 13 0.8 5 1.1 Janam ghutti 3 0.6 2 0.3 5 0.3 Other 34 6 13 14 19 4 6 3.1 48 8.3 4 2.3 101 6.2 23 5 Total (N) 562 93 480 195 575 174 1617 462 In the table 49 we looked at the proportion of mothers who had exclusively breastfed by background variables i.e. gender of the child, age and education of mothers, number of live children, location of PSU and wealth index. For this analysis, only mothers of children beyond 6 months of age were considered and all mothers who were currently breastfeeding but had children who were younger were not considered. (Bihar_NIPI, 2009) The situation of exclusive breastfeeding practices is not very encouraging in Bihar. Among the infants aged more than 6 months, around 27 percent of children were exclusively breastfed up to 6 months after birth while the remaining mothers (about 73 percent) discontinued exclusive breastfeeding within 6 months. (Bihar_NIPI, 2009) Exclusivity of breastfeeding was not influenced by educational status of women, locality of residence of women, birth order of the child or economic status of the family. But exclusive breastfeeding was highest (38.6 percent) among young 106

mothers within the age group of 15 to 18 years and lowest (16.7 percent) among oldest mothers. In fact with regard to education of the mother, economic profile of the family and number of live children, there is no significant correlation or trend between mothers residing in urban and rural areas. However urban mothers have shown a lower proportion of discontinuation of exclusive breastfeeding before six months of children s age. (Bihar_NIPI, 2009) In the table 5.10 we looked at the proportion of mothers who had exclusively breastfed by background variables i.e. gender of the child, age and education of mothers, number of live children, and location of PSU and wealth index. For this analysis, only mothers of children beyond 6 months of age were considered and all mothers who were currently breastfeeding but had children who were younger were not considered. (Bihar_NIPI, 2009) The situation of exclusive breastfeeding practices is not very encouraging in Bihar. Among the infants aged more than 6 months, around 27 percent infants were exclusively breastfed up to 6 months after birth while the remaining mothers (about 73 percent) discontinued exclusive breastfeeding within 6 months. (Bihar_NIPI, 2009) Exclusivity of breastfeeding was not influenced by educational status of women, locality of residence of women, birth order of the child or economic status of the family. But exclusive breastfeeding is highest (38.6 percent) among young mothers in the age group of 15 to 18 years and lowest (16.7 percent) among oldest mothers. In fact, education of mother, economic profile of family and number of live children, there seems to have no significant correlation or trend but mothers residing in urban areas showed a lower proportion of discontinuation of exclusive breastfeeding before six months of children s age. (Bihar_NIPI, 2009) Table 50: Period of exclusive breastfeeding by background variables, NIPI-08 Background variables < 6 months 6 months and more months Boys 908 73.9 320 26.1 Girls 813 72.2 313 27.8 107

Total 1721 73.1 633 26.9 Age of the Respondent (in Years) 15-18 35 61.4 22 38.6 19-21 281 73.6 101 26.4 Background variables < 6 months 6 months and more months 22-25 599 73.1 220 26.9 26-30 508 73 188 27 31-40 283 74.1 99 25.9 41-49 15 83.3 3 16.7 Total 1721 73.1 633 26.9 Years of schooling No schooling 1113 73.2 408 26.8 < 5 44 73.3 16 26.7 5-7 157 69.5 69 30.5 8-9 137 72.1 53 27.9 10-11 196 77.2 58 22.8 12 & Above 74 71.8 29 28.2 Total 1721 73.1 633 26.9 Number of Live Children 1-2 858 72.9 319 27.1 3-4 582 73.7 208 26.3 5+ 281 72.6 106 27.4 Total 1721 73.1 633 26.9 Location of PSU Rural 1527 73.6 549 26.4 Urban 194 69.8 84 30.2 Total 1721 73.1 633 26.9 Wealth Index Lowest 909 73.9 321 26.1 Second 251 71.3 101 28.7 Middle 205 73 76 27 Fourth 186 73.8 66 26.2 Highest 170 71.1 69 28.9 Total 1721 73.1 633 26.9 5.2.2 Child Morbidity and Treatment Diarrhoea and ARI have been identified globally as major threats to the survival of children under the age of five years. This is also true for India, where these two diseases have been the major causes behind infant mortality. Prevention as well as 108

