CHAPTER 1 INTRODUCTION
India has registered significant progress in improving life expectancy at birth, reducing mortality due to Malaria, as well as reducing infant and maternal mortality over the last few decades. In spite of the progress made, a high proportion of the population, especially in rural areas, continues to suffer and die from preventable diseases, pregnancy and child birth related complications as well as malnutrition. In addition to old unresolved problems, the health system in the country is facing emerging threats and challenges. The rural public health care system in many States and regions is in an unsatisfactory state leading to pauperization of poor households due to expensive private sector health care. India is in the midst of an epidemiological and demographic transition–with the attendant problems of increased chronic disease burden and a decline in mortality and fertility rates leading to an ageing of the population. An estimated 5 million people in the country are living with HIV/AIDS, a threat which has the potential to undermine the health and developmental gains India has made since its independence. Non communicable diseases such as cardio vascular diseases, cancer, blindness, mental illness and tobacco use related illnesses have imposed the chronic diseases burden on the already over stretched health care system in the country. Premature morbidity and mortality from chronic diseases can be a major economic and human resource loss for India. The large disparity across India places the burden of these conditions mostly on the poor, and on women, scheduled castes and tribes especially those who live in the rural areas of the country. The inequity is also reflected in the skewed availability of public resources between the advanced and less developed states.
Public spending on preventive health services has a low priority over curative health in the country as a whole. Indian public spending on health is amongst the lowest in the world, whereas its proportion of private spending on health is one of the highest. More than Rs. 100,000 crores is being spent annually as household expenditure on Health, which is more than three times the public expenditure on health. The private sector health care is unregulated pushing the cost of health care up and making it unaffordable for the rural poor. It is clear that maintaining the health system in its
1 present form will become untenable in India. Persistent malnutrition, high levels of anaemia amongst children and women, low age of marriage and at first child birth, inadequate safe drinking water round the year in many villages, over crowding of dwelling units, unsatisfactory state of sanitation and disposal of wastes constitute major challenges for the public health system in India. Most of these public health determinants are correlated to high levels of poverty and to degradation of the environment in our villages. Thus, the country has to deal with multiple health crises, rising costs of health care and mounting expectations of the people. The challenge of quality health services in remote rural regions has to be met with a sense of urgency. Given the scope and magnitude of the problem, it is no longer enough to focus on narrowly defined projects. The urgent need is to transform the public health system into an accountable, accessible and affordable system of quality services.
In this background the Government of India, with the objective of meeting the basic requirement of Health for all has launched the National Rural Health Mission in April, 2005 to carry out necessary architectural correction in the basic health care delivery system. The Mission aims at provision of comprehensive and integrated primary healthcare to the people, especially to the rural poor, women and children. It adopts a synergic approach by relating Health to determinants of good health viz of nutrition, sanitation, hygiene and safe drinking water. It also aims at mainstreaming the Indian systems of medicine to facilitate health care. The Plan of Action includes increasing public expenditure on health, reducing regional imbalance in health infrastructure, pooling resources, integration of organizational structures, optimization of health manpower, decentralization and district management of health programmes, community participation and ownership of assets, induction of management and financial personnel into district health system, and operationalising Community Health Centers, Primary Health Centers and Sub Centers into functional hospitals meeting Indian Public Health Standards. It also subsumes key national programmes like Reproductive and Child Health II project, the National Disease Control Programmes and the Integrated Disease Surveillance Project. It will also enable the mainstreaming of AYUSH —Ayurvedia, Yoga, Unani, Siddha and Homeopathy System of Health.
The Mission lists a set of core strategies to meet its goals like decentralized village and district level health planning and management, appointment of female Accredited
2 Social Health Activists (ASHA) to facilitate access to health services. The Mission attempts a major shift in the governance of public health by giving leadership to Panchayati Raj Institutions in matters related to health at district and sub district levels. Another key strategy of the Mission is decentralization of programmes for district level management of health. Under the scheme, all existing societies for health and family welfare programmes, Reproductive and Child Health and National Programmes for TB, Malaria, Blindness, Filaria, Kala Azar, Iodine Deficiency and Integrated Disease Surveillance, shall integrate into a unified District Health Mission. Funding for all these programmes will be eventually funneled into the District Health Mission, which will be empowered to formulate integrated health plan of the district. One of the core strategies of the Mission is to empower local governments to manage, control and be accountable for public health services at various levels. The Village Health and Sanitation Committee, the Standing Committee of the Gram Panchayat will provide oversight of Mission’s all activities at the village level and be responsible for developing the Village Health Plan with the support of the Auxiliary Nurse Midwife, ASHA, Anganwadi Worker and Self Help Groups. Block level Panchayat Samitis will co ordinate the work of the Gram Panchayats in their jurisdiction and will serve as link to the District Health Mission, which will be led by Zilla Parishad and will control, guide and manage all public health institutions in the district. States will be encouraged to devolve greater powers and funds to Panchayati Raj Institutions.
In light of the above background and also the fact as the Mission is now in its third year of existence, it is time to take stock of the operationalization of the Mission at the state, district and local level in the context of the Plan of Action evolved at the national level. Though, NRHM has an intensive accountability framework through a three way process of community based monitoring, external surveys and stringent internal monitoring but external surveys give an independent assessment of the functioning of the system.
