Executive Summary For action based PIP monitoring of NRHM for high priority districts proposed by MoHFW (GOI) a field visit was made to Singrauli district in Madhya Pradesh in March, 2014. For monitoring purpose District Hospital (DH) Singrauli, Community Health Centre (CHC) Khutar, 24X7 Primary Health Centre (PHC) Morwa, and Sub-Centre (SC) Chaura health facilities were visited. PIP monitoring included critical areas like maternal and child health, immunization, family planning, adolescent health, human resources and programme management, and qualitative interaction with beneficiaries to ascertain quality of services. Singrauli district provides public health services in urban areas through DH Singrauli. In the periphery 06 CHCs, 14 PHCs and 157 SHCs are providing health services. In Singrauli, all the CHCs and PHCs in the -district are functioning from government buildings and 142 out of 157 SHCs are functioning from government building. DH Singrauli is presently not functioning as a CeMONC facility. Caseload of cesarean section and critical care is shared by PSU hospitals in the district. In Singrauli district only two- fifth specialists and MOs are in position against the sanctioned posts. There are only two lady MOs in the district. Vacancies at district and block PMU are observed. The trainings on EmOC, LSAS, BEmOC, SBA, F-IMNCI, MTP, NSV, NSSK, IUCD and PPIUCD, Mini- lap, BSU have been received by different category of staff including doctors, SNs and para- medics. Singrauli district has limited availability of public health services beyond DH. Most of the diagnostic tests are available at the DH. In the peripheral health institutions diagnostic services are limited. Presently, there is no exclusive maternity hospital in Singrauli. Line listing of severely anaemic pregnant women is not separately reported by any of the health facilities. Although delivery points have been designated as L1, L2, L3, few are actually functional either due to shortage of manpower, diagnostic facilities or specialists and infrastructure. District level committee is formed for maternal death review. Except for Singrauli DH which has reported 05 deaths during April-February 2013-14 other health facilities have not reported any maternal deaths. Under reporting of maternal deaths is observed. Free JSSK services are provided including free drugs and consumables, free diet, free diagnostics, free blood transfusion and free transport to women with exemption of user charges in visited DH Singrauli, CHC Khutar and PHC Morwa. Beneficiaries received JSY payments at the time of discharge through an account payee cheque in the visited facilities. Beneficiaries face difficulty in opening new bank account. SNCU at DH is functional with trained doctors and nurses. Most of the SNCU equipments were being installed, and separate diagnostic facilities are being created. 1
In Singrauli district there are 4 NRCs of which a 20 bedded NRC is functional at DH Singrauli. Establishing more NRCs with all round facilities is urgently required to bring down the SAM rates in the district. RBSK scheme is yet to be launched in the district. DH Singrauli has facilities for sterilization including post partum sterilization on daily basis. CHC Khutar and PHC Morba has facilities for female sterilizations on fixed days. At SHC Chaura IUD insertion services are on fixed days anddistribution of condom and oral pills is done regularly. IUCD 375 is not yet introduced. An Adolescent Friendly Health Clinic previously functioning in DH Singrauli has become nonfunctional due to non availability of the counsellor. General cleanliness, practices of health staff, protocols, disinfection, autoclave functioning are being maintained at the visited facilities. Awareness of protocols among staff in periphery is low. Display of IEC material for MCH, FP, different services available, hospital timings, phone numbers are being maintained in the visited health facilities. Display of partographs, clinical protocols, EDL with free drug distribution caption was observed in all the visited health facilities. Clinical Establishment ACT is yet to be implemented in state for the registration and regulation of clinical establishments. Referral transport services are being provided in Singrauli district through 12 ambulances with staff and centralized call system '108'. Six MMUs are providing mobile health services in the periphery. In the district 857 ASHA's are presently working and 681 VHSCs are formed with all VHSCs having running accounts. All blocks have Block Community Mobiliser (BCM). Village level meetings are few and community participation is low. Urban RCH is at an elementary stage. Forty one USHAs have been appointed in the urban wards. The HMIS data uploading in health facilities is being carried out online. Data uploading is being done online since July, 2013. MCTS data indicates gaps in tracking of child immunization services children and MCH ANC services for pregnant women. Action Points 1. None of the CHCs of district Singrauli are providing any specialist services. Other services as per CHC norms are not provided properly. All the specialist posts should be filled on priority. 2. Lack of supervision was noticed at all levels. Monitoring mechanisms through supervisory visits need strengthening for corrective actions. 3. Reporting and reviewing of infant and maternal deaths needs stringent monitoring. 2
4. Staff quarters for Staff Nurse and other Para-Medical staff are not available at CHC Khutar and PHC Morwa. 5. Lines listing of severely anemic pregnant women have not been prepared at SHC Chaura. 6. ICTC/ PPTCT center is not available at CHC Khutar. 7. Proper facilities for Blood Bank and blood storage unit are lacking which needs immediate attention. 8. There is no system in place for preventive maintenance of equipments. 9. There is no fixed day for insertion of IUD in any of the CHC, PHC visited. 10. There is no functional NBSU in CHC, PHC visited. 11. There is no ARSH Clinic established and no manpower has been trained in any of the CHC, PHC visited. 12. Essential Drug List was not displayed in SHC Chaura. 13. IFA Blue, MifiPristone tablets, drugs for hypertension, Diabetes, Anti Allergy drugs are not available in SHC Chaura. 14. Blood Sugar testing Kit, Colour coded bins, RBSK pictorial tool kit is not found available in SHC Chaura. 15. There is no arrangement for Bio-Medical waste management. Even placenta is handed over to the attendants to dispose off in SHC Chaura. 16. SHC Chaura which is a delivery point is in a pathetic state. Though it functioning from two buildings both of them are in unauthorized occupation & clinic and delivery work takes place in dirty surroundings and unhygienic conditions. Residential building of Sub Center Chaura is in unauthorized possession of ANM of Sub Center Amaliya who lives with family and discourages patients coming there for medical help. One ANM (regular ANM) lives/occupies in area meant for labour room and second ANM (RCH, contractual) lives/occupies an area meant for clinic purpose. If unauthorized possession cannot be removed, the center should be shifted elsewhere, because institutional delivery in such a condition is unsafe, and is worse than home delivery. 3