effective treatment of these diseases depends on a host of individual, household and community level behavioural factors. One of the objectives of this study is to estimate the role played by such factors in determining the utilisation of formal healthcare to cure diarrhoea and certain respiratory illnesses plaguing newborns. The Reproductive Child Health program includes components like treatment of diarrhoea and ARI and health education to mothers on management of diarrhoea and danger signs of ARI. The paramedical and medical staff is trained to diagnose the cases of pneumonia among the children and treat the cases of pneumonia and diarrhoea. All the government health institutions are supplied with medicines necessary for the treatment of pneumonia and diarrhoea. The major findings of the study are as follows: (Bihar_NIPI, 2009) Prevalence of illness in children under study The following section looks at the prevalence of child morbidity and to know about about the incidence of diarrhoea and fever in children.. The survey involved asking questions to the mothers on the incidence of these conditions in the two weeks prior to the survey date. (Bihar_NIPI, 2009) Table 51: Prevalence of illness in children under study, NIPI-08 Jehanabad Nalanda Sheikhpura All NIPI Districts Indicator Rural Urban Rural Urban Rural Urban Rural Urban Total % % % % % % N % N % N % % of children with diarrhoea in last two weeks Yes 1.9 1.2 5.9 6.1 6.1 7.4 154 4.5 47 5.1 175 4.6 % of children with fever in last two weeks Yes 6.8 4.8 17.6 19 10.6 9.2 393 11.6 112 12.3 443 11.5 Table 52 shows that around 4.6 percent of children were suffering from diarrhoea and it is lowest among the children of Jehanabad (1.9 percent for rural and 1.2 for urban). About 12 percent of children were suffering from fever also and again Jehanabad secured lowest proportion of children with fever (6.8 percent for rural and 4.8 percent for urban areas). At the state level there is no significant difference 109

in the prevalence of diarrhoea and fever but both are more in urban areas than in rural areas. (Bihar_NIPI, 2009) As per NFHS-3 estimates, in Bihar 6.8 percent of children had ARI in past two weeks prior to the survey while the national average was 5.8 percent. After NFHS-1 prevalence of diarrhoea in Bihar reduced (17.7 percent) from the national average of 19.2 percent while for NFHS-3 the data in not available. (Bihar_NIPI, 2009) 5.2.3 Summary Observation Incidence of weighing a baby after birth is reported to be very rare in Bihar. T h e p r i m a r y r eason for this was revealed from Focus Group Discussion with ANM and in-depth interview w with ANMs, ASHAs and Anganwadi Workers where they stated that most of them were not equipped with a proper weighing machine for weight measurement of the newborn. (Bihar_NIPI, 2009) It is important to mention that first health check-up within ten days after birth was reported to be very low in Bihar. At the same time around two-third mothers received support from non-trained persons like mother/mother in-law, friends and dais while there should have been more involvement from ANM/ASHA/ AWW. (Bihar_NIPI, 2009) In Bihar the percentage of women initiating breastfeeding within an hour of childbirth is substantially less than the proportion of institutional deliveries, suggesting that even in health institutions also early initiation of breastfeeding was not ensured. ASHAs in rural areas are more close to mothers than any other health workers and they counsel them on breastfeeding practices like giving mother s first milk to the child, exclusive breastfeeding up to six months and improved immunity of the child due to mother s milk. (Bihar_NIPI, 2009) However, ASHAs, AWWs and ANMs are the people who v i s i t the community and stay there to interact with the general population. They are able to educate the 110

