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Home , Pulwama district

Jammu and 1) , Sophian

Major observations of Regional Evaluation Team, Bangaluru about the Evaluation work in Sophian District of & Kashmir in April, 2010.

I) Details of the visited Institutions:

District CHC/PHCs Visited HSCs Visited Visited Sophian CHC:Keller Gulshanabad, Qusbayar, Borihalan and Memender PHCs : Sedow and Vehil

II ) Major Observations

1. Human resources:

a) This Distt. is newly created and carved out from district during 2007. There are many posts of district level officers that are yet to be sanctioned i. e., Dy. CMO, Distt. T. B. Officer, Distt. Malaria Officer, Medical Officer and also District Nursing Supervisor. b) 12 out of 19 Posts of specialists of senior grade and 6 out of 10 posts of Community Health Officers were lying vacant. There are 4 blocks in the and posts of Block Accountants and Block data Asstt. posts were not sanctioned in any of this blocks under NRHM. Hence block programme managers were heavily burdened as they have to maintain accounts as well as information/ data pertaining to 4-5 PHCs and 4-5 Allopathic dispensaries. They have to make JSY payments also. c) 15 out of 75 posts of ANM/ MPW (F), 9 out of 39 posts of Jr. Pharmacists and 6 out of 21 posts of Lab Technician were lying vacant. d) In CHC Kheller 3 out of 7 posts of General Duty Doctors were vacant. 2. Functioning of Rogi Kalyan Samiti (RKS)

a) Rogi Kalyan Samiti has been registered in all the institutions i.e., One District Hospital, 4 sub district hospitals, 4 CHCs and 9 PHCs, in the District.

b) Funds @Rs 2,50,000 at CHC level and@ Rs 1,75,000 at PHC level were being provided every year as RKS corpus, AMG funds and untied funds in the district. Details of funds received and expenditure incurred in this regard are given below:

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Type of For CHCs For PHCs funds 2008-09 2009-10 2008-09 2009-10

(Upto Jan 2010)

Budget Exp Budget Exp Budget Exp Budget Exp

Corpus 7,00,00 3,99,70 7,00,30 4,91,13 13,00,00 5,31,503 16,68,497 8,53,13 fund

AMG 6,00,000 3,95,502 5,04,498 2,88,969 3,39,114 1,90,573 3,48,541 1,65,08 Fund

Untied 3,50,000 1,97,119 3,52,881 2,19,773 3,49,140 1,43,583 4,30,557 2,83,57 fund

c) In both the visited centres, viz. CHC Kheller and PHC Sedow meetings of RKS were being held regularly and funds were also being utilized after taking approval of the committee members as per norms. RKS conducts meetings of its members and take approval before incurring expenditure on the developmental activities of institution, such as making alterations, partitions, repair works purchasing of equipments, medicines, furniture etc.

3 Functioning of Village Health and Sanitation Committees (VHSCs):

It was reported that 87 VHSC has been set up in the district. Panchayats were not functional in the state as, no election was held for panchayats. Bank accounts to operate the VHSC funds were also not opened. Therefore budget is not released to the VHSCs. No activities were undertaken by VHSCs, since inception of the programme.

4. Janani Suraksha Yojana (JSY) a) Women belonging to BPL, SC/ST category family only are eligible to receive JSY cash incentive @ Rs. 500 per case for home deliveries. Above poverty line women are not eligible for JSY if delivery takes place at home. b) All category of women of are eligible for incentive for institutional delivery. Women of Urban Area are paid @ Rs. 1000 and Rural Area @ 1400 per case for institutional delivery. c) J & K being a high focus state, there is no restriction of number of deliveries for JSY cash payments; even higher order births / deliveries are also eligible for JSY cash incentives. d) ASHA gets Rs. 600 per case, if she accompanies the present mother to institution and be with her up to the completion of delivery. e) Over a period, there has been decline in the number of home deliveries and increase in the institutional deliveries. In the district, 7,793 deliveries were conducted in 2008-09. Out of them 156 were paid with JSY cash incentive. In the year 2009-10, out of total 7547 deliveries were conducted, payments were made to 2442. Total budget available for 2008- 09 was Rs. 47, 00, 000 and in 2009-10 Rs. 47,0053,40 and an expenditure of Rs. 1000660 was incurred during the year 2008-2009 and Rs. 40, 71, 450 in the year 2009-10.

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f) In the district, as there were no funds under JSY during 25/6/2007 to 10/2/09, payments were made to less number of beneficiaries during 2008-09. The district has decided not to take up the old cases for payments. g) Totally, 29 JSY beneficiaries were contacted in the field. It was observed that they had received full JSY cash incentive; MCH cards were issued to all and also ANC/PNC visits were made by ANMs. 5. Untied funds: a) The total budget for Untied funds including opening balance for the district was Rs. 10,46,500 in 2008-09 and Rs 11,29,881 for the year 2009-10. An amount of Rs 4,36,619 in 2008-09 and Rs. 4,10,791 was spent during 2009-10 respectively.. b) Apart from above untied fund for CHC and PHCs in the district, Untied fund were also released to all the sub centres @ Rs.10,000 per SC per year. c) In the visited SCs visited, the allotted amount could not be spent in time as the same was released only just before the closing of the financial year.

