1 Andhra Pradesh 1. District Chittoor Major Observations of Regional

Andhra Pradesh 1. District Chittoor

Major observations of Regional Evaluation Team, Banglore about the Evaluation work in Chittoor Districts of Andhra Pradesh, in June- 2009. I. Details of the visited Institutions: District PHCs Visited HSCs Visited Visited Chittoor PHCs:G.D.Nellore, V. Kota, D.M.Puram, Annuru, Renigunta, Kota, Karavetinagaram, Narasapuram, Dasarlapalli CHC Ramasundaram II. Major Observations:

1. Functions of Rogi Kalyan Samithi( RKS) a) Rogi Kalyan Samithiies known as Hospital Development Societies (HDS) in the State have been set up in all the visited PHCs and CHCs as well as District Hospital in the district. b) In the visited PHCs and CHCs, it was observed that the meetings of HDS were being held regularly; funds were provided and being utilized . 2) Functions of VHSCs a) 1381 VHSCs are set up out of 3161 revenue villages located in the district. b) In the district 4 sub-centres were visited by the team. it was observed that VHSCs wereconstituted, functioning and the budget released was spent. Money was spent within two months of its receipt, though as per norms funds are to be spent throughout the year. c) As per guidelines, there should be joint account in the name of Sarpanchs/Gram Panchayat President and ANM and both should sign the cheque to withdraw the allotted funds for VHSCs. VHSCs comprising Village Surpanch, ASHA, ANM and members jointly decide upon the modalities of work to be undertaken at the village level. d) All the basic level staff in all the PHCs visited pleaded that there should be no joint account system , as the Sarpachs/Panchayat Presidents are a political bigwig and ANM is a very low ranked government official, a non local woman, therefore has no voice in deciding how the fund can be utilized.

e) In majority of the cases, the Sarpanch withdraws entire fund and keeps with himself without executing any developmental activities. ANM is afraid of questioning the powerful mighty Sarpanch, and she is forced to bring some fake bills and /receipts showing some sanitation work or purchase of bleaching powder etc. to tally the money withdrawn from the bank, as she (ANM) being the government official, is answerable to any audit query,and Sarpanch is not responsibile to maintain the account. 3. Janani Suraksha Yojana (JSY) a) It was observed that the beneficiaries, were getting their payments under the scheme in most of the visited areas. b) During Sample check of JSY beneficiaries it was observed that on an average 30-70 cases were pending for payment of JSY cash benefit. c) It was also seen that average time gap between date of delivery and date of granting JSY cash incentive to the beneficiary is around 5-10 months in some sub-centres. d) All the concerned registers were maintained with complete informations in the district office and at the periphery level centres visited. 4. 24 hour delivery care system: a) In the district, 37 out of the total of 88 PHCs are functioning as 24 –hour delivery care institutions. But, out of this only 12 PHCs were having 2 Medical Officers(MO) and the remaining have only one MO. b) Pediatrician & Gynecologist do not visit these centres for specialist services because the renumeration offered to them per case is low(Rs. 700). c) Performance in 10 PHCs of the total 37 centres(24 hours delivery care) was below the stipulated minimum of 10 deliveries per month; the authorities explained that there are bigger hospitals and people prefer to go there for delivery. 5 Services of ASHA : a) ASHAs are called as Women Health volunteers(WHV) in the state. b) In the district 3328 ASHAs have been recruited against the requirement of 3628 and all have been trained by March 2009 and were provided with the drug Kits. c) ASHAs were being given a fixed amount of Rs. 450 per month as remuneration . d) During field visit 29 ASHAs were interviewed; all of them informed that they have received training . In some cases their monthly remuneration was delayed for 6 months due to delay in release of budget. 6. Untied funds at Sub-centres: 2

a) Funds for the year 2008-09 are provided to the sub-centres . For the current year 2009-10 funds were not released. b) It was observed that funds are divided into number of Gram-panchayats that come under the sub-centre area and allotted to joint account, as a result the ANM has to approach 2-3 Sarpanchs even to incur expenditure on Sub centre requirements. c) In the visited 4 sub-centres,untied funds was not utilized as per the guidelines.

7. Physical infrastructure 7.1 PHCs a) PHCs at Karavetinagaram and Ramasamudram were functioning in government buildings. b) Stock of contraceptives IFA syrup, and Vit. A tab/syrup was not available in PHC Karavetinagaram on the day of visiting .Vehicle was also not provided to this PHC. c) In PHC Ramasamudram there was no cold chain equipment. d ) AYUSH medical officer was available in the visited PHCs.

7.2 Sub Centres a) Sub centre D.M.Puram was functioning in a condemned building. SC Narasapuram and SC Dasarlapalli did not have any building; clinics and immunization sessions are being conducted in Anganawadi centre. b) Water facility, Electric connection, toilet and labour room facility were not available in the Sub-centre D.M.Puram. c) Examination table, benches for clients, cup board for drugs, delivery table, Mclntch sheets,Ambu bag,steam sterilizer, weighing machine(infant) DDKs, BP appratus were not available in majority of the visited Centres. d) Emergency contraceptive pills, Injection gentamicin EC pills, antiseptic solution,Tab. Oxytocin, Ampicillin, Inj. Gentamycine Kit A and Kit B etc were not available at any of the visited sub-centres. 8. Opinion and Knowledge of Community on Health Services: a) As many as 40 mothers were interviewed in the area of the centres visited for assessing their Knowledge & Opinion about the Health services . b) Post Natal services were mostly provided to the mothers.

c) Though villagers were mostly happy with the services received at PHCs; but it was found that 38 out of the 40 mothers interviewed were not aware about the symptoms of ARI and 16 mothers were not aware about use and side effects of contraceptive methods. 9. Maintenance of records and registers: a) Printed registers for FP, Child Immunization, MCH and Eligible Couple registers were mostly maintained or updated at the visited centres. b) As there was no supply of printed formats for monthly reports, JSY registration cards, xerox copies were used by the field level workers to maintain records. c) Non printed registers were maintained for Eligible Couple, Stocks and Cash Book for untied funds at sub-centre level. d) Annual action plan and PIP for 2009-10 was prepared by the district office as per the guidelines. Annual need for FW and RCH services had been calculated as per operational manual for preparation of state implementation plans. e) Timely reporting is being done in new HMIS forms for monitoring the progress of various programs under NRHM. f) Web based reporting is done from district to state level only and not yet started from peripheral institutions to district level.

2. District Nellore : Major observations of Regional Evaluation Team, Banglore about the Evaluation work in Nellore Districts of Andhra Pradesh, in June- 2009. I. Details of the visited Institutions:

Nellore PHCs Chakalakonda, Vinjamaru, Komarika, Kudithipalem, Nellore,Mypadu, Manabolu Madamanur, Cherlapalli

II. Major Observations:

1. Functions of Rogi Kalyan Samithee( RKS): a) Rogi Kalyan Samithi known as Hospital Development Society (HDS) were found to be set up in all the visited centres /institutions in the district.

4 b) It was observed that the meetings of HDS was being held regularly in PHC Manabolu district. But no meeting was being held in PHC Mypadu. c) Funds were available and being utilized as per norms in both the PHCs. c) It was found that PP Unit at Nellore town has no RKS and did not figure in allotment of HDS fund and therfore maintenance of building and other facilities were poor due to lack of funds. 2) Functioning of VHSCs a) VHSCs have been set up in all the 961 revenue villages in the district. b) In the district 4 sub-centres were visited by the team and it was observed that VHSCs were constituted, functioning and the budget released to them was spent . c) As per guidelines, there should be joint account in the name of Sarpanchs/Gram Panchayat President and ANM and both should sign the cheque to withdraw the allotted funds for VHSCs; It was noted that ANM had no voice in deciding how the funds are to be used. Surpanch/Panchayat President was dictating terms to ANMs. d) In majority of the cases, the Sarpanch withdraws entire fund and keeps with himself without executing any developmental activities. At the end, ANM is forced to bring some fake bills and /receipts showing some sanitation work or purchase of bleaching powder etc. to tally the amount withdrawn from the bank. ANM being a government official, is answerable to audit query, and Sarpanch is not responsible for maintaining in the account.