village mothers and train them periodically so as to eliminate the barriers more effectively. They also offer many incentives to these mothers. (Bihar_NIPI, 2009) A recent national level survey estimated morbidity among children to be low in the state or closer to the national level. However many children who suffered from an illness in the two weeks prior to the survey continued to be ill at the time of the survey. Although treatment was given to the children, it was given late which could be dangerous for baby s life. (Bihar_NIPI, 2009) Only 35 percent children with diarrhoea received ORS. 16 percent mothers with children who had diarrhoea in the two weeks prior to the survey revealed that they did not know what to do when child had diarrhoea. (Bihar_NIPI, 2009) Respondents utilizing government health care facilities are very low or negligible which not only costs extra to the poorer population but also push them to visit quacks and practice home remedy for any illness. (Bihar_NIPI, 2009) Almost 80 percent mothers stated that they are aware about pneumonia. However on looking into their awareness on the symptoms, it was found to be inadequate. This resulted in the children receiving much less or somewhat less intake of liquids and food than normal thereby affecting their health. (Bihar_NIPI, 2009) The above mentioned situations demand that there be some unified and concerted effort on the part of all service providers. (Bihar_NIPI, 2009) 5.3 Child Immunization The immunization of children against six serious but preventable diseases namely, tuberculosis, diphtheria, pertusis, t e t a n u s, poliomyelitis and measles is the main component of the child survival programme. As part of the National Health Policy, the National Immunization Programme is being implemented on a priority basis. The Government of India initiated the expanded Programme on Immunization (EPI) in 1978 with 111

the objective of reducing morbidity, mortality and disabilities among children from six diseases. (Bihar_NIPI, 2009) The Universal Immunization Programme (UIP) was introduced in 1985-86 with the objective of covering at least 85 percent of all infants against six vaccine preventable diseases by 1990. This scheme was been introduced in every district of the country. The standard immunization schedule developed for the child immunization programme specifies the age at which each vaccine should be administrated and the number of doses to be given. Routine vaccinations received by infants and children are usually recorded on a vaccination card that is issued for the child. (Bihar_NIPI, 2009) 5.3.1 Vaccination coverage This section provides the coverage details of different vaccinations including Polio 0, BCG, Polio 1, 2 and 3, Measles and Vitamin A and whether or not coverage varies across Districts, by sex of the child, location of the PSU, the child s birth order or even by the education of the mother. For this analysis, we had taken children who were 12-23 months of age and the evidence is entirely through service records, i.e. Immunization card available with the household concerned. (Bihar_NIPI, 2009) Table 52: BCG and Polio 0 coverage by background variables, NIPI-08 BCG Polio 0 Districts N % N % Jehanabad 304 98.7 98 31.8 Nalanda 249 97.3 22 8.6 Sheikhpura 214 95.1 67 29.8 BIHAR 767 97.2 187 23.7 Sex of the Child Boy 404 97.6 94 22.7 Girl 363 96.8 93 24.8 Location of PSU RURAL 677 97.1 165 23.7 URBAN 90 97.8 22 23.9 Birth order of child 112

1 197 99 36 18.1 2 to 3 303 96.8 77 24.6 4 to 5 165 95.4 41 23.7 6+ 100 98 32 31.4 Years of schooling No education 487 96.6 121 24 Below 5 20 100 6 30 5 to 7 78 98.7 18 22.8 8 to 9 68 98.6 20 29 10 to 11 88 96.7 20 22 12 & above 26 100 2 7.7 In all the sampled districts as high as 97 percent children received BCG but Polio 0 coverage was near about 24 percent. The coverage of Polio 0 was highest in Jehanabad (31.8 percent) but much lower in Nalanda (8.6 percent). (Bihar_NIPI, 2009) Coverage of Polio 0 was marginally higher among girls than boys but not significantly slow to conclude in favour of any gender bias in coverage. Polio 0 coverage in urban and rural areas is almost same. (Bihar_NIPI, 2009) Table 53: Child Immunisation Coverage in NIPI Districts, Bihar Bihar Jehanabad Nalanda Sheikhpura % % % % All Basic Vaccinations 41.4 38.3 54.2 47.2 BCG 81.5 74.5 88 85.4 POLIO3 53.1 48.3 62.8 48.7 DPT3 54.4 49.2 65.1 55.1 MEASLES 54.2 49.3 69.1 63.9 Percentage received at least one dose of Vitamin A 49.9 49.3 59.4 66 BCG and measles and 3 doses of polio and DPT Source: District Level Household Survey (2007-2008) DLHS3 shows that nearly more than half of the children received all three doses of DPT vaccination in Bihar while equal doses of DPT was recorded in Sheikhpura (55.1 percent). Consequently a slightly lower coverage of DPT 113

