Study No. 129

REPORT ON QUALITY MONITORING OF IMPORTANT COMPONENTS OF PROGRAMME IMPLEMENTATION PLAN (PIP) 2012-13

IN MAHABUBNAGAR DISTRICT OF ANDHRA PRADESH

K.V.R.Subrahmanyam

M.Sudhakar Babu

Population Research Centre,

AndhraUniversity,

Visakhapatnam-530 003.

July, 2013

Executive Summary

The Ministry of Health and Family Welfare, Government of India, New Delhi has entrusted the Population Research Centres (PRCs) in India to carryout quality monitoring of important components of Programme Implementation Plans (PIPs) in their respective States. The Population Research Centre, Visakhapatnamcarried out monitoring in four districts of Andhra Pradesh and submitted reports to Government of India for first and second quarters of the year 2012-13. Since, the monitoring of PIP could not be carried out for the third and fourth quarters, it is suggested by the ministry that PRCs should take up the task for the whole year (2012-13) in one or two districts in consultation with the respective state governments. Accordingly, the PRC, Visakhapatnam has carried out the monitoring of the PIP in Mahabubnagar district of Andhra Pradesh in consultation with the Mission Director, NRHM and Commissioner, Health & Family Welfare, Govt. of Andhra Pradesh. It may be noted that Mahabubnagar is one of the six high focused districts in Andhra Pradesh.

As reported by the Chief Administrative Officer, NRHM the District RoP of PIP was sent during last week of July, 2012 and the budget allocated for Mahabubnagar district isRs.6,608.77 lakhs.

During the discussion with the Mission Director (NRHM-AP) at Hyderabad it has been emerged that while the monitoring of JSSK, JSY and ASHA programmes at the district level is important, the role of Senior Public Health Officers (SPHOs) at the Community Health & Nutrition Clusters (CHNCs) is also to be examined in implementation of the important NRHM objectives.

On the suggestion of the Mission Director (NRHM-AP), the PRC team met the District Collector of Mahabubnagar district and appraised him about the PIP Monitoring in the district. While appreciating these efforts, he suggestedthe team to visitthe remote PHCsforfield study.Specifically, he suggested the PHCs under CHNCs of Atchampet, Narayanpet and Gadwal.

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Mahabubnagar distict has a population of 40,42,191 as per the 2011 Census. The overall sex ratio of the district is 975 while the child sex ratio is 932. The percentage urban of the district is 10.57. It is a vast district with 64 sub-district units (Mandals). The district has 84 functional PHCs of which 62 are round the clock PHCs. There are 675 Sub-Centres in the district.

The implementation of the JSSK is in 74 out of the 84 functional PHCs. As per the proceedings of the Commissioner, Family Welfare, Government of Andhra Pradesh and District Collector and Chairman of District Health and Family Welfare Society, Mahabubnagar district the entitlements for a normal delivery under JSSK will be of Rs.896/- and those for C-section delivery is Rs.5,446/-. Entitlements for the new born is Rs.500/-.

There are 62 round the clock PHCs (24X7 PHCs) and in all these PHCs, deliveries are taking place. However, the information regarding deliveries for the year 2012-13 reveals that only at 7 of these PHCs, 15 or more deliveries take place and in 33 PHCs, 5 or less deliveries are taking place per month.

The DM & HO and DPMO expressed difficulty in implementing the diet part of the JSSK saying that since the deliveries per day are only one or two at PHCs, no body is coming forward to supply diet.

The field visits with regard to JSSK reveal that the diet for the delivered women is not being provided at any of the facilities visited. The PHC records wherever available reflected expenditure towards all the JSSK entitlements ranging from Rs.708/- to Rs.1,008/- per beneficiary. The women interviewed on the field have not reported receipt of any of these entitlements.The average duration of stay at the PHC after delivery is between 4 – 6 hours.

No review meetings on JSSK are held so far with SPHOs/MOs at district level. So far monthly reports of JSSK transportation by 108 ambulances have not been submitted to the state. Monthly/quarterly progress reports on JSSK have not so

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far been submitted to the state by the districts. Monitoring of JSSK by the districts has not so far been taken-up. The district has not so far opened Grievance Redressal Cell for recording the JSSK related grievances from the public.