As a part of monitoring, MOHFW, therefore, proposed a rapid assessment regarding the implementation of NRHM by Population Research Centers (PRCs) in all the states and PRC Srinagar has been entrusted with the job of conducting the study in Jammu and Kashmir. Given the very wide scope of the Mission and diverse nature of its
3 activities, the Ministry decided that the rapid appraisal be restricted to selected core components that directly address the health and family welfare needs of the people. The Ministry identified the following four core components of the Mission to be taken up for rapid appraisal in some selected Districts in each State: 1. Utilization of Untied Funds at SC, PHC and CHC level, 2. Janani Suraksha Yojna for increasing institutional deliveries, 3. Facility Upgradation i.e. strengthening the health care services, 4. Assessment of Health and Family Welfare situation at the Village level. Brief features of these four components are as under
Utilization of untied funds NRHM has drawn a plan of action at all levels of the healthcare to build up sustainable healthcare delivery system, where all citizens have access to affordable and appropriate quality healthcare. To achieve its goals, NRHM in its strategies, set up a platform for involving the Panchayati Raj Institutions (PRIs) in primary health programmes and infrastructure. The Mission also envisages the following roles for PRIs: States are required to commit for devolution of funds, functionaries and programmes for health to PRIs. At grassroots level, Village Health Committee (VHC) has been formed to decentralize the planning and monitoring of various programmes. For strengthening the health centers, all the health facilities are provided with untied funds. Untied funds can be used only for the common good and not for the individual needs, except in the case of referral and transport in emergency situations. Each sub centre will have an untied fund @ Rs.10000 per annum. Likewise, each PHC and CHC is provided with untied funds of Rs. 25000 and Rs.50, 000 respectively for local health action. At sub centre level, the fund will be deposited in a joint account of the ANM and the woman Sarpanch or the woman member of Panchayat, but the account will be operated by ANM in consultation with village health committee and multipurpose health workers. At the PHC and CHC level, untied funds will be kept in the bank account of the concerned Rogi Kalyan Samiti (RKS)/Hospital Management Committee. The funds will be spent and monitored by RKS. This study will be undertaken to analyze the flow, utilization and adequacy of untied funds at sub centre and PHC level. It will also help to know how actively PRIs/RKS are involved with the utilization of untied funds.
4 Janani Suraksha Yojna (JSY) Janani Suraksha Yojna, an integral component for safe motherhood under NRHM, was launched in 2005 with the objective of reducing maternal and neo natal mortality. The scheme aims to promote institutional deliveries amongst poor pregnant women in all the states and Union Territories (UTs) of the country with special focus on low performing states (LPS). It is a 100 percent centrally sponsored scheme and links cash assistance with delivery and post delivery care. In availing institutional delivery services, the client is usually escorted, would be requiring transport to reach the institution and in case of complications, referral services would be required. The scheme has considered all these elements and has made provision for transport including referral and escort and at the same time invested in improving public health institutions and services through the Reproductive and Child Health (RCH) Programme interventions. This apart, states have been given flexibility to evolve public private partnership (PPP) mechanism and accredit private health institutions for providing institutional delivery services. The special dispensation for LPS in both rural and urban areas has been made and linked to the ASHA intervention. The LPS are those that have low institutional delivery rates and include Uttar Pradesh, Uttaranchal, Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Assam, Rajasthan, Orissa, and Jammu and Kashmir. In the remaining states and UT’s categorized as High Performing States (HPS) similar provisions have been made wherein Anganwadi worker or traditional birth attendant or ASHA like activist could be engaged and associated with the JSY scheme. The JSY focuses on : (1) Maternal care through micro planning of birth, (2) Cash assistance to all eligible mothers for delivery care, (3) Cash assistance for referral transport, (4) Cash assistance to institutions for hiring specialists for Caesarean Section or for the management of Obstetric complications and (5) Cash benefit to ASHA for facilitating institutional delivery. Here the evaluation exercise proposes to study the role of ASHA/ANM and other officials in promotion of JSY and its financial management.
Facility up gradation under NRHM
For meeting the health needs of the rural masses, one of the key strategies of the National Rural Health Mission is to strengthen all the health facilities by upgrading them with necessary infrastructure according to the type of facility (like CHC, PHC, SC
5 etc). The main aim is to strengthen hospital care for rural areas, provide specialized care to the community and also to improve the standard of quality of care in order to enhance the level of patient satisfaction. For this component, the objective of the evaluation study will be as to examine as to what extent the SCs, PHCs and CHCs have been upgraded under NRHM and also to examine the adequacy of infrastructure, furniture and equipment, medicine/drugs, manpower as per IPHS standards.
Assessment of Health and Family Welfare situation at village level It has been envisaged under NRHM that indicators of health depend as much on drinking water, nutrition, sanitation, female literacy, women’s empowerment as they do on functional health facilities. NRHM seeks to adopt a convergent approach for interventions under the umbrella of the district plan which seeks to integrate all the related initiatives at the village, block and district level. Wherever village committees have been effectively constituted for drinking water, sanitation, ICDS etc., NHRM attempts to move towards one common Village Health Committee covering all these activities. Panchayati Raj Institutions are being fully involved in this convergent approach so that the gains of integrated action can be reflected in district plans. Under NRHM, household surveys through ASHA, AWW will target availability of drinking water, firewood, livelihood, sanitation and other issues in order to allow a framework for effective convergent action in the Village Health Plans. Here, the evaluation study will try to assess the health and family welfare situation at village level and its covariates like household amenities, safe drinking water, sanitation, quality and coverage of health care services.