vaccination was observed in Jehanabad (all three doses of DPT vaccination.) (See table 54). (Bihar_NIPI, 2009) Table 54: Immunization coverage all basic vaccines District All Basic Vaccination N % Jehanabad 157 51 Nalanda 123 48 Sheikhpura 125 55.6 All basic vaccines cover the following: o BCG o DPT 1, 2 and 3 o OPV 1, 2 and 3 o Measles NFHS-3 shows that a third (32.8 percent) of the children in the age group of 12-23 months were fully immunised in Bihar. The immunisation figures for Bihar are worse than the national average. It is also noted that there is a steady increase in the immunisation coverage over the last two decades. (Bihar_NIPI, 2009) Outreach of the programmes and availability of the health services at an accessible place is of utmost importance in delivering a quality service. On interviewing mothers on the venue of vaccination, varied responses came out from the three districts. In Jehanabad (20 percent) and Sheikhpura (12 percent) sub centre was the most common place for women to bring their children for vaccination. However in Nalanda, it was PHC where (11.5 percent) most of children got vaccinated. The in-law s home and parent s home were next common places for vaccination in Sheikhpura. It was an altogether different scenario in Nalanda where most of the children were vaccinated in a SC (nine percent), PHC (11.5 percent) or government hospital (six percent). Taking Bihar as a whole, PHC (9 percent) and SC (14 percent) were most common, and the next common places were in law s home (4 percent) and parent s home (5 percent). (Bihar_NIPI, 2009) 114

Table 55: Problems faced by mother/community in vaccinating the child, NIPI-08 DISTRICT Jehanabad Nalanda Sheikhpura Total Total Total N % N % N % No time from daily wage work 300 23.8 349 26.7 319 25.1 Distance of Health Facility/ Vaccination Centre 286 22.6 243 18.6 235 18.5 Irregular presence of health professional 125 9.9 142 10.9 97 7.6 Non- availability of vaccines 112 8.9 184 14.1 55 4.3 DONT KNOW 93 7.4 63 4.8 185 14.5 NO PROBLEM FACED 566 44.8 561 42.9 562 44.2 OTHER 8 0.6 8 0.6 9 0.7 115