3. Janani Suraksha Yojana (JSY) a) It was observed that the beneficiaries were getting their payments under the scheme in most of the visited areas. It was also seen that average time gap between date of delivery and date of granting JSY cash incentive to the beneficiary is around 5-10 months in some sub-centres. b) It was observed during Sample check that in each SCs 12-60 cases were pending for payment at JSY cash benefit due to shortage of funds for 2008-09 and funds not being released for 2009-10. c) All the concerned registers were maintained with complete information in the district office and at periphery level centres visited.

4. 24 hour delivery care system:

a) 28 out of 61 PHCs In the district, are functioning as 24 –hour delivery care institutions. But, out of this only 19 PHCs are having 2 medical officers and the remaining have only one MO. b) Specialist services were not available in the PHCs as Pediatrician & Gynecologist do not visit these centres. The reason being low remuneration (@ Rs 700 Per Case) offered to them .

5 ASHA Scheme : a) ASHAs are called as Women Health volunteers (WHV) in the state. b) 2291 ASHAs have been selected, trained and provided with drug kits upto 2008-09 as against the requirement of 2949. c) Though ASHAs are receiving performance based remuneration and an expenditure to the tune of more than Rs. 77 lakhs incurred in the district during 2008-09 in this regard, the state has decided to provide each ASHA a fixed amount of Rs. 450 per month as remuneration due to budget deficit in the state . d) During field visit, 26 ASHAs were interviewed ,all have stated that they have received training and found that some of the ASHAs were yet to get the remuneration due to delay in release of budget. 6. Untied funds at Sub-centres: a) Funds for the year 2008-09 are provided to the sub-centres . For the current year 2009-10 funds were not released at the time of visit by the team. b) It is observed that the funds are divided into number of Gram-panchayats that come under the sub-centre area and allotted to joint account. As a result, the ANM has to approach 2-3 Sarpanchs even to incur expenditure on Sub centre requirements. c) In the visited 4 sub-centres,untied funds provided to VHSCs was not utilized as per the guidelines, Record for expenditure asalso not recorded in some of the sub-centres. 7. Physical infrastructure 7.1 .PHCs a) PHC Mypadu and Manabolu were functioning in government buildings. b) Telephone is not working in Mypadu PHC. OT is not functional since 3 months. c) AYUSH medical officer was not posted in Mypadu PHC . d) Stock of IFA (Small ) tablets was not available at PHC Mypadu.

7.2 Sub Centres 6

a) Sub-Centres at Kudithipalem, Komarika and Cherlapalli did not have building. The clinics and immunization sessions are being conducted in Anganwadi centres/Panchayat Building. Sub Centre Madamanur among the visited sub centeres was being run in rented building . b) Water facility, Electric connection , toilet and labour room facility is not available. ANM is not staying in the HQ. Funds were not released. c) Examination table, benches for clients, cup board for drugs, delivery table, Mclntch sheets,Ambu bag,steam sterilizer, weighing machine (infant), DDKs, were not available in the visited centres d) BP Apparatus was not in working condition at Sub-Centres Kudithipalem and Komarika. e) Emergency contraceptive pills, Injection gentamicin antiseptic solution,Kit A and Kit B etc were not available at any of the visited sub-centres. 8. Opinion and Knowledge of Community on Health Services: a) 40 mothers having child upto one year old were interviewed in the area of the centres visited for assessing the Knowledge & Opinion about the Health services b) Out of them, 36 mothers were not aware about the symptoms of ARI and 19 mothers were not aware about use and side effects of contraceptive methods. c) Post Natal services were mostly provided to the mothers. d) Villagers in the area of PHCs visited were found happy with the services received at PHCs. e) Villages in the sub-centres area were found happy with the services rendered by Male Health Workers.

9. Maintenance of records and registers: a) Printed registers for FP, Child Immunisation, MCH and Eligible Couple registers were mostly maintained and also updated at the visited centres. b) There was no supply of printed formats for monthly reports, and JSY registration at village level. c) Non printed registers were also maintained for Eligible Couple, Stocks and Cash Book for untied funds at sub-centre level. d) Annual action plan and PIP for 2009-10 was prepared by the district office as per the guidelines. Annual need for FW and RCH services had been calculated as per operational manual for preparation of state implementation plans. 7 e) Reporting is being done in new HMIS formats for assessing various health interventions initiated under NRHM timely from the peripheral institutions. f) Web based reporting is done from district to state level only and not yet started from peripheral institutions to district level.

3. Krishna District:

Major observations of Regional Evaluation Team, Banglore about the Evaluation work in Krishna Districts of Andhra Pradesh, in July, 2009.

I. Details of the visited Institutions:

District PHCs Visited HSCs Visited Visited Krishna PHCs: Penamalur, Gampalagudem, Goshala, Gampalagudem, Thotlavallur,Chowtapalli, Gudavalli, Laxmipuram, Kanchikacheria Athukur-II, Ganguru, Nidamanur-II, Ganugupadu, Paritala. II. Major Observations:

1. Human resources:

Posts of Pediatricians, Physicians, General Pathologists, Radiologist and Anesthetists were not sanctioned at CHC level Institutions. 28 posts of Staff Nurse and 14 posts of Pharmacists at CHC Level were lying vacant in the district. 22 posts of regular Staff nurse, 25 posts of ANMs/MPW(Female) and 111 Contractual posts of ANM were vacant at the PHC level. D.P.M. unit is not functioning at the Block level.

2. Functions of Rogi Kalyan Samithee( RKS) a) Rogi Kalyan Samithi known as Hospital Development Society (HDS) in the State were found to be set up in all the visited PHCs and CHCs as well as District Hospital in the District.

b) Funds were released to each HDS in the District and are being used. Meetings of HDS are being held as per norms.

3) Functions of VHSCs a) In the district 972 VHSCs were set up and each VHSC is eligible for fund ranging from Rs. 4500 to Rs. 18,500 depending on population covered. b) In the visited sub-centres meetings of VHSCs were observed to be not conducted on regular basis. c) The field staff in the visited centres reported that they have no voice on deciding the pattern, period and nature of expenditure of VHSC fund as the Gram Panchayat level representatives are over powering and take unilateral decisions.

4. Janani Suraksha Yojana (JSY) a) It was reported that women belonging to BPL, SC/ST category family only are eligible to receive JSY cash incentive for the first 2 deliveries @ Rs. 700 in Rural Areas and @ Rs. 600 in urban area in the state. b) During Sample check it was observed that on an average 20-25 cases were pending for payment to the JSY benificaries. c) As per the information received from the sub-centres at Gunugupadu, Lakshmipuram and Paritala, there were pending cases of payment of JSY cash benefits during 2008-9 and 2009-10. No funds was provided to these centres for 2009-10. d) JSY concerned registers were maintained with complete information in the district office as well as PHCs and Sub-centres visited. e) JSY cards were issued to all the beneficiaries and the concerned MOs were checking the registers every month.

5.Services of ASHA : a) ASHAs are called as Women Health volunteers(WHV) in the state. b) In the district 3347 ASHAs were selected, trained and provided with drug kits upto the end of 2008-09. c) ASHA is also involved as a member in VHSCs.

7. 24 hour delivery care system:

In the district, 28 out of total 69 PHCs were functioning as 24 hour delivery care institutions.

a. Of these, only 18 PHCs were having 2 Medical Officers(MOs) and the remaining 10 have only one MO. b. 16 of the total 28 PHCs working as 24 hours centres did not perform the stipulated minimum of 10 deliveries per month. Some of the PHCs like Vatsava , Seethnapalli and Chandrala performed less than 20 deliveries in the whole year. c. Equipment required for newborn care such as radiant warmer and photo therapy equipment were not available in these centres.