6. Services of ASHA : a) In the district there are 334 villages having a rural population of 3, 42, 581. 320 ASHAs were selected, trained and provided with drug kits upto the end of 2009-10. All of them are functioning in the field 30 New ASHAs were proposed to be inducted in 2010-11. b) An amount of Rs.32, 48, 00 in 2008-08 and Rs. 7,95,150 in 2009-10 was spent towards performance based remuneration to ASHAs . c) During field visits, in the selected PHCs, 19 ASHAs were interviewed. All have stated that they were getting the remuneration regularly . 7. 24 hour delivery care system: a) In the district all 4 CHCs were functioning as 24 hour delivery care institutions. None of the PHCs was functioning as 24x7care institution there was no separate budget released to these centres under this head of account. b) The visited CHC at Kheller was functioning as 24X7 delivery care institution. It has 7 Medical Officers and 11 Staff Nurses. CHC Kheller reported 57 deliveries in 2008-09 and 327 deliveries in 2009-10, It is a remarkable improvement in the number of deliveries. 8. Physical infrastructure and Stock position: 1) CHC: a) As newly created district, CHC Sophian is proposed to be upgraded to Distt. Level Hospital. At present all 4 CHCs in the district are functioning in Govt. Building. In CHC Kellar, Blood storage unit and incinerator facility were not set up. Neo natal resuscitation equipment was available but pediatrician post was vacant. OT was not functional. Telephone and vehicle facility was not there. b) Residential quarters for doctors and para medical staff were not available.

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ii) PHC

There are 9 PHCs in the district, out of them 6 were functioning in Govt. building and 3 were working in private rented buildings PHC visited of Sedow was functioning in Govt. building. Residential quarters for doctors and para medical staff were available. AYUSH MO under Unani was posted in the PHC. Stocks of vaccine, drugs and contraceptives were available.

(iii) Sub Centres a) Four Sub centres at Gulshanabad, Qusbayar, Borihalan and Memender were visited for on the spot verification of infrastructure and stock. b) Sub centre at Borihalan was functioning in Govt. Building and other 3 SCs were functioning in rented buildings Labour room was not available in any of the SCs visited. c) Examination table, delivery table, Mclntch sheets, Ambu bag, steam sterilizer, weighing machine(infant ) and BP Appratus were not available at Qusbayar & Borihalan sub-centres. Gulshanabad and Memender Sub-centers had no delivery table, delivery kit, Ambu bag, and IUD insertion kit etc. d) Drugs and other items like Thermometre, IUD, EC pills, Clorin solution, DDK, Gloves, Antiseptic solution, Injection Gentamycin etc. were also not available at Qusbayar and Borihalan among the visited sub-centres. 9. Opinion and Knowledge of Community on Health Services: a) In each of the 4 SCs visited, total 40 mothers having child up to one year of age were interviewed to assess their knowledge and opinion on the services rendered by ANMs. b) 36 (90%) respondents were not aware about danger sign of and 32(80%) mothers did not have the knowledge about advantages and side effects of contraceptive uses. c) Out of the contacted mothers, in 77% cases deliveries were institutional and 67.5% mothers received 3 PNC services. d) 10 villagers interviewed to assess their opinion about the performance of MPW (M). Villagers, Village leaders and School Teachers have expressed their satisfaction towards services of Male worker at PHC Vehil. He had achieved the target for blood sample collection and motivating persons for FP. In this SC, ANM and Pharmacist posts were vacant, since last 2 years MPW (M) has done outstanding work under NRHM Programme. e) Public opinion was good on the services being rendered by the PHCs visited by the team. Villagers expressed satisfaction on the overall functioning of PHCs. 10. Sample Verification of FP acceptors: a) Total performance of the district is very less as the entire district is in hilly area with scattered houses.

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Total Family Planning performance in the district: Year Sterilization IUD OP Cycles CC pieces 2008-09 158 481 2998 10576 2009-10 204 363 4744 18384 b) Out of 40 FW acceptors selected for sample verification 32 could be contacted for verification. Some discrepancies were seen in recording of total number of children and number of male children. Maintenance of records and registers at SC level: a) Sterilization, IUD and JSY beneficiaries registers were available only at block level. This record was not available at PHC/SCs. Registers like EC registers and stock registers were not updated at most of the visited centres. b) JSY Register maintained at PHCs and SCs has no information about place of delivery. Details of no. of living children, date of delivery, palace were also not recorded. Though printed JSY registration card was available in some SCs the same was not used.

11. Miscellaneous Observations and Suggestions:

a) No funds were given for office expenses to Block Programme Management unit. The BPMs had to spend their own money for office expenses for taking Photostat copies and for monitoring tours. No TA and DA are paid for block level persons. b) As per GOI pattern, each SC should have one MPHA (M) but in some of the visited SCs of Sophian district, the team observed that each SC is having staff as one pharmacist, one ANM/HW(M) and one safaiwala. It was observed that pharmacist work at the SC level is not justified as there is only 5-10 OPD cases per day at the SC and maintenance of drugs stock position at the SC is also not significant. c) The staff working under DPM Unit and BPM unit stated that the recent hike in salaries, the hike for all other category staff such as Doctors, Staff nurse, Para medics etc was 100% where as for the DPM and BPM unit it was only 10% hike. This may be locked into. d) Over a period, there has been decline in the number of home deliveries and increase in the institutional deliveries. In the district 7793 deliveries were conducted in 2008-09, out of which 3109 deliveries were conducted at home which comes around 40% of the total deliveries. Similarly, in the year 2009-10, out of total 7547 deliveries, 1847 (25%) were conducted at home Number of institutional Deliveries have been increased from 60% to 75% during the above period due to JSY incentives. But most of the home deliveries are done by Dais and not by ANMs. Female Multipurpose Health workers have not attempted or conducted any delivery.

