Quality Monitoring of NRHM State Programme Implementation
Plans in District Mandi of Himachal Pradesh
Prof. N. S. Bist
Dr. Yashwant Hartta
Santosh Kumar Limone
Population Research Centre
H. P. University, Summer-Hill
Shimla- 171 005
January, 2014
PIP Monitoring of Mandi District
Executive Summary
Mandi district is situated between “31o – 131 – 50” and 320 – 04 -30” north latitude and 760 - 37’ – 20” and 700 -2’ – 15” east longitude. It is bounded by Kangra on North West, Hamirpur and Bilaspur in the west, district Arki tehsil of Solan district in the South, Shimla on the South West and Kullu District in the East. According to the census 2011, the population of the district was 999578 and projection of population according to the household survey for the year 2013-14 is 1060696. The district has 10 development block and Health Block. Eight block are co-terminus with the development block, but 2 block named Ratti (Sadar) and Kotli (Rewalsar) are overlapping each other. The total number of village in Mandi district are 3338, total number of households 219994, literacy rate 82.81 per cent, sex ratio 1012 and sex ratio (0-6 years) 913 and density of population 253.
Health Infrastructure
One Zonal Hospital (DH), 5 CH, 12 CHC, 62 PHC, and 311 sub-centre are providing the health services in the district. The 243 sub-centres, 52 PHC, 12 CHC, and one Zonal Hospital are running in the government building, out of which 242 sub-centres, 32 PHC, 5 CHC, 5 CH and one Zonal Hospital are as per the IPHS norm. The 8 FRU i.e. Sarkaghat, Padhar, Karsog, Bagsiad, Baldwara, Zonal Hospital Mandi, Joginder Nagar and Sunder Nagar are designated FRU. But out of 8, only zonal hospitals are providing the FRU services and remaining others are not providing the services of FRU. Survey team visited CHC Padhar which as been upgraded as FRU. Only the signboards have been put without having any facility of FRU. The building of CHC is going to be constructed soon, money has been sanctioned and place has been marked. ESI medical college is going to be started from this session by utilizing the infrastructure of Zonal Hospital Mandi. In the district health facility are as per the requirement, but many of them not fulfill the norms of IPHS.
Human Resources
Some of the health are facilities not providing the services due to shortage of human resources. Fifty four medical officers, 7 Medical Officer (Dental) post are vacant. In the category of Para-medical staff 2 post of Chief lab-Technician, 29 Sr. Lab-Technician, 18 Pharmacist, 4 OTA, 6 Radiographer and one ECG Technician are vacant. In the category of Public Health staff, 124 post of MHW, MHS, 15 FHW and 16 Leprosy Worker are vacant. Under the category of Nursing, 2 matron, one ward sister and 20 staff nurse post are vacant. It is very essential to fill the post of Medical Officer, Para-medical staff Public health staff and Nursing staff may be on contract basis immediately. So that health facility provides timely services. Most of the laboratories in the district are outsourced.
Maternal Health
The Institutional deliveries were 65 per cent and no maternal death was reported. The Emoc facility are available in the district hospital. There are 14 delivery point which are known as Matri Sewa Kendras (MSK) where the institutional deliveries are conducted. Under the JSSK scheme, upto October,2013 total expenditure on ANC treatment was Rs. 20520, 636 normal deliveries and expenditure on this component was Rs. 380400. Eighty four-C-section were conducted and Rs. 255000 was spent one this. Under transportation, pregnant women were brought home from health institution, 61 IFT and 144 drop back. The pregnancy test kit “Nishchay” is not good many instruments in the packet do not give the test result. During the exist interview, the patients complaint that food given in the hospital during delivery time was not good in quality. Under the JSK, upto October, 2013, 2942 new women were registered and under JSY, 127 mothers were paid incentive for home deliveries. The health workers collect the bank account number of beneficiaries and give it to the block accountant. The block accountant directly transfers the money to the beneficiaries account.
