Quarterly Monitoring of
Programme Implementation Plan (PIP)
in Thane District, Maharashtra State
Rajarama K E T
M. N. Korkoppa
K. G. Kallihal
Population Research Centre
JSS Institute of Economic Research
Dharwad, Karnataka
PRC Analytical Report Number –11
October2013
1
Table of Contents
1 Executive Summary
2. Introduction
3 State Profile and District Profile
4 Key health and service delivery indicators
5 Health Infrastructure
6 Human Resources
7 Other Health System Inputs
8 Maternal Health
8.1 ANC and PNC
8.2 Institutional deliveries
8.3 Maternal Death Review (MDR)
8.4 Janani Shishu Samrakshana Karyakram (JSSK)
8.5 Janani Suraksha Yojana (JSY)
9 Child Health
9.1 SNCU & NBCC
9.2 Nutrition Rehabilitation Centre (NRCs)
9.3 Child Immunization
9.4 Rashtriya Bal Swasthya Karyakram (RBSK)
10 Family Planning
11 Adolescent reproductive Sexual Health (ARSH) Programme
12 Quality of Health Services
12.1 Infection Control
12.2 Biomedical Waste Management (BMW)
12.3 Information Education and Communication (IEC)
13 Clinical Establishment Act
14 Referral transport and Mobile Medical Units
15 Community Processes
15.1 ASHA
16 Disease Control Programme
16.1 Malaria
16.2 Tuberculosis Control Programme
16.3 National Leprosy Eradication Programme (NLEP)
17 Health management & Information System and Mother and Child Tracking System (HMIS & MCTS)
18 Key conclusions and Recommendations
19 Annexure.
A Rapid Evaluation of Programme Implementation Plan (PIP) in Thane District
1 Executive Summary
The evaluation of PIP was conducted in Thane district of Maharashtra state during 23- 27 September, 2013. The current study is intended to focus on all issues related to mother and child health, physical infrastructure, availability of manpower, equipment and drugs in government health facilities and implementation status of various health schemes etc. The field verification was conducted in District Hospital (DH), Thane, Sub Divisional Hospital (SDH), Bhiwandi, Rural Hospital (RH), AmbadiPhata, Primary Health Centre (PHC), Padgha and Health Sub Centre (HSC), Amane.
Health Infrastructure
In Thane district, 492 HSCs are functioning as against required710. Similarly, 78 PHCs are existing, but actual requirement is 107. Thirteen HSCs and one RH arefunctioning in non-government buildings. Electricity with power back up and running water facilities are ensured in all the surveyed facilities. Staff quarters are not available to staffs of SDH and RH. The labor rooms attached with toilets are available in all the visited hospitals. Separate male and female wards attached with toilet are also available in all the facilities except Rural Hospital. The wards and toilets are not clean.
Human Resources
In District Hospital, 11 posts have been laying vacant from 6 months to 2 years. No specialists post is deployed in RH. There is no dearth of man power in SDH, PHC and HSC.
Available Services
In DH, all major surgeries, trauma care, ENT surgery, full range of family planning services, blood transfusion, radiology and comprehensive pathology services are available. In SDHbelow mentioned few important medical services are not available. They are cardiology service and surgery, trauma care and blood transfusion facility. No specialized services are available in RH.
The suggestion & complaint box is hardly seen in the periphery level facilities. It is placed in appropriate place in SDH and DH. The Help Desk is seen only in District Hospital.
OPD Turnout
Daily average OPD turnout during the last two quarters in DH, SDH, RH, PHC and HSC were 2030, 1475, 146 and 222 respectively. Average daily cash collected in the form of user fee during the quarter in DH was Rs. 10150/-, in SDH was Rs 7375/- in RH was Rs. 730/-and in PHC was Rs. 1110/-.
Drugs
The DH, SDH and PHC had almost all the essential drugs and consumables for providing quality services to its clients. This was not found in RH.
Laboratory Service
The DH and SDH’s laboratories are well equipped to provide all types of laboratory services. No laboratory service is available in Rural Hospital.
AYUSH Unit
The AYUSH unit is fully operational only in District Hospital.Ayurveda, Homeopathy and Unani systems of medicine and services are available in the hospital. The AYUSH unit does not have separate consultation room and it is being done on the corridor.
