Evaluation of Programme Implementation Plan (PIP)

under NRHM in Sheohar district of Bihar State

Study Team

Dilip Kumar

S. K. Pandey

Population Research Centre

Department of Statistics

Patna University

Patna-800005

FOREWORD

At the instance of the Ministry of Health and Family Welfare (MoHFW), Government of India, New Delhi, our Centre had undertaken a study ‘Evaluation of Programme Implementation Plan (PIP) under NRHM in Sheohar district of Bihar State’. This study was launched by the MoHFW, Government of India on the urgent basis with the aim to improve the quality of services under NRHM.

A team of the technical staff had visited the Sheohar district to interview the health functionaries in the district public hospital, PHC and HSC for assessing the quality of NRHM services etc. on the basis of structured schedule, personal observations etc. The report has been written by Dr. Dilip Kumar, Joint Director and Sri S. K. Pandey, Analyst of the study team.

The present report provides some important findings regarding the district covered under the study. We hope these findings would be useful to the policy makers and researchers.

Amarendra Mishra

March 2014 Hony. Director

PRC, Patna

Executive Summary

It is the rapid evaluation of the PIP of National Rural Health Mission (NRHM). Technical staff of the Centre had visited in the Sheohar district to interview the health functionaries in the district sadar hospital, Primary Health Centre (PHC) and Health Sub Centre (HSC) to assess the availability of infrastructure facilities, human resources, programme management etc. The framed schedules and personal observation apart from the other records were used for the information collection from the district sadar hospital, Piprahi PHC and Singahi HSC level health functionaries in the Sheohar district of Bihar State during the assigned period of 19th February to 24th February 2014.

Situational Analysis in Sheohar district

Sheoharis an administrativedistrictin Bihar State. The district headquarters are located atSheohar, and the district is a part ofTirhut Division. This district was carved out of Sitamarhi district in 1994. There was one FRU in Tariyani but it is Naxal/Mao affected area so it has been closed as such there is no FRU in the Sheohar district.

Sheohar sadar hospital is 30-bedded. The district sadar hospital has the dilapidated condition of boundary wall. The district sadar hospital is likely to be shifted in newly constructed building soon. The Piprahi PHC is also functioning from its own old building but it has dilapidated condition of the boundary wall. The cleanliness of OPD room, other room/ward, compound and premises was good. The Singahi HSC is also functioning from its own building without the compound wall. The supply of water is through the hand pump. The cleanliness of HSC was good. It has poor sanitation facility and it needs maintenance properly.

The district sadar hospital lacks the full strength of permanent doctors and other specialists. The district sadar hospital has two OBG, two paediatrician, two general surgeons, two other specialists, six SNs, one LT on deputation. The posts of Pharmacist, Radiographer, RMNCHA / Councellors are vacant. None of the LHVs is functioning in the hospital at the time of survey also. The Piprahi PHC has four Medical Officers, four ANMs, one LT and one P.M.W. The posts of SNs/GNMs, Pharmacist LHV/PHN are vacant. The Singahi HSC has only one ANM functioning.

In the district sadar hospital, none of the medical personnel trained for the Emergency Obstetric Care (EmOC) and on the Basic Emergency Obstetric and newborn Care (BeMOC). None of the staff is trained on NSV in this PHC. In Piprahi PHC, staff has received training on SBA, IMNCI, IUD and RTI/STI. In Singahi HSC, the ANM was trained on the IMNCI in Sheohar during 3-10 Feb. 2013.

There are no functional newborn stabilizhation unit and the functional Sick Newborn Care Unit (SNCU) in the district sadar hospital. There is no functional new born stabilization unit in the Piprahi PHC.

In the district sadar hospital, there are supplies of OCPs and IUCDs and the EC pills. In the Piprahi FRU, there are supplies of EC pills, OCPs and IUCDs. No IUCDs cases were reported in the Piprahi FRU. In Singahi HSC, there was the supply of EC pills, OCPs and IUCDs.