Qualitative Monitoring of PIP 2013-14: District Singrauli (M.P.) 1. Introduction For action based PIP monitoring of NRHM for high priority districts proposed by MoHFW (GOI) a field visit was made to Singrauli district in Madhya Pradesh in March, 2013. DH (DH) Singrauli, Community Health Centre (CHC) Khutar, 24X7 Primary Health Centre (PHC) Morwa, and Sub-Centre (SC) Chaura health facilities were visited by PRC Singrauli. PIP monitoring included critical areas like maternal and child health, immunization, family planning, adolescent health, human resources and programme management, and qualitative interaction with beneficiaries to ascertain quality of services. Secondary data was collected for the structured format from the state and district HMIS data format that was already available at the respective Programme Management Unit. Primary data was collected for the qualitative responses in the format through interactions with the health staff during the visits to the health facilities. The reference point for examination of issues and status was 1st April 2013 for all selected facilities. Checklists were used to assess the availability of services. 2. State and District Profile Madhya Pradesh located in central India has 50 districts and 342 blocks with a total population of 7.2 crores (Census, 2011). Singrauli district is 50th district of Madhya Pradesh. It was granted district status on 24 th May 2008, with its headquarter at Waidhan. Sheopur Morena Bhind Gwalior Datia Madhya Pradesh Districts Shivpuri Tikamgarh Neemuch Chhatarpur Guna Ashoknagar Rewa Satna Mandsaur Panna Sidhi Rajgarh Vidisha Sagar Damoh Ratlam Shajapur Katni Shahdol Umaria Ujjain Bhopal Raisen Jabalpur Jhabua Sehore Anuppur Indore Narsimhapur Dewas Dindori Dhar Hoshangabad Alirajpur Mandla Harda Seoni West Nimar East Nimar Chhindwara Barwani Betul Balaghat Singrauli Burhanpur 4
It has been formed after dividing it from Sidhi district. Singrauli district is located at a distance of 712 kms from the state capital Bhopal. Singrauli has three tehsil namely Singrauli, Deosar and Chitarangi. It has three development blocks by the same name. Key Socio-Demographic Indicato Sr. Indicator MP Singrauli 2001 2011 2001 2011 1 No. of Districts 45 50 -- -- 2 No. of Blocks 333 342 -- 03 3 No. of Villages 55393 54903 744 744 4 No. of Towns 394 476 02 02 5 Population (Million) 60.34 72.52 0.22 1.17 6 Decadal Growth Rate 24.3 20.3 38.60 28.05 7 Population Density (per km 2 ) 196 236 162 208 8 Literacy Rate (%) 63.7 70.6 49.2 62.4 9 Female Literacy Rate (%) 50.3 60.0 31.5 49.9 10 Sex Ratio 919 912 922 916 11 Sex Ratio (0-6 Age) 918 912 955 921 12 Urbanization (%) 26.5 27.6 20.9 19.3 The population density of Singrauli district is 208 persons per sq. km as compared to 236 of M.P. The decadal growth rate of Singrauli has decreased from 38.60 to 28.05 percent during 2001-2011. Total literacy rate of Singrauli has increase from 49.2 to 62.4 during 2001-2011. Female literacy rate has increased from 31.5 to 49.9 during 2001-2011. The male-female sex ratio of Singrauli is 916 females per thousand males in comparison to 912 of M.P. The sex ratio for 0-6 years of age group in Singrauli district has decreased from 955 in 2001 to 921in 2011 but is higher than the average sex ratio of M.P. Singrauli is one of the 100 districts of Empowered Action Group (EAG) states of India where IMR is very high. Singrauli district a part of erstwhile Sidhi district is among 100 districts of Empowered Action Group (EAG) states of India of leading in Infant Mortality Rate (IMR), and belongs to top 25 administrative divisions in order of Maternal Mortality Ratio (MMR). 5
Key Health and Service Delivery Indicators Sr. Indicator MP Singrauli Source 1 Infant Mortality Rate (per 1000 Live Births) 65 -- AHS, 2011-12 2 Neonatal Mortality Rate (Per 1000 Live Births) 43 -- AHS, 2011-12 3 Post Neonatal Mortality Rate (Per 1000 Live Births) 21 -- AHS, 2011-12 4 Maternal Mortality Ratio (Per 100,000 Live Births) 277 -- AHS, 2011-12 5 Sex Ratio at Birth 904 -- AHS, 2011-12 6 Expected number of Pregnancies for 2013-14 2071294 35856 CNAA, GoMP 7 ANC Registration Up to December 2013 1363022 24517 HMIS, 2013-14 8 1 st Trimester ANC Registration (%) 52 45 HMIS, 2013-14 9 OPD cases per 10,000 population Up to Dec. 2013 2984 1668 HMIS, 2013-14 10 IPD cases per 10,000 population Up to Dec. 2013 320 164 HMIS, 2013-14 11 Estimated number of deliveries for 2013-14 1882992 32596 CNAA, GoMP 12 SBA Home Deliveries (%) Up to Dec. 2013 34 62 HMIS, 2013-14 13 Reported Institutional Deliveries (%) up to Dec. 2013 84 58 HMIS, 2013-14 14 Postnatal Care received within 48 Hrs. after delivery 74.2 -- AHS, 2010-11 15 Fully Immunized Children age 12-23 months (%) 54.9 -- AHS, 2010-11 16 Unmet Need for Family Planning (%) 22.4 -- AHS, 2010-11 3. Health Infrastructure in Singrauli District Singrauli district provides health services in urban areas through DH Singrauli, and in rural areas and peripheries through 06 CHCs, 14 PHCs and 157 SHCs. DH Singrauli, 06 CHCs and 14 PHCs are functioning from government buildings. Out of 157 SHCs 15 do not have a building of their own. Existing Health Facilities and Health Facilities Visited Health Facility Number Health facility Visited DH 1 DH Singrauli Community Health Centers 6 CHC Kuthar Primary Health Centers 11 PHC Morwa (24*7) Sub Health Centers 151 SHC Chaura (Delivery Point) 6