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2 District

Major observations of Regional Evaluation Team, Bangaluru about the Evaluation work in of Jammu & Kashmir in April, 2010.

I) Details of the visited Institutions:

District CHC/PHCs Visited HSCs Visited Visited Kulgam CHC:Kulgam Chidar, Redwani, Chogulpora and PHCs:.Manzgam, K. B. Pora, Kaimoh Gandhiwani

II) Major Observations

1. Human resources:

a. This District is a newly created district carved out from Anathnag district during 2007. There were still many posts of district level officers which are yet to be sanctioned. The district has 5 blocks and posts of block level Block Accountants and Block Data Asstt. Posts are not yet to be sanctioned. Block programme managers are heavily burdened as they maintains accounts as well as data pertaining to 4-5 PHCs and 4-5 Allopathic dispensaries. They have to make JSY payments also. b. 13 out of 21 posts of Jr. specialists and 5 out of 11 sanctioned posts of LHVs were lying vacant in the distict. c. In the visited PHC at Mazagaon, both posts of the regular MOs were vacant. PHC is being run by two doctors on contract basis under NRHM ( one Allopathic and 1 Unani doctor). 2. Functioning of Rogi Kalyan Samiti ( RKS)

a) Rogi Kalyan Samiti has been registered in all 4 CHCs and 19 PHCs in the District.

b) RKS funds @ 2,50,000 at CHC level and @ Rs 1,75,000 at PHC, level were being provided every year as corpus, AMG funds and untied funds in the district . The total budget for CHC level RKS and PHC level RKS from the following table:

Type For CHCs for the year For PHCs for the year of fund s

2008-09 2009-10 2008-09 2009-10

(Upto Jan 2010) (Upto Jan 2010)

Budget Expdr. Budget Expdr. Budget Expdr. Budget Expdr.

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Corpu 40000 33510 46489 46258 180000 177178 192821 188234 s 0 1 9 7 0 2 8 2 fund

AMG 40000 36877 43122 42940 450000 450000 600000 563642 Fund 0 2 8 8

Untied 20000 14973 25026 25026 450000 441482 483518 454892 fund 0 7 3 3

c) In the visited centres , viz. CHC Kulgam , PHC and PHC Mazagam meetings of RKS were being held regularly and funds were also being utilized after taking approval of the committee members as per norms. 3. Janani Suraksha Yojana (JSY)

Home Deliveries: a) Women belonging to BPL, SC/ST category family only are eligible to receive JSY cash incentive @ Rs. 500 per case. Above poverty line women are not eligible for JSY Payment if delivery takes place at home. b) Institutional Deliveries: Category of women are eligible for incentive, Women of Urban Area are paid @ Rs. 1000 and Rural Area @ 1400 per case c) J & K being the high focus state, there is no restriction of number of deliveries for JSY cash payments; even higher order births/ deliveries are also eligible for JSY cash incentives. d) ASHA gets Rs. 600 per case, if she accompanies the pregnant mother to institution and be with her upto the completion of delivery. e) In the district, 4922 deliveries were conducted in 2008-09. Out of these, JSY cash incentive was released to only 576 cases as the funds was released late. In the year 2009-10 (Upto Dec 2009) 5775 deliveries were conducted. Payments were made to 5143 beneficiaries. Total budget available for 2008-09 was Rs. 4,00,0,000 and in 2009- 10 it was Rs. 75,68,650 .An expenditure to the tune of Rs. 8,12,800 was incurred during 2008-09 and Rs. 68,76,724 in the year 2009-10 (Upto Dec 2009) f) Totally, 31 JSY beneficiaries were contacted by the team in the area of visited institutes. All the beneficiaries stated that they received full JSY cash incentive; MCH cards were issued to them and ANC/ PNC visits were made by ANMs. 4. Untied funds: a) The total budget for Untied funds for CHCs in the district was Rs. 2,00,000 for 2008-09 and Rs 2,50,263 for the year 2009-10. Expenditure to the tune of Rs 1,49,737 was incurred in 2008-09 and Rs. 2,50,263 was spent during 2009-10. Untied funds for PHCs in the district was Rs. 4,50,000 for 2008-09 and Rs 4,83,518 for the year 2009-10. Expenditure to the tune of Rs -

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4,41,482 was incurred in 2008-09 and Rs. 4,54,892 was spent during 2009-10 (Upto Jan 2010). Untied funds are given at the disposal of RKS. b) Apart from above untied fund for CHCs & PHCs the district had also received Rs. 8,10,000 during 2008-09 and 2009-10 as untied funds for strengthening the services of SCs . c) In the visited SCs, untied funds were not spent in time because as the same was released just before closing of the financial year (2009-10).