The access of the information on Adolescent Reproductive & Sexual Health (ARSH) through services at Sheohar district sadar hospital and Piprahi PHC is available with the limited scope. There is no separate room for the ARSH activities. At Singahi HSC, the access of it is almost negligible. The Sheohar district sadar hospital and Piprahi PHC have reported about a few facilities of infection control program. Most of the patients of such referred to the Sri Krishna Medical College and Hospital at Muzaffarpur.

There is no display of all the services (Citizen's charter) at the Piprahi PHC. There is no provision of services of hospital waste treatment and disposal of Bio-Medical Waste Management in all health facilities up to HSC level. They used to burn most of the disposable items in the open space or buried in the pit. Almost all the health facilities are lacking in proper disposal of waste. The health Centres used to burn the waste material in the open space and buried some of the waste outside the campus of the health Centres. The Piprahi PHC also requires more ambulances to carry more number of patients. The Global positioning system (GPS) in MMUs is not available.There is no coordination among health & ICDS workers. The district sadar hospital has the facilities of the treatment of Leprosies, Malaria, Kalazar and Tuberculosis (TB). The Piprahi PHC has also the facilities of the same. At the Singahi HSC, the patients are referred to the district sadar hospital. There is the provision of HIV/AIDS test up to the PHC level and patients used to get the treatment at the district sadar hospital.

At the Sheohar district sadar hospital and Piprahi PHC have no major chronic diseases control programme which needs more facilities for the effective treatment of the chronic diseases. The Piprahi PHC has limited facilities of the treatment of chronic diseases and the patients of such are referred from the Singahi HSC also.

The district sadar hospital effectively works for the births deliveries, the family planning services but overburden with the OPD and inward patients. Rogi Kalyan Samitis have been established at the PHC level and RKS funds are being utilized at the PHC and HSC levels.

Most of the ANMs and Data Operators need refresher training on the HMIS. The maternal death review is lacking at the PHC level and HSC level also. There is no reporting of the maternal deaths. There is no micro birth planning for the anemic pregnant women at the district level. There are no SMS alerts to the beneficiaries under the MCTS.

Evaluation of Programme Implementation Plan (PIP) under NRHM in Sheohar district of Bihar State

  1. Background

It is the rapid evaluation of the PIP under the National Rural Health Mission (NRHM) assigned by the Ministry of Health and Family Welfare, Government of India, New Delhi. The NRHM aims of providing equitable, affordable and quality health care services to the vulnerable sections of the population, particularly among the poor, women and children residing in rural areas.

The technical staff of the Centre had visited in the Sheohar district to interview the health functionaries in the District sadar hospital, PHC and Health Sub Centre (HSC) to assess the availability of infrastructure facilities, human resources, programme management etc. The framed schedules and personal observation apart from the other records were used for the information collection from the District sadar hospital, PHC and HSC level health functionaries in the selected Sheohar district during the assigned period of 19th February to 24th February 2014. In the Sheohar district, one district sadar hospital, Piprahi PHC and Singahi HSC had been covered apart from the information collected from the pregnant women and the women having 0-6 years of children.

  1. Demographic profile of Sheohar district

Sheoharis an administrativedistrictin Bihar State. The district headquarters are located atSheohar, and the district is a part ofTirhut Division. This district was carved out of Sitamarhidistrict in 1994. The district occupies anareaof 349km². The district comprises only one sub-division, Sheohar, which is further divided into five blocks: Sheohar, Tariyani, Piprahi, Dumri-Katsari and Purnahiya. According to the2011 Census, Sheohar district has apopulationof 656,246.The district has a population density of 1880 inhabitants per square kilometer.Itspopulation growth rateover the decade 2001-2011 was 27.2 percent. With regards to Sex Ratio in Sheohar, it stood at 893 per 1000 male compared to 2001 census figure of 885. The child sex ratio is 929 girls per 1000 boys compared to figure of 916 girls per 1000 boys of 2001 census data. Sheohar district had shown theliteracy rateof 54 percent compared to 35 percent in 2001. In 2011, children under 0-6 formed 19.61 percent of Sheohar District compared to 20.63 percent of 2001.