Antenatal Care (ANC)
Maternal care is ensured in all the visited facilities except RH. Number of pregnant women registered for ANC in DH during last 2 quarters was 1392, of which 97 percent (1362) registered in first trimester. Eighty four per cent of pregnant women received 4thANC. The ANC performance in SDH, PHC and HSC were also more or less similar. The line listing of pregnant women is not being done in any visited facility except in District Hospital.
Institutional Delivery
Safe delivery service is available in all the facilities except RH. Out of 1573 deliveries conducted in the DH, 225 (14.30 %) deliveries were Caesarian-section. In SDH, 2769 deliveries reported and 125 were Caesarian-section (4.5 per cent). Proportion of neonates initiated to breast feeding within one hour varies from 100 percent in PHC to 81 percent in SDH.
Maternal Death Review
Twenty notified facility based maternal death review committees have been formed in the District. Number of maternal death anticipated during the last quarter in the district was 5 and maternal death reported was also 5. The key causes of the maternal deaths in the district were severe anemia and Post-partum hemorrhage.
JananiShishuSamrakshanaKaryakram (JSSK)
The beneficiaries of JSSK had received most of the entitlements ensured in the scheme. The clients were asked to purchase medicines that are not available at their own cost. Registration fee, diet, available medicine, laboratory charges etc. were provided free of cost by the institutions.
JananiSurakshaYojana (JSY)
The JSY guidelines are followed and payments are being made according to eligibility criteria in the district. Of the total deliveries, 49 percent of deliveries were JSY beneficiary’s deliveries in Thane district. JSY payments are being made through A/C payee cheque for those who have bank account and through bearer’s cheque to those who do not have bank account.
SNCU & NBCC
Thane district has 57 NBCCs. The DH has functional SNCU.The unit is fully equipped in terms of drugs and equipments. Shortage of man power particularly, pediatrician is affecting the better functioning of the unit. In SNCU, 382 neonates had been admitted and 241 got well in the last quarter. Number of neonates died among the admitted was 28.
Nutrition Rehabilitation Centre (NRC)
The NRC which is established in DH has all infrastructures. Total number of beds available in NRC is 8. Number of children admitted to the centre during last quarter was 22 and average length of stay of children was 14 days.
Child Immunization
Immunization service is ensured in all the surveyed facilities except RH.The Japanese Encephalitis immunization is being administered only in DH. Alternative vaccine has not been introduced in Maharashtra state. The number of fully immunized children during last two quarters was445 in DH, 84 in SDH, 65 in PHC, and 105 in HSC.
RashtriyaBalSwasthyaKaryakram (RBSK)
In Thane district, total 82,009 children were screened and 25,113children were identified with one or other defects during the last two quartersunder RBSK. The number of infants admitted to NBSU/SNCU was 694 during last two quarters in DH. And, 52 SAM children weretreated in the DH.
Family Planning
All the services related to family planning are being provided in DH, SDH and PHC.Family Planning performance of the surveyed facilities during last two quarters reveals that all facilities are working well except RH. The Vasectomy sterilization had not been performed in any visited health institutions during last two quarters.
Biomedical Waste Management (BMW)
Color coded bags and buckets are available and being used in all the visited facilities. In PHC and HSC, staffs are not strictly adhering to the BMW norms. They are not treating the biological waste before disposing.
Information Education and Communication (IEC)
The posters on maternal health, JSY, JSSK entitlement, ANC, breast feeding and child immunization were displayed in the maternity wards and immunization room of the surveyed facilities. The posters oncommunicable and non communicable diseases were very much missing in the vicinity of the institutions.
Essential drug list has not been displayed in Sub Divisional Hospital and PHC whereas, in District Hospital, it is displayed but, not in right place. The partograph has not been displayed in labour room of any facility except in SDH.
Clinical Establishment Act
Clinical establishment Act is not in force in Maharashtra. However, they have Bombay Nursing Act which was introduced in 2006.
Referral transport and Mobile Medical Units
The health department of Thane district has 129 functional ambulances. Average number of ambulance available for every 100000 population is 37. All the surveyed facilities have ambulances. No other facility except District Hospital has the calling centre. The District Hospital has a mobile medical unit.