4. Human Resources Madhya Pradesh has 68 percent of specialists' vacancy at CHC and 34 percent vacancy of medical officers at PHCs as per RHS, 2012. In order to reduce the vacancy in rural areas the state government in Madhya Pradesh has introduced compulsory rural service as prerequisite for admission to post graduation courses or bonds which insists on rural service after the graduate medical course. In Madhya Pradesh, presently, MBBS pass-outs have to serve one year bond for compulsory rural services. The in-service doctors must serve for two years in rural area for eligibility for admissions in Post Graduate courses quota in government medical colleges. Recently the state government in 2013-14 has proposed to raise the salary of doctors to Rs. 1 lakh for serving in high focus /remote areas. Retention of doctors is a major challenge in M.P. In Singrauli district only two-fifth posts of specialists and MOs are in position against the sanctioned posts. There is paucity of lady MOs in the district. Inspite of recent appointments through MPPSC many doctors in the district have joined PG course. In DH Singrauli 6 specialists are working against the 15 sanctioned posts, 10 MOs are in position against 27 posts, 1 gynaecologist are in position against 2 posts, 2 paediatricians are in position against 6 posts, and there is anesthetist in the DH inspite of 2 sanctioned posts. There are 55 SNs working against 70 sanctioned posts and 10 ANMs working against their sanctioned posts in DH Singrauli. CHC Khutar does not have any specialists and is functioning with 2 MOs, 5 SNs and 2 ANMs. PHC Morwa is functioning with two MOs in position. Training Status/skills: Capacity Building: Along with ensuring availability of the health staff in the facilities NRHM focuses on build on the capacities of the existing staff and skill upgradation for which there are provisions for trainings at all levels. It is found that in DH various cadres of personnel are trained and skilled in EmoC, LSAS, BEmOC, SBA, MTP/MVA, NSV, F-IMNCI/IMNCI, NSSK, Mini Lap Sterilizations, Leprosy Sterilization, IUCD, PPIUCD, Blood Bank,/Storage, IMEP & Immunization & Cold Chain. In CHC Khutar various cadres of personnel trained are skilled only in SBA, MTP, NSSK, IUCD, Immunization & Cold Chain. In PHC Morwa that various cadres of personnel are trained and skilled in SBA, MTP and Cold Chain. 7
5. Other Health Systems Inputs Physical Infrastructure:- DH Singruali, CHC Khutar, PHC Morba & Sub Center Chaura all are functioning in government building and accessible to transport facility to reach there.in DH and CHC Khutar, PHC Morba electricity supply with power backup and 24 hours running water facility is found available. In Sub center there is no power back up and handpump facility is available and no 24 hours continuous water supply. Wards were found clean in all the visited health institutions but SC Chaura is occupied bv ANM for residential purpose. Separate male and female wards are found available in DH, Singruoli, It is found that there are no separate male and female wards in visited CHC and PHC. Blood Bank or Blood Storage Unit is found non-existent in any of the visited institutions. Availability of drugs:- In all the health institutions visited it is found that according Essential Drug List all the drugs are sufficiently available. The IFA (Blue) are not available in any of the visited health institutions. Computerized Inventory Management System is functional in DH Singrauli and CHC Khutar but not in the visited PHC and SC. Diagnostic tests:- The supplies of pregnancy testing kits, Urine albumin and sugar testing kit, OCPs, EC pills, IUCDs, sanitory napkins, Gloves, Mckintosh, Pads, Bandages and gauze etc are found available within expiry in DH, CHC, PHC & SC. Essential Equipments:- It is found that as per requirement in DH, CHC, PHC essential equipments are in position. OT equipments:- In DH all the equipments are available except multi para monitor, surgical diathermies, & C- arm units. In CHC Khutar & PHC Morwa the prescribed OT equipments are not available. Specialty care service:- In DH speciality care services of surgery, medical, obstetrics and gynaecology, emergency service, opthalmology and pathology are available but cardiology, trauma care ENT, radiology are not available. Specialist care services are not provided in the visited CHC Khutar. AYUSH services:- AYUSH services are not provided in the visited DH, CHC and PHC. 8
6. Maternal Health In Singrauli city there is no separate maternity wing in DH. 6.1 ANC and PNC Estimated pregnancies for 2013-14 for Singrauli district is 35856 of which 30206 (84 percent) pregnant women have been registered for ANC during April-2013-14. Forty seven percent women were registered in the first trimester. In DH Singrauli 3821 women were registered upto February 2014. In total 20 hypertensive cases were reported in DH Singrauli. IFA was received by 617 women in DH Singrauli and 519 TT injections respectively. Line listing of severely anaemic pregnant women is not separately done by any of the institutions. In case of pregnant women with anaemia a separate column in' the register was suggested. A total of 72 severely anaemic pregnant women were reported in DH upto February 2014. It was observed that at DH Singrauli and CHC Khutar most mothers stayed upto 48 hours after delivery but in SHC the mothers left within 24 hours raising questions about quality of care and ensuing risk for 'mothers. Service delivery in post natal wards: It is observed that all the mothers initiated breast feeding within one hour of the normal delivery, at the visited health institutions. Zero doze BCG, Hepatitis B and OPV & free diet given in district hospital, CHC & PHC but not in Sub center. JSY payments are given before discharge.in Sub health center for mothers here is no facility for accommodation for stay of 48 hours. 6.2 Institutional deliveries DH Singrauli, CHC Khutar, PHC Morwa and SC Chourah have reported 2333, 510, 393 and 453 deliveries respectively during April, 2013 to February, 2014. Hospital records show that during this period a total of 08 C-section deliveries are reported from DH Singrauli. Although 40 health facilities are designate as, L1 (16 ), L2 (20), L3 (4) delivery points, very few are actually functional, either due to lack of manpower, diagnostic facilities or specialists and infrastructure. Also weak data reporting from different sources like paper reports, register records, and HMIS reporting is observed. 6.3 Maternal death Review District level committee has been formed for maternal death review except DH Singrouli which has reported 05 deaths during April, 2013 to February, 2014. Other health 9
