CHAPTER IV HEALTH SCENARIO IN ASSAM WITH SPECIAL REFERENCE TO CACHAR DISTRICT

CHAPTER IV HEALTH SCENARIO IN ASSAM WITH SPECIAL REFERENCE TO CACHAR DISTRICT 4.1. Health Care System in India Health is a fundamental human right. It is the responsibility of the government to provide health care to all people in equal proportions. Ever since India's independence in 1947, various national health schemes and programs have been launched with the view to improve the health status of people of the country, especially for those living in rural areas. The construction of Primary Health Centres (PHCs) began in the early 1950s.By the 1970s one PHC per community development block (having a population of 60,000 on an average) had been achieved in accordance with the Bhore Committee s recommendation. Since, the average population of a block had increased significantly; the concept of sub-centre (SC) came into force. The structure of health care service in rural areas provides a network of sub-centres (SC) and Primary Health Centres (PHC), hospitals and dispensaries in government as well as private health sectors. Each sub-centre (SC) covers a population of 3,000 to 5,000, while the PHC covers 20,000 to 30,000 except in hilly areas where the population of 20,000 is the limit. The Government of India (GoI) launched the National Rural Health Mission (NRHM) on 12 th April 2005. The aim of NRHM is to bring about significant 59

improvement in the health system and the health status of the people. NRHM specially focuses on states, which have poor health outcomes and inadequate public health infrastructure and workers. The primary focus of the mission is to improve access to healthcare for rural people. It seeks to provide equitable, affordable and universal access to rural people, especially women and children. The main goal of NRHM is to reduce infant mortality rate (IMR) and maternal mortality ratio (MMR) by promoting newborn care, immunization, antenatal care, institutional delivery and post-partum care. The NRHM foundation is built on community involvement in drawing a village health plan under the auspices of Village Health and Sanitation Committee (VHSC). This would enable rural primary health care services accountable to the community and giving authority to the District Health Mission for implementation of inter-sectoral District Health Plan including drinking water, sanitation, hygiene and nutrition. The interface between the community and the public health system at the village level is entrusted to a woman. Accredited Social Health Activist (ASHA), a health volunteer, receiving performance based compensation for promotion of universal immunization, referral and escort services for reproductive and child health (RCH), construction of household toilets, and other health care delivery programmes. To promote institutional delivery, cash incentive programme under Janani Suraksha Yojana (JSY) is made an integral component of NRHM. Although NRHM aims to cover all the states of the country, special focus is given to 18 states - namely, Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, Jammu and Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttaranchal and Uttar Pradesh. 4.2. Public Health Care System in Assam According to the Economic Survey-Assam, 2011-12, the total fertility rate of the state is 2.7. The birth rate (per thousand) is 23.6 and death rate (per thousand) is 8.4.The infant mortality rate (per thousand) is 61 and maternal mortality ratio (2007-2009/death per lakh live birth) is 390. 60

4.3. Infrastructural Facilities in Assam Infrastructural facilities in Assam comprise of 22-district hospital (DH), 103- community health centres (CHC), 844 PHCs and 4592 SCs. There are 103 health facilities functioning on 24x7 basis and only 60 are functioning as first referral units (FRU). The 60 FRUs comprise 22 DHs, 2 sub-divisional hospitals (SDH), and 36 CHCs. Table IV.1: Health infrastructure in Assam Health institution Number Medical College 3 District Hospitals 22 Ayurvedic Hospitals 1 Ayurvedic Dispensaries 380 Unani Dispensaries 1 Homeopathic Hospitals 3 Homeopathic Dispensary 75 State Level Hospital 1 (MMC Hospital in Guwahati) Sub- Divisional Hospitals(SDH) 3 CHC 103 PHC 844 State Dispensary(SD) 239 Subsidiary Health Centre(SHC) 71 Sub-Centre 4592 B.Sc Nursing Colleges 1 24x7 Health Facilities 103 Source: NRHM-State Health Action Plan2007-08 (i) Private Health Facility in Assam The private sector hospitals in Assam are unevenly distributed. Most of the private hospitals are clustered in the Kamrup (Metro) district. At present, there are 61

