NRHM-PIP Monitoring for Gadag District, Karnataka
K S James
T N Bhat
Population Resarch Centre
Institute for Social and Economic Change
Bangalore-560072
October, 2013
NRHM-PIP Monitoring for Gadag District, Karnataka
October, 2013
Executive Summary
The PIP monitoring was undertaken in Gadag district in September 2013. The district hospital of Gadag, sub-district hospital of Ron, Laxmeshwar CHC of Shirahatti taluk, Dambabal PHC and Dambal B-SC of Mundargi taluk were visited as part of the monitoring. In addition, discussions were held with DHO, District Programme Officials, District Surgeon and other officials at the district head quarters. The major findings are emanated from the study are as follows.
Gadag district constituting 1.74 percent of the total population of Karnataka has a lower population growth than the state average. In the case of social indicators like literacy rate the district is on par with the state average. The male literacy level is 84.66 per cent and the female literacy level is 65.44 percent in 2011. However, many economic indicators fall short of state average. Agricultural labourers constitute 40.41 percent of the workforce, significantly higher proportion than the average of 25.67 percent for Karnataka.The fertility and infant mortality in Gadag was marginally higher than the state average indicating that the district is less developed in terms of demographic indicators as compared to Karnataka as a whole. The total fertility rate in the Gadag district is 2.3 as against the state average of 1.9 children per women in 2011. The mortality information available from earlier census (2001) also shows Gadag below the state average in terms of infant and child mortality rate. Comparable data for the recent times are not available.
On record, the district appears to be adequately developed in terms of creation of health facilities and patient bed population ratio, as the average population served by the PHCs, SCs and FRUs and expansion of inpatient beds in the district are not only below the national population norms prescribed for provision of primary health care but also lower than average population covered by the facilities in the country. Regarding creation of physical infrastructures and facilities such as availability of clinical/surgical instruments, laboratory equipments, supply of essential drugs, contraceptives, medical kits, etc., in the visited facilities, the information gathered suggest that infrastructures and supplies in the facilities appear to be developed satisfactorily. However, stinking toilet, piling up of dusts in the medical wards, laboratories and X-ray rooms, tobacco spitting and piled up garbage within and around the facility complex were common in the visited FRUs. But the situation was better in PHC.
The major problem noticed in the field work was lack of sufficient human resources, particularly the doctors. The visited primary level FRUs,i.e., SDH and CHC are found to be practically non-functional FRUSs as there are no specialist doctors in these facilities. Severe scarcity of doctors is observed for the posts of doctors at nearly 51 percent for general doctors and about 81 percent for specialist doctors vacant. The vacancy among paramedical staff is on average a little less than 30 percent for lab technicians, LHVs and ANMS. As a consequence of non-functioning of FRUs, there has been a severe burden on the District Hospital in terms of patient load. Even the District Hospital has a little over one-fourths vacant positions of doctors particularly for specialists. As a result, the service quality, cleanliness, etc in District Hospital are seriously affected.
ANC services are found to be satisfactorily provided by visits of pregnant mothers to the facilities and through outreach services with help of ASHA and Anganwadi workers as per guidelines. It is reported that, on an average daily about 30-40 percent of the OPD cases in the study facilities are for receiving for ANC services including follow-up check-ups, despite weekly fixed ANC day in the facilities.Some attention is necessary on the management of high risk pregnancy and delivery care. The PHCs and CHCs can only provide care and monitor risks during pregnancy as theydo not have medical facilities to conduct c-section and other complicated or risk deliveries. It is reported that risk pregnancies including high risk cases in the visited facilities on an average are about 15-20 percent. The high risk pregnancy cases, therefore, would be referred to the DH or SDHsfor delivery and their referral would be facilitated by the concerned CHC or PHC with the help of ASHA workers. But as the SDHs inn the district are also not fully equipped to take care of high risk pregnancies, they are shifted to DH. On average about 10-15 percent of the deliveries taking place in the DH are reported to be c-section and other complicated deliveries. The scanning costs incurred in private facilities are not reimbursed to women, which is permissible under JSSK funds; because of approval and accounting problems.