7. Physical infrastructure and Stock position: (i) PHCs a) PHCs at Chowtapalli, and Kanchikacheria were functioning in government buildings. b) PHC building at Kanchikacheria is in dilapidated condition, cement ceiling in most of the rooms and wards has fallen down and roof may collapse at any time. Director of state Health services has already issued order for shifting the PHC to some other premises but services were still continuing here. c) Residential quarters for Medical Officer were available in these PHCs. d) MO for AYUSH was not posted at PHCs Choutapalli. e) Stock of the most of the essential drugs is available in the centre.

(ii)Sub Centres a) Sub centre visited at Gunugapadu, Lakshmipuram, Paritala and Athukur-II were functioning in rented accommodation . There was no labour-room in these facilities. b) Examination table, delivery table, Mclntch sheets, Ambu bag, steam sterilizer, weighing machine(infant) were not available on majority of the visited Centres. d) Similarly, DDK, Gloves, Antiseptic solution, Tab. Metronidazole Cap. Ampiciline , chlorine solution etc. were also not available at any of the visited sub-centres.

8. Opinion and Knowledge of Community on Health Services:

a) To assess knowledge and community satisfactions 40 mothers of having upto one year old child were interviewed in the area of 4 sub-centres and found that most of them were happy having PNC services in time. b) More than 80% respondents were not aware about danger sign of ARI and 32.5% mothers do not have the knowledge about advantages and side effects of contraceptive uses. c) Public opinion was good on the services being rendered by the PHCs/CHCs visited by the team. Villagers expressed satisfaction on the overall functioning of PHCs.

9. Maintenance of records and registers at SC level: a) EC Registers as well as service registers being maintained but IUD, OP and Nirodh services registers were not updated . a) b) Printed JSY registration cards were not available at SC level

4. East Godavari District:

Major observations of Regional Evaluation Team, Banglore about the Evaluation work in East Godavari Districts of Andhra Pradesh, in July, 2009. I. Details of the visited Institutions:

East PHCs Pedapudi, Kirlampudi, Inavalli, Kotturu, Korumilli, Godavari Angara, CHC Jaggampet Pedapudi,S.Thimmapuram, Madapalli, Rajupudi, Kapileswarapuram, Kandregula, Geddanapalli, C.H.Lanka

II. Major Observations:

1. Human resources:

b) Posts of Pediatricians, General Pathologists, Physicians, Radiologist and Anesthetists were not sanctioned at CHC level Institutions in the district.

c) 98 posts of ANM/MPW female and 22 posts of Medical Officer were vacant at the PHC level. d) The post of Dy. CMO /Addl. DMHO was also vacant at the District Office.

2. Functions of Rogi Kalyan Samithi ( RKS) a) Rogi Kalyan Samithi known as Hospital Development Society (HDS) in the State were found to be set up in 21 CHCs and 71 PHCs as well as District Hospital in the district. b) During 2009-10, no budget was released by the state authority to the district. c) The state has taken a decision that from the current year mothers of BPL and SC /ST family who have undergone delivery at the Govt. institutions will only be eligible JSY cash benefit, with this decision the mothers undergoing delivery at home and at private accredited /unaccredited nursing homes /hospitals will not get any cash benefits. d) In the centres visited at jaggampet and Angora, meetings of RKS had been conducted on regular intervals and funds were utilized as per guidleines. e) All the JSY concerned registers were maintained with complete information in the district office and CHCs/PHCs and sub-centres visited. JSY cards were also issued to all the beneficiaries.

3) Functions of Village Health & Sanitation Committee(VHSCs) a) In the District, there are 1411 revenue villages but only 610 VHSCs have been set up. (b) In the 4 sub-centres visited, it was observed that VHSCs have been established and functioning; funds released were spent, but regular meetings are not being conducted. a) However, it was observed that large part of the budget is spent only on bleaching powder and labour charges.

4. Janani Suraksha Yojana (JSY) a) During 2009-10 no budget was released to the district. b) It is observed that on an average 15-70 cases were pending for payment of JSY cash benefit in every sub-centre.

c) Most of the sub-centres had no balance of JSY fund on the date of visit by the team in July, 2009. d) All JSY concerned registers were maintained with complete information in the district office and CHC/PHCs and Sub-centres visited. JSY cards were issued to all beneficiaries, and the concerned MOs were checking the registers every month.

5. Services of ASHA: a) ASHAs are called as Women Health volunteers (WHV) in the state. b) 4307 ASHAs were selected, trained and provided with drug Kits Upto the end of 2008-09 in the District. c) During the field visits, 10 ASHAs were interviewed in the selected PHCs. They were being given fixed amount of Rs. 450 per month as remuneration because of budget deficiency. In some cases payment of monthly remuneration were delayed upto 6 months due to delay in receipt of funds.

6. Untied Funds: a) It was observed that Rs. 10,000 untied funds allocated to each Sub-centre per annum is divided into number of Gram Panchayats that come under the SC area and kept into a joint account, as a result the ANM has to approach 2-3 Sarpanchs even to incur urgent expenditure for improving the services at the Sub Centres. b) The staffs of the Sub-Centres reported that in many instances Sarpanchs or Panchayat Presidents do not fully cooperate in the conduct of village Health Sanitation Committee meeting; instead they take unilateral decision and demand that entire money be given to them. ANMs being the lower cadre staff are having difficult times to handle the non-cooperative Sarpanchs. c) Untied funds provided to PHCs and CHCs was kept in joint account of Rogi Kalyan Samithi (called HDS) in the state and are being utilized as per guidelines. In 4 sub-centres visited, it was observed untied fund was not being utilized as per guidelines.

7. 24 hour delivery care system: 13

a) In the district, 28 out of total of 71 PHCs were functioning as 24 hour delivery care institutions. Out of these only 15 PHCs were having 2 medical officers and the remaining 13 have only one MO. In all the 28 PHCs one additional Staff nurse was posted on contract basis. b) 14 of the total 28 PHCs working as 24 hours deliver care centre did not perform the stipulated minimum of 10 deliveries per month.

8. Physical infrastructure and Stock position: (i) CHC/PHCs a) CHC Jaggampet & PHC Angara were functioning in government buildings. b) AYUSH MO was not posted in CHC and PHCs visited c) There was no stock of oral Pills and Condoms since April 2009 at CHC Jaggampet and stock of Vitamin A Syrup at PHC Angara.

(ii) Sub Centres a) Three of the 4 visited sub-centres were functioning in rented building with no proper facility for ANC/PNC care. SC Building at SC Kourmilli was condemned, used for clinic purpose only. b) In all the SCs visited there was no functional labour room and in none of the SCs deliveries were conducted. Toilets were not available in 3 of the 4 SCs visited. b) Examination table, delivery table, Mclntch sheets,Ambu bag,steam sterilizer, weighing machine(infant) were not available in Korumilli,Kottur and Rajupudi SCs. d) Similarly, Gloves, ORS packets, IUDs, EC Pills, Anteceptic solution,Clorine solution,Tab. Paracetamol,DDK,, Tab. Ampicillin, Inj.Gentamicine and Kit A & B were not available at most of the visited sub-centres.

8. Community Satisfaction on Health Services: a) To assess the opinion and knowledge about the health services 40 mothers of having child upto one year old were interviewed in the area of 4 sub- centres and found that 77.5% of them were not aware about danger sign 14

of ARI and 37.5 mothers do not have the knowledge about advantages and side effects of contraceptive uses. b) Public opinion was good on the services being rendered by the PHCs/CHCs visited by the team. Village leader, and ANC/PNC beneficiaries and others have expressed satisfaction on the overall functioning of PHCs.

9. Maintenance of records and registers at SC level: a) EC Registers as well as service registers being maintained were not updated in case of IUD, OP and Nirodh distribution. b) Printed JSY registration cards were not available at SCs visited. ***** 5. District: Medak

Major observations of Regional Evaluation Team, Bangluru about the Evaluation work in Medak Districts of Andhra Pradesh, in February , 2010.