Table 1: Some demographic facts of Sheohar district, 2001-11

Description / 2011 / 200122001
Actual Population / 656,246 / 515,961
Male / 346,673 / 273,680
Female / 309,573 / 242,281
Population Growth / 27.19% / 36.16%
Area Sq. Km / 349 / 349
Density/km2 / 1,880 / 1,478
Proportion to Bihar Population / 0.63% / 0.62%
Sex Ratio (Per 1000) / 893 / 885
Child Sex Ratio (0-6 Age) / 929 / 916
Average Literacy / 53.78 / 35.27
Male Literacy / 61.31 / 45.28
Female Literacy / 45.26 / 23.86
Total Child Population (0-6 Age) / 128,698 / 106,442
Male Population (0-6 Age) / 66,728 / 55,551
Female Population (0-6 Age) / 61,970 / 50,891
Child Proportion (0-6 Age) / 19.61% / 20.63%
Boys Proportion (0-6 Age) / 19.25% / 20.30%
Girls Proportion (0-6 Age) / 20.02% / 21.00%
  1. Results

Here we discuss about the status of health infrastructure, facility up gradation under NRHM and availability of Human Resources, Rogi Kalyan Samiti (RKS) and assessment of health and family welfare situation etc. of Sheohar district.

A. Situational Analysis in Sheohar district

  1. Infrastructure
  • It is situated in a separate building at Sheohar town. It is the district sadar hospital. The building is old with somewhat clean. It is 30-bedded hospital. It has the basic facilities needed, such as water supply, power supply etc. It has the standby generator facility. The district sadar hospital has the dilapidated condition of boundary wall. The district sadar hospital is likely to be shifted in newly constructed building soon. There was one FRU in Tariyani but it is Naxal/Mao affected area so it has been closed as such there is no FRU in the Sheohar district.
  • The Piprahi PHC is also functioning from its own old building but it has dilapidated condition of the boundary wall. There would be new construction in the boundary of this PHC. There is the availability of the facilities of labour room, laboratory, OPD room, electric supply. The Piprahi PHC has the facilities of computer for the Data Centre. The cleanliness of OPD room, other room/ward, compound and premises was good.
  • The Singahi HSC is also functioning from its own building without the compound wall. It has a small room for the regular supply and distribution of medicine among the villagers. The supply of water through the hand pump. The cleanliness of HSC was good. It has poor sanitation facility and it needs maintenance properly.
  1. Human Resources
  • The district sadar hospital lacks the full strength of permanent doctors and other specialists. The district sadar hospital has two OBG, two paediatrician, two general surgeons, two other specialists, six SNs, one LT on deputation. The posts of Pharmacist, Radiographer, RMNCHA / Councellors are vacant. None of the LHVs is functioning in the hospital at the time of survey also.
  • The Piprahi PHC has four Medical Officers, four ANMs, one LT and one P.M.W. The posts of SNs/GNMs, Pharmacist LHV/PHN are vacant. The Singahi HSC has only one ANM functioning.
  1. Other health System inputs