Chapter-6 Resource Persons 116

6. Resource Persons 6.1 List of Resource Person at State Level Name Designation Qualification DOJ Email Sh. Amarjeet Sinha, I.A.S. Sh.Sanjay Kumar, I.A.S. Dr.D.K.Raman Sh.Ashok Kumar Singh, B.A.S Sh.Jay Prakash Singh, B.A.S. Principal Secretry Executive Director Additional Executive Director Administrative Officer Deputy Collector I.A.S. I.A.S. 08.02.2010 ed_shsb@yahoo.co.in drdkraman@yahoo.com 10.11.09 administrativeofficer92@gmail.com B.Sc.(Geology) 23.06.10 jpchullu@gmail.com Lalit Bhushan Ranjan,B.A.S. Sh.K.L.Das Sh.P.N.Mishra Dr.Narendra Kumar Mishra Dr.A.K.Tiwary Dr.M. P. Sharma Dr.A. K. Shahi Ms.Rashi Jayaswal Deputy Collector Finance Manager Account Manager State Programme Officer State Programe Officer State Programe Officer State Programe Officer State Programe Manager M.A. (Econimics) 22.04.2010 04.02.08 fmshsbihar@gmail.com M.B.B.S, M.S. 02.12.09 nkmishra57@gmail.com M.B.B.S., H.M. Diploma 02.12.05 draketewary@yahoo.co.in M.B.B.S. 02.12.09 sharma_madan1@yahoo.co.in M.B.B.S. 02.12.09 drakshahi@gmail.com PGDRM, PGDHRM 08-02- 2008 rash_san@rediffmail.com Ms. Jyoti Verma Dy. Director M & E P.G.D.R.D 02-03- 2010 jyoti26.ranchi@gmail.com Dr. Jayati Srivastava Dy. Director - Training MSW,Ph.D 31.03.10 trainingcellshsb@gmail.com Mr.Gaurav Kumar Dy. Director MCH MBA- Public Health 29-03- 2010 ddmch.bihar@yahoo.com Mr.Ram Ratan Er. Alok Ranjan SPO-RI & Polio Consultant cold chaincum-i/c BS(HB) & Med.Anatomy (AIIMS), PGDCH (CMC Vellore) B.Tech + M.B.A. 02.03.10 rraiims@gmail.com 21.12.05 coldchainbihar@gmail.com hkbihar@gmail.com 117

Housekeeping Sh. Ranjeet Samaiyar Sh Arvind Kumar Sh. Atul Verma Consultant NRHM System Analyst-cum- Data Officer Data Officercum-I/C Complaint Cell MBA (Health) 01.08.08 nrhmbihar@gmail.com MCA 01.08.08 PG in Computer Science/IT statehealth_society@yahoo.co.in, arvindkr05@gmail.com" 23.12.05 atulverma10000@gmail.com 6.2 List of Resource person at District Level S.No. District D.P.M 1 Jehanabad 2 Nalanda 3 Patna 4 Sheikhpura Mr.Niwish Manan Mr. P. P Chakariyar Mr. Piyush Ranjan Mr. Acharya Mamat Code No. Office No. Fax No. CUG No. Contact No D.A.M Contact No M & E Officer Contact No 9473191879 9835400289 06112 230414 230558 9473191889 9473191889 0612 2300658 9473191891 9334122969 06341 225031 225031 9473191897 9334269382 Mr. Kausal Jha Mr. Nirbhay Kr. Mr. B. Rai Mr. Pankaj Kumar 9939391876 9430287252 9431268013 Mr. Arvind Kumar Mr. Kumar Manoj Mr. Shiv Krishna Murti 9334956994 9431261867 9973448760 Mr. Gautam 9934066861 Sl.No Location Designation 1 Mobile Number Moic - Ratni Faridipur PHC 9470003325 2 Moic - Jehanabad Sadar PHC 9470003326 3 D.M 9470003327 4 Ghosi MOIC 9470003328 5 ACMO 9470003329 6 Jehanabad C.S 9470003330 7 Moic - Mukhudumpur PHC 9470003331 8 DS - Sadar Hospital. Jehanabad 9470003332 9 Moic - Hulasganj PHC 9470003333 10 Moic - Modanganj PHC 9470003334 11 Moic - Kako PHC 9470003335 12 DIO 9470003336 118