5. Services of ASHA : a) In the district there are 406 villages having a rural population of 6,60,291. Presently, 629 ASHAs were functioning, trained and provided with drug kits . There was a proposal for induction of 100 more ASHAs in 2010-11 b) In the year 2008-09, an amount of Rs.4,42,900 was spent towards the performance based remuneration to ASHA and an amount of Rs 17,39,230 were spent during 2009- 10 for the same purpose. c) During field visits, in the selected PHCs, 21 ASHAs were interviewed. All have stated that they were getting the performance based remuneration regularly. However, It was also stated that early child registration honorarium @ Rs. 50 per case was not being paid since 2008-09. d) It was observed that ASHAs have to visit Block Medical officer for review of work but TA / DA for this visit is not being paid, as practiced in other states. 6. 24 hour delivery care system: a) In the district, 4 CHCs and 12 PHCs were functioning as 24 hour delivery care institutions. There was no separate budget released to these centres in this regard. b) The visited CHC Kulgam and PHCs at Kaimoh and Mazagaon were functioning as 24X7 delivery care institutions. CHC Kulgam has 7 Specialists, 6 Medical Officers and 7 Staff Nurses. It conducted 1,444 deliveries during 2009-10; PHC Kaimoh has 2 doctors and 2 staff nurses and it has been conducted 136 deliveries. PHC Mazagaon has 2 doctors and 3 staff nurses but could only conduct 23 deliveries which is far below the stipulated number of 120 deliveries year for a 24X7 centre.

7. Physical infrastructure and Stock position: I) CHC/PHC:

a) CHC/at Kulgam, PHCs at Kaimoh and Mazagam were functioning in Govt. buildings. These centres were well equipped. Stocks of essential and desirable drugs were available. They were designated to work as 24X7 delivery care institution.

b) Incinerator was not available at CHC Kulgam.

(iii) Sub Centres a) Sub centres at Chidar, Redwani, Chogulpora and Gandhwani were visited for physical verification. Sub centre at Chogulpora was functioning in Govt. building and other 3 SCs in

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rented buildings. ANMs were not staying at the Headquarters. Labour room was not available in any SC.

b) Examination table, delivery table, Mclntch sheets, Ambu bag, steam sterilizer and weighing machine (infant) were not available at Chidar and Chogulpora sub-centres. Redwani and Gandhwani SCs had no delivery table , delivery kit, Ambu bag, and IUD insertion kit etc. c) Drugs and other items like Slides for blood test, Thermometer, IUD, EC pills, Chlorin solution, DDK, Antiseptic solution, Injection Gentamycin, etc. were also not available at one or the other visited sub-centre. 8. Opinion and Knowledge of Community on Health Services:

a) In the 4 SCs visited, total 40 mothers of having child up to one year of age were interviewed to assess knowledge and opinion on the services rendered by the ANMs .

b) 35(87.5%) respondents were not aware about danger sign of ARI and 31(77%) mothers did not have knowledge about advantages and side effects of contraceptive uses. c) 26(65%) deliveries were institutional and 27(67.5%) out of 40 mothers received 3 PNC services. d) In all the visited SCs, MPW (M) post was vacant. e) Public opinion was good on the services being rendered by the PHCs/ visited by the team. Villagers expressed satisfaction on the overall functioning of PHCs. 9. Maintenance of records and registers at SC level: a) Eligible couple Registers Sterilization Registers, IUD registers and stock registers were not found maintained in the visited PHCs viz. K.B.Pora, PHC Manzagam, and PHC Kaimoh. b) JSY Register maintained by PHCs and SCs has no information on place of delivery, Date of delivery, number of living children etc was not recorded. Though JSY registration cards were available in some SCs they were not being used. 10. Miscellaneous Observations and Suggestions: a) The national NRHM ratio of 1 ASHA /1000 Population is fine in the many other states which have higher density of rural population located in plain and easily accessible villages may require 1 ASHA/500 Population. This would ensure better coverage. The state authorities may kindly look into this. b) MPHW (M) & (F) / Pharmacists at SCs are not doing any field work. No follow up for FW cases and ANC/PNC cases were done. c) FP performance is very poor in the district. In the entire district only 36 sterilization cases during 2008-09 and 66 cases during 2009-10 were reported which required attention.

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3) District Samba

Major observation of Field Survey Unit (FSU) of Regional office for Health & Family Welfare, Jaipur about evaluation work in of J & K State in the month of November, 2010.

I) Details of the visited Institutions:

District PHC /CHC visited HSCs visited visited Samba CHC: Ramgarh Rigal, Manguchack, Chachawal, PHC: Sanoora and Mandal, Khara and Sandhi Purmandal :

II) Major Obervations

2) Human Resources: Posts of large number of specialist were vacant in Samba district. 21 posts of specialist as against 34 sanctioned posts and 17 posts of Assistant surgeons out of 57 sanctioned posts were lying vacant in the district. 3) Functioning of Janani Suraksha Yojana (JSY): a) JSY was implemented in the district since April, 2008. 2737, 3854 and 2039 institutional deliveries were conducted under JSY during 2008-09, 2009-10 and 2010-11 (upto Oct. 2010) respectively. Thus the quantum of institutional deliveries has gone up due to JSY. The district received sufficient funds under JSY scheme. b) In the visited CHC at Ramgarh and PHCs at Sanoora and Purmandal, the services under JSY were being provided to the beneficiaries satisfactorily. There were sufficient funds for proper functioning of JSY. The Cash book was properly maintained at the CHC and PHCs. c) The visited Sub-Centres at Rigal, Manguchack, Chachwal, Mandal, Khara and Shandhi were accredited for JSY but these centres were lacking Labour room facility and therfore, deliveries were not conducted. Most of the SCs were functioning in rented building except Sub centres Rigal and Chachwal which were functioning in the Govt. building. d) The team observed that the transportation amount to the JSY beneficiaries who were not accompanied by ASHAs was not paid by MO (I/C) in PHCs Sanoora and Purmandal.