With these broader aspects of assessment, specific objectives of the study are: Utilization of Untied Funds To examine the utilization of untied funds under different activities at SC, PHC and CHC level To highlight the problems faced by CHC and PHC Incharge and ANMs in receiving and utilization of funds To seek the opinions of CHC and PHC Incharge and ANMs regarding the sufficiency of funds
6 To study the role of VHSC particularly Lady Sarpanch/Panch at sub centre level and Rogi Kalyan Samitis in the utilization of funds at CHC and PHC level.
Janani Suraksha Yojna To assess the role of ANMs/ASHAs in providing services to the beneficiaries of the JSY To seek the opinions of ANMs/ASHAs regarding the sufficiency of funds and timely disbursement of funds To study the role of other health officials in the implementation of the scheme at district Review engagement of private sector including accreditation and compensation To highlight the problems faced by beneficiaries in receiving the services/funds
Facility Upgradation under the NRHM To assess the level of Upgradation of health facilities To assess the availability and adequacy of infrastructure, furniture, equipment, Medicines/drugs and vehicle in the sub centres, PHCs and CHCs To examine the availability of manpower- medical & paramedical To assess the availability of type of services and facilities To assess the clients perception regarding quality of services through exit interviews and seek views of the community To seek opinion of doctors and Para medics regarding the type and quality of services provided to the community by them.
Assessment of Health and Family Welfare Situation at the Village level Assessment of health and family welfare situation in the village in terms of availability of drinking water, sanitation, functional health facilities, quality of services provided, nutritional status, women’s empowerment, maternal and child health, disease prevalence etc.
Methodology
For achieving the above mentioned objectives, both primary and secondary level data was collected through instruments structured at different levels. The secondary data
7 regarding the physical and financial progress of the schemes was collected from various health associated with the implementation of NRHM. Information regarding the implementation of the schemes, planning, monitoring and problems of the schemes was also collected using questionnaires at State, district, CHC, PHC, Sub Centre and village and household level. The Ministry identified two districts namely Baramulla and Rajouri districts for rapid appraisal in consultation with this PRC. The present report pertains to Baramulla district.
A set of 11 questionnaires were used for rapid appraisal exercise: the State Schedule, District Schedule Part A, District Schedule Part B District Hospital, Community Health Centre (CHC) Schedule, Primary Health Centre (PHC) Schedule, Sub Centre / ANM Schedule, ASHA Schedule, Gram Panchayat Schedule, Household Schedule, Exit Interview Schedule for IPD patients and Exit Interview Schedule for OPD patients. The overall content and format of the Questionnaires were determined in the Annual Meeting/Workshop of the Population Research Centers held in Srinagar in June, 2008. Based on the recommendations of this workshop, the questionnaires were finalized by MOHFW at New Delhi. The household, ASHA and Exit Interview questionnaires used in Baramulla were bilingual, consisting of questions in both Urdu and English. Before printing these questionnaires, pretest of the Urdu questionnaires was carried out by the PRC.
Sample Design The selection of the districts, sample design and methodology for conducting the survey was done by the PRCs in consultation with the officials of the Statistics Division of the Ministry of Health and Family Welfare, Government of India, New Delhi. In Jammu and Kashmir, two districts namely Rajouri in Jammu Division and Baramulla in Kashmir Region were selected for rapid appraisal. It was also decided that reports for the two districts will be prepared separately. For Baramulla district it was planned to collect information from the District Hospital, 2 CHCs, 4 PHCs and 12 Sub Centers. Baramulla district has a total of 6 CHCs/Sub District Hospitals. These are Uri, Chandoosa, Dangiwacha, Sopore, Pattan, and Tangmargh. It was planned to select 2 CHCs in the district. The 2 CHCs were to be selected in such a way that at least 1 CHC is farthest from the district HQ and the at least 1 is a FRU. From each CHC, two
8 PHCs were to be selected based on distance from headquarter and 24x7 functioning. In block Sherri we selected the CHC Chandoosa (which is hilly and backward) and from this CHC we selected PHC Fathegrah (24X7) and PHC Singhpora. Similarly from CHC Pattan, PHC Wanigam (24X7) and PHC G. K. Qasim were selected. It was also planned to select 3 Sub centers from each PHC and all were to be vertically under the same PHC with at least one SC to be farthest from the selected PHC. From each Sub Centre catchment area we selected 2 villages. The first village was the village where Sub Centre is located and the second village was the village which is farthest from the Sub Centre. The names of CHCs, PHCs, Sub Centers and Villages are as under:
Table 1: Sample Selection in Baramulla district of Jammu and Kashmir State selected CHC selected PHCs selected SCs selected villages
Chandoosa Fathegrah (24x7) Laridora Laridora Dangerpora Malpora Malpora Wanchal Kahwara Kahwara Kahwara Bala Singhpora Kanispora Kanispora Check Kanispora Singhpora Singhpora
Kalampora Uplina Uplina
Dardpora Pattan Wanigam (24x7) Andergam Andergam Khambyar Yatipora Yatipora
Bon Mohalla Resripora Resripora Seeru/Gudwani G. K. Qasim Archanderhama Archanderhama
Purni Sadarshah Agrikalan Agrikalan
Dangerpora
Matipora Matipora
BoniChakal Total =2 4 12 24
9 It was planned to cover 50 households in each village. The target of 1200 households was achieved during the field study due to the maximum efforts of the interviewers and the supervising staff. Apart for getting information from the households at the village level, information through structured questionnaires was also collected from ANMs, ASHAs and Sarpanch/Member Gram Panchayat/village head/Chairman VHSC. At the PHC and CHC level, in addition to getting information from the in charge about the physical infrastructure, manpower, drugs, equipment type of facilities provided, we had planned to conduct Exit interviews with In patient and Out door patient to get their opinion and satisfaction about the services availed by them. A similar exercise was also planned for the district Hospital. However, due to the non availability of in patients at PHCs and CHCs, Exit Interviews for In Patients at CHCs and PHCs were not conducted. The Exit Interviews were successfully completed with 67 out patients and 11 in patients. Apart from this information was collected from the office of Chief Medical Officer, District Programme Management Unit regarding the implementation of NRHM in the district. Besides, relevant information regarding the implementation of NRHM at the State Level was collected from the Office of Directorate of Family Welfare and RCH, Srinagar.