131 private sector hospitals in Assam scattered over 13 districts. At present, 18 mother Non-Governmental Organisations (MNGOs) operating in the state for 20 districts and for other 7 districts, selection process is going on. These are Rural Women Upliftment Association in Nalbari and Barpeta districts, Voluntary Health Association of India in Lakhimpur and Sonitpur districts and Deshabandhu Club in Karimganj and Karbi Anglong districts.mother Non-Government Organisation are working for providing quality of antenatal care (maternal and child health), adolescent and reproductive health, prevention and management of RTI and gender aspects. Strengthening institutional deliveries and immunisation for children and providing essential neonatal care, family planning, young eligible couples and adults are providing awareness information of family planning and community-based distribution of contraceptives are other focused areas of work. They are also focusing on reducing the prevalence of RTI/STI through networks with the government and local organisations. Under the initiative of NRHM, all the MNGO activities are monitored at block level by the block coordinators. At district level, monthly reviews are also carried out. (ii) Human Resource in Assam Out of a total requirement of 412 medical personals, only 365 are in position and 117 have been appointed on contractual basis under NRHM. Similarly, around 178 medical doctors have been appointed on contractual basis under the same mission. Yet, 61 PHCs are still without doctors (NRHM 2007-08). Similarly, 2112 staff nurses have been recruited under NRHM and still there is serious shortage of staff nurses. However, an innovative idea of introducing Rural Health Practitioners (RHPs) by imparting 3 years training to 10+2 pass outs is expected to improve rural health services. (iii) Caseload Caseload is the number of cases handled (as by a court or clinic) usually in a particular period. Caseload at present has improved significantly in the state. Number of institutional deliveries has increased (NRHM 2007-08) Introduction of 62

Rural Health Practitioners (RHP) under NRHM has been as innovative idea and is going to make a huge difference in delivery of health services at PHC levels in Assam. Improvement in use of human resources has facilitated evening OPDs in Assam and is expected to bring effective utilization of existing physical health infrastructure in Assam. (iv)quality of health service Quality and outreach of the health services in the state has improved on several accounts with the introduction of Rural Health Practitioners (RHPs). This has largely facilitated improvement in the quality of health services in the rural areas. Substantial improvement in patient friendly physical infrastructure/ health facilities and mobilization of human resources has reported brought up the quality of health services in the rural areas (NRHM 2007-08). As reported, most of the health facilities were found to be clean with sufficient lighting and clean toilets. Segregation of waste with deep burial and construction of pits has been initiated in most of the DHs and CHCs and some lower level health facilities. (v) Outreach of the Health Services With the introduction of ASHAs and AYUSHs health reach has spread to the interiors of the state. ASHAs are the visible face of NRHM and JSY work of ASHAs is quite popular among the rural women in the state. At present, there are 26,225 ASHA workers in 26312 villages of Assam. Awareness programmes supplement the activities of these workers. A weekly radio programme on ASHAs seems to be quite popular in the state. ASHAs in the state are given incentive as well as referral transport money for accompanying pregnant women. AYUSH implies Ayurveda, Yoga, Naturopathy, Unani, Siddha and Homoeopathy. NRHM aims at improving and correcting the deficiencies in the healthcare delivery system with a focus on integrating all the available healthcare facilities like AYUSH along with ongoing programmes. The department of Health and Family Welfare has taken an initiative with Department of AYUSH, Government of India for strengthening of health care facilities at all levels by integrating AYUSH systems in National Health Care Delivery Systems. Physical and functional integration of AYUSH systems are the most important strategy of 63