1 D.S. - Sub divisional Hospital,Hilsa 9470003502 2 DIO - Nalanda 9470003503 3 D.M - Nalanda 9470003504 4 Moic - Silow PHC 9470003505 5 D.S. - Sadar Hospital, Nalanda 9470003506 6 C.S. - Nalanda 9470003507 7 Moic - Tharthari PHC 9470003508 8 Moic - Noorsarai PHC 9470003509 9 Moic - Harnaut PHC 9470003510 10 Moic - Islampur (Referal) PHC 9470003511 11 Moic - Ekangarsarai PHC 9470003512 12 Moic - Biharsharif (Sadar) PHC 9470003513 13 Nalanda Moic - Chandi PHC 9470003514 14 Moic - Nagarnausa PHC 9470003515 15 Moic - Karai parsurai PHC 9470003516 16 Moic - Hilsa PHC 9470003517 17 Moic - Sarmera PHC 9470003518 18 Moic - Bind PHC 9470003519 19 Moic - Asthawa (Referal) PHC 9470003520 20 Moic - Prwalpur PHC 9470003521 21 Moic - Katarisaria PHC 9470003522 22 Moic - Rahui PHC 9470003523 23 Moic - Giriyak PHC 9470003524 24 Moic - Rajgir (Referal) PHC 9470003525 25 Moic - Bain PHC 9470003526 26 ACMO - Nalanda 9470003527 1 Moic - Chewara PHC 9470003728 2 Moic - Ariari PHC 9470003729 3 C.S 9470003730 4 D.M 9470003731 5 ACMO 9470003732 6 Sheikhpura Moic - Shekhopursarai PHC 9470003733 7 Moic - Ghatkusumbha 9470003734 8 D.S - Sub. Div. Hos.Sheikhpura 9470003735 9 DIO 9470003736 10 Moic - Barbigha PHC 9470003737 11 Moic - Sheikhpura Sadar PHC 9470003738 1 DIO 9470003548 2 Superintendent Cum HOD, Eye 9470003549 3 Moic - Asthawa 9470003550 4 Patna Moic - Athmalgola Phc 9470003551 5 Principal 9470003552 6 HOD, Medicine 9470003553 7 HOD, E.N.T 9470003554 119

8 Fatuha, MOIC 9470003555 9 HOD, Surgery 9470003556 10 HOD, Orthopadic 9470003557 11 HOD, Plastic Surg. 9470003558 12 HOD, Aneathesia 9470003559 13 HOD, Neuro Serg. 9470003560 14 HOD, P.M.R. 9470003561 15 HOD, O.B.S. & Gyane. 9470003562 16 HOD, PEDIA 9470003563 17 HOD, Readiotherapy 9470003564 18 HOD, Skin, V.D. 9470003565 19 HOD, Psychiatrist 9470003566 20 HOD, F.M.T. 9470003567 21 Superintendent 9470003568 22 Principal 9470003569 23 HOD, Readiotherapy 9470003570 24 HOD, Skin 9470003571 25 HOD, Psychiatrist 9470003572 26 HOD, Aneathesia 9470003573 27 HOD, E.N.T 9470003574 28 HOD, F.M.T. 9470003575 29 HOD, P.S.M. 9470003576 30 HOD, Medicine 9470003577 31 HOD, Surgery 9470003578 32 HOD, O.B.S. & Gyane. 9470003579 33 HOD, Paedia 9470003580 34 HOD, Eye 9470003581 35 HOD, Orthopadic 9470003582 36 S.D.H. G.G.S. Patna 9470003583 37 DS - S.D.H. Danapur PHC 9470003588 38 RDD 9470003599 39 C.S 9470003600 40 DM/ PATNA 9470003601 41 42 Bidhayak Hospita Virchand Patel Path Patna Dr. Sushila Prasad New Garden Hospital 6/C, MOIC 9470003612 9470003614 120