I. Details of the visited Institutions:

Districts Visited PHCs Visited HSCs /UHPsVisited Medak PHCs:Gummad Annaram, idala, Vavilala,Bidekanna,Kupnag Jhrasangam and Ramachandrapu ar,Bandalaguda and Tellapur ram II. Major Observations: 1. Human resources: a. Key posts like 19(13%) Posts of Medical Officers, 44 (48%)posts of staff nurse, 34(32%) posts of Health Supervisor(female) 2(2%) posts of Health Supervisor(male ) 95(19%) posts of ANM/MPW (Female), 82(37%) posts of MPW (Male) 11(16%) posts of Pharmacist and 7(7%) posts of Lab Technician were lying vacant in district. b. In the visited PHC Gummadidala,, 1 post of Pharmacist against sanctioned 1 was also lying vacant. In PHC Jaharasangam , 1 post os 1st ANM against 7 sanctioned, and 1 post of 2nd ANM against sactioned 6 were also lying vacant.

2. Functioning of Rogi Kalyan Samithee( RKS) a) Rogi Kalyan Samithi known as Hospital Development Society (HDS) in the State were found to be set up in all peripheral 8 CHCs, 64 PHCs , One District Hospital and 2 sub district hospitals in the District. b) PHCs and CHCs in the district were provided Rs. 25 ,000 per PHC and Rs. 50,000 per CHC+ Rs. 50,000 AMG and the Hospital Development Society (HDS) fund of Rs. 1,00,000 totally Rs. 1,75,000 /- released every year. and the fund was kept in the joint account of the Rogi Kalyan Samithi. c) The total budget for HDS in the district was Rs. 10500000- for 2008-09 and Rs 99,00,000/- for the year 2009-10 Upto Dec 2009. Expenditure of Rs 90,00,000/- was incurred in 2008-09 and Rs. 72,00,000 was spent during 2009-10 up to Dec 2009. b) In both the centres visited, viz. PHC Gummadidala and PHC Jaharasangam meetings of HDS are being held regularly and funds are being utilized after taking approval of the committee members of HDS as per norms. . 3) Functioning of VHSCs

(a) In the district , 1059 VHSC are set up. Each VHSC is eligible for a fund of Rs. 10,000 annually , VHSC fund is jointly operated by the village Sarpanch and ANM of Sub centre. (b) In the visited sub-centres meetings of VHSCs were observed to be conducted only once in year and the money is spent in 2-3 months span, whereas the money is kept for doing sanitation work for the whole year. The ANMs in the visited centres reported that they have no voice on deciding the pattern, period and nature of expenditure of VHSC fund ,as the Gram Panchayat level representatives take unilateral decisions. (c) In the visited sub centre it was also noticed that the Sarpach would withdraw the whole amount of 10,000 in one go and give bills as if it has been spent of labour charges and bleaching powder. This is also done only once in a year. (d) The total budget for VHSCs in the district was Rs. 101,00,000/- for 2008-09 and Rs 1,10,50,000/- for the year 2009-10 Upto Nov 2009. Expenditure of Rs

10009500/- was incurred in 2008-09 and Rs. 6698500/- was spent during 2009- 10 upto Nov 2009.

4. Janani Suraksha Yojana (JSY) a) Women belonging to BPL, SC/ST category family only are eligible to receive JSY cash incentive for the first 2 deliveries @ Rs. 700 in Rural Areas and @ Rs. 600 in urban area . b) In the district 54326 deliveries were conducted during 2008-09. Out of them 29273 were paid JSY cash incentive in the year. Upto Nov 2010 payments were made to 9961 beneficiaries only whreas 45118 deliveries were reported during the year 2009-10. c) Of the total 54326 deliveries during2008-09, 28104 (52%) took place in private hospitals. More than 50% deliveries are conducted in private sector. Govt. sector contributed 41% and Home deliveries stood at 6.7%. Out of 3666 home deliveries 2209 were done by trained dais. Untrained Dais conducted 951 deliveries. This shows that Health Staff should be improve their services. d) The total budget for JSY in the district was Rs. 2,14,51,185/- for 2008-09 and Rs 74,15,785/- for the year 2009-10 Upto Nov. 2009. Expenditure of Rs20,491,400/- was incurred in 2008-09 and Rs. 5653058/- was spent during 2009-10 upto Nov.2009. For the period 2009-10. e) During visit to the sub-centres at Annaram, Vavilala, Bidekanna and Kuppanagar pending cases for JSY payment were reported for both 2008-09 and 2009-10 upto January 2010. f) It has been reported that in SC Vavilala budget was received very late , hence JSY payment could not be done during 2009-10. g) Totally, 46 JSY beneficiaries were selected and 39 contacted in the field. All the beneficiaries stated that they received full JSY cash incentive; MCH cards were issued to all, ANC/PNC visits were made by ANMs. 5) Untied funds: a) Untied funds for PHCs to the extent of Rs. 1650000, was available for the year 2008-09 in the district . Out of it Rs. 1625000 was spent during the year. For the year 2009-10, (Upto Dec 2009) Rs.1950000/- was released

but details of expenditure was not available from the PHCs at district headquarters. . b) PHCs and CHCs in the district were provided Rs. 25 ,000 per PHC and Rs. 50,000 per CHC and the fund was kept in the joint account of the Rogi Kalyan Samiti. In both the centres visited, at CHC Gummadilala and PHC Jaharasangam this fund was utilized as per norms. c) Untied funds of Rs. 10,000 per SC per annum has been released for 2008- 09 and 2009-10. For the year 2009-10, Sub centres at Annaram,Vavilala,Bidkenna, and Kuppanagar had utilized the amount for 2008-09. The funds for 2009-10 was in balance till the date of visiting the centres. d) Untied funds of Rs. 10,000 per annuam is actually meant for the up keep of sub-centre building and for purchasing of necessary items arequired at the centre, but it is observed that , this fund is also divided into number of gram panchayats that come under SC area and allotted to joint account, as a result the ANM has to approach 2-3 Sarpanchs even to incur expenditure on SC requirements.

1. Services of ASHA : a) ASHAs are called as Women Health volunteers(WHV) in the state. In the district 2129 ASHAs were selected, trained and provided with drug kits upto the end of 2008-09. There was is no proposal for more ASHAs .For the year 2009-10An amount of Rs. 9283200 was spent towards the payment of performance based remuneration to ASHA scheme during 2009-10 upto January 2010.

7. 24 hour delivery care system: a. In the district, 36 out of total 64 PHCs were functioning as 24 hour delivery care institutions. b. Funds to the extent of Rs. 4478550 was available for the year 2008-09 in the district . The whole amount was spentt during the year. For the year 2009- 10, a budget of Rs. 4905000/- was available to district and an amount of Rs.

2556332/- was spent upto Dec. 2009. basis staff nurse is not being paid their salary regularly. c. Expenditure was mainly towards payment of salarieshonorarium to contact basis staff, contingent workers and night duty allowances. . d. During 2008-09, 21 of the total 36 PHCs working as 24 hours 6 centres did not perform the stipulated minimum of 10 deliveries per month.

8. Physical infrastructure and Stock position:

1) PHC a) PHCs at Gummadidala, Jaharasangam weres functioning in government building. b) AYUSH MO is posted in PHC Jahasangam but not in PHC Gummadidala. c) Residential quarters for Medical Officer were not available in both the PHCs.

(iii) Sub Centres a) Sub centres at Vavilala and Bidekanna were functioning in Govt. Buildings . SC at Annaram was functioning in rent free accommodation while SC Kuppanagar was working in a rented accommodation. b) There was no functional labour-room in any of the Subcentres visited.

c) Examination table, delivery table, Mclntch sheets, Ambu bag, steam sterilizer, weighing machine(infant) were not available on majority of the visited Centres. d) Similarly, DDK, Gloves, Antiseptic solution, Tab. Metronidazole Cap. Ampiciline , chlorine solution etc. were also not available at any of the visited sub-centres. e) More that 50% furniture , Equipments and drugs were not available in the centres visited as result service delivery could not be maintained effectively.

