MAPPING OF ULTRASOUND CLINICS AND United Nations Population Fund State Health Society, Bihar 55 Lodi Estate, New Delhi 110 003, India Pariwar Kalyan Bhawan ASSESSMENT OF STATUS OF IMPLEMENTATION India.unfpa.org Sheikhpura. Patna-800 014 www.statehealthsocietybihar.org OF PC & PNDT ACT IN BIHAR Mapping of Ultrasound Clinics and Status of PC & PNDT Act Implementation in Bihar This report is an outcome of a study commissioned by Government of Bihar in collaboration with United Nations Population Fund (UNFPA), New Delhi to map ultrasound facilities and to assess the status of the PC & PNDT Act implementation in the State. Period of the study : December 2012 Report published : December 2014 Design credit : Rouge Communications All rights reserved. The contents, analysis, opinions and recommendations expressed in the report are solely the views of the author and do not necessarily represent the views of the United Nations Population Fund – UNFPA. The document may be quoted, reproduced or translated, either in part or full, with due acknowledgements. UNFPA will not, in any way, be liable for the use, or any consequences arising out of the use of any other information from this report. The report is for informing and educating the public at large and is not to be sold or used for commercial purposes. MAPPING OF ULTRASOUND CLINICS AND ASSESSMENT OF STATUS OF IMPLEMENTATION OF PC & PNDT ACT IN BIHAR Study Report Study Commissioned by Government of Bihar, supported by United Nations Population Fund (UNFPA) Study undertaken by Social and Rural Research Institute (SRI), A Specialist Unit of IMRB International, New Delhi STATE HEALTH SOCIETY, BIHAR jkT; LokLF; lfefr] fcgkj ifjokj dY;k.k Hkou] 'ks[kiqjk] iVuk& 800 014 Pariwar Kalyan Bhawan. Sheikhpura. Patna- 800 014, Tel: 0612-2290340, 2281545, Fax: 2290322, website: www.statehealthsocietybihar.org jk"Vhª ; xkz eh.k LokLF; fe’ku Foreword Bihar had a very proportionate sex ratio at the beginning of 20th century but by the third quarter of that century, a gradual declining trend emerged. The overall sex ratio declined from 1061 in 1901 to 918 in 2011, while the child sex ratio also declined from 981 in 1981 to 935 in 2011. The child sex ratio is a crucial indicator of the status of women and girls in the society and a decline in this ratio is indeed a matter of great concern. The recent decline in child sex ratio, while attributable to factors like gender differential in mortality, and the misuse of modern diagnostic technology like ultrasonography which provides easy access to sex determination and sex selection in a socio-cultural milieu that prefers sons over daughters. In the given scenario, the state has been forced to implement the Pre-Conception & Pre-Natal Diagnostic Technique Act to regulate misuse of technology. However, the Census 2011 data on child sex ratio reveals that a lot more needs to be done in the state to strengthen the implementation of this much needed Act. The Government of Bihar is committed to improve this demographic phenomena with the regulatory measure. Apart from this restrictive enforcement, number of proactive measures have been undertaken to address this attitude of gender discrimination. Social welfare schemes such as Kanya Suraksha Yojna, free education to girls, Bicycle Yojna, 50% reservations to women in Panchayat elections and 35% reservation in the appointment of constables have been devised to defeat the social milieu of considering girl child as a compulsory burden as a non-earning member of the family. Concerted efforts have also been made to address the alarming decrease in the number of girls under 6 years, as compared to boys. This study is one of the initiatives which was undertaken to assess the status of implementation of the PCPNDT Act in the state and to map the number and locations of ultrasound machines. This study undertaken in collaboration with UNFPA also assessed the compliance of registered facilities to the Act, as well as the capacities of the state and district appropriate authorities to implement this Act. This study report has highlighted the grey areas in the implementation of the Act and has provided clear insights on ultrasonography centers operational in the state without registration. The findings of the study provide the need for plugging gap in the policy and programmatic directions for all the key stakeholders working on the issue in order to improve the situation in the state. The findings incorporated are really important for the state and would definitely contribute to guide us in preparing a comprehensive road map for addressing many aspects related to the issue of declining sex ratio in the state. (Sanjay Kumar Singh) Secretary Health-cum-Executive Director State Health Society, Bihar Acknowledgements As one of the key measure to address gender biased sex selection and to reverse the distorted sex ratio at birth, the Government of Bihar is implementing the Pre-Conception and Pre-Natal Diagnostic Technique (PCPNDT) Act to regulate the proper use of modern medical