Field work The Data was collected during January February, 2009. Data was collected by a team, consisting of 6 field investigators, a supervisor cum editor and a field coordinator. Each field investigator was assigned to collect information for a particular scheme. Before the field work, the team members received training for six days, which consisted of instructions in interviewing techniques and field procedures for the survey, a detailed review of the NRHM, JSY, ASHA, Untied Funds etc, review of each item in the questionnaire, mock interviews between participants in the classroom and practice interviews in the field. Besides the main training, one day training was specially arranged for supervisors/editors. The supervisors/editors were trained to hold formal discussions with the officials involved with the implementation of the NRHM and record their observations regarding the facilities, service delivery, record maintenance, problems and other related issues. Senior officials of the PRC coordinated the data collection activities and also had formal discussions with the officials involved with the implementation/
10 execution of NRHM at State and District level. The Director and the Project Coordinators also visited the field to monitor the data collection activities and ensure good quality data.
During the course of field work, information was collected from 12 Sub Centers covering 24 villages. A total of about 1300 households were visited and interviews could be successfully completed for 1200 households. Besides, we collected information from 28 ASHAs, 17 Sarpanch/Member Gram Panchayat/village head/Chairman VHSC. Information was successfully completed from all the 12 Sub Centers, 4 PHCs, 2 CHCs and District Hospital Baramulla. So far as the Exit Interviews are concerned, the findings are based on the responses collected from 67 Out Patient and 11 In Patients. During the data collection extensive qualitative information was gathered to supplement the quantitative information.
Data processing All completed questionnaires were sent to the PRC office for data processing. This process consists of office editing, coding, data entry and machine editing. Four data entry operators under the supervision of one PRC Data Entry Supervisor were responsible for data entry and computer editing operations and data quality checks. The data was entered and tabulated with the help of four microcomputers using CSPro software, which was developed by PRC Pune. All data entry and editing operations took about two months.
Presentation of Findings This report is divided into ten chapters. Chapter 1 is the introduction. Chapter 2 deals with the health care facilities available in the State Level. Similarly, Chapter 3 presents the situation of NRHM at the District level, with special reference to District Hospital. Chapter 4, 5, and 6 are similar presentations respectively for CHCs, PHCs, and SCs. Chapter 7 is based on the information collected from households on various aspects of NRHM. Chapter 8 and 9 is based on the information regarding ASHAs and GPs. Information collected from respondents at health facilities for OPD and IPD is presented in chapter 10. A summary of the findings relating to the district as a whole assessed from the pooled data and some recommendations are provided at the beginning of the report.
11 CHAPTER 2 STATE PROFILE AND STATUS OF NRHM
Introduction
The land of snow clad mountains that shares a common boundary with Afghanistan, China and Pakistan, Jammu and Kashmir is the northernmost state of the Indian Union. Known for its extravagant natural beauty this land formed a major caravan route in the ancient times. Trade relations through these routes between China and Central Asia made it a land in habited by various religious and cultural groups. Kashyapa is said to have laid the foundation of Kashmir, which was referred to as 'Kashyapamar'. Owing to the several climatic conditions during winter people here lead a nomadic life with their cattle. It was also during the reign of Kashyapa that the various wandering groups led a settled life Buddhism influenced Kashmir during the rule of Ashoka and the present town of Srinagar was founded by him. This place was earlier called 'Srinagari' or Purandhisthan. The Brahmins who inhabited these areas admired and adorned Buddhism too. From the regions of Kashmir Buddhism spread to Ladakh, Tibet, Central Asia and China. Various traditions co existed till the advent of the Muslims. The Mughal had a deep influence on this land and introduced various reforms in the revenue industry and other areas that added to the progress of Kashmir. In 1820 Maharaj Gulab Singh got the Jagir of Jammu from Maharaj Ranjit Sigh. He is said to have laid the foundation of the Dogra dynasty. In 1846 Kashmir was sold to Maharaj Gulab Singh. Thus the two areas of Kashmir and Jammu were integrated into a single political unit. A few chieftains who formed part of the administration were of the Hunza, Kishtwar, Gilgit Ladakh. During the Dogra dynasty trade improved, along with the preservation and promotion of forestry. Art and crafts also developed through encouragement. After, independence of India in 1947 this region formed a part of the Indian Territory and is an integral region that contributed its part to preserve the unity and integrity of India.