The HMIS data for the district during 2013 January-March quarter suggest that institutional deliveries were almost universal at 99 percent while mothers receiving postnatal check-up within 48 hours and, between 48 hours and 2 weeks of delivery were very high at about 70 percent and 89 percent, respectively. The implementation of JSSK has been quite satisfactory in the district. The food has been provided to the mothers. However, due to larger waiting time and inaccessibility, most often women commute from home to facility by private vehicle. The JSY money was paid to 54 per cent of eligible women during the time of survey. Some instances of denying JSY incentives citing more than two children as the reason was also found during the field visit which were brought to the notice of the authorities.The SNCU is reported to be functioning smoothly as per guidelines. The Immunisations of children regularly take place in the PHCs and SCs. The percentage of children immunised are nearly complete according to the data available from the facilities. Family Planning services are also given at various levels and one death due to sterilisation was reported in this year 2013-14. It is reported that FP services are easily accessible and satisfactorily available in the district. At the same progress of IEC activities on the program is found to quite satisfactory.ASHAs found to be playing a critical role and their retention rate is also satisfactory. In the recentpast, there has not been many drop outs of ASHA workers in the district. Gadag has district now coordinated mechanized biomedical waste management unit initiated recently in 2013. The biomedical wastes collected in the facilities are lifted through specially designed carrier vehicles to the district within 48 hours. It is an outsourced system by segregation of biomedical wastes within the facilities. The staff is trained on segregation of biomedical wastes and the system is working smoothly. The HMIS data system is working well. The MCTS is not yet complete as many times the ANM does not enter the details through the mobile.
NRHM-PIP Monitoring for Gadag District, Karnataka
October, 2013
1Introduction
Themonitoring of NRHM-PIP was undertaken in September 2013 in the district of Gadag, Karnataka as part of monthly monitoring. The district hospital (DH) of Gadag, sub-district hospitals(SDH) of Ron and Laxmeshwara, Shirahatti taluk CHC, Dambal PHC and Dambal B-SC of Mundargi taluk were selected for the field visit. The fieldwork for the appraisal was conducted during 3rd week of September. The field team consisted of Prof. K S James and Dr. T N Bhat of PRC-Bangalore. The appraisal provides a review of key population and demographic indicators, health infrastructure facilities, human resources and other inputs. The appraisal also provides insights on MCH service delivery including JSSK and JSY schemes, FP and ARSH services, functioning of bio-medical management, referral transport and ASHA scheme, communicable and non-communicable service delivery, HMIS and MCTS. The study is based on qualitative approach through discussions with district health officials, MOs and other health staff of the visited facilities and finally through exit interview of beneficiaries. The available quantitative data from the respective facilities are also used for the assessment. The DPMO and other district supervisory staff have accompanied the field team during the visit.
2State Profile and district profile
Karnataka located in the southern part of India has a population of about 61 millions in 2011 and retains the 9th rank as in terms of population size among the Indian states. The decadal population growth rate of the state during 2001-11 is about 15.6 percent which is nearly four percentage points lower than the national average. The population growth recorded a decline of 1.91 percentage point in ten years in comparison to 17.5 percent registered during 2001. However, the density of population in the state (321 per sq. Km) is below the national average.Around 39 percent of the state population is living in urban areas; which is considerably higher than the national average. The state has witnessed an increase of 4.68 in the proportion of urban population in the last decade. The urban population of the state steadily is increasing due to its rapid efforts towards development and progress. The sex ratio (females per 1000 males) is 973 recording a marginal increase in comparison to the previous decade and is about 20 points higher than the national average. The child sex ratio also recorded a marginal increase from 946 in 2001 to 948 in 2011. As witnessed during the previous decades, the overall literacy (effective) level of the state has increased from 66.44 percent in 2001 to 75.36 in 2011 with male literacy rate of 82.5 percent against female literacy rate of 68.1 percent. The female literacy level is nearly 15 percentage points lower than among males in 2011. Around 17 per cent of the state’s population comprises of Scheduled Castes and about 7 percent of Scheduled Tribes. Agricultural labourers constitute about 26 percent of the total workforce in the state; about 40 percent among females workers and 18 percent among male workers.