mainstreaming under NRHM. Integration is facilitated by appointing AYUSH doctors and creating infrastructure according to local needs. AYUSH doctors may be used to facilitate management of programmes, monitoring and effective implementation of various interventions under NRHM. At present, ayurvedic and the homoeopathic are functioning as the two systems of medicine under AYUSH. Director of Health Service, Govt. of Assam controls the Ayurvedic and Homoeopathic Dispensaries attached to District Civil Hospital, CHC, and PHC and SD. Table IV.2: List of medical colleges in Assam Sl.no District Name of the medical colleges 1 Kamrup (Metro) Gauhati Medical College, Guwahati 2 Dibrugarh Assam Medical College, Dibrugarh 3 Cachar Silchar Medical College, Silchar 4 Jorhat Jorhat Medical College, Jorhat 5 Barpeta Barpeta Medical College, Barpeta 6 Sonitpur Tezpur Medical College, Tezpur 7 Kamrup (Metro) Govt. Ayurvedic College, Guwahati 8 Kamrup (Metro) Govt. Homeopathic Medical College, Guwahati 9 Jorhat Govt. Homeopathic Medical College, Jorhat 10 Nagaon Govt. Homeopathic Medical College, Nagaon (vi)various Maternal and Child Health schemes sponsored under NRHM (a) Janani Suraksha Yojana Janani Suraksha Yojana (JSY) is a safe motherhood intervention under NRHM being implemented with the objective of reducing maternal and neo 64

natal mortality by promoting institutional delivery among poor pregnant women. The scheme provides cash assistance to mothers who have delivered in government health institutions, accredited private hospitals and sub-centres. This scheme gives rupees 1400 to mothers from rural and rupees 1000 to mothers from urban areas. Table IV.3: Year wise break up of JSY beneficiaries in Assam Year Beneficiaries 2011-12(April-January) 3,28,926 2010-11 3,91,675 2009-10 3,66,596 2008-09 3,27,894 2007-08 3,04,741 2006-07 1,82,873 2005-06 17,523 (b) Janani Sishu Suraksha Karyakram Janani Sishu Suraksha Karyakram (JSSK) implemented from February, 2012. It is a national initiative to make available better health facilities for women and child. The new initiative of JSSK is to provide free and cashless services to pregnant women including normal deliveries and caesarean operations and sick new born (up to 30 days after birth) in government health institutions, accredited private hospitals and sub-centre in both rural and urban areas wherein the delivery is conducted. Entitlements for pregnant women under the schemes are free and cashless delivery, free caesarean section, free drugs and consumables, free diagnostics tests such as blood test, urine test etc. Free nutritional diet during stay in health institutions (up to 3 days for normal delivery and 7 days for caesarean sections), free nutritional supplement such as Horlicks to the mothers, free ultra sonography, and free tests required for blood transfusion. Also, free conveyance 65

from home to health institution, between health institutions in case of referral and free drop back home after delivery under Aadarani Scheme. Exemption from all kind of user charges, including for seeking hospital care up to 6 weeks post delivery for post natal complications. Exemption for newborn till 30days after birth are free treatment at the public health institutions, drugs and consumables, diagnostics such as blood test, urine examination and other user charges. (c) Mamta The Mamta scheme seeks to reduce IMR and MMR, by insisting on post-delivery hospital stay of 48 hours of the mother and the newborn. Skilled doctors address any complication that may arise during this period. During discharge from hospital, the mother receives a gift hamper called the Mamta kit. This kit contains essential products for the baby such as baby powder, baby oil, a mosquito net, a flannel cloth etc. After 48 hours of stay in hospital, the Mamta kit is given to the mother. It is available at government health institutions, accredited private hospitals and sub-centre wherein the delivery is conducted. In 2011-12(April-Jan) total beneficiaries received Mamta kit is 2, 02,009 whereas it was 1, 59,196 in 2010-11. (d) Village Health and Nutrition Day Village Health and Nutrition Day (VHND), the main objectives of Village Health and Nutrition Day (VHND) are to ensure safe motherhood, childcare and awareness generation among the rural masses right at the village level. On that day, routine immunization of children aged between 0-9 months and vaccination of pregnant women are done at the village itself. It organized on a predetermined and publicised date every month, the VHND allows people to get in touch with health workers and discuss health related issues. ASHA organises VHND with the Village Health and Sanitation Committee (VHSC) in her village in a Wednesday once in a month in cooperation wherein ANMs deliver the services. (e) Mamoni Mamoni (cash assistance to pregnant women for nutritional support @Rs. 1000/-in two instalments).it is a scheme of the government of Assam that 66