The state of Jammu and Kashmir is situated at the extreme north of the country. It is situated between 320 17' N and 37° 6' N latitude, and 73° 26' E and 80° 30' E longitude. The state occupies a position of strategic importance with its borders touching the neighbouring countries of Afghanistan in the north west, Pakistan in the west and
12 China and Tibet in the north east. To its south, lie Punjab and Himachal Pradesh two other states of India. The total geographical area of the State is 2, 22,236 square kilo meters. This includes 78,114 sq km under illegal occupation of Pakistan, 5,180 sq km handed over by Pakistan to China, and 37,555 sq km under occupation of China. Geographically, the Jammu and Kashmir state is divided into four zones. First, the mountainous and semi mountainous plain commonly known as Kandi belt, the second, hills including Siwalik ranges, the third, mountains of Kashmir valley, and Pir Panjal range and the fourth is Tibetan tract of Ladakh and Kargil. The state comprises 22 districts in three administrative divisions namely Jammu, Kashmir and Ladakh. Kashmir division comprises the districts of Anantnag, Pulwama, Srinagar, Budgam, Baramulla, Kupwara, Bandipora, Shopian, Kulgam, and Ganderbal. Jammu division comprises the districts of Jammu, Kathua, Udhampur, Rajauri, Poonch, Doda, Samba, Resai, Kishtwar, and Ramban. Ladakh division consists of Kargil and Leh districts. Each region has distinct social, economic, linguistic and cultural characteristics.
As already mentioned the state of Jammu & Kashmir has an area of 2,22,236 sq. km. and a population of 10.14 million (5360926 males and 4782774 females), accounting roughly for 1 percent of the total population of the country. There are 22 districts, 107 blocks and 6652 villages. The State has population density of 45 per sq. km. (as against the national average of 312). The decadal growth rate of the state is 31.42% (against 21.54% for the country) and the population of the state continues to grow at a much faster rate than the national rate. As per the state estimates for 2008, the population of the state is 12.37 million out of which 6423000 are males and 5943000 are females. The sex ratio of the population (number of females per 1,000 males) in the State according to 2001 Census was 892, which is much lower than that of the country as a whole (933). Twenty five percent of the total population lives in the urban areas which is almost the same as the national level. Scheduled Castes population accounts for about eight percent of the total population of the state as against 16 percent at the national level while as the Scheduled Tribe population accounts for 11 per cent of the total population of the state as compared to eight percent at National level. The State is one of the most educationally backward states in India. As per 2001 Census, the literacy rate among population age 7 and
13 above is 54 percent, compared with 65 percent for India as a whole. Female literacy (41 percent) continues to be lower than the male literacy (54 percent).
On the demographic front, too, the State has to do a lot to achieve the goals of New Population Policy 2000. The Total Fertility Rate of 2.4 in Jammu and Kashmir is slightly lower than the TFR of 2.7 at the National Level. With the introduction of Reproductive and Child Health (RCH) Programme, more and more couples are now using family planning methods. As per National Family Health Survey 3 (NFHS 3), about 45 percent of women are now using modern family planning methods as compared to 49 percent in India as a whole. According to Sample Registration System (SRS, 2008), Jammu and Kashmir had an infant mortality rate of 51 per 1,000 live births, a birth rate of 19.0 and a death rate of 5.8 per 1,000 population. The corresponding figures at the national level were 55, 23 and 7.4 respectively. NFHS 3 has also estimated an infant mortality rate of 45 per 1,000 live births and a birth rate of 20.9 for Jammu and Kashmir. The corresponding figures for the national level are an infant mortality rate of 57 per 1,000 live births and a birth rate of 18.8 per 1,000 population. According to latest estimates, expectation of life at birth in Jammu and Kashmir has increased to 65.3 years as compared to 62.5 at the national level and the gap between the life expectancy at birth by gender in the State has gradually closed down and currently the female life expectancy is higher (66.8 years) than male life expectancy (64.1 years).
With the implementation of RCH Programme more and more women are coming forward to utilize antenatal and post natal care services. As per NFHS 3, 85 percent of women who gave birth in the five years preceding the NFHS 3 survey had received antenatal care from a health professional. Similarly, more and more women are now utilizing institutional services for delivery as about half of the births in the five years prior to the survey in Jammu and Kashmir took place in a health facility. Jammu and Kashmir is also progressing well in the field of child immunization. More than 90 percent of children have been immunized against various vaccine preventable diseases, however, because of drop outs only two thirds (67%) of children age 12 23 months in Jammu and Kashmir are fully vaccinated against six major childhood illnesses: Tuberculosis, Diphtheria, Pertussis, Tetanus, Polio, and Measles.