6.3 NGOs in Bihar NGOs working on Health sector 1. Adarsh Chikitsha Sewa Sanstha Parameshara Rupouli via Jhausharpur (R.S.) Madhubani - 847403 Bihar Tel : Fax : E-mail : Website: www.indiasocial.org Contact: Secretary Activities : ADOLESCENT HEALTH AND NUTRITION; TRAINING; IEC MATERIAL; EDUCATION 2. Bihar State AIDS Control Society S.I.H.F.W. Building Sheikhpura Patna - 800014 Bihar Tel : 0612-2290278 2286437 Fax : 0612-2282082 E-mail : biharsacs@gmail.com Website: www.bsacs.org Activities : AIDS BIHAR; AIDS PREVENTION; HIGH RISK GROUP; SEX WORKER; INNOVATIVE PROJECT AIDS 3. Centre for Health & Resource Management (CHARM) Main Road Budha Colony Patna - 800001 Bihar Tel : 0612-2525527 9431493870 Fax : E-mail : shakeel456@rediffmail.com Website: Contact: Executive Director Activities : CHILD HEALTH; HEALTH COMMUNICATION; HEALTH COMMUNICATION MATERIAL; COMMUNICATION MATERIAL; FLOOD MEDICAL RELIEF; IEC MATERIALS; AIDS; KALAZAR CONTROL; SENSITIZATION WORKSHOP; FLASH CARDS 4. DEEPALAYA (Institute for Mental Health & Rehabil.) Kailashpuri Srinagar Hata Purnea - 854301 Bihar Tel : 06454-226146 Fax : E-mail : Website: Contact: Secretary Activities : MENTAL HEALTH; REHABILITATION; SELF HELP GROUPS; HEALTH ISSUES 5. EPOS Health (India) Pvt. Ltd. Bihar Office Tel : 0612-2271609 68/A, Patliputra Colony Fax : Patna - 800013 Bihar E-mail : bjo@epos.in eposhq@epos.in Website: www.epos.in Contact: Senior Vice President Activities : PUBLIC HEALTH; HEALTH COMMUNICATION; HOSPITAL PLANNING; PUBLIC PRIVATE PARTNERSHIP; HUMAN RESOURCE DEVELOPMENT AND MANAGEMENT; QUALITY MANGEMENT SYSTEM AND ACCREDITATION; STRATEGIC PLANNING AND MANAGEMENT; ORGANIZATION SYSTEMS AND DEVELOPMENT 6. Indian Council of Acupressure Yoga Radhika Kunj Nechua Jalalpur Gopalganj - 841503 Bihar Tel : 06156-287522 09934969232 Fax : E-mail : Website: Activities : ACUPRESSURE; YOGA; NATUROPATHY; HEALTH AWARENESS; HEALTH CAMPS; TRAINING; ADOLESCENT HEALTH AND NUTRITION; EDUCATION; RESEARCH STUDIES; 121

ADVOCACY 7. Kurji Holy Family Hospital Sadaquat Ashram Patna - 800010 Bihar Tel : 0612-2262540/156 2264117 Fax : E-mail : khfhosp2@sancharnet.in Website: Contact: Community Health Project Activities : HEALTH CARE; EDUCATION; POOR; MARGINALIZED GROUPS; SLUM DWELLER; COMMUNITY HEALTH 8. Monghyr Chakshu Yojana Samiti Radiant Chemical Compound Avantika Road Jamalpur P.O. Monghyr - 811214 Bihar Tel : Fax : E-mail : Website: Contact: President Activities : HEALTH SERVICES; RURAL HEALTH; FREE EYE TEST; LOW COST SPECTACLES 9. Monghyr Chakshudan Yojana Samiti Choramba Road Tel : 06344-222560 9204086500 Monghyr - 811201 Fax : Bihar E-mail : Website: Contact: Secretary Activities : HOSPITAL; DISPENSARIES MEDICAL RELIEF CAMPS; NURSING MOTHER; CHILD HEALTH; EYE DONATION; CHILD WELFARE 10. Nari Nidhi 2/29, State Bank Colony-II, Tel : 0612-2593018 9934262978 Bailey Road Fax : 9430013517 (M) Patna - 800014 E-mail : narinidhi_pat@sify.com Bihar Website: Contact: Secretary Activities : CHILD HEALTH; WOMEN HEALTH; SELF HELP GROUPS; REPRODUCTIVE HEALTH; FEMALE FOETICIDE; AYURVEDA; POLIO ERADICATION AWARENESS; KOPAL; ICDS 11. Priyadarshini Swasthya Sanstha 'Urmila Sadan' Mishri Tola Tel : 9234755878 9939681225 Tekari Road Fax : 9334051887 P.O. Mahandru E-mail : psss1@rediffmail.com Patna - 800006 Website: Bihar Contact: Secretary Activities : WOMEN WELFARE; EDUCATION; WOMEN'S HEALTH; REPRODUCTIVE HEALTH; ICDS; BALIKA SAMRIDDHI YOJANA; CAMPS CHILDREN; KISHORI SHAKTI YOJANA; MAHILA MANDAL; MAHILA PANCH; MAHILA SAMAKHYA; SANJEEVANI; SWADHAR; SHORT STAY HOMES; WOMEN IN DISTRESS 12. Voluntary Health Association of Bihar West of Ganga Apartment L.C.T. Ghat Mainpura Patna - 800001 Bihar Tel : 0612-2266605 236712 (R) Fax : 0612-2266884 E-mail : bvha@sancharnet.in Website: Contact: Executive Director Activities : CHILD HEALTH; WOMEN HEALTH; HEALTH COMMUNICATION; SEMINAR; PATIENT CARE; HEALTH SERVICES 122