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4) Untied Fund:- a) The District authority received the grant from the State authority under flexi pool for JSY, Untied fund, VHSC fund and AMG etc. CHC, PHCs and sub-centres were receiving untied funds regularly and utilising it. b) In the visited CHC Ramgarh, Rs. 2, 00,000 as AMG was provided in year 2009-10 and the same was utilised fully during the year. During the current year 2010-11 Rs.1,00,000 was received by the CHC and out of it an amount of Rs. 24,562 was spent upto Oct. 2010. c) In the visited PHCs at Sanoora and Purmandal, the untied fund @ Rs. 25,000 was given annually in the year 2009-10 and in the current year 2010-11. The allotted funds were not fully utilised by the PHCs during the year. AMG @ Rs. 50,000 was allotted to PHCs Sanoora and Purmandal each during 2009-10 and 2010-11 and the amount was fully utilised. d) During 2009-10 and 2010-11, the SCs visited at Rigal, Mangu, Chachawal, Mandal and Khara received untied funds @ Rs. 10,000 each year respectively and the fund was utilised except the SCs Rigal and Manguchack during 2010-11 till the month of Oct. 2010.

5) Functioning of Rogi Kalyan Samitis (RKS): a) RKS has been constituted in 15 centres in the district but the information related to RKS meetings held was not available at district level. b) During visit to CHC Ramgarh, it was observed that the RKS was formed but its meetings were not held regularly. Expenditure statement regarding untied fund, AMG etc. was maintained properly at CHC Ramgarh. c) The RKS was formed at the PHCs Sanoora and Purmandal, but the RKS meetings were not held regularly in these PHCs and expenditure and funds position was not made available to the team at the time of visit.

6) Services of ASHA Scheme: a) As against the requirement of 294 ASHAs for 250 villages in the district 269 ASHAs have been selected up to the visiting month and all were equipped with drug kit. Out of these, 223 ASHAs received 5th module training. None of the ASHA was a DOTS provider.

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b) In the visited SCs viz., Rigal, Mangu chack, Chachawal, Mandal and Khara, it was noticed that All ASHAs received training up to 5th module. In all these sub-centres, ASHA did not prepare Micro birth plan and the list of adolescent girls of her area. c) None of the ASHAs provided transport facilities to the pregnant women and the transport amount received by ASHA was not given to JSY beneficiaries escorted by them. Institutional deliveries were conducted in these SCs and they accompanied most of the pregnant women for institutional deliveries.

7) Village Health Sanitation Committees (VHSCs): a) In the district, 386 Village Health Sanitation Committees (VHSC) had been set up and ASHA was a member in all the VHSC. For recording the proceedings of VHSC, printed register was not given to ASHA. It was reported that documentation of the VHSC meeting was not properly maintained at visited sub-centres. b) During visit to the VHSCs in the area of sub-centres Mandal, Khara, Rigal and Manguchack, various irregularities in the functioning of VHSCs were noticed. The fund for VHSC is not disbursed to the visited sub-centre. The ASHAs and MPW (F) were unaware about the role & responsibilities of VHSC. c) The roles of VHSC were not satisfactory. The fund for VHSC was not allotted to all the visited sub-centres. Proceedings of VHSCs meetings are not recorded by ASHA. No regular meetings organised. No work was done in the villages in respect of Village health & sanitation. During the field visit to Rigal sub-centre, it was noticed that at some places the drains and dirty water was spreading in the lane in front of some houses but such sanitation issues were never discussed in VHSC meeting.

8) 24 hour delivery care system: a) In the district, there is only one CHC at Ramgarh. Despite being a FRU, the CHC Ramgarh did not have functional Blood Storage Unit and was functioning as 24 x 7. It had well equipped labour room. b) In addition, out of 13 PHCs in the district, 3 PHCs were declared 24x7 hour services but the visited PHCs were not working as per guidelines of 24x7. c) At the PHCs Sanoora and Purmandal, the delivery load was very low. It is important to note that no delivery was conducted in night hours since 2008-09 at both PHCs Sanoora and Purmandal because of three reasons, (i) the hospital hour was 10.00 A.M. to 4.00 A.M., (ii) most of the staff were residing in Jammu and other places and (iii) there was no efforts by the staffs to make the institution functional for conducting deliveries. The PHCs were lacking in some infrastructural facilities viz., shortages of rooms, beds, benches, counter for condoms, toilets for staff, curtains for privacy for the patients and benches etc. 9) Physical infrastructure: i) CHC:

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a) Visited CHC at Ramgarh was located in Govt. Building and was having regular water supply and electricity. It was a 20 bedded CHC. The physical infrastructure of the CHC was good. The cleanliness and IEC display was also good at the CHC.