ASHA
In Thane District, 3302 ASHA are functioning against 3397 required. ASHAs kit is available with all of them and it is beingreplenished as per their requirement.
Malaria
The prevalence of malaria in Thane district is 1.19 percent. Altogether, 6408 malaria cases were detected during April 2013 to August 2013 in the district. Total treated patients in the same period were 6208.
Tuberculosis Control Programme
The prevalence of TB in the district is 10.14 percent (697). The number of sputum collected and tested in the district during the last quarters was 6692. And, DOTS provided to 625 persons.
National Leprosy Eradication Programme (NLEP)
The prevalence rate of leprosy in the district is 1.64 per cent. Number of leprosy cases detected during April 13 to August 13 was 1225. The leprosy treatments were provided to 1870 active cases and 1134 RFT cases.
Mother and Child Tracking System (MCTS)
Name based tracking of pregnant women is being done in the district. Information on both mother and children are collected and maintained in the visited PHC and HSC under MCTS. The work plan is being generated and is being used for tracking the beneficiaries in the district. Telephone numbers of either beneficiary’s or their close relatives is also available.
Recommendations
- Since Sub Centre is the grass root level health facility, setting up of required number of HSC and PHCsin the district is to be done on an urgent basis.
- The Rural Hospital, AmbadiPhata is located in a central place, but it lacks basic infrastructures. Necessary infrastructure, manpower and other facilities are to be provided to it.
- Vacant specialist posts in the District Hospital have to be filled up to ensure effective implementation of different components of NRHM. Remuneration and other facilities of specialist doctors to be made par with other reputed health institutions.
- In DH and SDH, wards, labour rooms and surroundings lack cleanliness. The hospital Authority should pay more attention to keep the hospital and its premises clean and tidy.Cleaning task can be entrusted to private agencies.
- Displayed posters have fading look and messages are not visible properly. It can be replaced with new and unblemished posters. The posters on national programme have to be displayed in appropriate places.
2 Introduction
The Ministry of Health and Family Welfare (MoHFW), Government of India (GOI) had asked Population Research Centre (PRCs) to involve in quarterly monitoring of important of components of the State Programme Implementation Plan (PIP). Accordingly, PRCs are conducting monitoring study on crucial components of the NRHM activities in the assigned
districts. The Ministry of Health and Family Welfare had asked PRC, Dharwad to conduct evaluation of PIP in 8 districts of Maharashtra, in 5 districtsof Karnataka and in onedistrict of Andhra Pradesh. In order to accomplish the task, depending on the availability of man power, Population Research Centre, Dharwad formed five teams, each team consisting of three members. One team had visited the Thane district ofMaharashtra state in the month of September, 2013 for conducting the evaluation of PIP for the first quarter of the financial year2013-14. This report contains the monitoring findings of Thanedistrict.
Objectives
The current study is intended to focus on all issues related to mother and child health, physical infrastructure, availability of manpower, equipment and drugsin government health facilities and implementation status of various health schemes etc. The specific objectives of the study are outlined below.
To assess the implementation of Reproductive and Child Health Activities Proposed in the 2013-14PIP;
To know the available physical infrastructure, equipment and drugs in government health facilities;
To know the available manpower and their training status in government health institutions;
To assess the implementation status of JSY and JSSK schemes;
To examine the displayof IEC materials, management of biomedical waste and cleanliness in government health facilities;
Methodology and Sample Coverage
In order to fulfill the specific objectives of the study, the basic requirement was to collect the data fromthe government health institutions.As mentioned earlier, study district was selected by the Ministry. The MoHFW suggestedto coverone DistrictHospital (DH), one Sub-Divisional Hospital (SDH), one Community Health Centre/Rural Hospital (CHC/RH), one Primary Health Centre (PHC)preferably 24×7 and one Health Sub-Centre (HSC) in the selected block of the selected district. Following the guideline, the study team selected and visited DistrictHospital, Thane, Sub-Divisional Hospital, Bhiwandi, Rural Hospital, AmbadiPhata, Primary Health Centre, Padgha IPHS (24×7) and Health Sub-Centre, Amane. The team selected health facilities of Bhiwandi block except DistrictHospitalas entire Thane is urban. The check list for different levels of facilities designed by the MoHFW was used to collect information. Besides, discussions were also held with DistrictRCH Officer, District Surgeon (Civil Surgeon), DistrictProgramme Manager (DPM), and other District level Officials. The data was collected from Medical Officers or Staff Nurse of each department. The team also verified service registers toassess the status of updating. Further, exit interviews were also conductedwith the beneficiaries of JSSK in the facility where in-patient service was available.Altogether, 10 exit interviews were conducted(4 in DH, 4 in SDH and 2 in PHC).The field verification was done during 23rd September to 27th September, 2013.