encourages pregnant women to undergo three ante-natal check-up which identify danger signs during pregnancy(needing treatment) and offer proper medical care. Under this scheme, at the time of registration, every pregnant woman receives a booklet on tips on safe motherhood and newborn care titled Mamoni. During subsequent ANC check-up, the pregnant women are provided with an amount of Rs1000 (in two instalments first for second ANC and second for third ANC) for expenses related to nutritional food and supplements. Every government health institution offers this service for women who have registered in their place. Since inception of scheme, total 9, 16,391 beneficiaries received first instalment and 7, 39,270 received second instalment of Mamoni schemes. In the year 2011-12(Apr- Jan) total 2, 65,558 beneficiaries received first instalment and 2, 30,452 received second instalment of Mamoni benefit. (f) Majoni Social assistance to the girl child born in the family up to second issue is given a fixed deposit of Rs. 5,000/- for 18years. On her18th birthday, the girls will be able to encase the fixed deposit. In case she is married before attaining 18 years of age, the fixed deposit will be forfeited. This scheme is applicable to families who are limiting themselves to two children. Since inception, a total of 1,74.942 and in the year 201-12 (Apr-Jan) total 53,484 beneficiaries received Majoni fixed deposits. 4.4. Health Scenario in Cachar District Since the introduction of NRHM in 2005, the health scenario in Cachar District had witnessed a noticeable upswing. Presently, the health services have reached every nook and corner of the district. A number of new interventions in the form of evening Outdoor Patient Department (OPD), Mobile Medical Unit (MMU), formation of Village Health and Sanitation Committees (VHSC) in almost each villages, Public Private Partnership (PPP) with charitable hospital, tea garden hospitals and EMRI, 24x7 delivery facility with child care unit etc. has been taken up to strengthen the existing health care services. 67

(i) Indicators of Progress (a) Evening OPD With the launch of evening OPD in Cachar district, the daily wages earners whose working hours clashed with day OPD can now avail the free services of evening OPD. Initially it was started in two health institutions viz- S. M.Dev Civil Hospital, Silchar and Kalain CHC, Kalain in the month of May 2008. Later on, the services have been extended to another two numbers of health institutions namely Borkhola BPHC and Lakhipur BPHC in the month of September 2008. (b) Formation of VHSC (Village Health and Sanitation Committees) In order to create public awareness about the different health programmes and to provide overall health facilities to the community especially at grass root level, 1359 nos. of VHSC have been formed in Cachar District. With active participation of auxiliary nurse midwife (ANM), accredited social health activist (ASHA), anganwadi worker (AWW) and panchayat members, the committees are playing a vital role in making health services more accessible and affordable to the mass. Table IV.4: District wise health infrastructure in Assam Sl.No. Districts Block PHC Mini PHC SHC State Dispensary Sub Centre Total 1 2 3 4 5 6 7 8 Upper Assam 1 Dibrugarh 6 12 0 9 236 263 2 Jorhat 7 18 1 9 144 179 3 Sibsagar 8 22 4 1 230 265 4 Golaghat 5 27 2 5 154 193 5 Lakhimpur 6 12 3 5 166 192 6 Dhemaji 5 10 1 3 99 118 7 Tinsukia 4 10 1 5 163 183 Total 41 111 12 37 1192 1393 Central Assam 1 Kamrup Rural 13 23 0 27 350 413 2 Kamrup Metro 1 8 0 14 5 28 68

1 2 3 4 5 6 7 8 3 Nagaon 11 24 3 19 355 412 4 Sonitpur 7 23 6 8 293 337 5 Darrang 7 22 3 14 308 354 6 Morigaon 3 3 6 13 117 142 Total 42 103 18 95 1428 1686 Lower Assam 1 Nalbari 7 35 5 15 211 273 2 Bongaigaon 6 18 4 14 119 161 3 Goalpara 5 16 2 12 146 181 4 Dhubri 7 10 5 13 275 310 5 Kokrajhar 4 5 7 24 139 179 6 Barpeta 9 28 4 8 327 376 Total 38 112 27 86 1217 1480 Barak Valley& Hills District 1 Cachar 8 13 2 2 264 289 2 NC Hills 3 2 2 2 65 74 3 Hailakandi 4 6 1 2 104 117 4 Karbi- Anglong 8 25 7 9 104 153 5 Karimganj 5 8 2 6 218 239 Total 28 54 14 21 755 872 Total(Assam) 149 380 71 239 4592 5435 Source: NRHM-State Health Action Plan 2007-08) Table IV. 5: Block PHC wise status of VHSC formation Name of BPHC No. Of VHSC Bikrampur 129 Borkhola 167 Dholai 191 Jalalpur 224 Harinagar 131 Lakhipur 176 Sonai 196 Udharbond 145 Total 1359 69