b) The drug position was found satisfactory and neonatal Resuscitation Equipments, Anaesthesia Equipments were available at the CHC Ramgarh. ii) PHC: a) The PHCs at Sanoora and Purmandal were having Labour room. The delivery load at both the PHCs was very poor and in spite of the availability of the services of Gynaecologist at Purmandal PHC, the performance in terms of delivery was very poor. The post of Lab Technician was vacant at PHC Sanoora. b) Both the PHCs had adequate infrastructure & human resources for 24x7 services. There was shortage of quarters for MO and other staff. c) There was no toilet facility at PHC Purmandal, but the same was available at the PHC Sanoora. Both the PHCs were not as per IPHS. d) It was observed that both the visited PHCs viz. Sanoora & Purmandal did not have Functional Operation Theatre with OT table. e) Some of Prophylactic Drugs like IFA Syrup & Vitamin-A Tab etc. were also not available at both the PHCs. iii) Sub-Centres: a) It was observed that the cleanliness at sub-centre viz. Rigal, Mangu chack, Chachawal, Mandal and Khara was good. Only 2 SCs were functioning in Govt. Buildings. b) The labour room was available at all the visited SCs. Cupboard for drug and Anticeptic solution were not available at the SCs Khara and Sandhi. c) At Mandal sub-centre Nishchy kit and condom was not available. IUD was not available at Khara sub-centre. Steam sterilizer was not available at Khara, Rigal and Mandal sub-centres. DDK was not available at all the visited sub-centre and delivery kit was not available at Mandal and Rigal sub-centres. The infant weighing machine was not functional at Rigal sub-centre. Cap Ampiciline and Inj. Gentamycine were not available at Khara and Mandal sub-centres.

10) Community Satisfaction / Opinion: a) The team contacted 40 mothers to know the awareness of various health parameters and all of them informed that ANM was available when they needed. b) Deliveries of 34 contacted mothers were conducted by the trained persons. 3 (7.5%) mother were visited by

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the health personnel with in 24 hour after delivery, 15 (37.5%) were visited within 3 days, 20 (50.0%) were visited within 7 days of delivery and 2(5.0%) after 7 days. c) 14 (35.0%) out of 40 contacted mothers had given breast feeding within half an hour and rest 26 (65.0%) within one hour or more. 38 (95.0%) mothers were aware of breast feeding and complementary feeds. d) ARI awareness was found in 20 (50.0%) mothers. 30 (75.0%) mothers knew the use of ORS. All the mothers were having Contraceptive awareness, but the knowledge of its side effects was not known to all mothers. e) The team visited the PHC of Sanoora & Purmandal and evaluated the opinion of the public on their functioning. The Public of Sanoora & Purmandal PHCs was dissatisfied with the functioning of the PHC. Some people informed that after 4 PM no staffs are available for attending emergency and the staffs was not taking interest to conduct the delivery at the PHC in day time also. It was observed that in some cases the delivery conducted during day time were discharged before 4 PM on the same day of delivery. 11) Maintenance of Records and Registers: a) It was observed that ANC & Immunization record registers were available at the SCs visited. b) The record maintenance needed further improvement at the visited CHC/PHCs/SCs. The register like EC register, Sterilization, IUD, OP, CC Stock register were not properly maintained at visited sub-centres. b) All the available registers were not regularly checked by the supervisory officers. c) Case cards for Cu-T were not maintained at the visited centres or at the reporting units. 12) Other Observations and Suggestions: a) As none of the visited SCs was having labour-room, mothers have to go to the district hospital for delivery. Most of the SCs of the district were running in the rented rooms. So, all SCs should be provided proper infrastructures. b) The meetings of RKS should be held regularly. c) The citizen charter was not displayed at the visited PHCs Sanoora and Purmandal. The complain & suggestion box, separate counter for Condom and OP was also not available at all the visited PHCs.

d) The visited 24 x 7 hours services needed to be strengthened at PHC level and prompt action should be taken to restrict the flow of pregnant women from 24 x 7 PHC areas to district hospital of Samba & Jammu. The district authority should ensure that all the staff stay at the HQ particularly at 24 x 7 institutions.

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4)District

Major observation of Regional Evaluation Team, Patna about the Evaluation work carried out in of Jammu and Kashmir State during June 2010.

I. Details of the visited institutions:

District Visit CHC and PHC Visited HSCs Visited

Anantnag CHC – Fhatepura, Nawgawan and Akoora

PHC – Verynag and Mattan

II. Major findings

1) Health Human Resources: Most of the sanctioned posts of Medical and Para Medical were filled up in the district.

2) Rogi Kalyan Samiti (RKS) & Village Health and Sanitation Committee (VHSC): i) As reported, RKS has been registered at all the institutes i.e, District Hospital, MCH Centre, 5 CHCs and 26 PHCs in the district. Quarterly meeting of Rogi Kalyan Samiti was regularly being conducted at visited CHC Bijbehara and PHC Mattan but it was observed to be irregular at PHC Verynag. ii) There were 421 VHSCs formed in the district and ASHA was working as a member of VHSC. 3) Services of Janani Suraksha Yojna (JSY): i. Janani Sureksha Yojana has been implemented in the District. However JSY funds were not provided in time and also not sufficient. ii. The payment of JSY beneficiaries were not found updated at the visited centers for 2009-10 and 2010-11. iii. The team contacted 28 JSY mothers and found 6 of them did not receive incentives in time. iv. It is also observed that Transport was arranged by the beneficiaries themselves, transport charges have not been provided to the beneficiaries. Role of ASHA for providing services to the beneficiaries was not found satisfactory. v. Deliveries of all the respondents was normal but PNC follow-up by health personnel was found poor in the field.

4) Functioning of ASHA Scheme: i) 665 ASHAs for 605 villages in the district were selected and all of them received training upto 2nd module, and only 225 ASHAs have been given 3rd module of training. ii) Drug Kits were provided to all selected ASHAs during 2008-09.