14 Table I: Demographic, Socio economic and Health profile of Jammu & Kashmir State as compared to India figures
S. No. Item J&K India 1 Total population (Census 2001) (in million) 10.14 1028.61 2 Decadal Growth (Census 2001) (%) 31.42 21.54 3 Crude Birth Rate (SRS 2007) 19.0 23.1 4 Crude Death Rate (SRS 2007) 5.8 7.4 5 Total Fertility Rate (SRS 2007) 2.3 2.7 6 Infant Mortality Rate (SRS 2007) 51 55 7 Maternal Mortality Ratio (SRS 2004 2006) NA 254 8 Sex Ratio (Census 2001) 892 933 9 Population below Poverty line (%) 3.48 26.10 10 Schedule Caste population (in million) 0.77 166.64 11 Schedule Tribe population (in million) 1.11 84.33 12 Female Literacy Rate (Census 2001) (%) 43.0 53.7
The State has made tremendous progress during the planned era in terms of development of health infrastructure, manpower and provision of necessary inputs in the health institutions. Besides, opening new medical units, requisite inputs have been provided into the higher institutions including PHCs, CHCs, District Hospitals and tertiary care hospitals. Efforts are underway to ensure that the health care facilities reach the farthest and remotest corners of the State. At the Tertiary level, the State has one Institute of Medical Sciences, (Deemed University), 4 Medical Colleges having 12 Associated Hospitals, One Ayurvedia Hospital and three Dental Colleges. At Secondary level, the State has 22 District Hospitals (14 old and 8 new) and 85 Sub District/CHCs (excluding 8 Sub District Hospitals which are under up gradation as District Hospitals). Primary Health care services are being provided by 375 PHCs, 238 Allopathic Dispensaries, 1907 Sub Centers, 346 Medical Aid Centers, and 417 ISM dispensaries. Besides, 302 institutions are delivering area specific health care services which include STD/VD Clinics, TB Centers, Leprosy Centers and other Centers. The state is short of manpower almost at all the levels and to make progress in this regard various steps are underway to tackle this issue.
15 Table 2: Health Infrastructure of Jammu & Kashmir
Particulars Required In position shortfall Sub centre 1666 1888 Primary Health Centre 271 374 Community Health Centre 67 80 MPW (Female)/ANM at SCs & PHCs 2262 1588 674 Health Worker (Male) MPW(M) at SCs 1888 377 1511 Health Assistant (Female)/LHV at PHCs 374 62 312 Health Assistant (Male) at PHCs 374 334 40 Doctor at PHCs 374 643 Obstetricians & Gynecologists at CHCs 80 26 54 Physicians at CHCs 80 46 34 Pediatricians at CHCs 80 33 47 Total specialists at CHCs 320 142 178 Radiographers 80 61 19 Pharmacist 454 456 Laboratory Technicians 454 395 59 Nurse/Midwife 934 68 866
The State Government, from time to time has made efforts to develop the state and lot of investments has been made in every sector. But when the efforts of the government started to bear fruits, a critical phase started in the State in 1989, which shattered the whole tree of development. Consequently, the development scenario of the state came to a complete halt and state economy went in a reverse gear. This resulted in the decline in the per capita income and gross domestic product. However, during the last five years, the State has again started to invest in rebuilding the necessary infrastructure and an era of development seems to have ushered in the State. The state government is making efforts to put the state economy back on track. The government of India is also helping the State in its developmental efforts and to mitigate the hardships faced by the people in the State during the last 18 years.
16 The Union government is also investing directly in the State in a big way. A number of Centrally Sponsored Schemes (CSS) in the sectors of rural development, urban development, health and family welfare, education, agriculture, women and child development, sanitation, housing, safe drinking water, irrigation, transport, border area development, social welfare are being implemented in the State like other parts of the country. The objective of all these schemes is to generate employment, improve the quality of life, reduce poverty and economic inequality, and human deprivation. Besides, these schemes aim at creation of basic infrastructure and assets propitious for economic development in rural areas.
The Hon’ble Prime Minister launched the NRHM on 12th April 2005 throughout the country including the State of Jammu and Kashmir with the basic objective of providing accessible, affordable and accountable health care in rural areas. Its primary focus is on making the public health system fully functional at all levels. While detailing the functioning of the NRHM, the present planning process initiated in the State provides the entire framework for making the Public Health System fully functional and standardized upto the Indian Public Health Standards at all levels. In doing so, it emphasizes the need for communitisation of the Public Health System, improved financing and management of public health, human resource innovations, and a long term financial commitment to enable the state and districts to undertake programmes aimed at achieving the Mission goals.
National Rural Health Mission envisages the planning process to be participatory and decentralized starting with the Village. It seeks to empower the community by placing the health of the people in their own hands and determine the ways they would like to improve their health. This is the only way to ensure that health plans are local specific and need based. The States are supposed to facilitate the processes by providing enabling environment and required financial and technical support. In our state, NRHM was launched in April 2005 with the rest of the country and is being implemented by the Department of Health and Medical Education, Government of Jammu & Kashmir.
The organizational set up for the implementation of various schemes under NRHM in the state is given as under:
17
18 In order to achieve the desired goals under NRHM, the State government is taking concrete steps to strengthen all the 1907 SCs and provide required staff and basic infrastructure in them. Efforts are also on to strengthen all the 375 PHCs and 85 CHCs by providing necessary inputs and man power. In the first Phase the State has identified 187 PHCs for up gradation to make them functional on 24X7 bases. Besides, 56 CHCs have been identified for up gradation to serve as FRUs as per guidelines under IPHS. The FRUs are being equipped with necessary diagnostics services, biometric systems, communication facilities, blood storage facilities, and ambulance tie ups for providing good quality referral services. Autonomy has been given to these facilities through Rogi Kalyan Samitis to improve the quality and range of services. To further strengthen the decentralization process and monitoring system as close to field realities, the Divisional Directorates of Health Services Head Quartered in the two capital cities of Srinagar (summer Capital) and Jammu (Winter Capital) are proposed to be strengthened with GIS based programme Management Information System (MIS).