  • In the district sadar hospital none of the medical personnel trained for the Emergency Obstetric Care (EmOC) and on the Basic Emergency Obstetric and newborn Care (BeMOC). Two of the staff nurses have been trained in the Navjaat Shishu Suraksha Karykram (NSSK). Four of the staff nurses have received training of SBA. The training on NSV and MTP/MVA was nil. The training on Mini-Lap sterilization, Laproscopy-sterilisation was also nil among the staff of the district sadar hospital. Thirteen ANMs received training on IUCD and seven ANMs received training on the PPIUCD. There is no blood storage facility in hospital. In Piprahi PHC, none of the staff trained on BeMOC. None of the staff is trained on NSV in this PHC. In Piprahi PHC, staff has received training on SBA, IMNCI, IUD and RTI/STI. In Singahi HSC, the ANM was trained on the IMNCI in Sheohar during 3-10 Feb. 2013.
  • In the district sadar hospital, except the functional foetal Doppler/CTG and functional mobile light, functional ILR and Deep Freezer, all the equipments like BP instruments, MVA/EVA equipment etc. is reported to be available and functional. Barring O.T Tables, and functional O.T lights, ceiling, other items like; functional anesthesia machine, mobile ventilators, functional C-arm units etc. are reported to be not available in the district sadar hospital. In Piprahi PHC, most of the essential equipments are reported to be functional except of the laboratory equipments like functional centrifuge. In Singahi HSC, only BP instrument and stethoscope, adult weighing machine and needle & hub cutter was reported to be available and physically verified also.
  • Most of the essentials drugs are reported to be available except the computerized inventory management in the district sadar hospital. The Piprahi PHC, it was reported about the availability of the essential drugs except the supplies of ORS packets, Zinc tablets and sanitary napkins. The Singahi HSC reported about the non supplies of Magnesium Sulphate injection, Oxytocin injection and Misoprostol tablets.
  1. Maternal health
  • The total deliveries conducted in the district sadar hospital were 23493 and 17469 in the 1st and 2nd quarters respectively. The number of C-section deliveries conducted in the district sadar hospital was nil in the 1st and 2nd quarters respectively. There was no maternal death reported in the district sadar hospital for review.
  • In Piprahi PHC, the number of ANC1 registration was 1030 in the first quarter and 715 in the second quarter. The ANC3 registration was reported to be 564 and 348 in the first and second quarters respectively. The total deliveries conducted in the PHC were 605 and 538 in the 1st and 2nd quarters respectively. There was no maternal death reported in the 1st and 2nd quarters in the PHC for review. There were 9 and 11 still births in the 1st and 2nd quarters respectively in the PHC. The JSY payment is being given to mother through the bearer cheques before discharge from the hospital.
  • In Singahi HSC, the number of ANC1 registration was 18 in the first quarter and 20 in the second quarter. The number of deliveries conducted at home by the ANM of HSC was nil in the 1st and 2nd quarters respectively. There are many non-SBA deliveries in HSC areas. There was no maternal death in the 1st and 2nd quarters in the HSC for review. There was no still births reported in the in the HSC.

