Alappuzha - PIP Report

POPULATION RESEARCH CENTRE

KERALA

1Executive Summary

The implementation of Government sponsored programmes under NRHM has been providing good quality health care to the people. After 5 years of implementation in the state, there has been tremendous progress in access to services especially the rural masses. Evaluation and monitoring are integral components for the success of any programme. The present report is one in this direction that provides inputs into service delivery aspects under NRHM in the district of Alappuzha as part of the monthly monitoring of NRHM PIP in Keral initiated by Govt. of India and carried out by the Population Research Centre, Kerala. The health facilities selected in Alappuzha district are District Hospital Alappuzha, Kurathicad CHC, Chettikulangara PHC, and Nadakkavu SC. The field work was done during the first week of October 2013.

The Taluk hospital, Mavelikarawas upgraded to DH level in the recent past. With increasing demand from the public for services that they expect from a DH, human resource and the infrastructure short comings pose to be a challenge. All the sanctioned posts are suitable for a Taluk level hospital. No change in the staff pattern has been made along with upgradation to DH.Service delivery at the Orthopedic, PP Unit, Paediatric wing and Gynaec wing are mostly affected by lack of sufficient staff. The hospital is presently managing with RSBY support. Supply of drugs for smooth functioning of projects from the KMSCL is problematic. AYUSH services are not offered in any of the selected facilities.

JSSK has been successfully implemented in the district. Yet IEC activities regarding JSSK entitlements have to be improved at the community level as beneficiaries were found to be ignorant about most of the free entitlements. Pregnant women are aware of the birth preparedness and JSY but not about JSSK. Only 30 percent of pregnant women are aware about JSSK programme and most of them gathered sufficient information from the health facility.Palliative care project is running successfully in the hospital. JSY payments are properly documented. CHC and PHC are doing palliative care programme.Source reduction activities and NCD services are organized quite satisfactorily. As Nadakkave SC functions in a rented building, utilization of the facility is less. Awareness on breastfeeding initiation within an hour after birth is universal in the area of Nadakkavu sub centre.No separate Nutrition Rehabilitation Centre is present in any of the facilities visited or any other facility selected. ARSH clinics should be set up. In the CHC and PHC and the SC, the necessary registers like OPD, IPD, ANC, Indoor bed head ticket, Family Planning, Immunization etc are available and correctly filled in the facility. The average OPD in Chettikulangara PHC is almost double the numbers in Kurathicad CHC. The service load in terms of ANC, immunization, FP services are much greater in the PHC. School health programmes are being organized regularly in the CHC and PHC area. Biomedical waste management is not as per IMEP protocols in the PHC and SC. Infection control measures in the PHC are has to be stepped up.

2Introduction

The implementation of Government sponsored programmes under NRHM has been providing good quality health care to the people. After 5 years of implementation in the state, there has been tremendous progress in access to services especially the rural masses. Evaluation and monitoring are integral components for the success of any programme. As part of the monitoring of NRHM activities in the state, Population Research Centres were made nodal agencies in their respective states to review the activities under NRHM. The present report is based on monthly monitoring activities initiated by Ministry of Health and Family Welfare, Government of India. Alappuzha district forms the area of present study. The health facilities selected in Alappuzha district are District Hospital Alappuzha, Kurathicad CHC, Chettikulangara PHC, and Nadakkavu SC. The field work was done during the first week of October 2013. About 7 JSSK beneficiaries present at the time of visit were interviewed and for household level interviews, 10 households each with pregnant women and 0-6 children were included in the interview from the SC area.

3State Profile and district profile

Kerala is divided in 14 districts. There are 152 blocks and 1018 villages in the state. The population of the state as per Census of India 2011 is 33406061 out of which 16027412 are males and 17378649 are females. The sex ratio of 1084 females to 1000 males gives Kerala the distinction of having the only state with sex ratio favourable to females in the country. Kerala is also the most literate state with 93.91 percent of its population literate. The density of population is 860 persons per sq.km.

Kerala / Alappuzha District
No. Districts / 14
No. of Blocks / 152 / 12
No. of Villages / 1018 / 91
Population (2011) / 33406061 / 2127789
Literacy / 93.91 / 96.26
Sex Ratio / 1084 / 1100
Density of Population / 860 / 1501

Source: Census of India 2011

Alappuzha district was formed on 17th August, 1957 and consists of six taluks Cherthala, Ambalappuzha, Kuttanad, Karthikappally, Chengannur and Mavelikkara. There are 12 Blocks,91 Villages, 73 grama panchayats and 5 Municipalities. It is the smallest district in Kerala with a total area of 1414 sq. kmsforming 3.64 percent of the total state area and so the second most densely populated district (1501 persons per sq.km). The district head quarters is located at Alappuzha. It is one of the most literate districts with a literacy rate of 96.26 percent. The health service delivery in the public sector is rendered through 1 District Hospital, 1 Women and ChildrenHospital,1 General Hospital, 7 Taluk Hospitals, 16 CHCs, 56 PHCs,366 SCs, 2 TB Centres and 1 other hospital.