facilities have not reported any deaths. Under reporting of maternal deaths is observed indicating weak monitoring. Facility based Maternal Death review is not taking place at peripheral level. 6.4 Janani Shishu Suraksha Karyakram (JSSK) A total of 20 beneficiaries were interviewed through exit interviews at facility level and at the household level visited in different villages visited. Out of these beneficiaries 10 received ANC care, 7 deliveries and 7 immunization cares. Most of the interviewed beneficiaries had heard about JSSK and free services received. All of them were registered with the ANM/ASHA. In the exit interviews beneficiaries reported to have received free JSSK services including free drugs and consumables, free diet, free diagnostics, and free transport with exemption of user charges in DH Singrauli CHC Khutar and PHC Morwa. However at PHC Morwa and SHC-Chaura all the JSSK benefits like free food and diagnostic facilities were not available. At village level the beneficiaries were not provided discharge card after delivery. Some of the beneficiaries did not receive MCP cards from ANM or ASHA and some beneficiaries did not receive JSY payments because bank accounts were not operationalised. 6.5 JSY In Singrauli district the JSY guidelines regarding payments to beneficiaries are being followed by making payments through an account payee cheque at the time of discharge up to January & February, 2013-14 at the visited facilities. The payment in this mode is creating problems for beneficiaries who find it difficult to open bank accounts. It was observed that most of the beneficiaries leave the health facility before 48 hours except DH. This raises questions about the quality of care received at the institutions. District officials like SDM, Tehsildar MOs, DPM monitor payments by doing physical verification of payments in their respective areas. The direct transfer scheme is implemented since January, 2014. 7. Child Health 7.1 SNCU The state has a functional SNCU unit in all 50 districts with 30931 inborn and 28799 out born Neonates treated during the year 2012-13. SNCU in Singrauli DH is functioning. 10
There are 2 regular and 2 contractual Medical Officers, 2 regular & 13 contractual staff nurse 15, 2 ANM, 1 Wardboy, 2 Ayas, 3 Security guard, 2 Sweepers, 1 Data Entry Operator, 1 Lab Technicains are in position. Most of the SNCU equipments are being installed, and separate diagnostic facilities created. Medical officers and staff nurses are trained for SNCU. During April, 2013 to February, 2014 total admissions of 113 inborn and 63 out born children were reported. Out of these 88 children cured, 15 not cured and 9 children were referred. 7.2 Nutritional Rehabilitation Centres M.P. has 10.8 million children of 0-6 years (Census, 2011) out of which an estimated l.3 million children are Severe Acute Malnourished (SAM) as per the SAM rate of the state. The state has 280 functional NRCs. In Singrauli district presently 4 NRCs are functional of which 1 is located at DH Singrauli, 1 each in three CHCs Sarai, Devsar and Chitrangi. NRC in DH is 20 bedded and 10 beds each available the in three CHCs. In NRCs trained manpower and necessary equipments are available. The visited NRC in DH Singrauli it is observed that 260 infants were admitted from April 2013 out of which only one child was referred. Rest of the children recovered. 7.3 Immunization The pockets of low immunization coverage in Singrauli district have been identified and district and block level plans have been prepared for 2014-15. Micro plans have been prepared for different blocks by DIO. The district has prepared a plan for intensification of RI for low immunization coverage areas. Alternate vaccine delivery system is in place in the district. The birth dose of immunization is being ensured for all newborns delivered before discharge at DH, CHC & PHC. Immunization services are available on fixed days in the visited health institutions. Due list of children generated through MCTS was not observed during the field visit. 7.4 Rashtriya Baal Swasthya Karyakram (RBSK): RBSK is yet to be initiated in the district. 11
8. Family Planning DH Singrauli has facilities for sterilization including post partum sterilization on daily basis. At CHC Kuthar there is no Surgeon. The Surgeon is called from DH for performing operations as per requirement. At PHC Morwah camps for sterilization are organized. IUCD is sufficiently available in all the visited health institutions but in PHC Morwa IUCD is not inserted as there is no trained personal available. PPIUCD services are available only at DH. During April-February 2013 total coverage of sterilization in Singrauli district is 4296 (VT:71; LTT:4222;CTT:3) thus accomplishing 0.1 percent sterilization to total institutional deliveries, in comparison to 1.7 percent achieved by the state (CNNA, February, 2013). No death during sterilization is reported. Ten post partum sterilizations were reported in the district. There were 1467 IUD insertions and 843 IUD removal in the district upto February 2013. There were 6293 OP users and 395 condom users in the district (CNNA Report, February, 2014). 9. Adolescent Reproductive and Sexual Health (ARSH) ARSH clinic not existing in Singrauli district due to non availability of counselor. 10. Quality in Health Services Infection Control: General cleanliness, practices of health staff, protocols, fumigation, disinfection, autoclave functioning are observed in DH Singrauli, CHC Khutar and PHC Morwa bur not in SHC Chaura. Although CHC Khutar is in adequate waiting space for patients is lacking. Biomedical Waste Management: Segregation of bio medical waste is being done at DH Singrauli CHC Khutar and PHC Morwa but not in SC Chaura. Outsourcing for disposal of Biomedical waste management is found in DH, CHC & PHC. Awareness amongst staff on cleanliness and hygiene practices is satisfactory in in DH Singrauli, CHC Khutar and PHC Morwa but poor at SHC Chaura. IEC: Display of list of services available, immunization schedule, clinical protocols EDL with information on free drug distribution is available, timings of health facility and phone numbers, awareness generation chart were displayed in visited institution. 11. Clinical Establishment Act Clinical Establishment ACT is yet to be implemented in the state for the registration and regulation of both private and public clinical establishments. 12
