1.District:- Chandel Major observations of Regional Evaluation Team, Kolkata on the Evaluation work carried out in of Manipur during the month of August, 2011. I. Details of the visited Institutions: District visited D.H., CHC and PHCs visited SCs visited Chandel DH: Chandel Aimol Thampak, Komla CHC: More Thambi, Unopat and Saivom PHCs: , and More

II. Major Observations: 1. Health Human Resources: a. No sanctioned strength of the staff was available at district office. At district headquarter no one was aware about the sanctioned strength of staff in the district. b. Acute shortage of Specialists and Medical officers was observed in the visited institutions. 5 posts of Specialist, 4 posts of MO and 4 posts of GNM/Staff Nurse were lying vacant at District Hospital. 3 posts of Specialist, 13 posts of MO, 15 posts of GNM/Staff Nurse were vacant in the Centres of CHC Moreh. c. The PHC Chakpikarong was functioning with single AYUSH, MO. d. Under District Programme Management Unit (DPMU), one post each of District Programme Manager, District Data Manager, Block Account Manager, Block Data Manager and 2 posts of Block Programme Manager were lying vacant since long in the district. 2. Functioning of Rogi Kalyan Samiti (RKS): It was reported that RKS has been constituted and registered in the visited CHC and PHCs in the district, but the meetings of RKS were not being held regularly. 3. Functioning of ASHA and Village Health Sanitation & Nutrition Committee (VHSNCs): a. As targeted, 550 ASHAs have been selected in the district and provided training up to 6th module. 550 ASHAs had been provided drug kits during 2010-11 but no drug kit has been provided to them during the year 2011-12 till the visiting month. b. As reported 542 VHSNCs were functioning in the district and all are having ASHA as a member of the committee. c. Untied funds for VHSNC to the tune of Rs. 67,00,399 including opening balance of Rs. 35,00,399 were available for the year 2010-11 and out of that the amount of Rs. 39,76,150 was utilized by the VHSNCs within the period in the district. Opening balance amounting to Rs. 27,24,249 available in the year 2011-12 was lying unspent till the time visit of the team in the district and no VHSNC Untied fund was provided to the district during current year 2011-12. 4. Services of Janani Suraksha Yojana (JSY): a. Rs. 12,65,800 was spent in the district under the scheme out of an amount of Rs. 13,36,600 available during the year. No fund was released to the district during current year 2011-12 up to the date of visit. b. It was reported that, 1986 and 312 deliveries were identified for JSY payment under the scheme in the year 2010-11 and 2011-12, out of that 1876 and 151 JSY beneficiaries were paid with JSY incentive during last year and current year respectively. c. C - Section delivery facility was not available in the district as a whole. During visit to the centres, it was observed that sufficient funds were not provided in time to the visited facilities. Registers for JSY were maintained properly containing the list of beneficiaries to whom cash had been distributed and registers were checked properly by concerned Medical officer In charge. d. 36 JSY beneficiaries contacted for on the spot verification in the district and it was observed that MCH cards were issued to all of them. Three consecutive ANC checkups was not given to all the beneficiaries. Beneficiaries were not getting incentive amount on the date of discharge due to delay in submitting the cards along with necessary papers to the office of the hospital. 5. 24 hours delivery care services: a. 24 hours delivery care system implemented in 4 institutions i.e. in District Hospital, 1 CHC and 2 PHCs in the district. b. Facility for caring mothers and new born care were found inadequate at most of the visited centres. Blood storage facility was not available at CHC and PHCs visited. Required number of para-medical staff for conducting 24x7 delivery was also not there at the visited facilities.

6. Untied Funds: a. Every CHC, PHC and Sub Centre was being provided funds @ Rs. 50,000, Rs. 25,000 and Rs. 10,000 per year respectively as Untied funds in the district. The position of Untied funds for the year 2010-11 is given below: (In Rs.) Sr. Particulars Opening Fund Expenditure Balance No. Balance Received 1 For CHCs Nil 50,000 Nil 50,000 2 For PHCs 2,22,040 75,000 2,71,540 25,500 3 For Sub Centres 25,47,495 3,60,000 3,35,747 25,71,748 b. Untied Fund released to the visited PHCs/CHC and utilized by them in the year 2010-11 in the district are given below: (in Rupees) Name of Institutions Opening Released Expenditure Balance Balance CHC Moreh Nil 50,000 Nil 50,000 PHC Chakpikarong 25,000 25,000 50,000 Nil PHC Moreh Nil Fund not provided PHC Tengnoupal Record not made available