Table 1: Key Population and Socio-economic Indicators of Karnataka and Gadag District.
Indicator / Karnataka / Gadag DistrictNo. of Districts 2011 / 30
No. of Blocks (Tahasils) 2011 / 176 / 5
No. of Villages 2011 / 29340 / 322
Population 2011 / 6,10,95,297 / 10,64,570
Population Growth Rate 2001-11 / 15.67 / 9.61
Population Share to the Total / 5.05 / 1.74
Density of Population per Sq. Km 2011 / 319 / 229
Percent Urban Population 2011 / 38.67 / 35.63
Sex Ratio 2011 (Females per 1000 Males) / 973 / 982
Percent Literacy 2011: Total
: Males
: Females / 75.36
82.47
68.08 / 75.16
84.66
65.44
Percent Literacy 2011 : Males
: Females
: Total / 82.47
68.08
75.36 / 84.66
65.44
75.16
Percentage of SC Population 2011
Percentage of ST Population 2011 / 17.15
6.95 / 16.36
5.79
Workforce participation Percent 2011: Total
: Males
: Females / 45.62
59.00
31.87 / 46.57
57.79
35.13
Percent Workers as Agr Laborers 2011 : Total
: Males
: Females / 25.67
17.97
40.33 / 40.41
28.32
60.65
The district of Gadag is located in the middle part of ‘Northern Karnataka’belongs to the erstwhile ‘Mumbai Karnataka’ region. It has nearly 1.74 percent of the total population of Karnataka. The district has achieved considerable decline of population growth in the last decade with population growth rate of 9.54 percent during 2001-11, which is significantly lower than the state average. The overall sex ratio of the district is 982 higher than the state average, and the child sex ratio of 947 which is somewhat close to the state average. The literacy level in the district is 75.16 which is close to the state average. The male literacy level is 84.66 per cent and the female literacy level is 65.44 percent in 2011.Around 16 percent of the population in the district belongs to the Scheduled Casteswhile 6 percent to the Scheduled Tribes.Density of population in the district is lower than in the state at 229 persons per sq. km against the state average of 329 per sq. km. The level of urbanization in the district is below the state level as proportion of population living in urban areas of the district is about 36 percent against 39 percent the state average according 2011 Census. The female work participation in the district is 35 percent which is higher than the state average of 32 percent. Agricultural labourers constitute 40.41 percent of the workforce, significantly a higher proportion than the average of 25.67 percent for Karnataka.Agricultural labourers among males and females in the district are about 28 and 61 percent. The district is, thus, developed somewhat on par with the state in terms of social indicators while poorly developed with respect to economic indicators in comparison to the state.
3Key health and service delivery indicators
The total fertility rate has come down below replacement level in the state and stands at 1.9 children per women in 2011. Thus, in the demographic front, Karnataka is much above the national average. The total fertility rate in Gadag district estimated from the census 2011 is 2.3 children per women slightly higher than state average. The infant mortality rate (IMR) in the state according to the Sample Registration System is 35 in 2011 and maternal mortality ratio is 178 per 100,000 births in 2007-09. Both these rates are much lower than the national average of 48 and 212 respective for IMR and MMR. The IMR has registered significant decline in the state during the last six years of NRHM period. It has declined from 50 in 2005 to 35 in 2011. However, the level of infant mortality rate still relatively high compared to the neighboring states like Kerala and Tamil Nadu.
The most of the infant deaths in the state is concentrated in the neonatal stages. The neonatal mortality rate in Karnataka is around 24 and early neonatal deaths is around 20 per 1000 live births. It indicates that most of the children are dying soon after the delivery which can be addressed only by providing better hospital care.
The mortality information for the district comes from HMIS data and as such are not strictly comparable with the SRS figures of the state. The IMR and the MMR of the district estimated from HMIS is significantly lower than the SRS estimate for the state. However, the census estimate of IMR based on 2001 census was higher for Gadag than the state. The 2011 IMR for Gadag was 64 as against the state average of 54.