12. Referral transport and MMUs Singrauli district has 12 Janani Express and 01 ambulance operated with staff and centralized call centre '108'. Janani Express call centre is established in DH providing round the clock service. Dedicated register for in-bound (Home to facility) and out-bound (Facility to Home) JE services are maintained. During April, 2013 to February, 2014 transport facility by Janani express were provided to 5043mothers and drop back facility to 3496 mothers. A total of 126 sick children were provided transport facility and 74 children received drop back facility. A total 777 mothers and children received referral transport services. 13. Community processes Accredited Health Social Activist: In the district 857 ASHA's are presently working and 681 VHSCs are formed with all VHSCs having running accounts. All blocks have Block Community Mobiliser (BCM). Village level meetings are few and community participation is low. District Community Mobiliser (DCM) who is overall incharge of ASHA programme has not been appointed. All 3 blocks have Block Community Mobiliser (BCM). Skill development: During the year 2013-14 in CHC Khutar out of 264 ASHAs 228 have completed 6& 7 module training and out of 7 ASHAs under SHC Choura 6 have completed this training. Different programme officers in Singrauli district are providing orientation to ASHAs for National Health Programmes like TB, Malaria, Leperosy, etc. at the block level. ASHA Resource Centre has been formed at the state level to monitor the progress of ASHAs. Mentoring Group for community Action provides supportive services. Functionality of the ASHAs: Drug kit replenishment is done based on demand and availability of drugs. Payments to ASHAs have been regularized based on certification by the concerned ANM. However, analysis of highest and lowest paid ASHA has been carried out by the district although population norms and activeness of ASHA are the deciding factors. Urban RCH: The urban RCH is at an elementary stage. Forty one USHAs appointed in the urban wards of the district have been 14. Good Practices and Innovations District has is yet not evolved any innovative health care delivery practices. 13
Percent regitered children in MCTS with DOB in April, 2013 PIP 2013-14 Monitoring Report (MP) 15. MCTS and HMIS In Singrauli district out of 182 health facilities, presently 177 health facilities (DH, 6 CHCs, 25 PHCs and 145 SHCs) are reporting online for HMIS from June, 2013. Earlier uploading was taking place in R-HMIS for all the facilities and consolidated report was submitted. Data entry operators are available in 4 blocks in the district. DH Singrauli does not have a regular DEO for HMIS data entry and this task is carried out by computer operator of another programme with no training about the data elements of HMIS. In Singrauli, district M&E officer and three data entry officers have recently received training on HMIS at state level. 100.0 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 Gap in child immunization service for children with DOB in April, 2013 by different vaccination for MP and Singrauli, MCTS 2013-14 accessed on 26.05.2014 BCG OPV0 HEP0 DPT1 OPV1 HEP1 DPT2 OPV2 HEP2 DPT3 OPV3 HEP3 Measles Vit A Madhya Pradesh 92.0 81.7 77.1 81.2 81.2 81.0 75.9 75.8 75.6 71.9 71.7 71.4 58.0 57.2 55.6 Singrauli 73.7 50.4 49.0 61.9 61.0 55.7 45.2 45.1 45.0 38.5 38.3 35.8 19.3 18.9 16.9 All Vaccinati on Total Number of Children with DOB in April, 2013: 158582 (MP) and 2304 (Singrauli) MCTS accessed on 26.05.2014 indicates gaps in tracking of child immunization services for children with DOB in April, 2013 varying between 70 percent for BCG to 17 percent for all vaccinations, indicating poor data updation for all services provided. For all the vaccines tracking of child immunization services is weak. Similarly, gaps in tracking of pregnant women with LMP of June, 2013 is observed which varies between 100 percent for ANC 1 to 13 percent for TT2 booster provided. In Madhya Pradesh, delivery is reported for 23 percent of registered women with LMP in June, 2013 while in singrauli it is only 5 percent. MCTS updation of child immunization for all vaccines is lower in Singrauli district (17 percent) as compared to the state average (56 percent). Similarly, for maternal health updation of full ANC services is 24 percent for Singrauli district as compared to state average (32 percent). MCTS data entry is outsourced in Singrauli district and lacks stringent monitoring follow up. 14
Services to pregnant women with LMP in June, 2013 (%) PIP 2013-14 Monitoring Report (MP) 100.0 100.0 Gap in Maternal Health Services to the pregnant women with LMP in June, 2013 for MP and Singrauli, MCTS 2013-14 accessed on 26.05.2014 70.1 76.775.5 84.0 76.1 50.0 56.1 56.4 59.6 39.6 38.6 29.3 39.5 31.6 24.2 42.9 23.9 12.3 13.3 5.7 ANC1 ANC2 ANC3 ANC4 3 ANC's Full ANC TT1 TT2 TTBooster IFA Deliveries Reported Madhya Pradesh Singrauli Total Number of Pregnant Women with LMP in June, 2013: 127392 (MP) and 2079 (Singrauli) 16. Key Conclusions and Recommendations / Action Points Paucity of specialists and trained staff at all levels was observed. Specialists and Staff vacancies in all categories must be filled up. Adequate recruitment of staff nurses to suffice the requirements of PHCs and CHCs is essential. It is essential to increase the bed capacity of DH considering the high case load. All the vacancies at district and block PMU must be filled up immediately. PMU at district and block level need orientation to ensure that processes of planning, organizing and monitoring are carried out efficiently in the district. Orientation of data analyst at the DPMU and BPMU's is essential to ensure the quality of data and regular updating. For HMIS and MCTS data special training of DEOs is essential in the district. Provision of residential and amenities for medical officers for retention is necessary. Blood bank and blood storage unit facility is lacking which needs immediate attention. IMNCI trainings for senior ANMs should be taken up at the earliest. VHSC meetings need to be monitored and supervised and BCC through community participation needs to be increased, because community participation is low. Monitoring mechanisms through supervisory visits are weak in the district. It is essential to strengthen the monitoring chain to track the progress of the different health facilities. Line listing of severely anaemic pregnant women is not separately reported by any of the institutions. In case of pregnant women with anaemia a separate column in the register was suggested for tracking severely anaemic women. Reporting and reviewing of infant and maternal deaths needs stringent monitoring. 15