c. No untied fund has been provided to the district for the year 2011-12. d. It was observed that fund was utilized for purchase of Generator, printer, Laboratory items, gas box, stationary and expenditure on Photocopy etc. by the visited PHCs. 7. Physical infrastructure (HSC/PHC/RH) (i) Health Sub Centres: a. The Sub centres visited at Aimol Thampak, Komla Thambi, Unopat and Saivom were not as per IPHS. Labour room facility was available only at Sub Centres Unopat and Saivom. Electricity supply was irregular. No mobile phone has been provided to the ANMs. b. Ambu bag/suction, Steam sterilizer, RDT kits, Heamoglobinometer, DDKs, Santary Napkins, Oxitocine tablets, Kits- A & B and Gentamycin injection were not available at all the visited centres. c. Delivery table, Mclntosh sheet and CuT insertion kit were not available at the Sub Centres Unopat and Saivom. d. ORS packets, Co-trimoxazole tablets, EC Pills and Condoms were not available at Sub Centres Aimol Thampak, Unopat and Saivom. e. Vitamin- A solution and Oral Pills at Sub Centre Aimol Thampak, Delivery kit and Chloroquine tablets at Sub Centre Komla Thambi, CuT and Chloroquine tablets at Sub Centre Unopat and Delivery kit, Vitamin- A solution, Oral Pills and Chloroquine tablets at Sub Centre Saivom were not available on the day of visit. (ii) PHCs/CHC/DH: a. District Hospital at Chandel, CHC at Moreh and PHCs at Chakpikarong, Tengnoupal and Moreh were visited by the team in the district. New building for DH was under construction. Electricity supply in these institutions was irregular. Labour room was not functional at PHCs Tengnoupal and Moreh. b. Blood storage unit, Sick New born Care Unit and Anesthesia equipment were not available at District Hospital Chandel and CHC at Moreh. c. Ambulance, Auto clave and Operation Theatre at District Hospital Chandel and X-ray facility, Resuscitation equipment, Neonatal Resuscitation equipment and CuT insertion kit at CHC Moreh were not available. d. The building of PHC Tengnoupal was in bad condition, entire roof and wall of the building was damaged. Rest of the building was leaking during rain. There was no safe OPD room, ward, labour room, office room, store room, dressing room etc. as a result records, registers, medicine and the equipments were getting damaged. e. Functional Operation Theatre was lacking in the visited PHCs. There was also no Ambulance/ Jeep in these PHCs. f. Telephone facility was not provided to PHCs Chakpikarong and Tengnoupal. Cold chain equipments at PHCs Chakpikarong and Moreh were not available. Oxygen cylinder was not available at PHC Tengnoupal. g. PHC Moreh had a very nice labour room, but deliveries were not conducted there for want of equipments/ instruments. Presently labour room was used for store. 8. Opinion and awareness of the Community on the Health Services:

(i). ANMs Services:

a. 20 mothers having child up to one year age were interviewed for assessing their opinion and knowledge about the services provided by the concerned ANMs at Sub Centre level. Mothers were satisfied with the services. b. Most of the interviewed mothers were not aware about use of contraceptive and its side effects. Post natal services were also poor in the area of Sub Centres Kamala Thabi and Unopat.

(ii). HW (M) Services:

Though the villagers in area of Kamala Thabi Sub Centre were satisfied generally with the services of MPW (M), their dissatisfaction was mainly towards not staying of MPW (M) at sub centre headquarters, his irregular visit to the villages and also the services relating to environmental sanitation, group meeting on health topic and STD / HIV/AIDS etc.

(iii). Services of PHC:

a. In the area of visited PHCs at Chakpikarong and Tengnoupal, the RCH beneficiaries i.e. pregnant women, recently delivered mothers, mothers with two years old child etc. and local persons who generally use the services at PHCs were contacted to know the overall functioning of PHCs. It was observed that the services in respect of early registration of ANC, 3 Ante Natal checkups, referral transport, awareness of sick new born care and motivation about uses of contraceptive etc. needed improvement in the areas of both the visited PHCs.

b. The Medical officers at PHCs Chakpikarong and Tengnoupal were not visiting villages regularly. 9. Sample Verification of F.W. acceptors: a. The team selected a total of 22 acceptors of spacing methods of family planning and out of that 16 (73%) could be contacted for sample verification. b. Among the contacted acceptors, 9 (56%) informed that they did not receive any follow up service. c. 91 beneficiaries of BCG/ DPT/ Polio and Measles were also selected and out of that 79 (87%) beneficiaries were contacted in the area of visited centres. All contacted beneficiaries confirmed the services and 48 (61%) beneficiaries were provided Follow up services by the health staff. d. No sterilisation operations have been performed in the whole district due to absence of Surgeons and Anesthetists. This situation is very serious and state authority should take an early corrective action to improve it.