9. Opinion and Knowledge of Community on Health Services: 19

(a) In each of the 4 SCs visited, 10 mothers of having child upto one year of age were interviewed to assess knowledge and opinion on the services rendered by ANMs and found that most of them were happy having PNC services in time. (b) More than 87% respondents were not aware about danger sign of ARI and 22% mothers do not have the knowledge about advantages and side effects of contraceptive uses. (c) Person contacted expressed satisfaction towards the performance of MPW(M). He had achieved the trget for blood sample collection and motivating persons for FP. (d) Public opinion was good on the services being rendered by the PHCs/CHCs visited by the team. Villagers expressed satisfaction on the overall functioning of PHCs.

10. Maintenance of records and registers at SC level: (a) EC Registers and Stock registers were not found updated in visited Sub Centres. (b) Stock registers were not maintained for equipments and drugs purchased under NRHM. (c) Cash book for untied funds is kept in Annaram SC only. (d) Follow up entries are not made in FW registers. IUD, OP and Nirodh services registers were not updated . (e) As printed stock registers were not supplied to SCs for the last 2-3 years registers Staff is facing difficulty in maintaining records on on non printed books or xerox copies. Printed JSY registration cards were not available at SC level.

11) Important Observations and Suggestions:

(a) Under JSY in Andhra Pradesh, cash incentives are paid to deliveriesOccuring in Govt. institutions only. Cash incentives are not paid to cases of home deliveries and deliveries in private institutions.

(b) At the sub-centres, delivery rooms were not established., some of the visited sub-centres are working with inadequate furniture,equipments,drugs and other essentials. (c) The contractual ANMs posted under Europian commission scheme get only a fixed salary of Rs. 5000/- per month, since 2003 their salaries are not raised. Regular ANMs get more than 10,000/- and other allowances also. Contractual ANMs do not get any other allowances. This is a disturbing factor and comes in the way of efficient service delivery. (d) It was observed that meetings of VHSCs were observed to be conducted only once in when the money comes and the entire money was spent within a spn of 2-3 months, large lpart of the money is spent of bleaching powder and labour charges. Idially the budget should be divided into 4 quarters so that m oney is available for all the 4 quarters for taking up sanitation work in any health eventuality that may arise in future quarters. a. The Sarpach does not call the SC ANMs or any other members of the committee such as Anganwadi worker or ASHA while executing the sanitation work. Sarpanchs simplly give the bills for entire Rs. 10,000 as he has spent for labour charges and purchasing bleaching powder. The work shown are cleaning of sewerages, leveling of earth , spraying of bleaching powderd etc. The nature of sanitation work executed is such that no one can verify at a later period. The whole money is spent in one go and the said work is done in 2-3 weeks. Thereafter there is no work for VHSCs until the next year budget arrives. MOs and Health supervisors do not take interest in supervising the way of utilization of funds. b. . It is suggested that The financial power as a joint signatory may be withdrawn from sarpanch ando persons from the other Govt. department such as school teacher or Headmaster of education department may be given the power. A Govt servent will be accountable in future for audit. While Sarpanch is notanswerable to Govt. This model is working in Gujarat state efficiently where the school teacher is a joint signatory.I

(e) In the visited centres Untied funds were not utilized as per norms. Untied fund is meant purely for strengthening of services at SC . The ANM did not know how the Sarpanch spent the money. Rs. 10,000/ is withdrawn in one go and has been shown as used. Sarpanch gave vouchers /bills for the entire amount.

6. Hyderabad city Districts

Major observations of Regional Evaluation Team, Bangluru about the Evaluation work in Hyderabad city Districts of Andhra Pradesh, in February , 2010.

I. Details of the visited Institutions:

Hyderabad city .UFWC: UHPs: Balagunj, Sriramnagar, Borbanda, Panipura.

II. Major Observations:

1. Human resources: a) Most of the sanctioned posts were in position except 10 posts of Public Health Nurse and 104 posts of MPW (Male) b) At the district office, under statistical section 1 Statistical officer and 1 Deputy Statistical Oficer is posted for Hyderabad city which covers 50 Lakh population, covering 72 peripheral health institutions, 11 major Govt. Hospitals and 7 voluntary Health Organisations. The staff strength under statistical division is quite inadequate to collect the required data /information at district level. c) It was felt that there is inadequate sanctioned staff strength in UHPs/UFWCs or /Maternity centres. To manage heavy workload, that I , 2 days in a week theatre days making payments to the JSY and sterilization cases, attending of out patient of of average 60-70 per day and immunization session and conducting of ANC/PNC clinic every week. Without posts of staff nurse to assist in OT and Pharmacist to dispense drugs, and manage drugs stores.it was very difficult to look day to day work.In this situation the staff like staff Nurse , Pharmascist

and Jr. Assistant is felt highly required in such urban centres. ANMs of these centres are used for night duties for conducting deliveries . This affects their field work outreach services. a) 2. Functioning of Rogi Kalyan Samithee( RKS) a) Rogi Kalyan Samithi is not applicable in this district. No funds are released under this head. This is a purely urban district.

3) Functions of VHSCs a) This scheme is not applicable in this district. No funds are released under this head. This is a purely urban district.

4. Janani Suraksha Yojana (JSY) b) Women belonging to BPL, SC/ST category family only are eligible to receive JSY cash incentive for the first 2 deliveries @ Rs. 700 in Rural Areas and @ Rs. 600 in urban area in the state. Mostly JSY cash incentive was given only for Deliveries undertaken in Govt. institutions . c) In the district 86134 deliveries were conducted during 2008-09. Out of them 34454 were eligible for JSY cash incentive but payments were made to 26054 beneficiaries only. d) Similarly, Upto till Dec 64451 deliveries were conducted during 2009-10. Out of them 25780 were eligible for JSY cash incentive but payments were made to 17480 beneficiaries only. e) The total budget for JSY in the district was Rs. 1,87,38,254/- for 2008-09 and Rs 11332154/- for the year 2009-10 Upto Dec. 2009. Expenditure of Rs16,219,400/- was incurred in 2008-09 and Rs. 10488300/- was spent during 2009-10 upto Dec.2009. . f) Totally, 65 JSY beneficiaries were contacted in the area of sub-centres field. All the beneficiaries stated that they received full JSY cash incentive; MCH cards were issued to all, ANC/PNC visits were made by ANMs.

23 g) JSY concerned registers were maintained with complete information in the district office as well as PHCs and Sub-centres visited. JSY cards were issued to all the beneficiaries .

5. Services of ASHA : a) The scheme is applied only for slum areas in the district. 1021 WHVs were selected, trained and povided with drug kits upto the end of 2008-09. a. An amount of Rs. 2,77,21,60 was spent towards payment of remuneration based on performance to ASHAs during 2009-10 Jan 2010. ASHAs were getting performance based remuneration regularly.

6. 24 hour delivery care system: a) In the district, 10 institutions, ( 5 maternity centres, 2 UHPs and 3 UFWCs ) s were functioning as 24 hour delivery care institutions. b) All Maternity centres have 3 additional Staff Nurses and in UFWCs 2 additional ANMs are posted under 24X7 scheme. c) The total budget for the 24 hour delivery care in the district was Rs. 1,6687,57/- for 2008-09 and Rs 1133300/- for the year 2009-10 Upto Nov. 2009. Expenditure of Rs16,39,257/- was incurred in 2008-09 and Rs. 1264900/- was spent during 2009-10 upto Nov.2009.Expenditure was mainly towards payment of salaries and Night duty allowance to contact basis staff.