Apart from supporting the Village Health and Sanitation Committees (VHSC) for implementing village action plans, the government plans to thoroughly orient the members of these committees about NRHM and village level actions to be taken up for improving health sector. Other new initiatives also include introducing of telemedicine services, promoting public private partnership and health insurance system for the needy, satellite based monitoring system for mobile health services, operationalising EMRI, state of art GIS based health management information system, Integrated BCC/ IEC, ASHA mentoring systems, introducing maternal death audits, strengthening convergence among different departments and agencies, etc as integral parts of the State PIP. State, as an innovation, proposes to provide incentives to AWW for strengthening the quality of monthly Village Health and Nutrition Days (VHND).
One of the key approaches to strengthen programmes more effective is convergent action. In this context, environmental concerns like hygiene and sanitation practices, waste disposal, water pollution, etc, will be addressed. Besides, following strategies are planned by the State Government to achieve the objectives of NRHM.
19 1. Increasing access to improved healthcare at household level through the female health activist (ASHA), especially to the vulnerable sections of the population. 2. Strengthening capacities for data collection, assessment and review for evidence based planning, monitoring and supervision through GIS based M&E system 3. Introducing Community monitoring and Concurrent Evaluation of the health programmes. 4. Formulating transparent policies for recruitment, induction and career development of Human Resources for health. 5. Developing capacities of the State Health System through the operationalization of SHSRC and ASHA Resource centre/ Support system. 6. Promotion of Public Private Partnerships for achieving public health goals. 7. Regulation of Private Sector including the informal rural practitioners to ensure availability of quality service to citizens at reasonable cost. 8. Mainstreaming AYUSH – revitalizing local health traditions. 9. Effective and viable risk pooling and social health insurance to provide health security to the poor by ensuring accessible, affordable, accountable and good quality hospital care. 10. Decentralization of Health Programme Management to district, block and further down to improve health service delivery specific to local needs.
Progress Made In accordance with the National Rural Health Mission, Jammu & Kashmir State has launched the National Rural Health Mission in the State. It has set up required institutional mechanisms at the State and District levels for implementing the Mission activities. Since the constitution of the State and District Health Missions, significant progress has been made in merging multiple societies at the State and District levels. All the vertical health societies created under different programmes have been merged in to State Health Society. The State has entered into a Memorandum of Understanding with the Central Government to access funds under the NRHM from the centre. However, there is not yet a common bank account for all the programmes in the State Health Society. The State has established a State Programme Management Unit (SPMU) in Jammu. Secretary Health and Medical Education has been designated as the Mission Director and Project Director RCH as the Director NRHM. The State Programme Management Unit has State Programme
20 Manager, Finance Manager, Accounts Manager, and a Data Entry Officer. To further strengthen the State Health Society, 4 officers serving in the government have been inducted on deputation. They include Director Finance & Accounts, State and Divisional Nodal Officers. There are 2 Divisional Programme Management Units one each in Kashmir and Jammu. Divisional Programme Manager, Divisional Accounts Officer and a Divisional Data Assistant form the present Divisional Programme Management Unit. In addition to some newly created districts the erstwhile 14 Districts have set up District Health Societies and District Program Management Units (DPMU). The DPMU consists of District Programme Manager, District Finance Manager and District Data Assistant. Process is on to establish DPMU in remaining districts. The Block level Program Units have been established in 91 Blocks through NRHM resources with the support of a Block Manager.
In order to upgrade the health facilities to IPHS, a facility survey was conducted during 2006 2007, based on which the facilities requiring repair, renovations and new constructions have been identified. During 2007 08, besides 14 district hospitals, 39 CHCs were upgraded to function as FRUs. Thus a total of 53 health instituations were made functional FRUs by mid of 2008. Similarly 96 PHCs had been provided required infrastructure and staff to function on 24X7 bases and out of these, 85 were made functional on 24X7 bases during 2007 08.
The government also started the process of constitution and registration of Rogi Kalyan Samitis (RKS). A total number of 474 Rogi Kalyan Samitis (Hospital management committees) were registered as per the GOI guidelines by April 2008. All the 474 Rogi Kalyan Samitis (14 DHs, 85 CHCs and 375 PHCs) have been provided corpus fund amounting to Rs. 5.00 lacs, Rs 1.00 lac, and Rs. 1.00 lac each respectively. More significantly, these Samitis have also been allowed to retain user charges including other revenue generated through sale of OPD Tickets etc for overall development of their respective health facility as envisaged. All the 85 CHCs and 375 PHCs have also been provided untied funds of Rs. 50,000 per CHC and Rs. 25,000 per PHC. Joint accounts have been made operational for 1750 SCs. Untied fund @ Rs. 10,000 each has been released to 1907 SCs, however annual maintenance grant of Rs. 10,000 was released to only 644 SCs.
21 Though the funds are allocated to the districts as flexi pool funds but other criterion like size of the districts, previous years expenditure as well as activities to be undertaken are also taken into account while allocating funds to the districts. The fund flow to districts is being done through electronic transfer.