4 Key health and service delivery indicators:

The decentralized health care delivery system in the state has helped to achieve low levels of fertility and mortality. The CBR in the state is 15.2, and the TFR is 18 as per the latest report of SRS (2011). Child Mortality rate (3) U5MR (13), IMR (12), NMR (7), Peri-natal MR (10), Still BR (6) are the lowest for any state in the country. As per the DLHS-3 estimate the mean number of children ever born in the Alappuzha district is 1.8 children. Census data based indirect estimate of CBR shows that the fertility declined from 15.2 births per 1000 population in 1994-2000 to 12.8 by 2004-10. TFR is 1.5 (2001). Census data based estimates of sex ratio at birth is 951 female children per 1000 male children as against 918 during the period April-September 2013. Service delivery statistics available from HMIS (April-September 2013) shows that in Alappuzha district the proportion of deliveries shared by public and private hospitals is 47 and 53 percent respectively. The proportion of C-Section to total deliveries is 53 percent in Public hospitals and 48 percent in private hospitals. First semester ANC registration is about 79 percent and more than four-fifths of the women registered for ANC receive 100 IFA tablets. All the children born are given BCG and OPV0 vaccine at birth.

5Health Infrastructure:

District Hospital Mavelikarais easily accessible from the nearest road. It functions in a group of independent Government building(s). At a first glance on entering the hospital complex, one gets a view of buildings at the time of Maharajas of Travancore and also some present day hospital buildings. So the various departments are put up in separate buildings in one compound at this hospital. In the Medical Superintendent’s words who is a resident of the same town, the building where the medical ward is put up was built in 1890 when it began functioning as a General Hospital. Later about 70years or so it started functioning as a Taluk Head Quarter Hospital. But recently Government of Kerala has upgraded it into a District hospital. So in the true sense, when one assesses the facilities required for a District Hospital, it falls short of the requirements. The Medical Superintendent says that with the upgradation, the public demand for services have increased but the hospital lacks both infrastructure and human resources to function as a District Hospital. A proposal has been moved to the Government for the construction of a five storeyed building to bring all the services under one roof as any other District Hospital in the state and the hospital management committee is awaiting sanction. There is no staff quarters. Power backup supply is available only in the Theatre and labour room.

The maternity section and the administrative wing are put up in a new building. These buildings are in good condition. The wards in the old buildings are maintained neatly though it is very difficult to maintain. The labour room is neat with attached toilet and new born care unit is within the labour room itselfwith all necessary equipments except Ventilators. Using NRHM funds in the third floor of the new building an operation theatre has been setup recently. There is no Blood Bank. The Blood Storage Unit is non-functional. So it is outsourced.

Kurathicad CHC is easily accessible from the nearest road, functioning in a Government Building and in good condition.Staff quarters is available for medical officers, JPHN, LHS,HS and Clerk.The CHC has no delivery point.Clean wards separate for males and females are available. It is 25 bedded CHC, separate toilet for males and females. Adequate water and electric supply is ensured in the facility. Citizen Chart is displayed in the CHC. .Complaint or suggestion boxes are available.

Chettikulangara PHC – This PHC is under Kurathicad CHC. Catchment population of the area is 42134. Facility is easily accessible and functioning in Government building and in good condition. No staff quarters are available. Electricity is there but with no power back up. Water supply is there. BP instrument and Stethoscope, adult weighing machine and infant weighing machine and needle and Hub cutter is available and functional. Facility for oxygen administration is there. Autoclave is not functional. No laboratory services are in the PHC.EDL and computerised inventory management is not doing.

Nadakavu SC - This sub centre is under Chettikulangara PHC. Catchment population of the area is 5213. At the day of visit JPHN, JHI and ASHA workers were present in the SC. It is 2 km away from PHC and is 13km away from CHC and more than 16km from District Hospital, Mavelikara and 5km from Kayamkulam Taluk Hospital. It is functioning in a room of a rented building which has no ventilation and water supply and has electricity but without backup. Approach roads have no directions to the SC. No quartersare available to ANM or ANM is not residing at the SC. No complaint /suggestion box is available. Since it is a room in a shop no burial pit for biomedical waste management.

6Human Resources:

District Hospital Mavelikara–In this hospital upgraded to DH level, human resource shortage has been reported. All the sanctioned posts are suitable for a Taluk level hospital. No change in the staff pattern has been made along with upgradation to DH. Out of 2 sanctioned post of Senior consultants and Paediatrician one post each is vacant. 2 General Surgeons, 2 Specialists, 2 Gynaecologists, 2 Ophthalmologists, 2 Orthopaedicians, 2 ENT Specialists, 2 Dental specialists, 9 MOs, 44 SNs, 1 JPHN (regular) and 2 JPHNs under NRHM, 3 LTs, 4 Pharmacists, 1 LHV, 2 Radiographers, 2 ECG Technicians, 2 Ophthalmic Assistants, and 1 Dental Technician forms the Human Resource of this DH.

Gaps

Service delivery at the Orthopedic, PP Unit, Paediatric wingand Gynaec wing are mostly affected by lack of sufficient staff. The hospital is presently managing with RSBY support.

The JPHNs who are given multiple responsibilities, find it difficult to cater to the needs of the people in the municipality area.