7. Infrastructural facilities:

The team visited UHP at sriramnagar, Borubanda , Panipura .and UFWC at Balaganj UFWCs and UHP were having more or less same facilities . They are functioning in Govt. buildings, with minor OT, delivery room, OPD, witing hall for patients , injection room , stores etc. Most of the building are built under IPP VIII and can cater to all the services under RCH Programme. 24

AYUSH MO is posted in almot of the UHPs and UFWCs. But not under NRHM. They were posted by Municipal corporation of Hyd. s

8. Community satisfaction /Opinion on Health Services: Public opinion was good on the services being rendered by the UHPs/UFWCs visited by the team. ANC/PNC beneficiaries expressed satisfaction on the overall functioning of the centres visited.

9. Maintenance of records and registers : a) Printed registers for sterilization cases were maintained at the visited centres. Immunisation & MCH , stocks and cash books are maintained at UHP, UFMC and MC levels. b) EC register was not found updated. C) Stock registers are not found updated. Similarly, FW stocks registers were not updated. . d) Follow up entries are not made in FW registers. .

10. Important Observations and Suggestions: h) Most of the old UFWCs and UHPs are not well maintained due to lack of funds. All these centres built 15 yers ago under AIPP VII now need maintenance. There is no contingency fund, no maintenance grants, no Travelling llowances for outreach services, . In some of the UHPs there was no ater supply nd bathrooms are blocked . Most of the patients (females and children) and staff find it difficult without wash rooms. There is no seating arrangements in waiting hall for OPD patients. State authority is looking into the mtter of improving the zPublic services. conveyed that i) It was felt that there is inadequate sanctioned staff strength in UHPs/UFWCs or /Maternity centres. To manage heavy workload, that I , 2 days in a week theatre days making payments to the JSY and sterilization cases, attending of out patient of of average 60-70 per day and immunization session and conducting of ANC/PNC clinic every week. Without posts of staff nurse to assist in OT and Pharmacist to dispense drugs, and manage drugs stores.it was very difficult to look day to day work.In this situation the staff like staff Nurse , Pharmascist 25

and Jr. Assistant is felt highly required in such urban centres. ANMs of these centres are used for night duties for conducting deliveries . This affects their field work outreach services. j) UHPs/UFWCs were functioning in good buildings will all facilities. Still,It was felt that these facility centres were not used to the optimum level. They are being used as outpatient clinics for ANC/PNC and immunization. ************ 7. District: West Godavari

Major observations of Regional Evaluation Team, Banglore about the Evaluation work in West Godavari Districts of Andhra Pradesh, in January , 2010.

I. Details of the visited Institutions:

District PHCs /CHCs HSCs Visited Visited Visited West CHC:Manchali Vatluru Kotturu, Aravelli, Unikili, Godavari PHC Pedapadu, Kalamooru, Uppaluru, Yendagandi, and PN Nidamuru and Kolanu. P.N.Kalanu.

II. Major Observations:

1. Human resources:

c. Key posts like 19(13%) Posts of Medical Officers, 11 (8.3%)[posts of staff nurse, 18(13%) posts of Health Supervisor(Male) 6(7%) posts of Health Supervisor(Female ) 79(12%) posts of ANM/MPW (Female), 75(19%) posts of MPW (Male) and 15(26%) posts of Lab Technician were lying vacant in district. d. In the visited CHC Manchili, 1 post of Medical Officer against sanctioned 2 , and 2 posts of MPW(Male ) against sanctioned 5 were vacant. One sanctioned post of Pharmacist was also lying vacant. c) Posts of Lab technicians has not been filled at PHCs visited by the team. Most of the posts of staff nurse and MPW (M) were lying also vacant.

2. Functioning of Rogi Kalyan Samithee( RKS) (a) Rogi Kalyan Samithi known as Hospital Development Society (HDS) in the State were found to be set up in all peripheral 5 CHCs, 69 PHCs , District Hospital and 6 sub district hospitals in the District. PHCs and CHCs in the district were provided Rs. 25 ,000 per PHC and Rs. 50,000 per CHC and the fund was kept in the joint account of the Rogi Kalyan Samithi. In both the centres visited, at CHC Manchili and PHC Pedapadu this fund was utilized as per norms. (b) The total budget for HDS and AMG in the district was Rs. 13,615,742/- for 2008-09 and Rs 8,087,436 for the year 2009-10 Upto Dec 2009. Expenditure of Rs 10,857,306 was incurred in 2008-09 and Rs. 5474409 was spent during 2009-10 upto Dec 2009. (c) In both the centres visited, viz. CHC Manchili and PHC Pedapadu meetings of HDS are being held regularly and funds are being utilized as per norms. 3) Functioning of VHSCs (a) In the district 888 VHSCs were set up and each VHSC is eligible for fund ranging from Rs. 4500 to Rs. 18,500 depending on population covered. a. In the visited sub-centres meetings of VHSCs were observed to be not conducted on regular basis. The ANMs in the visited centres reported that they have no voice on deciding the pattern, period and nature of expenditure of VHSC fund as the Gram Panchayat level representatives are over powering and take unilateral decisions. (b) The total budget for VHSCs in the district was Rs. 9,349,733/- for 2008-09 and Rs 86,11,856/- for the year 2009-10 Upto Dec 2009. Expenditure of Rs 8,965,877/- was incurred in 2008-09 and Rs. 3,120,664/- was spent during 2009-10 upto Nov 2009. a. For the period 2009-10, fund was released only in Dec. 2009 and hence the amount was not spent. 4. Janani Suraksha Yojana (JSY) a) aWomen belonging to BPL, SC/ST category family only are eligible to receive JSY cash incentive for the first 2 deliveries @ Rs. 700 in Rural Areas and @ Rs. 600 in urban area in the state. JSY cash incentive was given only for Deliveries undertaken in Govt. institutions in 2008-09. 27

Deliveries undertaken in private institutions and Home deliveries were given cash incentive upto the year ending March 2008, provided they satisfy the conditions mentioned above. b) In the district West Godavari 76899 deliveries were conducted during 2008-09. Out of them 30500 were identified eligible for JSY cash incentive but payments could be made to only 27637 beneficiaries only. c) Of the total 76899 deliveries during2008-09, 40481 (52%) took place in private hospitals. Similarly Of the total 56658 deliveries, 31637 (52%) took place in private hospitals upto Dec 2009 in the current year. Thus, there is significant contribution by private sector hospitals in this area of service. d) The total budget for JSY in the district was Rs. 2,50,86,963/- for 2008-09 and Rs 1,53,82,363/- for the year 2009-10 Upto Dec 2009. Expenditure of Rs1,89,75,600/- was incurred in 2008-09 and Rs. 78,09,240/- was spent during 2009-10 upto Dec 2009. For the period 2009-10, fund was released only in Dec. 2009.

e) During Sample check it was observed that for 2008-09 28 cases in SC Vatluru and 21 cases in SC Kotturu were pending for JSY payment. Similarly, upto Nov. 2009-10, 84 cases in SC Vatluru and 57 cases in SC Kotturu were pending . Few cases in SC Aravelli and Unikil were also pending for all the 4 sub-centres for both the years. So on an average 20-25 JSY cases were pending for payment of JSY cash incentive in each SC. h) Totally, 61 JSY beneficiaries were selected and 57 contacted in the field. All the beneficiaries stated that they received full JSY cash incentive; MCH cards were issued to all, ANC/PNC visits were made by ANMs. 5. Untied funds: a) Untied funds to the extent of Rs. 7927046 was available for the year 2008- 09 in the district . Out of it Rs. 6282242 was spent during the year. For the year 2009-10, a budget of Rs. 6360804 was available to district and an amount of Rs. 2591651 was spent upto Dec 2009. b) PHCs and CHCs in the district were provided Rs. 25 ,000 per PHC and Rs. 50,000 per CHC and the fund was kept in the joint account of the Rogi

Kalyan Samithi. In both the centres visited, at CHC Manchili and PHC Pedapadu this fund was utilized as per norms. c) Untied funds of Rs. 10,000 per SC per annum has been released for 2008- 09. For the year 2009-10, Sub centres Valturu and Kotturu under PHC Pedapadu had not received the funds till the time of visit by the evaluation team. d) During the visit staff of the sub-centres stated that reported that sarpanchs do not actively co-operate in the conduct of VHSC meeting and take unilateral decisions. They demand the whole money put at their disposal. It is suggested that in such situation medical Officers/Health supervisors of the concerned PHC have to intervene to see that there is no misuse of untied funds at VHSCs. e) Untied fund of Rs. 10,000 per SC per annum is actually meant for up keep of Sub-centre building and for purchasing of necessary items required at the centre, but it is observed that the fund is also divided into number of Gram panchayats that come under the SC area and allotted to joint account., as a result the ANM has to approach 2-3 Surpanchs even to incur expenditure on SC requirements.