Table 2: Key Demographic Indicators of Karnataka and Gadag District.
Indicator / Karnataka / Gadag DistrictEstimated TFR / 1.9 (SRS (2011) / 2.3 (Census 2011)
Estimated CBR: / 13.79 (HMIS 2010-11) / 16.17 (HMIS 2010-11)
Estimated Birth Rate / 18.8 (SRS 2011) / 18.8 (Census 2011)
Estimated Death Rate / 7.1 (SRS 2011) / -
Estimated IMR / 35 (SRS 2011) / 18 (District HMIS 2013)
MMR / 178 (SRS 2007-09) / 132(District HMIS 2013)
Percent Child Population 0-6: Boys (Census 2011) : Girls
: Total / 11.87
11.57
11.72 / 12.67
12.21
12.44
4Health Infrastructure:
The primary healthcare services in the Gadag district is presently rendered through 37 PHCs of which 24 PHCs are 24X7 PHCs, 174 SCs and 7 FRUs that includes a DH, 4 SDHs (taluk level) and 2 CHCS. In terms of population served by the facilities, on an average there is a PHC and a SC established for every 18,500 and 3900 rural population respectively and a FRU for every 1,50,000 population in the district.Average number of beds available per 10,000 population in the PHCs is about 3, while in the case of FRUs it is nearly 130 beds per 1 lakh population with overall beds per 1 lakh population being 150 in the district.The average population served by the PHCs, SCs and FRUs and provision of inpatient beds in Gadag are better than the prescribed norms suggesting that health facilities are extensively developed in the district. Evidently, the population served and beds provided in the visited facilities are found to be well below national population norms and average. The district, thus, appears to be adequately developed in terms of creation of institutional infrastructures and patient bed population ratio.
As regards building infrastructure in the visited facilities, Dambal PHC is recently renovated recently at cost of about Rs. 20 lakhs. The Ron sub-district hospital is also constructing a new building on the first floor of the existing building with additional inpatient wards, and, the district hospital has newly a constructed building located on the outskirts of Gadag town by up-gradation of facilities with 600 inpatient beds in addition to the old 300 bedded district hospital converted as uni-purpose district maternity and child hospital. The new general district hospital has become operational since April 2013. It is said that a Government Medical College is being established within the new district hospital campus next year.
Although, the physical and medical infrastructure is adequately created in the district, the provision of services is hampered by the non-functioning of many facilities due to shortage of doctors, staff nurses and ANMs. The health facilities have been expanded rapidly in the district but there is severe scarcity of human resources. Of course, the situation is observed to be much similar in other of parts of Karnataka as well, i.e., health institutions have been expanded disproportionate to human resources availability. Evidently, functions and service delivery wise Ron sub-district hospital and CHC are found to be to be practically non-functional FRUs because of vacant positions of regular MOs and specialist doctors. In fact, Ron sub-district is functioning without even single regular MO or specialist doctor in position. It is found during the field visit that the OPD and IPD services in Ron sub-district hospital are handled by the AUSH doctors and staff nurses (mostly working under NRHM), and hospital administration is handled by an In-charge MO on part time basis deputed from a PHC. The maternal health and gynecological related cases in the Ron sub-district hospital are attended by a lady Obstetrician appointed under NRHM recently. The situation is somewhat similar in the Laxmeshwara CHC where only one regular doctor is rendering the services assisted by an AYSH doctor and staff nurses, and hospital administration is handled by an in-charge MO deputed from a PHC. Obviously, the effective functional load of primary level FRUs, i.e., the sub-district hospitals and CHCs is actually transferred to the district hospital where the services are in great demand specifically with respect to complicated maternal care services, treatment of non-communicable diseases and casualty cases. This was evident from the overcrowded OPD and IPD wards in the district hospital, particularly in the maternity and child health hospital during the field visit. The bed occupancy rate is very high in the district hospital, particularly, in the maternity and child health wards. The demand for services is found to be quite high in the visited facilities particularly the Ron sub-district hospital and Lakshmehwara CHC.