technology like ultrasonography. Addressing gender biased sex selection has also been one of the areas of priority programming for UNFPA in India. Extensive research and advocacy has been supported to arrest decline in ratios. In view of this, the state government wanted to partner with UNFPA to understand the effectiveness of Act implementation in the state, map the number of ultrasound facilities and assess capacities of state and district authorities to implement the Act. Based on the request from state health society and Department of Health, this study was commissioned by UNFPA to undertake detail mapping of functional ultrasonography centers in the state, assess the compliance by the center with the Act and effectiveness of Act implementation in the state. The study also attempted to test the methodology of mapping of centres given its potential for replication in other states. Alongwith development of detailed tools, through snowballing, efforts were made to tap into the information network on the ground to identify especially those ultrasound facilities that may be operating illegally. Thus, a wider listing of all the ultrasonography centers was enabled, beyond the registered ones already on government records. This study would not have been possible without the support of Department of Health, State Health Society, radiologists and gynaecologists who assisted with critical information. UNFPA is particularly thankful to Shri Deepak Kumar – Principal Secretary Health, Shri Sanjay Kumar Singh – Executive Director, State Health Society and Dr. N. K. Mishra – State Programme Officer for their guidance and valuable suggestions. The support of all the civil surgeons was much needed and valuable to complete the data collection from the private providers. UNFPA also takes this opportunity to thank all the team members from Social and Rural Research Institute for their tireless efforts in facilitating all aspects of this study, particularly, managing data collection on this sensitive issue at the field level. Ms. Ena Singh, Dr. Nilesh Deshpande, Ms. Dhanashri Brahme and Mr. Sanjay Kumar of the UNFPA team have made key contributions in conceptualizing the study, ensuring data quality, strengthening the analysis plan and firming up findings and recommendations emerging from this study. The support provided by Ms. Vidya Krishnamurthy in proof reading and design coordination is also acknowledged. Ms. Frederika Meijer UNFPA Representative 1 Table of Contents Executive Summary 5 PART I - INTRODUCTION 17 Background of the Study 17 Objectives of the Study 17 Research Design 18 Key Information Areas 21 Implementation Protocol and Data Management for the Study 21 Ethical Considerations 25 Limitations of the Study 26 Outline of the Report 26 PART II - MAPPING ULTRASONOGRAPHY FACILITIES 27 State Overview 27 Registered Facilities 28 Unregistered Clinics 36 District-wise Distribution of Ultrasound Facilities 39 PART III - IMPLEMENTATION OF PCPNDT ACT 41 Overview 41 District Appropriate Authority 41 District Advisory Committee 47 District-wise Interviews 50 Information from State Level Interviews 52 PART IV - SUMMARY OF FINDINGS 55 Understanding the Progress in Act Implementation in the State 55 PART V - RECOMMENDATIONS AND POINTS OF ACTION 57 ANNEXURES 59 Annexure I 59 Directory of Registered Facilities Annexure II 94 Directory of Unregistered Facilities Annexure III 100 Directory of Unverified Facilities 2 List of Tables Table 1. Sex ratio across world regions 9 Table 2. Sex ratio in India, 1951 to 2011 10 Table 3. Number of villages and Urban Agglomerations by child sex ratio 10 (Census 2001) Table 4. Overall sex ratio by state 11 Table 5. Overall sex ratio trends in Bihar 12 Table 6. Child sex ratio trends in Bihar 12 Table 7. USG facilities identified and listed in the state 27 Table 8. Number of facilities originally listed with the government and their verified registration status 28 Table 9. Registered USG facilities interviewed in the state 28 Table 10. Details of number of radiologists and technicians employed by facility 31 Table 11. Whether owner is key operating person in the facility 31 Table 12. Details of facilities based on number of machines possessed 32 Table 13. Registration details of machines in registered ultrasound facilities 32 Table 14. Number of details mentioned on all verified registration certificates 33 Table 15. Unregistered USG facilities identified and interviewed in the state 36 Table 16. Details of number of radiologists and technicians employed by facility 37 Table 17. Whether owner is key operating person in the facility 37 Table 18. Distribution of ultrasound facilities in the state 39 Table 19. Completed district level interviews with DAA and DAC 41 Table 20. Current status of DAC positions as informed by the DAA 42 Table 21. Number of DAC members who have received trainings as per the DAA 43 Table 22. Information on monitoring visits by the DAA (in absolutes) 44 Table 23. Information on records submitted by the registered clinics to the DAA 45 Table 24.