2. Services of ASHA : a) ASHAs are called as Women Health volunteers(WHV) in the state. In the district 3260 ASHAs were selected, trained and provided with drug kits upto the end of 2008-09. There is no proposal for more ASHAs . An amount of Rs. 1,08,31,045 was spent towards the scheme during 2009-10 upto Dec 2009. c) ASHA is also involved as a member in VHSCs.

7. 24 hour delivery care system: e. In the district, 31out of total 69 PHCs were functioning as 24 hour delivery care institutions. f. Of these, only 14 PHCs were having 2 Medical Officers(MOs) and the remaining 10 have only one MO. 13 PHCs were having 2 Staff Nurses and the remaining 18 have only one Staff Nurse posted..

29 c) Funds to the extent of Rs. 2549468 was available for the year 2008-09 in the district . Out of it Rs. 2137144 was spent during the year. For the year 2009-10, a budget of Rs. 3158324 was available to district and an amount of Rs. 3107817 was spent upto Nov. 2009. a. Expenditure was mainly towards payment of honorarium to contact basis staff. e) During 2009-10 16 of the total 14 PHCs working as 24 hours 6 centres did not perform the stipulated minimum of 10 deliveries per month. f) Contract basis staff nurse is not being paid their salary regularly. 8. Physical infrastructure and Stock position: (i) CHC: CHC Manchili visited was functioning in Govt. building. Telephone is not provided. All the materials and equipments as listed in form NRHM-7 were supplied except vehicle. Blood storage unit is not set up. Residential quarters for MOs were old and condemned. Epidosyn and Duvodelon tablets were not in stock on the day of visit. ii) PHC a) PHCs at Pedapadu, was functioning in government building. All the materials and equipments as listed in form NRHM-7 were supplied except vehicle. AYUSH MO of Homeo branch is posted there. b) Residential quarters for Medical Officer were available.. c) Stock of the most of the essential drugs is available in the centre.

(iii) Sub Centres a) Sub centre at Kotturu was functioning in Govt. Building . SCs at Vatluru, Aravelli, Unikili were functioning in rent free accommodation . It was observed that SCs Vatluru and Aravelli were using gram panchayat building and still rent was being drawn. b) There was no functional labour-room 3 Subcentres visited. c) Examination table, delivery table, Mclntch sheets, Ambu bag, steam sterilizer, weighing machine(infant) were not available on majority of the visited Centres.

d) Similarly, DDK, Gloves, Antiseptic solution, Tab. Metronidazole Cap. Ampiciline , chlorine solution etc. were also not available at any of the visited sub-centres.

9. Opinion and Knowledge of Community on Health Services: a) To assess knowledge and community satisfaction 40 mothers of having a child upto one year age were interviewed in the area of 4 sub-centres and found that most of them were happy having PNC services in time. b) 70% respondents were not aware about danger sign of ARI and 15% mothers do not have the knowledge about advantages and side effects of contraceptive uses. c) Public opinion was good on the services being rendered by the PHCs/CHCs visited by the team. Villagers expressed satisfaction on the overall functioning of PHCs. d) In each sub-centre visited at Kotturu ,Vatluru and Unikili 10 persons were interviewed and found that MPWs(M) were not staying in the SC HQ. Villagers were happy with their work. All have achieved their target for collecting blood smears and motivating persons for FP methods.

10. Maintenance of records and registers at SC level: a) EC Registers are no being maintained in Kotturu and Unikili Sub Centres. b) Stock registers are not being maintained in any of the sub centres visited. c) Cash book for untied funds is kept in Vatluru SC only. d) Follow up entries are not made in FW registers.as well as service registers being maintained but IUD, OP and Nirodh services registers were not updated . e) As printed registers were not supplied to SCs for the last 2-3 years registers are being maintained on non printed books or xerox copies. Printed JSY registration cards were not available at SC level 11. Important Observations and Suggestions:

a) Some of the SCs which are functioning in the rent free buildings provided by village local panchayats are drawing Sub centre clinic rent @ Rs. 250

per month. This is a false claim the district authorities may look into the matter. b) At the sub-centres, delivery rooms were not available. Some of the viisited SCs were having only 50% of the required furniture, drugs and equipments c) SC Untied funds were released very late. Hence staff of SC could not plan the expenditure for every quarter separately.

8. District Karimnagar

Major observations of Regional Evaluation Team, Banglore about the Evaluation work in Karim Nagar Districts of Andhra Pradesh, in January , 2010.

I. Details of the visited Institutions:

Karimnagar PHC/CHC: Eradapalli,Thadikal,Mar Sankarapatna,Vemulawad ripalli,Mallaram,Palakur a and Putnur. ti and Thakkalapalli

II. Major Observations:

1. Human resources: a) Key posts like 21(14%) posts of staff nurse, 12(18%) posts of Health Supervisor(Male ) 24(30%) posts of Health Supervisor (Female), 118 (20%) posts of ANM/MPW (Female), 153 (48%) posts of MPW (Male) and 15(17%) posts of Pharmascists and 11(15%) posts of Lab Technician were ying vacant in district. b) In the visited PHC at Shakarapatnam, , single sanctioned post of staff nurse and 4 posts of MPW(M) out of 5 sanctioned were lying vacant. c) Similarly, 1 Post of Lab technitian out of 2 sactioned is vacant in PHC Vemulawada. Only one sanctioned post of Pharmasist has not been filled at PHC Putnur. 2. Functions of Rogi Kalyan Samithee( RKS)

32 a) Rogi Kalyan Samithi known as Hospital Development Society (HDS) in the State were found to be set up in all peripheral 6 CHCs, 71 PHCs , District Hospital and 6 sub district hospitals in the District. b) In both the centres visited, viz. CHC Shankarapatnam and PHC Vemulawada and Pedapadu meetings of HDS are being held regularly and funds are being utilized as per norms. c) The total budget for HDS in the district was Rs. 1,10,07,477/- for 2008-09 and Rs 1,40,48,196 for the year 2009-10 Upto Dec 2009. Expenditure of Rs 64,09,281 was incurred in 2008-09 and Rs. 59,03,600 was spent during 2009- 10 upto Dec 2009. d) The budget for AMG in the district was Rs. 38,00,000/- for 2008-09 and Rs 1900,000 for the year 2009-10 Upto Dec 2009. Expenditure of Rs 19,00,000/- was incurred in 2008-09 and Rs. 35000/- was spent during 2009-10 upto Dec 2009. In both the centres visited, viz. CHC Shankarapattanam and PHC Vemulawada meetings of HDS are being held regularly and funds were being utilized as per norms. 3) Functioning of VHSCs a) In the district 1194 VHSCs were set up and each VHSC is eligible for fund ranging from Rs. 4500 to Rs. 18,500 depending on population covered. b) The total budget for VHSCs in the district was Rs. 11,833,476/- for 2008- 09 and Rs 13,450,267/- for the year 2009-10 Upto Nov 2009. Expenditure of Rs 10,323,209/- was incurred in 2008-09 and Rs. 2,979,063/- was spent during 2009-10 upto Nov 2009. For the period 2009-10, fund was released only in Dec. 2009 and hence the amount was not spent. c) In the visited sub-centres meetings of VHSCs were observed to be not conducted on regular basis.) The ANMs in the visited centres reported that they have no voice on deciding the pattern, period and nature of expenditure of VHSC fund as the Gram Panchayat level representatives are over powering and take unilateral decisions. d) SC Untied funds were released very late. Hence staff of SC could not plan the expenditure for every quarter uniformly. Money is spent within 2-3 months. For the period 2009-10, fund was released only in Dec. 2009 and hence the amount was not spent at the time of teams visit. 33