10. Reconciliation of the reporting performance: Institution wise reported figures reported by the district office for CuT, Oral Pills and Nirodh did not tally with the reports available at some of the visited centres. Reporting system was also very poor in the district. It was observed that the post of District Data Manager is vacant since long in the district headquarter. 11. Registers, records and reports maintained at the visited centres: a. In the visited Sub centres and PHC/CHC, service registers in respect of Eligible Couple survey, Family Planning, ANC & PNC and Stock register of family welfare were not maintained properly. b. Annual District Health Plan (ADHP) for the current year 2011-12 have been prepared at District, CHCs and PHCs level and transmitted to higher authority in time but the same was not prepared by visited Sub centres. c. Printed register for Family Planning, Eligible Couple survey, ANC, PNC, Child immunisation, JSY, Untied Fund, Cashbook and Stock book etc. were supplied to all facility level, but maintenance of these registers was found very poor. Only JSY register was maintained properly. Child Immunisation registers were maintained, but not in properly. Doses were not given in proper time as per the records. d. Monthly performance report in HMIS format was sent through web based system at district level only. Visited PHCs were not sending their on line reports, because internet facility was not provided there. 12. IT Infrastructure and Mother & Child Tracking System: a. Team found that computers were available at district level and all CHC/ PHCs level (one in each). Internet connectivity was found available at district and PHC Moreh only. But the same facility was not provided to other CHC and PHCs. b. MCH Tracking system was not implemented in the district. 13. Miscellaneous observations and suggestions: a. Monitoring and supervision required to be increased by the concerned officers and staff in the district. b. Routine Immunisation programme was conducted on regular basis. But Records/ registers reflected that most of the children were not fully immunized and doses were not given in proper time. It was observed that involvement of ASHAs and ANMs was poor in this regard. c. During visit to PHC Tengnoupal, It was observed that the Medical Officer, Pharmacist, Block Programme Manager, Block Data Manager, Block Account Manager and Cleark were not present even in the working hour at PHC. OPD of the PHC was totally absent on the day of visit.

2.District:- Major observations of Regional Evaluation Team, Kolkata on the Evaluation work carried out in of Manipur during the month of August, 2011. I. Details of the visited Institutions: District visited D.H., CHC and PHCs visited SCs visited Thoubal CHC: Yairipok Khoiram Kikru, Sora, PHCs: Khoiram, Pallel and Irengband and Waithou