The payments under JSY scheme are being made through cheques in the district. The beneficiaries received the payments within a week to one month after delivery. However, there are some instances where the payments are delayed upto 6 months.

Most of the ASHAs in the district received induction training as well as training in module 6 and 7. The average incentive received by the ASHAs ranged between Rs.600/- to Rs.800/-. Although many of the ASHAs confirmed update receipt of incentive, a few instances of delayed payments is noticed.

The maternal death reporting has improved in the district as revealed by the information given by the district officials. Sixty-six maternal deaths have been reported in 2012-13 while only 36 are recorded during 2011-12. The maternal death review is being done by the District Collector and the District Medical and Health Officer is instructed to carry out the review regularly.

There is disparity between information provided by the DPMU at the district with respect to human resources and the actual position at the facilities at the time of visit. It is noticed particularly with respect to the position of staff nurses.

The Senior Public Health Officers (SPHOs) at the cluster level need to be sensitized on redeployment of health staff depending on the performance at facilities under their jurisdiction. There is conspicuouslack of supervision on their part in issues relating to attendance, record maintenance and performance. Their active supervision helps in lot of improvement in uploading of MCTS and HMIS data.

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QUALITY MONITORING OF IMPORTANT COMPONENTS OF

PROGRAMME IMPLEMENTATION PLAN (PIP) 2012-13

IN MAHABUBNAGAR DISTRICT OF ANDHRA PRADESH

I. INTRODUCTION:

The Ministry of Health and Family Welfare, Government of India, New Delhi has entrusted the Population Research Centres (PRCs) in India to carryout quality monitoringof important components of Programme Implementation Plans (PIPs) in their respective States. It has been decided that each PRC would submit a qualitative report every quarterto the Ministry based on the information gathered from the State and through visits to districts and facilities. As such the PRC, Visakhapatnam is engaged in carrying out the quality monitoring of PIP of Andhra Pradesh and carried out the monitoring in four diatricts of Andhra Pradesh viz. Srikakulam and Nellore for the first quarter of 2012-13 and Vizianagaram and Anantapur for the second quarter of 2012-13. Since, the monitoring of PIP could not be carried out for the third and fourth quarters, it is suggested by the ministry that PRCs should take up the task for the whole year (2012-13) in one or two districts in consultation with the respective state governments.

Accordingly, the PRC, Visakhapatnam has carried out the monitoring of the PIP in Mahabubnagar district of Andhra Pradesh in consultation with the Mission Director, NRHM and Commissioner, Health & Family Welfare, Govt. of Andhra Pradesh. It may be noted that Mahabubnagar is one of the six high focused districts in Andhra Pradesh.

It is proposed to visit the State headquarters first for having a discussion on the PIP with the State Officials. As such, the PRC team met the Commissioner of Health and Family Welfare (CHFW) of Andhra Pradesh and also the Mission Director (NRHM-AP). They were apprised about the quality monitoring of certain key items of PIP of Andhra Pradesh.

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The inputs obtained from the State pertaining to the actions initiated/planned for implementation of PIP during the first and second quarters(2012-13) have already been reported on the following key items (in our First and second quarter reports):

  1. Mandatory disclosures.
  2. Key conditionalities.
  3. Incentives.
  4. Road map for priority action with regard to some of the key strategic areas outlined in RoP.

Such information could not be obtained for the third and fourth quarters as the State level Nodal Officer is new and was of little help in this regard.

However, during the discussion with the Mission Director (NRHM-AP), it has been emerged that while the monitoring of JSSK, JSY and ASHA programmes at the district level is important, the role of Senior Public Health Officers (SPHOs) at the Community Health & Nutrition Clusters (CHNCs) is also to be examined in implementation of the important NRHM objectives.

II. FINDINGS OF MONITORING IN MAHABUBNAGAR DISTRICT:

On the suggestion of the Mission Director (NRHM-AP), the PRC team met the District Collector of Mahabubnagar district and appraised him about the PIP Monitoring in the district. While appreciating these efforts, he suggestedthe team to visitthe remote PHCsforfield study.Specifically, he suggested the PHCs under CHNCs of Atchampet, Narayanpet and Gadwal.