5) Untied Funds: i. AS reported, during 2009-10, Rs. 3,00,000 for CHCs, Rs.6,50,000 for PHCs and Rs.11,40,000 for sub centres, as untied funds were provided in the District, out of that Rs.2,59,537 at CHCs level, Rs. ,28,547 at PHCs level and Rs.52,000 at all sub centres level were spent. ii. It was also reported that PHC didn’t utilize the funds; PHC Mattan was not given funds and utilization of funds at visited sub centres was very poor during 2009-10. iii. No untied fund for the year 2010-11 was provided to the CHCs, PHCs and sub centres in the district.

6) 24x7 Delivery Care Service:

i. 24 hours delivery care system was implemented at MCH centre, 5 CHCs and 5 out of 26 PHCs in the district. ii. Adequate facilities for caring mothers and children were available at the visited CHC Bijbehara and PHC Mattan but the same was inadequate at PHC Verynag. Blood Storage was available at CHC Bijbehara iii. It was observed by the team that the strength of Paramedical staff is inadequate at visited PHCs for 24x7 hour services.

7) Physical infrastructure:

a) CHC:

i. CHC Bijbehara, infrastructure was satisfactory. ii. There was no neo-natal resuscitation equipment and some of the drugs were found inadequate.

iii. Residential quarters for Para Medical staff and M.O. were not available in sufficient number.

b) PHC:

i. PHCs Verynag and Mattan have their own buildings with the basic facilities. ii. Telephone, minor surgical equipments, Labour Room and functional operation theatre with OT Table were not available at PHC Verynag. Resuscitation equipments, OT table and residential quarters for MOs were not available at PHC Mattan. c) HSC

i. Sub-Centres Nawgawan and Akoora were functioning in the rented buildings. Basic facilities like water, electricity, toilet, labor room were not available in both the sub centres. ii. Some of the essential furniture, equipments and drugs like examination table, cupboard, delivery table, ambubag, delivery kit, IUD insertion kit, weighing machine, thermometer, co-trimoxazole Ecpills, chlroquile tablet, oxytocin tablet, ampicillin tablet etc. in these centres were not available. iii. Space & facility for conducting deliveries and display of posters on the wall of centres, was lacking there. iv. ANMs were not provided SBA training.

8) Community satisfaction on overall services: i. The team contacted 18 mothers of upto one year old child, they informed that ANMs

were not available as and when needed in both sub centres at Nawgawan and Akoora. ii. The services i.e. baby weighted after birth, use of DDK during home delivery and 3

Post Natal check up; knowledge/awareness regarding danger sign of ARI, proper use

of ORS, contraceptive methods etc. were not found satisfactory as informed by the respondents in the area visited in both sub centres. iii. Community was dissatisfied for want of regular stay of MO at PHC head quarter and

his regular visit to the periphery level villages.

9) Sample Verification of F.W. Acceptors: i. The team contacted 19 (70%) acceptors of Family Planning out of selected 27 in

different centres in the district. During verification, discrepancies were found in the

recorded data i.e. age of spouse in 8 (42%) cases and in the age of last child in 13

(68%) cases.

ii. Follow up services to the 16 acceptors (84%) observed to have not been provided by the health personnel.

10) Reconciliation of reported performance:

i. Reported figures, under IUD, OP and Condom scheme for the year 2009-10 and 2010-11 (up to May 2010-11) available in the district office did not tally with the figures maintained at the visited centres at Verinag, Bijbehara and Mattan. ii. IUD figures at blocks Verinag, Bijbehara and Mattan did not match with the number of cases recorded at service registers for both the years 2009-10 and 2010-11.

11) Maintenance of Registers and Records:

i. Eligible Couple registers and PNC registers were not maintained properly at all the centres visited.

ii. Oral Pills distribution registers were not maintained at PHCs Verinag & Mattan.

iii. Condom service registers were not made available at all the PHCs and CHC.

iv. Incomplete registers of Cu-T were found at the block head quarters visited in the district.

v. Stock registers for FW items were maintained, but without details.

12) Other Observations and Suggestions: i. Contractual staff (MOs, DPM, DAM, Assistant, BHM and Staff Nurses etc.) under NRHM were not receiving their salary from the month of Feb. 2010 in the district. It was also reported that their consolidated monthly salary is much less than the amount prescribed by GOI. District authority may look their grievances. ii. Lack of supervision & monitoring was found at PHC and Sub-centre level; records/registers at PHC/sub-centre level were not checked by supervisory staff on regular basis

iii. Out of 114 sub-centres, only 17 sub centres were functioning in Government Buildings. There was no quarter for ANM and water supply in these centres was also not there. Similarly, 06 PHCs out of 26 PHCs were functioning in private building.

5) District

Major observation of Regional Evaluation Team, Patna about the Evaluation work carried out in of Jammu and Kashmir State during June 2010.

I. Details of the visited institutions:

District Visit CHC and PHC Visited HSCs Visited

Udhampur CHC – Ramnagar Bilaspur Dhema, Battal and Mand

PHC – Majalta and Tikri

II) Major Observations

1. Human Resources:

i) District was facing hardship in providing effective health care delivery to the people due to large no. of vacant posts. 52 of 115 sanctioned posts of Medical officers, 6 out of 40 posts of Lab. Technicians, 4 of 5 BEE posts and all 5 sanctioned posts of MPW (M) were lying vacant in the district. ii) Post of District Programme Manager (DPM) under NRHM was vacant.

2. Functioning Rogi Kalyan Samiti (RKS) and Village Health and Sanitation Committee (VHSC): i. Rogi Kalyan Samitis have been constituted in all 21 PHCs, 2 CHCs and District Hospital in the District. ii. In the visiting centres, it was found that RKS meetings were being conducted on quarterly basis regularly. iii. 360 VHSCs were constituted in the district and all VHSCs were having ASHA as a member.