II. Major Observations: 1. Health Human Resources: a. Position of human resource was satisfactory. However, some posts were vacant. 2 posts of Specialist (out of 10 sanctioned), 3 posts of MOs (out of 69 sanctioned) and 2 posts of MOs (Contractual) out of 18 sanctioned were vacant in the district. b. In the category of para-medical, 6 posts of ANMs/MPW (out of 90 sanctioned), 3 posts of MPW (M) out of 34 sanctioned, 2 posts of GNM/Staff Nurse (out of 85 sanctioned), 2 posts of Lab Technician (out of 18 sanctioned) and 3 posts of Pharmacist (out of 40 sanctioned) were lying vacant there. c. Under District Programme Management Unit (DPMU), one post each of District Account Manager and Block Programme Manager and 3 posts of PHC Accountant were lying vacant in the district as a whole. 2. Functioning of Rogi Kalyan Samiti (RKS): It was reported that RKS has been constituted and registered in the visited CHC and PHCs in the district, but the meetings of RKS were not being held regularly. 3. Functioning of ASHA and Village Health Sanitation & Nutrition Committee (VHSNCs): a. Against the target of 525 ASHAs, for 525 villages in the district, 365 ASHAs have been selected in the district and provided training up to 6th module. All 365 ASHAs had been provided drug kits during 2010-11. b. As reported 525 VHSNCs were functioning in the district and all are having ASHA as a member of the committee. c. Untied funds for VHSNC to the tune of Rs. 1,14,69,486 including opening balance of Rs. 62,19,486 were available for the year 2010-11 and out of that an amount of Rs. 74,71,326 was utilized during the period in the district. Similarly, funds to the tune of Rs. 76,48,160 including opening balance of Rs. 39,98,160 was available in the district and out of that Rs. 9,53,743 could be utilized during current year 2011-12 (up to July, 2011). 4. Services of Janani Suraksha Yojana (JSY): a. As reported, funds amounting to Rs. 34,92,093 were available under the scheme for the year 2010-11 in the district and out of that Rs. 26,65,198 were spent. Similarly, Rs. 3,45,100 have been spent against available amount of Rs. 19,81,895 during current year 2011-12 under the scheme. b. 3700 and 487 deliveries were eligible under JSY scheme in the year 2010-11 and 2011-12 respectively in the district and all eligible beneficiaries were paid with JSY incentives. c. During visit to the facilities in the district, it was observed that records/ registers were not maintained properly to check the status of funds, beneficiaries and related details. d. 23 JSY beneficiaries contacted in the district for on the spot verification and it was observed that MCH cards were issued to all of them. Beneficiaries mostly didn’t have receive three consecutive ANC checkups in the visited area. e. Beneficiaries were not paid incentive amount on the date of discharge due to delay in submitting the cards along with necessary papers to the office of the hospital. 5. 24 hours delivery care services: a. 24 hours delivery care system implemented in 5 institutions i.e. 4 CHCs and 1 PHC in the district. b. Facility for caring mothers and new born care were found inadequate at most of the visited centres. Blood storage facility was not available at CHC and PHC visited. Required number of para-medical staff for conducting 24x7delivery was also not there at the visited facilities. C- Section delivery facility was not available at CHC Yairipok. 6. Untied Fund: a. Every CHC, PHC and Sub Centre were being provided untied funds @ Rs. 50,000, Rs. 25,000 and Rs. 10,000 per year respectively in the district. The position of Untied funds for the year 2010-11 and 2011-12 as given below- (In Rs.) For the year 2010-11 Sr. No. Particulars Opening Balance Fund Received Expenditure Balance 1 For CHCs 3,09,180 2,50,000 4,59,591 99,589 2 For PHCs 3,03,027 3,00,000 4,07,136 1,95,891 3 For Sub Centres7,36,328 5,00,000 7,28,461 5,07,867 For the year 2011-12 1 For CHCs 99,589 2,50,000 74,987 2,74,602 2 For PHCs 1,95,891 3,00,000 1,39,526 3,66,365 3 For Sub Centres5,07,867 5,10,000 1,36,741 88,126 b. Untied Fund released to the visited PHCs/CHC and Utilized by them in the year 2010-11 in the district is as given below (in Rupees) Name of Institutions Opening Released Expenditure Balance Balance CHC Yairipok 1,00,000 25,000 1,05,982 44,018 PHC Khoiram 25,089 25,000 39,048 11,041 PHC Pallel 41,800 25,000 39,552 37,248 PHC Lilong 25,000 25,000 25,000 Nil

c. No untied fund has been provided to the institutions by district office for the year 2011- 12. d. It was observed that fund was utilized for purchase of petrol for generator, medicine, furniture, sign board, payment of transportation, campus cleaning, organization of camps in remote area, printing and Laboratory items etc. by the visited PHCs. 7. Physical infrastructure (HSC/PHC/RH) (i) Health Sub Centres: a. The Sub centres visited at Khoiram Kikru, Sora, Irengband and Waithou were not maintained as per IPHS. Electricity supply and Labour room facility was available only at Sub Centre Waithou. ANMs were not staying at Sub centre headquarters in the visited centres. b. Delivery table, Mclntosh sheet, Heamoglobinometer, Santary Napkins, Kits- A & B and Gentamycin injection were not available in the visited centres. c. Ambu bag/suction, EC Pills, Oxitocine tablets, Nischay pregnancy test kit and RDT kit were not available in most of the visited Sub centres. d. Delivery kit, CuT insertion kit, Co-trimoxazole tablets and CuT at Sub Centre Khoiram, Toilet facility, Steam sterilizer and DDKs at Sub Centre Sora, Toilet facility, Steam sterilizer and Oral Pills at Sub Centre Irengband and Co-trimoxazole tablets and CuT at Sub Centre Waithou were not available as observed by the team during the visit. (ii) CHC/ PHCs: a. The visited CHC at Yairipok and PHCs at Khoiram, Pallel and Lilong were not maintained as per IPHS. b. The visited CHC at Yairipok was upgraded in the year 1996. CHC was functioning in the old PHC building with inadequate space, facility, equipments and human resources. CHC building was being constructed since last 12 years but still incomplete. c. Ambulance/Jeep, Functional Operation Theatre, Residential quarter for Medical Officer and 24x7 service facility was not available in the visited PHCs. d. Telephone facility, Labour room table and IFA (L & S) tablets/ Syrup were not available at PHCs Khoiram and Pallel. Residential quarter for Medical Officer was not avaliable there. In PHC Lilong, residential quarters were constructed but not yet handed over. e. Due to want of equipment and other facilities, Labour room was not functional in PHCs at Khoiram and Lilong, and the same was not available PHC Pallel. f. Oxygen cylinder and Resuscitation equipment in PHCs at Khoiram and Lilong were not available. There was no supply of Oral Pills since 2 years in PHC Khoiram and Vitamin- A syrup in PHC Pallel. 8. Opinion and awareness of the Community on the Health Services:

(i). ANMs Services: a. 20 mothers having child up to one year age were interviewed for assessing their opinion and knowledge about the services provided by the concerned ANMs at Sub Centre level. Mothers were satisfied with the services. b. Most of the interviewed mothers were not aware about danger signs of ARI, use of ORS and use of contraceptive and its side effects. Post natal services were also found poor in the area of Sub Centres Sora and Irengband.

(ii). HW (M) Services:

Though the villagers in area of Sora and Irengband Sub Centres were satisfied generally with the services of MPW (M), their dissatisfaction was mainly towards not staying at sub centre headquarters, irregular visiting the villages and also the services relating to environmental sanitation, group meeting on health topic and STD / HIV/AIDS etc.

(iii). Services of PHC:

a. In the area of visited PHC at Khoiram, the RCH beneficiaries i.e. pregnant women, recently delivered mothers, mothers with two years old child etc. and local persons who generally use the services at PHC were contacted to know the overall function of PHC. It was observed that the services in respect of early registration of ANC, 3 Ante Natal checkups, referral transport, awareness of sick new born care and motivation about uses of contraceptive etc. needed to improve in the areas of PHC visited.

b. The Medical officer at PHC Khoiram was not visiting villages regularly.

9. Sample Verification of F.W. acceptors: a. The team selected a total of 22 F.W. acceptors for sample verification and all cases were contacted. b. Among the contacted acceptors, 20 (80%) informed that they did not receive any follow up service. c. 59 beneficiaries of BCG/ DPT/ Polio, Measles and Vitamin- A was selected and out of that 46 (71%) beneficiaries were contacted. All contacted beneficiaries had received doses. Only 12 (26%) beneficiaries were provided follow up services by health staff. d. No sterilisation operations have been performed in the whole district due to absence of Surgeons and Anesthetists. This situation is very serious and early action may be taken to improve the situation.

10. Reconciliation of the reporting performance: a. Figures reported by the district and those at the individual centres for Oral Pills and Nirodh did not tally with each other. The details are given below: Name of the During the year 2010-11 Centres Oral Pills distributed in cycle Condoms distributed in pieces District Reporting District Reporting office Centres office Centres CHC Yairipok 288 NA 3210 NA PHC Khoiram 150 35 130 47 PHC Pallel 34 37 121 138 PHC Lilong 51 61 1470 157 During the year 2011-12 CHC Yairipok 70 NA 760 NA PHC Khoiram 27 27 33 63 PHC Pallel 13 14 70 80 PHC Lilong 17 50 440 1016

b. Further, the Institution wise reported figures by district office for CuT did not tally with the reports available at CHC Yaripok and PHC at Lilong for the year 2010-11 & 2011- 12 and PHC Pallel for 2011-12. 11. Registers, records and reports maintained at the visited Centres: a. In the visited Sub centres and PHCs/CHC, service registers in respect of Eligible Couple survey, Family Planning, ANC & PNC and Stock register of family welfare were not maintained properly. b. Annual District Health Plan (ADHP) for the current year 2011-12 have been prepared at district level only and transmitted to higher authority in proper time but the same was not prepared by visited CHC, PHCs and Sub centres. c. Printed register for Family Planning, ANC, PNC and Child immunisation etc. were supplied to all facility level, but maintenance of these registers was found very poor. d. Monthly performance report in HMIS format was sent through web based system at district level only. However, visited PHCs were not sending their on line reports, because internet facility was not provided there.

12. Miscellaneous Observation and Suggestions: a. Routine Immunisation programme was conducted on regular basis. But Records/ registers reflected that most of the children were not fully immunized and doses were not given in proper time. It was observed that involvement of ASHAs and ANMs is poor. b. The team observed that coordination between existing regular officials and contractual officials was absent which is affecting performance of the programmes. For example, in some of the of Sub centres regular ANMs was not serious about their work while the contractual ANM has to carry out all responsibilities.