The information at the District level is gathered on the important components of the PIP particularly with respect to Maternal Health viz. JSSK, JSY, ASHA services, Line Listing of severe anemic pregnant women and low birth weight babies, MDR from the District Programme Management Unit (DPMU). To study

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the implementation of these programmes at field level three 24X7 Primary Health Centres (PHCs) were selected, keeping in mind the suggestion of the District Collector and considering the number of deliveries at the PHCsand implementation of Janani Sishu Suraksha Karyakram (JSSK). Further, from each PHC two Sub-Centres – one with highest number of deliveries and the other which is farthest from PHC headquarters were selected. All the available women who delivered at the selected PHCs during 2012-13 from the villages of selected Sub-Centres and available ASHAs were interviewed for their feedback on thebenefits to be provided to them.The PRC team visited the district headquarters and the selected facilities during 17 – 21 July, 2013.

The major findingsof the monitoring process are presented in two parts. Part -A presents the District Level information and Part-B deals with the Field Level findings.

Part – A:District Level

Profile of the District

A brief profile of the Mahabubnagar district is presented below.

Sl.
No. / Indicator / Number/
Percentage / Source
1 / Total population / 4042191 / 2011 Census
2 / Males / 2046247 / 2011 Census
3 / Females / 1995944 / 2011 Census
4 / Density / 219 / 2011 Census
5 / Sex Ratio / 975 / 2011 Census
6 / Child Sex Ratio / 932 / 2011 Census
7 / Percent Urban Population / 10.57 / 2011 Census
8 / No. of Mandals (Sub-District Units) / 64 / 2011 Census
9 / No. of Villages / 1553 / 2011 Census
10 / Number of PHCs (24x7) / 62 / DPMU-Mahabubnagar
11 / Number of PHCs (regular) / 23* / DPMU-Mahabubnagar
12 / Number of Sub-Centres / 675 / DPMU-Mahabubnagar
13 / MPHA (F) In Position / 625 / DPMU-Mahabubnagar
14 / 2ndANM (under NRHM) In Position / 596 / DPMU-Mahabubnagar
15 / Staff Nurse (under NRHM) In Position / 110 / DPMU-Mahabubnagar
16 / ASHA workers In Position / 3727 / DPMU-Mahabubnagar

* There is no clarity about the functioning of one PHC namely Amrabad.

The district administration is showing a total of 85 PHCs for all purposes.

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As per the information provided by the DPMU the district RoP was received by them through mail on 06-7-2012. It may also be noted that the State Programme Management Unit (SPMU) has displayed district RoPs on NRHMState website. As per the district RoP, approved amount allocated to the district for the year 2012-13 is Rs. 6608.77 lakhs. The DPMU at this district is aware of the new guidelines issued with respect to JSSK.

The major findings of the discussions held at the district are as follows:

  1. Implementation of JSSK:

1.1.As per the information provided by DPMU, the JSSK is being implemented in 74 out of the 85 Primary Health Centres of the district.

1.2.As per the Proceedings of the District Collector and Chairman of District Health & Family Welfare Society, Mahbubnagar (Proc. Rc. No.707/A.3.FW/2011) the following are the entitlements of the Pregnant Woman and New Born.

Pregnant Women:

Normal DeliveryC-Section

  1. DiagnosticRs. 40/-Rs.40/-
  2. DrugsRs.300/-Rs.1600/-
  3. Blood Transfusion -- Rs. 800/-
  4. DietRs. 56/-per day for 3 daysRs.56/-per day for 7 days
  5. Referral/transportRs. 500/-*Rs.750/-
  6. Obstetrician Charges --Rs.1200/-
  7. Anesthetist Charges --Rs.1000/- per unit

*Prefer 108 (or) as per local rates

New born Care: Rs.300/- & Pediatrician Charges: Rs.200/-

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As per the above proceedings, the entitlements for a normal delivery under JSSK will be of Rs.896/- and those for C-section delivery is Rs.5,446/-. Entitlements for the new born is Rs.500/-.

1.3.The DM & HO and DPMO expressed difficulty in implementing the diet part of the JSSK saying thatsince the deliveries per day are only one or two at PHCs, no body is coming forward to supply diet.

1.4.No review meetings on JSSK are held so far with SPHOs/MOs at district level.

1.5.So far monthly reports of JSSK transportation by 108 ambulances have not been submitted to the state. Monthly/quarterly progress reports on JSSK have not so far been submitted to the state by the districts.