Annexure 1 Health Infrastructure available in the district: As on March, 2014 No. of institutions Available Located in government buildings 16 Felt need for additional number of health facilities No. of Health Facilities having inpatient facility No of beds in each category* DH 1 1 0 1 120 Exclusive MCH hospital 0 -- -- -- -- SDH CHC 06 06 0 05 102 PHC 14 14 0 08 48 SHC (under PRIs) 0 0 0 0 0 SCs 157 142 0 0 0 AYUSH Ayurvedic -- -- -- -- -- AYUSH(Homoeopathic) -- -- -- -- -- AYUSH (Others) -- -- -- -- -- *: DH has sanctioned strength of 200 beds however, only 120 beds are functional 2 Physical Infrastructure Infrastructure ( / No) DH CH CHC PHC SHC Remark Health facility easily accessible from nearest road head Functioning in Govt. building Building in good condition No Staff Quarters for MOs -3 Staff Quarters for SNs -3 No No Staff Quarters for other categories -3 No No Electricity with power back up * *without power backup Running 24*7 water supply * *Hand pump Clean Toilets separate for Male/Female No No Functional and clean labour Room Functional and clean toilet attached to labour room No* *Non functional, poor condition Clean wards * *ANM Occupied for residential purpose Separate Male and Female wards (at least by No No partitions) Availability of Nutritional Rehabilitation Centre No Functional BB/BSU, specify No No Separate room for ARSH clinic No No Availability of complaint/suggestion box No No Availability of mechanisms for Biomedical waste management (BMW)at facility No
Infrastructure ( / No) DH CH CHC PHC SHC Remark BMW outsourced No Availability of ICTC/ PPTCT Centre No Availability of functional Help Desk No No No 3 Human Resources No. and types of HRH required vs Available, Postings. Health Functionary Required (Sanctioned) Available DH CH CHC PHC SC DH CH CHC PHC SC Gynecologist 2 01 1 0 Pediatrician 6 01 2 0 Anesthetists 2 01 0 0 Cardiologist 1-0 - General Surgeon 1 01 1 0 Medicine Specialist 1 01 1 0 ENT Specialist 1 0 Ophthalmologist 1 1 Ophthalmic Asst. 2 1 Radiologist 1 0 Radiographer 2 2 Pathologist 1 1 LTs 6 2 01 MOs 27 02 10 02 02 AYUSH MO 0-0 - - LHV 1 01 1 01 - ANM 10 02 2 10 02 02 2 MPHW (M) 0 1 0 - - 0 Pharmacist 6 01 2 01 01 Staff nurses 70 07 0 55 05 02 0 RMNCHA+ Counselor 0 0 No. of Trained Persons and skills of various cadres vis-à-vis service delivery (, No) Training programmes DH CHC PHC SC Remark No. EmOC -2 No No. LSAS -2 No No. BEmOC -2 No No No. SBA -1-5 -3-2 No. MTP/MVA -1-1 -1 No. NSV -2 No No No. F-IMNCI/IMNCI -1 No No No. NSSK -1 No No. Mini Lap-Sterilizations -2 No No No. Laproscopy Sterilizations -1 No No. IUCD -1 No No. PPIUCD -1 No No. Blood Bank / storage -2 No No. IMEP -1 No No. Immunization and cold chain -1 No. Others (specify)-------- - - - - 17
4 Other health System inputs Availability of drugs and diagnostics, Equipments (Mention / No) DH CH CHC PHC SC Remarks Availability of EDL and Displayed * *but not displayed Availability of EDL drugs No. and type of EDL drugs not available No - (Collect Separate List) Computerized inventory management No No IFA tablets IFA tablets (blue) No No No No IFA syrup with dispenser Vit -A syrup ORS packets Zinc tablets Injection Magnesium Sulphate Injection Oxytocin Misoprostol tablets Mifepristone tablets No No Availability of antibiotics Labeled emergency tray Drugs for hypertension, Diabetes, common ailments e.g PCM, metronidazole, anti-allergic drugs etc. Partial* *Only PCM Available Adequate Vaccine Stock available Supplies (Check Expiry Date during visit to the Facility) Pregnancy testing kits Urine albumin and sugar testing kit OCPs EC pills IUCDs Sanitary napkins Gloves, Mckintosh, Pads, bandages, and gauze etc. Laboratory and Other Diagnostic tests Haemoglobin CBC Urine albumin and sugar Blood sugar RPR Malaria T.B No HIV No No Liver function tests (LFT) Ultrasound scan (Ob.) Ultrasound Scan (General) X-ray ECG Endoscopy Others, pls specify No No 18
DH CH CHC PHC SC Remarks Essential Equipments Functional BP Instrument and Stethoscope Sterilized delivery sets Functional Neonatal, Pediatric and Adult Resuscitation kit Functional Weighing Machine (Adult and child) Functional Needle Cutter Functional Radiant Warmer No* *Bulb only Functional Suction apparatus No Functional Facility for Oxygen Administration Functional Foetal Doppler/CTG Functional Mobile light Delivery Tables Functional Autoclave Functional ILR and Deep Freezer Emergency Tray with emergency injections MVA/ EVA Equipment No No Functional phototherapy unit No OT Equipments O.T Tables No No Functional O.T Lights, ceiling No No Functional O.T lights, mobile No No Functional Anesthesia machines No No Functional Ventilators No No No Functional Pulse-oximeters No No Functional Multi-para monitors No No No Functional Surgical Diathermies No No No Functional Laparoscopes No No Functional C-arm units No No No Functional Autoclaves (H or V) Blood Bank / Storage Unit Functional blood bag refrigerators with chart for temp. recording Sufficient no. of blood bags available No No Check register for number of blood No No bags issued for BT in last quarter Checklist for SHC Haemoglobinometer Any other method for Hemoglobin Estimation Blood sugar testing kits BP Instrument and Stethoscope Delivery equipment Neonatal ambu bag No 19 No No