Child Health
Under the Child health care, 4 Sick New Born Care Unit (SNBCU) has been established in Sunder Nagar, Joginder Nagar, Sarkhaghat and Karsog. The 9 New Born Care Centre (NBCC) has been established in Padhar, Ratti, Baladwara, Gohar, Sandole, Bagsaid, Dharampur, Janjehle and Ladbharol. The CHC Padhar was visited by team and it was observed that NBCC was not properly established and not properly equipped due to non-availability of staff and specialist doctor. It is essential for proper working of NBSU and NBCC to fill the post of child specialist and gynecologist. In the district cold chain facility has been available at PHC and CHC level. There was no shortage of vaccine and its deliveries in appropriate time. Under the immunization, programme BCG coverage was 46.71 per cent, OPVO dose 26.92 per cent, Hep-BO dose 22.28 per cent, Measles, D.P.T. 67.95 per cent, TT 10 years 77.93 per cent upto October, 2013 against the target which was planned for this financial year 2013-14. Every health facility has already prepared the microplan that how much immunization session will be planned and held.
Family Planning
At present contraceptive prevalence rate is 80 per cent. There is decrease in the Unmet need for modern family planning methods from 12 per cent to 6 per cent by 2013-14. Increase in the awareness level of emergency contraception has increased to 80 per cent in this year. The PPIUCD (Cu-To 375) has been introduced and all institutional deliveries are motivated to accept the new Cu-T375 at all the delivery point. Each block has their own surgical team trained in NSV and Mini Lap or laparoscopic sterilization method. A day has been fixed for getting the services in all CH/CHC. Due to proper implementation of Family Planning Programmes in the district, total fertility rate declined from 3.8 in 1981 to 3.2 in 1991 and further declined to 2.2 in 2001 and it was 1.9 in 2009. There were complaints regarding the Pregnancy Kit “Nishchaya” that kit is not giving appropriate results. The quality of many kits was very poor.
Adolescents Reproductive and Sexual Health (ARSH)
Under the ARSH, counseling was provided regarding high risk behavior, unsafe sex practice, nutritional advice, and also easy and confidential access to MTP, RTI/STIs detection and treatment. Ratti block was taken as “Adarsh Block” for ARSH activities. This includes one CHC and 4 PHC of Block (Ratti CHC and PHC Katalula, Nagwain, Baggi and Shivabadar selected for ARSH Programme). One Medical Officer, 6 FHW and One staff nurse were trained for ARSH in collaboration with E-MAMTA and Lund University, USA. The “Yuva Swasthya Paramarsh Kendra” (YSPK) has been set up at every CHC level and weekly time is fixed up to PHC level. The ARSH clinics has been established in every facility but their function is not up to the mark due to non availability of staff. Sanitary Napkin Scheme is not working satisfactory due to poor quality of “Sanitary Napkins.” Adolescent girls are not using the Sanitary Napkins due to its poor quality.
Quality of Health Services
The Geneal Cleanliness in the health facility was satisfactory. In district hospital, cleanliness is done by the private firm. The “New Vision” was given the cleanliness contract. The cleanliness condition of CHC Padhar was not satisfactory this was due to no availability of “Safai Karamchari”. The
work of Bio-medical waste has been outsourced. The private firm “Eagle Services” has been given the contract @ Rs. 6.29 per bed per day has to pay to the firm for disposal of bio-medical waste. The firm has established incinerator plant at Kullu district for the disposal of bio-medical waste. Under the IEC activity, the appropriate material has been displayed in the health facility. The material regarding MCH, Family Planning, and list of Essential Drugs has been displayed on Sign Boards. There were 10 wall writing in each block with size 5’x4’ in yellow and block colour. The wall paintings are there where visibility is good, i.e. near PHC, Hospital, School and bus stand where the people gather. In addition the rallies were organized on different days, quiz, folk shows and IPC workshop were also organized. Meetings were organized with PRI, Mahila Mandals, and Self Help Groups.