4. Janani Suraksha Yojana (JSY) a. Women belonging to BPL, SC/ST category family only are eligible to receive JSY cash incentive for the first 2 deliveries @ Rs. 700 in Rural Areas and @ Rs. 600 in urban area in the state. JSY cash incentive was given only for Deliveries undertaken in Govt. institutions in 2008-09. Deliveries undertaken in private institutions and Home deliveries were given cash incentive upto the year ending March 2008, provided they satisfy the conditions mentioned above. b) In the district Karimnagar, 72474 deliveries were conducted during 2008-09. Out of them 63705 were eligible for JSY cash incentive but payments were made to 29323 beneficiaries only. c) Of the total 72474 deliveries during2008-09, 55882 (77%) took place in private hospitals. Thus there is more than 3/4th contribution by private sector . Govt. institutions contributed 11% and home deliveries stood at 12% although there is no cash incentive for home deliveries. d) The total budget for JSY in the district was Rs. 3,40,26,400/- for 2008-09 and Rs 1,92,43,332/- for the year 2009-10 Upto Dec 2009. Expenditure of Rs2,01,15,875/- was incurred in 2008-09 and Rs. 54,55,100/- was spent during 2009-10 upto Dec 2009. For the period 2009-10, fund was released only in Dec. 2009.

e) During Sample check it was observed that upto 2008-09 28 cases in SC Eradapalli and 48 cases in SC Thadikal were pending for JSY payment. Similarly, 39 cases in SC Marripalli and 44 cases in mallaram l were also pending for 2008-09. Few cases for all the 4 sub-centres for 2009-10 were also pending. f) Totally, 53 JSY beneficiaries were contacted in the field. All the beneficiaries stated that they received full JSY cash incentive; MCH cards were issued to all, ANC/PNC visits were made by ANMs.

5. Untied funds: a) For Sub centres Untied funds to the extent of Rs. 6126617 was available for the year 2008-09 . Out of it Rs. 52,77,774 was spent during the year. For the year 2009-10, district had Rs. 6568843 as untied funds out of which 34

1321000 has already been spent till Nov. 2009. Untied funds of Rs. 10,000 per SC per annum has been released for 2008-09 and 2009-10 . SC Untied funds were released very late. Hence staff of SC could not plan the expenditure for every quarter separately. b) The district was provided Rs. 25 ,000 per PHC and Rs. 50,000 per CHC and the fund was kept in the joint account of the Rogi Kalyan Samithi. In both the centres visited, at CHC Manchili and PHC Pedapadu this fund was utilized as per norms. The total budget for CHC/PHC under Untied Funds was Rs.3639560/- for 2008-09 and Rs 1890654 for the year 2009-10 Upto Dec 2009. Expenditure of Rs 1748906 was incurred in 2008-09 and Rs. 543589/- was spent during 2009-10 upto Dec 2009.

6. Sevices of ASHA : a) ASHAs are called as Women Health volunteers(WHV) in Andhra state. In the district Karim nagar, 2709 ASHAs were selected, trained and provided with drug kits upto the end of 2008-09. b) There is no proposal for more ASHAs for 2009-10 . An amount of Rs. 1,11,55,640 was spent towards payment of remuneration based on performance to ASHAs during 2009-10 upto Dec 2009. c) ASHA is also involved as a member in VHSCs.

7. 24 hour delivery care system: b) In the district, 35out of total 71 PHCs were functioning as 24 hour delivery care institutions. b) Funds to the extent of Rs. 29,08,263 was available for the year 2008-09 in the district . Out of it Rs. 11,74,130 was spent during the year. For the year 2009-10, a budget of Rs. 351233 was available to district and an amount of Rs.24,63,200 was spent upto Nov.2009. Expenditure was mainly towards payment of honorarium to contact basis staff. d) During 2009-10, upto Nov. 2009, 32out of the total 35 PHCs working as 24 hours 6 centres did not perform the stipulated minimum of 10 deliveries per month. 8. Physical infrastructure and Stock position: 35

(ii) PHCs a) PHCs at Shankarapattanam and Vemulawada were functioning in government buildings All the materials and equipments as listed in form NRHM-7 were supplied except vehicle in both the PHCs.. AYUSH MO of Homeo branch is posted in PHC Shankarapattanam.. b) Residential quarters for Medical Officer were not available for any of the to PHCs visited. c) Stock of the most of the essential drugs were available in the centre.

(iii) Sub Centres a) Sub centre at Thadikal and Marriapalli were functioning in Govt. Building . SCs at Eradappalli is functioning in rent free accommodation and SC Mallaram in a rented building. b) Delivery is not being conducted in any of the SCs visited. Because there was no labour-room 3 Subcentres visited. In SC Mallaram SC though Labour room is available, no delivery has been conducted in last 3 months of the inspection. c) Examination table, delivery table, Mclntch sheets, Ambu bag, steam sterilizer, weighing machine(infant) were not available on majority of the visited Centres. d) Similarly, DDK, Gloves, Antiseptic solution, Tab. Metronidazole Cap. Ampiciline chlorine solution etc. were also not available at any of the visited sub-centres. e) Availability of furniture &, equipment was less than 50 % of the required level in the SCs , hence they were not able to function properly drugs were

9. Opinion and Knowledge of Community on Health Services: a) To assess knowledge and community satisfactions 40 mothers(ten from each SC area) of having last child upto one year age were interviewed in the area of 4 sub-centres and found that most of them were happy having PNC services in time.

b) 85% respondents were not aware about danger sign of ARI and 20% mothers do not have the knowledge about advantages and side effects of contraceptive uses. c) Public opinion was good on the services being rendered by the PHCs/CHCs visited by the team. Villagers expressed satisfaction on the overall functioning of PHCs. d) In each sub-centre visited at Marripalli and Mallaram 10 persons were interviewed and found that MPWs(M) were not staying in the SC HQ. Villagers expressed satisfaction towards their work. Both the MPW(M)s had achieved their target for collecting blood smears and motivating persons for FP methods. .

10. Maintenance of records and registers at SC level: a) Register for referral sterilizations was not maintained in PHC Vemulawada and PHC Putnur.. b) EC register was not found updated in any PHC or SC visited. c) Stock registers were not found updated in any PHC visited. Stock registers are not maintained for equipments and drugs purchased under NRHM funds at SCs. d) As printed registers were not supplied to SCs for the last -3 years the staff of SC were finding it difficult to keep records on non printed books or xerox copies. Printed JSY registration cards were not available at SC level.

11) Important Observations and Suggestions:

a) PHC Putnur has to cover a population of 3,80000 where as norm for a PHC is to cover 30,000 people. This comes to 12 times extra burden for a PHC where staffing pattern has remained the same.

b) PHC Putnur has no vehicle and the MO incharge is expected to go round and cover the town population of 2,80000 where 5 urban centres are functioning.

37 c) Some of the SC buildings which are functioning in the rent free building provided by village local panchayats are drawing Sub centre clinic rent @ Rs. 250 per month. The district authorities may look into the matter. d) At the sub-centres, delivery rooms awere not available. Some of the vioisited SCs were having only 50% of the required furniture, drugs and equipments

e) During the visit staff of the sub-centres stated that reported that sarpanchs do not actively co-operate in the conduct of VHSC meeting and take unilateral decisions and demand the whole money put at their disposal. In such situation medical Officers/Health supervisors of the concerned PHC have to intervene to see that there is no misuse of untied funds. *******************