Adult weighing machine Infant/New born weighing machine Needle &Hub Cutter Color coded bins RBSK pictorial tool kit No No Specialty Care Services Available in the District DH CHC Remarks Separate Women s Hospital No No Surgery No Medicine No Ob&G No Cardiology No No Emergency Service No Trauma Care Centre No No Opthalmology No ENT No No Radiology No No Pathology No AYUSH services DH CHC PHC Remarks Whether AYUSH facilities available at the HF No No No If yes, what type of facility available - - - Ayurvedic - 1 Homoeopathic -2 Others (pl. specify) -3 Whether AYUSH MO is a member of RKS at facility NA NA NA Whether OPDs integrated with main facility or NA NA NA they are earmarked separately Position of AYUSH medicine stock at the faculty NA NA NA User Charges for Different Services (1-Free for Preg.Women, 2-Free for Children, 3-Free for Both Preg. Women and Children, 4-Free for All) Services DH CHC PHC SHC Remarks Haemoglobin Hb test 4 4 4 4 Urine Pregnancy Test 1 4 4 4 Malaria PF/PV testing 4 4 4 4 Urine (Microscopy, Acetone) 4 4 4 Slide Collection for PBF & Sputum AFB 4 4 4 Blood Sugar 4 4 4 Serum Urea 4 4 4 Serum Cholesterol 4 4 4 Serum Bilirubin 4 4 4 Typhoid Card Test 4 4 4 Blood Typing 4 4 4 Stool Examination 4 4 4 ESR 4 4 4 Complete Blood Picture 4 4 4 Platelet Count 4 20
Services DH CHC PHC SHC Remarks PBF for Malaria 4 Sputum AFB 4 SGOT liver function test 4 SGPT blood test 4 G-6 PD Deficiency Test 4 4 4 Serum Creatine / Protein 4 4 4 RA factor (Blood Grouping) 4 4 4 HBsAG 4 4 4 VDRL 4 4 4 Semen Analysis 4 X-ray 4 - - ECG 4 - - Liver Function Test 4 - - RPR for syphilis 4 - - RTI/STI Screening 4 4 4 HIV 4 4 4 4 Indoor Fees 4 4 4 4 OPD fees 4 1 1 4 Ambulance 4 - - Food for Inpatients 4 4 4 5 Maternal health (Give Numbers since April'2013) up to February 2014 5.1 ANC and PNC Services Delivered DH CHC Jun 2013 to Feb. 2014 PHC Jun 2013 to Feb. 2014 ANC registered 3821 306 464 190 New ANC registered in 1st Trim 30 236 81 ANC 3 Coverage 110 195 99 ANC 4 Coverage 33 Ng Line listing severely anemic pregnant women Identified hypertensive pregnant women No. of B-Sugar tests conducted No. of U-Sugar tests conducted No. of protein tests conducted No. of pregnant women given TT - 2 & Booster 72 14 07 0 SC 20 NG NG Ng 519 67 119 114 No. of pregnant women given 100 617 153 244 175 IFA No. of women receiving PNC visits Within 48 hours 178 376 157 Between 48 hours & 14 days 0 82 261 Whether the documentation and follow-up satisfactory If not, record reasons Remarks 21
Services Delivered DH CHC Jun 2013 to Feb. 2014 PHC Jun 2013 to Feb. 2014 No. of Pregnant women referred 500 86 5 No. of MTP before 12 weeks 134 0 0 NA No. of MTPs after 12 weeks 46 0 0 NA SC Remarks 5.2 Institutional deliveries DH (April 2013 to Feb. 2014) CHC PHC SHC Remarks Normal Deliveries conducted 2333 510 393 453 C- Section deliveries conducted 08 0 0 NA No. of Assisted Deliveries (Ventouse / Forceps) 01 0 0 NA Number of patients provided EmOC 0 0 0 NA No. of Obstetric complications managed (Please 0 0 0 0 note type of complications during visit) No. of Neonates initiated breastfeeding within 2180 481 373 467 one hour No. of Still Births 105 11 10 04 5.3 Maternal death Review DH CHC PHC Remarks Total maternal deaths reported 5 0 0 Number of maternal death reviews during the quarter 0 0 0 Key causes of maternal deaths found Anemic, Eclampcia, PPH, Home Delivery NA NA 5.4 JSSK DH CHC PHC Remarks Free and zero expense delivery & caesarean section Free drugs and consumables Free diet up to 3 days during normal delivery and up to 7 days for C-section, Free essential and desirable diagnostics (Blood & urine tests, USG, etc) during Ante Natal Care, Intra Natal Care and Post Natal care Free provision of blood, however relatives to be encouraged for blood donation for replacement. Free transport home to hospital, inter-hospital in case of referral drop back to home 5169 777 3570 Exemption of all kinds of user charges 22
5.5 JSY Status of implementation, payment to home deliveries, payment mode- direct transfer, acc. Payee or bearer cheque, record keeping DH CHC PHC SC Remarks JSY payments are made as per the eligibility criteria indicated in JSY Guidelines No delays in JSY payments to the beneficiaries. Full amount of financial assistance to be given to the beneficiary before being discharged from the health facility after delivery. Payments mode Cash-1 Cheque bearer-2 Cheque a/c payee-3 Direct transfer-4 Others (specify ) -5 Physical (at least 5%) verification of beneficiaries to be done by district level health authorities to check malpractices. Grievance redressal mechanisms as stipulated under JSY guidelines to be activated in the district. Proper record maintained for beneficiaries receiving the benefit Up to Jan.- 3 Since Feb - 4 5.6 Service delivery in post natal wards Parameters (Ask during visit to confirm the status) All mothers initiated breast feeding within one hour of normal delivery Up to Feb.-3 Since March -4 Up to Feb.- 3 Since March -4 Up to Feb.-3 Since March -4 No No No No DH CHC PHC SHC Remark Zero dose BCG, Hepatitis B and OPV given No Counseling on IYCF done Counseling on Family Planning done Mothers asked to stay for 48 hrs * *No facility for stay JSY payment being given before discharge Any expenditure incurred by Mothers on travel, drugs or diagnostics(please give details) No No No No Diet being provided free of charge No 23
6 Child health (Give Numbers Since April'2013) 6.1 SNCU / NBSU ( / No) DH CHC PHC SC (NBCC) Remarks Whether SNCU / NBSU exist. No No No Necessary equipment available No No No Availability of trained MO and staff nurses No No - No. of admissions No. of Children Inborn Out Born Cured Not cured Referred Others (specify) 113 63 88 15 09 - - - - - - 6.2 NRCs DH CHC Remarks Whether NRC exist at the facility No Whether necessary equipment available No Availability of trained manpower No If yes, number of admissions with SAM 260 - No. of sick children referred 01 - Average length of stay 45-6.3 Immunization (Give Numbers since April'2013) up to February 2014 DH CHC (Jun-2013 (Junto Jan- 2013 to 2014) Feb.- 2014) PHC (Jun- 2013 to Feb.- 2014) SC (April- 2013 to Feb.- 2014) No. of Children given birth dose (Polio/Hap-B) BCG 1712 501 384 447 DPT1/Penta1 506 40 211 192 DPT2/Penta2 408 27 177 178 DPT3/Penta3 373 20 139 168 Polio0 1667 488 384 170 Polio1 488 40 211 192 Poli02 408 27 177 178 Polio3 373 20 139 168 Hep 0 1098 404 352 118 Hep 1 449 40 211 192 Hep 2 403 27 177 178 Hep 3 376 20 139 168 Measles1 399 47 112 246 Measles2 55 0 0 21 DPT booster 260 4 85 112 Polio Booster 261 4 85 112 No. of fully vaccinated children ORS / Zinc Ng Ng Remarks 24