Clinical Establishment Act
The Clinical Establishment Act 2010 was implemented in 2011. All the government and private health institution will be registered under the Clinical Establishment Act. Till October 2013, 472 applications from government institute and 287 from private institutes have been received. The 323 registration certificates have been issued for Government Institutes. The private institutes registered under the CEA were 287. The Registration fee is between Rs. 500-2500 per institute. The private health institutions are registered initially for one year. The further registration will be given after the inspection of team.
Referral Transport and MMU
In Mandi district,26 health facilities are having “108” Ambulance vehicle. These Ambulance vehicles are providing transportation only for picking up the patients, but not for dropping back the patients in the district. The district hospital on an average received 10 to 15 calls in a day, but at CHC Padhar 2-3 calls were received in a day and PHC Barot on an average received one call per day. The working of call centre of “108” Ambulance was very good. There were no complaints against the call centre. On an average Ambulance 108 covers 30 to 40 kms. distance in per visit. There is no MMU in the district and no health services are provided through MMU.
Community Process
In Mandi district, no ASHA workers were appointed till October, 2013. But the Principal Secretary (Health) vide letter No. 5439 dated 23.10.2013 approved the instruction for the appointment of ASHA worker in the state and also instructed that recruitment process has to be initiated and completed by 15 December 2013. In the district 1222 ASHA worker will be appointed. As per the discussion with the health functionaries, it was revealed that they are facing many problems in the appointment of ASHA workers. The main problem is that there are many aspirants in the Gram Sabha and secondly local politics. The VHSC fund was not used in time by the Panchayat due to differences between FHW and Vice-Pardhan of Panchayat.
Disease Control Programmes
The district is almost free from Malaria. Total number of slides collection up to October was 1990s, but P. vivax 25 and P. faiciparum nil and 25 Malaria care was treated. Under the T. B. programs in the district Mandi, Joginder Nagar, Sarkaghat, Karsog and Gohar have T. B. Units. Total detection rate per lakh population was 197. The 734 smear positive cases put on treatment. The success rate for NSP cases detected in last three corresponding quarters was 87.8. Under the leprosy Control Programme 1.32 new cases has been detected and cases on record at the end (PR) were 0.14. The grade II disability among new cases was nil and re-constructive surgery conducted was also nil. The treatment completion rate was hundred per cent. The 6 batches of newly appointed Medical Officer, 4 batches of Pharmacist and one batche of Lab-technician has undergone the training.
HMIS and MCTS
All the health facilities SC, PHC and CHC were regularly reporting the data on HMIS format according to the record/register maintained in the sub-centre. Facility wise data entry was started since August 2013. All the sub-centers of the district had sent the data before 6th of every month to the PHC and some directly to the BMO. The data entry was done at BMO level and two data entry operator has been appointed through outsource from M.K. Construction Ltd. The PHC Katula and Mandap were upgraded to CHC. But in the Ministry HMIS portal, both the PHC degination has not changed. In the HMIS format for PHC, there is no column for MCH in the PHC for home deliveries. Under the MCTS in every sub-centre, there is a separate register for MCTS. There is big problem of internent connectivity in Ladbharol, Janjehli and Rohanda block. The V-set has been set up in Janjehli block but still it is not working properly. District hospital data entry operator reveals that she has entered the 916 cases but the ID was generated only for 883 and 33 women ID was not generated. In the district hospital deliveries were also conducted from the other district which is near by. The child ID will not be given/generated because central server does not open and not generate the other district ID for child. The pregnant women come for delivery in the district hospital and in many ANC cards the ID number was not written which created problems in tracking and some times double entry was done in some cases. It is essential that health worker write the ID number on ANC card and health worker receive the calls of beneficiaries and must enter the phone number of pregnant women beneficiaries.
Key Recommendations
(1) To fill the post of Medical Officer, Para-medical staff, Publish Health staff and Nursing immediately through contract basis.
(2) To check the quality and quantity of “Sanitary Napkin” under ARSH.
(3) Under the Family Planning Programme the quality of pregnancy kit “Nishchay” quality may be improved.
(4) There should be a provision for drop back the patient by the Ambulance “108”.