(c) Public Private Partnership (PPP) Mode The mission speaks about successful partnership with a variety of non- Government stakeholders, including voluntary agencies, trustees, institutions, etc. The district of Cachar has already made a Memorandum of Understanding (MOU) with a private body of repute for providing long-term health care services particularly safe motherhood and childcare services. From 1 May 2007, partnership on a PPP (Public Private Partnership) mode, with Siv Sundari Nari Sikshashram and Antenatal Clinic of Silchar to provide Janani Suraksha Yojana service to the beneficiaries and childcare services including immunization was included. The District Health Society, Cachar has also undertaken nine tea garden hospitals under PPP mode. The Memorandum of Understanding with these tea garden hospitals has already been executed and need based fund have also been released to them from the earmarked amount of Rs.15.00 lacs to each tea garden hospitals on the basis of action plan. The names of the tea gardens are Koomber, Lakhipur, Narainpur, Pathicherra, Cossipur, Bhuban Valley, Rukni, Duwarbond, Subhong. The studies villages are not impacted by these hospitals. Initiatives have been taken up for inclusion of fifteen more tea garden hospitals in the second phase. In this phase, both Katigorah Pt-III and Balirband are expected to be covered. (d) Man Power Strengthening A total of 412 health service providers have already been engaged under NRHM in different health institutions especially in the rural areas of the Cachar district. Apart from the following, in order to strengthen the management of district and block levels, district programme management unit (DPMU) and block programme management unit (BPMU) has been setup. 70

Table IV.6: Number of health service providers Staff Number Medical officer (MBBS) 10 Medical officer (BAMS) 4 Dental Surgeon 1 Specialist 0 General Nurse Midwife(GNM) 118 ANM 250 Pharmacist 9 Lab Technician 19 Radiographer 1 Total 412 (e) 24x7 Delivery Room Up to 2011, the district has operationalised five fully equipped newly constructed Labour Rooms having facility for newborn care corner and 4 bedded ward. These health institutions are - Narsingpur MPHC under Dholai BPHC, Joypur SHC under Harinagar BPHC, Katigorah MPHC under Jalalpur BPHC, Sonabarighat SHC under Sonai BPHC and, Fulbari MPHC under Bikrampur BPHC. With the inclusion of the above, the district has extended its 24x7-delivery facility up to 16 health institutions. In addition to above, similar construction works are also going on in Banskandi MPHC under Lakhipur BPHC, Thaligram MPHC under Udharbond BPHC, Chibitabichia MPHC under Borkhola BPHC, and Borjalenga MPHC under Dholai BPHC. (ii) Infrastructure For development of infrastructure, a sum of Rs. 90.00 lac have been released for repairing and renovation of existing hospitals. For repairing of doctors and nurses quarters, an amount of Rs.120.00 lacs has been received by the district authorities for the following health institutions- Borkhola BPHC, Jalalpur BPHC,Sonai BPHC, Harinagar BPHC, Salchapra MPHC, Dholai BPHC, Lakhipur 71