Lack of trained staff is also seen. As per the details provided by the PRO, only 1 doctor is trained in EmOC and BeMOC. Only 2 SNs have received training in PPIUCD and 1 doctor in IUCD.

As the SNCU is coming up, more SNs are needed at the SNCU and NBSU

In Kurathicad CHCstaffing pattern has been reported to be adequate with 3 MOs, 4 SNs, 6 ANMs, 1LT, 1 Pharmacist, 1 LHV, 1 HS, 1 PHNS, 1 HI, 4 JHIs, 2 Nursing Assistants, 1 HA, 2 JPHNs for School Health Programme doctors and 4 staff nurses and separate staff for NCD Clinic: 1 MO, 1 DEO, 1 Dietician and, 2 SNs. Remuneration of NRHM staff is reported to be less. Training status of the staff presently employed is less. As it not a delivery point staff who have undergone training required to handle maternal health are not posted and among the MOs posted, in general medicine, adequate training has been reported

Chettikulangara PHC – HR at the PHC is 3 medical Officers, one staff nurse, 8 JPHN, one pharmacist, 2 LHV. None are trained in the last year except one got training in IUD insertion.

Nadakavu SC - One JPHN and one JHI are in the sub centre.JPHN knows how to measure BP. Skill of the JPHN in measuring BP is also good. There is no equipment in the subcentre tomeasure haemoglobin, urine albumin and protein. JPHN has the skill for identifying high risk pregnancy. JPHN does not know about partograph as delivery services are not there.

7Other health System inputs

District Hospital Mavelikara- District Hospital, Mavelikara provides following services: surgery, medicine, ophthalmology, ENT, Anesthesia, Orthopedics, Paediatrics, Psychiatry, Dental, NSV(family planning) services and gynaecology. It is 347 bedded hospital with a large number of OPD ( Q1-71078 and Q2-63511 ) and IPD (Q1-2276, Q2- 2144) during the 2013-14.

There is no case of severely anemic women and maternal death..So there is no register available regarding the above. Foetal Doppler/ CTG, MVA equipment, CT Scanner , Ultrasound Scanner (general) are not available at the facility , All other equipments including OT equipments are available and functional. EDL is available and displayed in the pharmacy. Computerised inventory management system has been started but is not completed. The process is going on and will be completed soon. IFA Tablets, Zinc tablets and Vitamin A are out of Stock. Tablets Misoprostol is out of stock so it is locally purchased. Sanitary napkins are not in stock. All other essential drugs are available and distributed to the patients.Equipment maintenance is very difficult for want of staff. Grievance redressal mechanism is there. Tally is not implemented.

Gaps

Difficulty in getting medicines in time and as per demand from the KMSCL. So the hospital manages with HMC fund. Delay in time between demand and supply is the main reason.

Space in the laboratory is inadequate. Endoscopy service not available,

Kurathicad CHC- . In the first quarter 4253 out patients utilized the services given by the facility and 5524 in the second quarter. 21 in-patients were there in the first quarter and 32 in the second quarter. The expected pregnancies in the catchments area of the facility is 182 in both the quarters and the women tracked in MCTS are 69 and 38 respectively. Line listing of severe anaemic women has been initiated at subcentre level. High risk pregnancies are identified and referred to the DH Mavelikara.

BP apparatus, Stethoscope, needle cutter, emergency tray with emergency injections are available and functional.There is no functional ILR, Deep freezer and semi auto analyser.There is functional autoclave but not in good working condition.EDL is displayed in the pharmacy. Some kind of intolerance is felt among children when they consume IFA tablet blue. IFA syrup with dispenser and zinc tablets are out of stock. Supply of sanitary napkins is not in the CHC, PHC or in the subcenters.

A good lab facility is available in the CHC except the testing of CBC and RPR. Microscope, Hemoglobinometer, centrifuge, reagents and testing kits are available and functional in the laboratory. Leptospirosis and Dengue fever,Platelets testing are conducted inthe CHC if needed. Only one staff in the lab and daily 150 -200 patients tests referred from the OP are made. So there is shortage of staff. 70 Patients were there in the IPD last month. She is able to handle the IP cases only.

The necessary registers like OPD, IPD, ANC, Indoor bed head ticket, Family Planning, Immunization etc are available and correctly filled in the facility. A separate register is not kept for microplan for immunization.

Gaps identified

Supply of drugs for smooth functioning of projects from the KMSCL is problematic. Only 50 percent of demand is met and that too quite late after request. So the facility is forced to manage the drug supply so as to run the NCD clinics by using the HMC funds.

AYUSH services are not offered in any of the selected facilities

Chettikulangara PHC – OPD attendance during April-June is 7552 and that of July-September is 9186. There is no IP facility in the centre.Neither a maternal death nor a neonatal death was reported in two quarters. OPD register ANC register PNC register, equipment register, stock register and sub stock register is being maintained. JSY payments are made at delivery points. So no separate register is kept for JSY payments.

One infant death was reported at the centre. Number of VHND meeting during six months is 11. Service delivery data submitted for MCTs updation is 12 each in the two quarters.