Bihar NGO working on Nutrition CARE India Bihar House 100, Road 1 E New Patliputra Colony Patna - 800013 Bihar Tel : 612-2276991 2276735 Fax : E-mail : cbox@careindiabih.org Website: Activities : COMMUNITY NUTRITION; MATERNAL NUTRITION; CHILD NUTRITION; MICRONUTRIENTS The Hunger Project Tel : 0612-2207705 Bihar Office Fax : 0612-2231826 Mehman Sarai, First Floor (Behind Imarat Rizvi) E-mail : bihar_@thp.org Website: www.thp.org Bank Road, Patna - 800001 Bihar Activities : MALNUTRITION; HUNGER; MATERNAL HEALTH; COMMUNITY NUTRITION; POVERTY; CHILD MORTALITY; PRIMARY EDUCATION; GENDER EQUALITY; AIDS; PANCHAYATI RAJ; NUTRITIONALLY VULNERABLE GROUPS; WOMEN'S EMPOWERMENT; ENVIRONMENT; GLOBAL PARTNERSHIP Ministry of Health & Family welfare funded Field NGOs BIHAR Patna Bihar Voluntary Health Association, West of Ganga Apartment, Mainpura, Patna-800 001 Arpan Gramin Vikas Samiti Mr. Ram Babu PO- Maner, Dist Patna- 801108 Ph-9835256391 Patna Zila Gramin Vikas Samiti Mr. Umesh Kumar House of Dr. Kapil Deo Narayan Singh, Rd No. 9, East Patel Nagar, Post- Shastri Nagar, Patna- 800023 Ph- 0612-2604300, 9431071556 123

Phualwari Jagriti Kendra Mr. Dinesh Kumar Vill Atwarpur, PO- Kurthoi, Ps Phulwarisharif, Patna Ph-2511534 Bhartiya Gramin Vikas Evam Ayurveda Sewa Sansthan Dr. Anil Kumar Singh Kararia Bhawan, East Lohanipur, railway Hunder Rd. Kadamkuan, Patna-800003 Ph- 0612-268896, 9431457942 Nalanda Bihar Voluntary Health Association, West of Ganga Apartment, Mainpura, Patna-800 001 Bhartiya Jan Utthan Parishad Mr. Abhishek Bhartiya Moh-Kammaruddinganj, PO- Biharsharif, Dist Nalanda - 803101 Ph- 06112-223373/223887, 9431023131, 9934048651 Nisha Bunai Silai School Mr Harikant Jha Quamaruddinganj, PO- Biharsharif, Dist Nalanda- 803101 Ph- 06112-221890/223877, 9835008979 124

Maahila Samaj Vikas Sansthan Mrs. Alam Ara Moh-Sherpur PO- Biharsharif, Dist Nalanda- 803101 06112-222452 Sarvodaya Vikas Jyoti Prof Ajay Sharma At & PO- Barbigha, Dist Sheikhpura- 811101 Ph- 06112-272069/272071, 9934026208 125

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Appendix-I Funds Flow Mechanism for SHS Bihar Source- (Bihar DET Report, Apr,2010) 129