BPHC,Udharbond BPHC, Joypur SHC. New construction of fifty-four numbers of sub-centres under NRHM and ten numbers of sub-centres under 12th Finance Commission are also being executed through PWD. Out of which, construction works of 40 nos. of sub- centres have already started. This will facilitate better health reach in the near future. (iii) Supply of Free Medicines The NRHM has made available medicine to meet the need of the hour, so that people do not only get advice and prescription from health care providers but also sufficient medicines. There is a dedicated district level District Medical Store with available workers. Cachar district also has Regional Drug Ware House and District Drug Store Manager with additional staffs that ensure the availability of medicines in the periphery level. (iv)awareness about the Health Information Awareness amongst people about the facilities provided by the government must be ensured so that people could get the utmost profit from these programmes. For that purpose, quarterly newsletter is published from the District Health Society. The ANM, AWW and ASHAs are also identified as necessary channel to fulfil the publicity to the grass root level on monthly Health Days in every village. Leaflets, pamphlets, banners, posters, calendars are also made available to the public from time to time for providing information on different issues and programmes. Local cable network, radios are also taken into account for the publicity. At present, all the Health Institutions are equipped with Citizen Charter, which provides information about what services are available in the hospital, how the patient can avail the service, and how the complaints regarding services/denial will be addressed. Public information is displayed on boards showing list of available medicines, JSY complaint box, etc. As a part of IEC, BCC, block PHCs are conducting street play in association with NGOs of their locality. 72

(v) Mobile Medical Unit (MMU) and EMRI -108(Mrityunjoy) Ambulance service Towards the end of the year 2008-09 the district had launched Mobile Medical Unit (MMU)- Hospital on Wheels to provide basic health care services in the unserved and uncovered areas especially in the case of critical patients. The MMU is to ensure regular schedule of outreach clinics and providing free of cost medicine, radiological and laboratory facility, speciality medical services through specialists from the district hospitals, etc. MMU will also help in reduction of MMR and IMR by awareness creation among the uncovered mass by displaying IEC materials on different ongoing programmes of NRHM. Another new initiative was of EMRI -108 emergency ambulance service (Mriyunjoy) on 3 rd December 2008. In the first phase, eight ambulances have been introduced in Cachar district. These ambulances are placed at following stations- 1) Sonai PHC, 2) Dholai PHC, 3) Udharbond PHC, 4) Borkhola PHC, 5) Lakhipur PHC, 6) Bikrampur PHC, 7) Jalalpur PHC and 8) Sahay NGO at Meherpur, Silchar. These ambulances are providing emergency services throughout the district. This service is also available in the study villages. 4.5. Health Infrastructure of Study Villages Katigorah BPHC is situated in Jalalpur area of Katigorah. The Jalalpur BPHC falls under Katigorah constituency and it contains two development blocks namely Katigoragh development block and Kalain development block. Studied area falls under Jalalpur BPHC. In Katigorah PHC, 24x7 delivery unit is going to be upgraded to a 30 bedded model hospital. The CHC is located about 13 kms away from the BPHC and MPHC is located about 27 kms away from the BPHC. 73

Table IV.7: Vital statistics and socio-demographic scenario of the Katigorah Block Sl.no. Particulars Figure 1. Total Population of the CD block 236531 2. No. of villages under block PHC 187 3. Total population of the BPHC 1,94,576 4. Total male population of the CD block 103251 5. Total female population of the CD 101473 block 6. Total SC population of the CD block 81889 7. Total ST population of the CD block 2837 8. No. of Anganwadi Centre in the block 356 9. No. of mini PHC under block PHC 01 10. No. of sub centre 18 Source: NRHM Table IV.8: Health infrastructure of Jalalpur PHC Health facility Number MPHC 01 CHC 01 SC (temporary building) 18 SC (permanent building) 05 SC ( rented building) 13 SC (with single ANM) 01 SC (with double ANM) 17 SC (newly constructed but not handed over) 06 Source: NRHM (i) Private Health Facility and NGO activities in the Block There is no private hospital or nursing home functioning under Jalalpur PHC. However, one Field Level NGO (FNGO) namely Siddheswar Pragati Sangha under Mother NGO Scheme is being selected for implementation of Reproductive and 74