1.6.Monitoring of JSSK by the districts has not so far been taken-up.

1.7.The district has not so far opened Grievance Redressal Cell for recording the JSSK related grievances from the public.

  1. Deliveries at PHCs:

2.1.As per the information provided by the DPMU there are 62round the clock (24X7) PHCs and in all these PHCs, deliveries are taking place. However, the information regarding deliveries for the year 2012-13 reveals that only at 7 of these PHCs, 15 or more deliveries take place and in 33 PHCs, 5 or less deliveries are taking place per month.

2.2.There are 23 regular (non-24X7) PHCs. In 8 of these PHCs, not even a single delivery took place during 2012-13. In another 3 PHCs, less than 5 deliveries took place while in only 2 PHCs, 5 – 10 deliveries took place per month.

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  1. Janani Suraksha Yojana (JSY):

3.1.The payments for all the JSY beneficiaries are being made through cheques.

3.2.As per the list of beneficiaries under JSY provided by the DPMU, the total JSY beneficiaries for the year 2012-13are8920.

  1. ASHAs:

4.1As per the District Abstract of Human Resources provided by the DPMU, there is a sanction for 4543 ASHAs in the district against which 3727 ASHAs are in position.

4.2Medicine kits were given to ASHAs at the time of appointment and they are not in use at present.

4.3As per the details provided by the DPMU, in 12 out of the 85 PHC areas, payments of ASHAs were pending from one to six months. Also, there are some pending cases in urban areas.

  1. Second ANMs:

5.1.In the 675 Sub-Centres, there are 674 sanctioned Second ANM positions against which 596 arein position.

5.2.For all the Second ANMs, area and population are ear marked by dividing each Sub-Centre area and population between the regular and second ANMs.

5.3.The immunization sessions are being conducted jointly by the two ANMs although the other services were being given independently.

5.4.The untied fund of the Sub-Centre continues to be with the regular ANM.

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  1. Line Listing of Severe Anemic Pregnant Women:

6.1.As per the information provided by the DPMU Line Listing of Severe Anemic Pregnant Women has not been done.

6.2.Apparently the district administration is not aware of carrying out the Line Listing of Severe Anemic Pregnant Women.

6.3.However, the number of severe anemic women by each cluster (CHNC) is given by the DPMU from MCTS portal. It is quite disturbing to note that only 55 mothers in the district were recorded to be severely anemic as the district is known for high levels of anemia among pregnant women.

  1. Line Listing of Low Birth Weight Babies:

7.1.As per the information provided by the DPMU Line Listing of Low Birth Weight Babies has not been done.

7.2.Apparently the district administration is not aware of carrying out the Line Listing of Low Birth Weight Babies.

7.3.However, the number of low birth weight babies by each cluster (CHNC) is given by the DPMU from MCTS portal which showed only 881 babies in the district to be of low birth weight. This figure is 3,293 as per HMIS portal.

  1. Maternal Death Reporting and Review:

8.1.Training with respect to Maternal Death Reporting is given to the Senior Public Health Officers (SPHOs) of different Clusters (CHNCs).

8.2.However, the training at the PHC level in the clusters has not been carried out.

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8.3.According to DPMO the ASHAs and MPHSs(Female) who are the Nodal Officers of the ASHAs were sensitized to gather information on Maternal Deaths and report back.

8.4.As per the information obtained from the DPMU, the number of maternal deaths recorded during 2012-13 is 66 as against 36 recorded for the year 2011-12. This indicates that there is an obvious improvement in the reporting of maternal deaths.

8.5.The causes recorded for maternal deaths are mainly PPH (18), anemia (4), PIH (4) and HTN (4).

8.6.However, as per the information provided by the DPMU, one maternal death review meeting was held in Dec 2012 under the chairmanship of the District Collector. Where in, three maternal deaths were reviewed. During the course of our discussion with the District Collector, he told that a gynecologist is invited to the review meetings in order to sensitizethe medical officer and other doctors about the treatment procedures and precautions in dealing with pregnancy complications. Further, he added that a series of instructions were issued to the DM&HO to review all maternal deaths with the SPHOs and Doctors in sub-district level committee meetings every month regularly and thoroughly.