3 State Profile and District Profile
Maharashtra state is in western region of India. The area of the state is 3,08,000 square kilometers. Maharashtra comprises 35districts, 109 sub divisions and 357 taluks. According to 2011 census, it is the second most populous statein India, with 9, 68,78,627 inhabitants. The state has a population density of 315 inhabitants per sq kilometer. Its population growth rate during the decade 2001-2011 was 14.80per cent. It has a sex ratio of 922 females for every 1000 males and a literacy rate of 77.20 percent.
Thane district is in Maharashtra state. It is situated between 18° 42'and 20° 20' north latitudesand
72° 45'and 73° 48' east longitudes. The area of the district is 9558 square kilometers. Thane comprises 15 taluks. This district is presently the only district in India which comprises 7 municipal corporations and 5 municipal councils. According to 2011 census, it is the most populated district in India, with 1, 10, 54, 131 inhabitants. The district has apopulation density of 1157inhabitants per sq kilometers. Its population growth rate during the decade 2001-2011 was 39.94 per cent. It has a sex ratio of 880females for every 1000 males and aliteracy rate of 86.18 percent.
4 Key health and service delivery indicators
The key health and service delivery indicators showgeneral health condition of the population and how effectively health programmes have been implemented in the region. A few key health and service delivery indicators are discussedbelow in brief.
Mortality
Infant Mortality Rate (IMR) and Maternal Mortality Rate (MMR) shows Thane district is in a better position compare to the Maharashtra state. For instance, the IMR in Thane district is 20.7, whereas, it is 28 for the state.
Antenatal Care (ANC) and Post Natal Care (PNC)
The number of antennal care visits and timing of the 1stvisit are important for the health of mother and outcome of the pregnancy. The percentage of pregnant women who received their first ANC in the first trimester in Thane district was less than the state percentage (51.8 % against 58.7%). However, the proportion of pregnant mothers who received at least 3 ANC during their last pregnancy in Thane district was 86.7 percent. The corresponding percentage for the state was 80.2 percent. The pregnant women who received one TT injection were almost same in Thane district (77 %) and Maharashtra state as whole (78 %).
More than 96 per cent of women have delivered in health institution in Thane district as well as in the State. About 36 percent and 44 percent of mothers who delivered in health institutions discharged with 48 hours in Thane district and Maharashtra state respectively. All the home deliveries were conducted by skilled birth attendant.
Immunization
The percentage of children (12-23 months) who received full immunization in Thane district is 94 percent and it was 95 percent in the state.
Family Planning
The contraceptive prevalence rate (CPR) for any method in Thane district was 60 percent. The corresponding rate for any modern method was 57 percent in the district. The CPR in Maharashtra state for any method and for any modern method was 67 per cent and 65 per cent respectively. The unmet need for any method is 12 percent in the district.
5 Health Infrastructure
Infrastructure is one of the basic components for providing high quality RCH services. Different aspects of infrastructure facilities available with the various levels of health facilities were collected during the study. This section provides the information regardingthe available health infrastructure facilities in the visited hospitals.In Thane district, 492 HSCs are functioning against required 710. Similarly, 78PHCs exist,but the actual requirement is 107. However, there is no dearth of Rural Hospitals in the district as reported by the DistrictHealth Officials.Each block in Thane district has a SDH. Because of shortage of PHCs and HSCs, existing facilities have extra work load that affects in delivering quality services. In order to fill up the gaps, the District Authority has submitted a proposal to state government for opening of required number of health facilities. Out of 492 functioning HSCs, 13 HSCs are running in non-government buildings. One Rural Hospital (RH), Bhiwandi is functioning under a small rented building. Availability of required size land is a hurdle to construct aHospital building to RH, Bhiwandi.