Child Health Project and the FNGO has completed their RCH-II project in 2009-10.The role of NGO in health activities are poor in case of studied villages.researcher observed only one NGO performing health activities in the studied area, namely Siddeswar Pragati Sangha, Katigorah. (ii)infrastructure of PHC and BPHC under Study Area There are three types of health facility in the area: BPHC at Jalalpur, CHC at Kalain and PHC at Katigorah. The main building of Jalalpur BPHC is quite small and congested. The wards and OPD rooms are very small and have no laboratory facility. There is one small medicine storeroom; however, there is a need for one general medicine storeroom and one malaria storeroom. There is no separate room for laboratory technician (LT). Due to repeated flood, there are a good number of areas, which cannot be covered by BPMU, which is largely responsible for poor performance of healthcare. There are more than 23 backward villages including tea gardens where there is no sub-centre. About 40 villages have remained uncovered by sub centre, creating immense difficulties in distribution of ANM in uncovered villages. Under the CHC at Kalain, which is a fertility referral unit, there is lack of specialist like gynaecologist, surgeon, GNM, dresser and mother blood bank storage facility. The Katigorah mini PHC is operating with only three GNMs and is providing 24X7 services with a skeletal staff. There are two MOs including one RHP and one doctor. They are, however, both male doctors. (iii)achievement of governmental schemes in studied area Under JSY birth certificates are issued to all institutional delivery cases during the time of discharge. JSY payments are being made during discharge from hospital. During 2010-11, 100 per cent institutional delivery and payments are provided with JSY without any backlog. With JSY, institutional delivery increased and home delivery decreased. In case of Mamoni performance, during registration, Mamoni books are distributed in all VHND sites and in every VHND meeting, importance of Mamoni is shared with the beneficiaries. Four number of ANCs are engaged. PHC tried to make regular payment of Mamoni. Regarding Majoni performance during 2010-11, Majoni forms are distributed to the beneficiaries 75

during their discharge from the hospital. Birth certificates are issued during discharge. ASHA and ASHA facilitators are mobilize during the collection of forms. Majoni lists are displayed frequently and reports, records and returns are updated regularly. Regarding Mamata kit (under Assam Vikash Yojana), all the JSY mothers are motivated to stay 48 hrs through GNM, ANM and ASHA. Importance and benefits of Mamata is being displayed in banners and hoarding. PNC services are developed with medical officers and staff nurse. During the time of discharge, kits are distributed to mother. Stocks and registers are updated regularly. Total no. of girl child born Table IV.9: Majoni performance in block PHC (2010-11) Total no. of form distributed to beneficiaries Total no. of form submitted to the District Total fixed deposit certificate distributed to the beneficiaries 718 663 567 567 800 600 718 663 567 567 400 200 0 Fig.4.1: Graphic representation of Majoni performance in block PHC (2010-11) Table IV.10: Mamata performance in block PHC (2010-11) Name of institution Total no. of institutional delivery Mother stayed 48hrs after delivery Jalalpur BPHC 671 400(60%) 400 Kalain CHC 1599 466(30%) 466 Katigorah PHC 533 165(31%) 165 Total Mamta kit distributed to mother 76

Jalalpur BPHC Kalain CHC Katigorah PHC 1599 671 533 466 466 400 400 165 165 Total no. of institutional delivery Mother stayed 48hrs after delivery Total Mamta kit distributed to mother Fig. 4.2: Graphic representation Mamata performance in block PHC (2010-11) The proportion of institutional delivery in Katigorah block is 533 but only 165 mothers stay in hospital after such delivery for two days, indicating that the newborn and mother are deprived of much need health care in the initial stage. Table IV.11: VHND performance in block PHC (2007-11) Year Total no. of villages Total no. of ASHA No. of VHND No. of VHND organised 2007-08 230 260 0 8988 2008-09 230 260 2120 1762 2009-10 230 260 2411 2275 2010-11 230 267 2244 21711 77

2007-08 2008-09 2009-10 2010-11 2411 2244 2120 2275 2171 1762 898 230230230230 260 260 260267 0 Total no. of villages Total no. of ASHA No. of VHND No. of VHND organised Fig. 4.3: Graphic representation of VHND performance in block PHC (2007-11) The government health outreach programmes and schemes, in the opinion of the NRHM workers has brought about a visible change in the overall reproductive health scenario of the entiree district, including the study area. However, the general health initiatives still requires more efforts. 78