5.Child health

  • As reported, there are no functional newborn stabilizhation unit and the functional Sick Newborn Care Unit (SNCU) in the district sadar hospital. The number of children fully immunized was 29 and 23 in the first and second quarters in the district sadar hospital.
  • There is no functional new born stabilization unit in the Piprahi PHC. The number of children fully immunized was 853 and 584 in the first and second quarters in the PHC. The number of children given ORS with Zinc was 1098 and 1183 in the first and second quarters in the PHC.
  • The number of children fully immunized in the 1st and 2nd quarters was 10 and 12 in the Singahi HSC. In the Singahi HSC, there was the availability of Vitamin A syrup, ORS packets and Zinc syrup.
  1. Family Planning
  • In the district sadar hospital, there are supplies of OCPs and IUCDs and the EC pills. The number of IUCD insertions was reported to be 99 and 103 in the 1st and 2nd quarters respectively in the district sadar hospital. The number of tubectomy cases was reported to be 21 and 24 in the 1st and 2nd quarters respectively in the district sadar hospital. The number of vasectomy cases was reported to be nil in the 1st and 2nd quarters in the district sadar hospital. There was no any case of Minilap in the district sadar hospital.
  • In the Piprahi FRU, there are supplies of EC pills, OCPs and IUCDs. No IUCDs cases reported in the Piprahi FRU. The number of tubectomy cases was reported to be 262 and 267 in the 1st and 2nd quarters in the FRU. The number of vasectomy cases was reported to be nil in the 1st and 2nd quarters in the FRU. The number of Minilap cases was reported to be nil in the 1st and 2nd quarters in the FRU.
  • In the Piprahi PHC, there are supplies of EC pills, OCPs and IUCDs. The number of IUCD insertions was reported to be 245 and 112 in the 1st and 2nd quarters respectively in the PHC. The number of Minilap cases was reported to be 48 and 109 in the 1st and 2nd quarters respectively in the PHC.
  • In Singahi HSC, there was the supply of EC pills, OCPs and IUCDs. In Singahi HSC, the number of IUCD insertions was reported to be nil in the 1st and 2nd quarters.
  1. ARSH
  • The Adolescent Reproductive & Sexual Health (ARSH) is one of the important activities under the NRHM. As we know the age of 15-19 years is very vulnerable age group deserving of special attention and support. The access of the information on Adolescent Reproductive & Sexual Health (ARSH) through services at Sheohar district sadar hospital and Piprahi PHC is available with the limited scope. There is no separate room for the ARSH activities. At Singahi HSC, the access of it is almost negligible.
  1. Quality in health services
  • The Sheohar district sadar hospital and Piprahi PHC have reported about a few facilities of infection control program. Most of the patients of such referred to the Sri Krishna Medical College and Hospital at Muzaffarpur.
  • It was found that there is no display of all the services (Citizen's charter) at the Piprahi PHC. It is needed to display all of the services (Citizen's charter) provided by the health facilities as well as display of it in the prominent places of the villages. It is very important to assess the impact of IEC/BCC activities, resources and methods to undertake mid corrective measures.
  • As reported, there is no provision of services of hospital waste treatment and disposal of Bio-Medical Waste Management in all health facility up to HSC level. They used to burn most of the disposable items in the open space or buried in the pit. The district sadar hospital and the PHC have sanitation facility but needs maintenance properly. Furthermore, almost all the health facilities are lacking in proper disposal of waste. The health Centres used to burn the waste material in the open space and buried some of the waste outside the campus of the health Centres.
  1. Referral transport and MMUs
  • There is the availability of the ambulance at the district sadar hospital. As per the discussion with the officials of the hospital they require more number of the ambulances to carry more and more patients from the remote areas of the district. The Piprahi PHC also requires more ambulances to carry more number of patients. The Global positioning system (GPS) in MMUs is not available.
  1. Community processes
  • As reported, the ANMs require refresher training time to time. There is no coordination among health & ICDS workers. There is poor coordination between the MOIC and Mukhiyas also. The ASHAs also needs more motivation and remuneration for the effective work.
  1. Disease control programmes
  • As reported, the district sadar hospital has the facilities of the treatment of Leprosies, Malaria, Kalazar and Tuberculosis (TB). The Piprahi PHC has also the facilities of the same. At the Singahi HSC, the patients are referred to the district sadar hospital. There is the provision of HIV/AIDS test up to the PHC level and patients used to get the treatment at the district sadar hospital.
  1. Non Communicable Disease
  • At the Sheohar district sadar hospital and Piprahi PHC have no major chronic diseases control programme which needs more facilities for the effective treatment of the chronic diseases. The Piprahi PHC has limited facilities of the treatment of chronic diseases and the patients of such are referred from the Singahi HSC also.
  1. Good Practices and Innovations
  • The district sadar hospital refers the patients of serious ailments to the Sri Krishna Medical College Hospital (SKMH) at Muzaffarpur. The district sadar hospital effectively works for the births deliveries, the family planning services and overburden with the OPD and inward patients. Rogi Kalyan Samitis have been established at the PHC level and RKS funds are being utilized at the PHC and HSC levels. The District Health Society is monitoring the progress on the regular basis at the PHC and HSC levels.
  1. HMIS and MCTS
  • The District sadar hospital and Piprahi PHC have the facilities of data entry of HMIS. Most of the ANMs and Data Operators need refresher training on the HMIS. The ANM of the Singahi HSC used to report about the HMIS data to the PHC regularly.
  • The maternal death review is lacking at the PHC level and HSC level also. There is no reporting of the maternal deaths. There is no micro birth planning for the anemic pregnant women at the district level. There are no SMS alerts to the beneficiaries under the MCTS.

B. Key Conclusions and Recommendations