DH (Jun-2013 to Jan- 2014) CHC (Jun- 2013 to Feb.- 2014) PHC (Jun- 2013 to Feb.- 2014) SC (April- 2013 to Feb.- 2014) Ng Vitamin - A No. of immunisation sessions planned 90 No. of immunisation sessions held 74 Maintenance of cold chain. Specify problems No No No - (if any) Whether micro plan prepared Whether outreach prepared Stock management hindrances (if any) No No No No Is there an alternate vaccine delivery system Remarks 6.4 Number of Child Referral and Death DH CHC PHC SHC Remarks No. of Sick children referred 113 01 0 0 No. of Neonatal Deaths 05 0 0 0 No. of Infant Deaths 0 0 0 7 Family Planning DH CHC June 2013 Feb,2014 PHC June 2013 Feb,2014 SC April,2013 to Feb, 2014 Remarks Whether FP services provided (/No) * *Spacing method only Whether IEC material available IEC activities during the quarter No IUCD type available 375/380 * *available but not in use due to no trained person available. Whether PP IUCD services available at the facility No Male Sterilization (VT+NSV) 40 0 Female Sterilization (CTT+LTT) 1906 21 Minilap sterilization 0 0 IUCD 25 0 11 PPIUCD 487 0 0 Condoms 8220 22 97 118 Oral Pills 731 0 24 119 25
8 Quality in health services 8.1 Infection Control General cleanliness, practices of health staff, protocols, fumigation, disinfection, autoclave DH CH CHC PHC SC Remarks General cleanliness Good Good Good No Condition of toilets Good Good Good Poor Building condition Good Good Good Good Adequate space for medical staff No No Adequate waiting space for patients No Practices followed Protocols followed No Last fumigation done No No Use of disinfectants No Autoclave functioning 8.2 Biomedical Waste Management DH CHC PHC SC Remarks Whether bio-medical waste segregation done No Whether outsource No If not, alternative arrangement Pits-1 Incineration-2 Burned -3 Others (specify) --4 4-packed & return to attendant 8.3 IEC (Observe during facility visit) DH CHC PHC SC Remarks Whether NRHM logo displayed in both languages Approach road have direction to health facility No No Citizen Charter No Timing of health facility List of services available Protocol poster JSSK entitlements (displayed in ANC clinic/pnc clinic/wards) Immunization schedule FP IEC User charges No No No No EDL No Phone number Complaint/suggestion box No No No Awareness generation charts Others (specify) 26
8.4 Quality Parameter of the facility (Through probing questions demonstration assess does the staff know how to) Essential Skill Set ( / No) DH CHC PHC SHC Remark Manage high risk pregnancy No No No Provide essential newborn care (thermoregulation, breastfeeding and asepsis) Manage sick neonates and infants No No No Correctly uses partograph No Correctly insert IUCD * *IUD not inserted in PHC Correctly administer vaccines Segregation of waste in colour coded bins No No Adherence to IMEP protocols 27 Out sour ced Out sou rce d Bio medical waste management Updated Entry in the MCP Cards Entry in MCTS Action taken on MDR No No No 9 Referral transport and MMUs # of MMUs, Service utilization data, issues DH CH CHC PHC Remarks Number of ambulances of different types (give details) 13 Ambulance per lakh population Availability of call centre Number of clients utilized ambulance services Number of clients utilized ambulance services at night Number of times the ambulance services could not be provided Average kms per day Average kms per visit Number of MMU 2 Micro plan prepared GPS installed Monthly Performance monitoring Number of patients served during the last quarter 10 Community processes 10.1 ASHA CHC PHC SC Remarks Number of ASHAs required 7 Number of ASHAs available 264 7 Number of ASHAs left during the quarter 12 0 0 Number of new ASHAs joined during the quarter 19 0 0 All ASHA workers trained in module 6&7 for 228 6 implementing home based newborn care schemes Availability of ORS and Zinc to all ASHAs Availability of FP methods (condoms and oral pills) to all No
CHC PHC SC Remarks ASHAs Highest incentive to an ASHA during the quarter 13900 5000 13900 Lowest incentive to an ASHA during the quarter 150 1500 1500 Whether payments disbursed to ASHAs on time Whether drug kit replenishment provided to ASHAs ASHAs social marketing spacing methods of FP 11 Disease control programmes District total National Malaria control programme Number of slides prepared 7178 Number of positive slides 149 Availability of Rapid Diagnostic kits (RDK) Availability of drugs Availability of staff Revised National Tuberculosis Programme (RNTCP) Number of sputum tests 7598 No. of positive tests 496 Availability of DOT medicines All key RNTCP contractual staff positions filled up Timely payment of salaries to RNTCP staff Timely payment to DOT providers National Leprosy Eradication Programme (NLEP) Number of new cases detected 137 No. of new cases detected through ASHA 08 No. of patients under treatment 121 DH CHC PHC SC Remarks 12 Non Communicable Diseases ( / No) DH CHC PHC Remarks NCD No No Establishment of NCD clinics No No Type of special clinics (specify) Availability of drugs NA NA Type of IEC material available for prevention of NCDs NA NA 13 Record maintenance (Verify during facility visit) 1= Available and undated/ correctly filled; 2=Available but not updated; 3=Not available Record DH CHC PHC SHS Remark OPD Register 1 1 1 3 IPD Register 1 1 1 1 ANC Register 1 1 1 1 PNC Register 1 1 1 1 28
Record DH CHC PHC SHS Remark Indoor bed head ticket 1 1 1 3 Line listing of severely anaemic pregnant 1 3 3 3 women Labour room register 1 1 1 1 Partographs 1 1 1 2* Not filled FP-Operation Register (OT) 1 1 * *Central register maintained at block level OT Register 1 1 NA FP Register 1 1 1 3 Immunization Register 1 1 1 1 Updated Micro plan 1 1 1 1 Blood Bank stock register NA NA Referral Register (In and Out) 1 1 1 1 MDR Register 1 3 3 3 Infant Death Review and Neonatal Death 1 3 3 Review Drug Stock Register 1 1 1 1 Payment under JSY 1 1 1 1 Untied funds expenditure (Check % 3 expenditure) AMG expenditure (Check % expenditure) 3 RKS expenditure (Check % expenditure) 14 HMIS and MCTS (Verify during facility visit) DH CHC PHC SC Remarks Dedicated Staff available for HMIS and MCTS Quality of data Timeliness Completeness Consistent Data validation checks (if applied) 15 Additional / support services Services DH CHC PHC Remark Regular Fogging (Check Records) No No No Functional Laundry/washing services Availability of dietary services Appropriate drug storage facilities Equipment maintenance and repair mechanism Grievance Redressal mechanisms No No Tally Implemented No No 29