3. Functioning of ASHA Scheme:

i. Out of 488 ASHAs selected in the district, 427 ASHAs were in position presently. ii. All ASHAs given 5 Module of training and also provided with Drug Kits.

4. Untied Funds

i. An amount of Rs. 1,00,000 was provided to 2 CHCs as untied funds during 2009-10 and they have utilized Rs.80,780 for strengthening the services. The fund was not provided in 2010-11 till the time of visit. ii. As per the district report, a provision of untied fund of Rs.5,25,000 was made during 2009-10 for PHCs and an amount of Rs.6,94,206 (including previous year balance) was utilized for strengthening the services at PHC level. No fund for the year 2010-11 was provided till the visit of the team. iii. As reported, an amount of Rs.6,91,512 was provided in 2008-09 and it was utilized in the year 2009-10. Similarly, Rs. 97,000 which was sanctioned for the year 2009-10 was released in the month of June during financial year 2010-2011. It was also reported that utilization of untied funds at sub centre level is very poor.

5. Services of JSY:

i. During visit to the various centres in the district, it was found that the services under Janani Suraksha Yojana are being provided to the people in proper way. ii. Sufficient funds under the scheme were provided to all centres in time. iii. Due to incomplete documents, the payments to 404 JSY beneficiaries for the year 2009-10 could not be settled. iv. The team contacted 16 JSY beneficiaries and they had been provided with the JSY incentives at the time of discharge from the hospital. Transport charges were also paid in time to the beneficiaries. 6. 24 hours delivery care Services

The services were available in 2 CHCs and 6 out of 21 PHCs in the District. Manpower in the

Facilities for caring mothers and children was available but Doctors/Specialist and some Paramedical staff for providing 24x7 services was found inadequate at visited Block PHCs. Blood storage facility was available at CHC Ramnagar.

7. Physical infrastructure a) Sub Centres: i. Both the sub centres at Battal and Mand were functioning in their own building. Labor room was not available at Battal. ii. Furnitures & equipments like Ambu bag /Suction, Steam Sterilizer, Torch, Stove and Infant Weighing Scale were not available in Battal Sub centre and IUD Insertion Kit, Torch and Stove were not available in Mand sub centre. iii. Drugs like DDKs, Emergency Contraceptive Pills, Clorin Solution (Bleaching Powder), Metronidazole Tablets, Oxytocin Tablets and Gentamycin Injection were not available in Battal Sub centre. In Mand Sub centre drugs like Emergency Contraceptive Pills, and Oxytocin Tablets were not available.

b) CHC/PHC:

i. Residential quarter for Doctors and Para Medical staff were not found in CHC Ramnagar. Supply of essential drugs was also inadequate. ii. Operation Theatre in PHC Majalta was being used for OT cum labor room as there was no separate Labour room. iii. Functional Operation Theatre was not available at Tikri PHC. Residential quarters need repair in this PHC.

8. Community Knowledge and Opinion on Health Services: a) ANMs Services i. As many as 18 mothers having child upto one year old were interviewed in the area of Sub-centres at Battal and Mand and found that they were unhappy with irregular availability of the ANMs. ii. Awareness about the use of DDK during home delivery, 3 Post Natal check up, knowledge on ARI and contraceptive methods was not upto the mark among the respondents in both the Sub-centres. b) PHC Services

In the area of PHCs Majalta and Tikri, knowledge and awareness of some of the beneficiaries on ANC/PNC danger sign of sick newborn, contraceptive methods, referral services and STD/HIV-AIDS were poor. The contacted local persons who utilize the services in PHCs expressed their dissatisfaction on irregular stay of MO at PHC headquarter and also irregular visit of Medical Officer in the village area. .

9. Sample Verification of Family Welfare Acceptors:

i. 66 FW acceptors were selected for sample verification, out of that 46 (69.6%) acceptors were contacted. ii. During verification, discrepancies were found in the recorded data i.e. age of spouse in 24 (52%) cases and in the age of youngest child in 23 (50%) cases. iii. No follow up services were received by 32 acceptors (70%) by the health personnel. 10. Reconciliation of the reporting performance:

Performance figures reported under sterilization, IUD OP and Nirodh of Family Welfare methods for the year 2009-10 and 2010-11 by the District and Block headquarter did not tally each other. The number of beneficiaries was also not equal as recorded in the service register.

11. Maintenance of Records and Registers i. Eligible couple survey register and PNC service register were not maintained at all the visited centres in the district. ii. Cu-T service register, Oral Pills service register, Condom service register and FW stock register were not maintained properly. iii. Cu-T performance could not be verified for want of complete service registers at visited CHC/Block PHCs. iv. ANC & Child Immunization registers were properly maintained with all necessary details at visited Centres. v. PNC register was not maintained at any institution

12. Other Observations:

i. Lack of supervision & monitoring was found at PHC and Sub centre level. Record keeping

and maintenance of records/registers at PHC/Sub-Centre level were not checked by

supervisory authority.

ii. Additional ANMs where required have not been sanctioned in the district even though there

is provision under NRHM. iii. Out of 114 Sub-Centres, only 33 Sub-centers were having its own government

accommodation, while rest 81 Sub centers were functioning in private building. In the same

manner 06 PHCs out of 21 PHCs were functioning in private building.