The State has also initiated the process of selection and training of ASHAs and has by now completed it. About 9800 Female Accredited Social Health Activists (ASHA) have been selected and put in place in all the villages. Of the 9764 ASHAs selected, 9500 have been trained in Module I and 8648 in Module II. Training in module II is under progress. ASHA kits having generic drugs (both Allopathic and AYUSH) have been supplied to 9400 ASHAs. However, State needs additional 500 ASHAs to cover all the hamlets. A total of 6788 Village Health and Sanitations Committees have been constituted. During 2007 08 a total of 48464 number of VHND have been organized at various AWCs (Anganwadi Centers) in the State but there has been a sharp decline in organizing the VHNDs during 2008 09. As far as family planning services are concerned, 1295 persons accepted NSV and another 11854 couples accepted laprolization to plan their families.
Some progress has also been made in involving private health institutions for achieving public health goals. As per the information provided by SPMU, one MNGO from each district (so far 13 MNGOs) has been engaged for implementation of various programmes related to RCH II, disease control, PPI etc. overall six private health facilities (Nursing Homes) have been identified for the implementation of JSY and testing facilities. But these facilities have not yet been given any financial assistance for the implementation of JSY. Though the JSY scheme was launched in the State in 2006 2007, but because of certain irregularities in its implementation, the scheme was discontinued in 2007 2008. Consequently, the number of JSY beneficiaries declined from 13127 in 2006 07 to 10568 in 2007 2008. The number of institutional deliveries has also declined from 224888 in 2006 2007 to 151244 in 2007 2008. Information regarding the number of registered JSY women and number of women opting for institutional deliveries by caste was not available from any official source in the state. Due representation has been given to AYUSH persons in all the committees which have been formed at state or district level. AYUSH persons were also involved in the training of ASHAs. The AYUSH facilities have been made
22 available in 294 PHCs of the state till June 2008. Overall 294 AYUSH doctors and 183 persons of Paramedical staff with AYUSH knowhow have been appointed on contractual basis during the same time.
District Action Plans for 2007 2008 have been prepared for all the 22 districts. The government used the services of a private agency for the preparation of District Action Plans. Our discussions with the health officials at various levels expressed that the DAPs prepared by the private agency do not depict the grass roots level picture of the districts. They mentioned that different districts vary considerably in terms of topography, climate, socio economic and health indicators and health infrastructure, but the district action plans have not taken into account all these diversities. District Action Plans for the current year have not yet been prepared for all the districts in the state.
23 CHAPTER 3 DISTRICT PROFILE AND DSITRICT HOSPITAL
About the District Varamulla city (the present Baramulla town) is as old as the valley of Kashmir. The history of the place starts from the time when the entire valley was a vast lake known as SATISARAS. The history of Kashmir thus originates with the history of Varamulla. In RAJATARANGINI” the first chronicle of Kashmir ‘VARAHAMULLA’ finds its mention in it.
According to Kalhana, in memory of VARAHA AVTARA (Vishnu) the first teeratha of Kashmir valley was built by Hindus near the place where the mountain was cut and the place was named “VARAHAMULA” meaning a boar’s place, in Sanskrit. Foreigners who visited this place pronounced Varahamula as “Baramulla” where as the Kashmiris still call this place Varamulla. In addition to this legend, there are other versions about the name of the place. One version is that since river Jhelum flows down after getting a bend in its flow at this place, hence the name “Varamulla” “Var” in Kashmiri means a bend and “Hull” means a place. But the popular view as to how the place came to be known as “Baramulla” is that the waters of “Sati Saras” lake were drained off by a volcanic eruption at twelve places in the close vicinity of Baramulla. The place was thus assigned the name “Baramulla” meaning 12 bores.
The city of Baramulla having been founded by Raja Bhimsina in 2306 B.C. has a hoary past. The city held the position of a gate way for the valley. There was a watch station know as “Drang” (present Drangbal village) where there was strong guard. The visitors were received at this station. The famous Chinese visitor, Heiun Tsang was received here by Raja Darlubdurana, the then King of Kashmir, in 631 A.D. This watch station existed upto the 19th century. Moorecraft, an English historian, visited this station in 1823 A.D. During the Buddhist period Baramula was the zenith of its glory and was the famous city of the valley. ‘Alburoni’ describes Baramulla as the prosperous trading centre of the valley. Mughal emperors had a particular fascination for the city of Baramulla. Being the gate way to the valley it was a halt age station for them during their visits to the valley. In 1508 A.D. emperor Akbar, who entered the
24 valley via Pakhil, spent a few days at Baramulla and according to “Tarikh Hassan” the city, during Akbar’s stay, had been decorated like a bridge. Jhangir also had a stay at Baramulla during his visit to Kashmir in 1620 A.D.
From the very beginning Baramulla has enjoyed religious importance. The construction of Hindu Teeratha and Buddhist Vihars made this city sacred to Hindus as well as Buddhist. In the 15th century the place became important to Muslims also, as the famous Muslim saint Sayed Janbaz Wali, who visited the valley along with his companions in 1421 A.D., chose Baramulla as the centre of his mission and after his death was buried there. His shrine attracts pilgrims from far and wide. In 1584 the sixth Sikhguru visited the city and Gurdwara “Chatti Padshahi” was constructed in his memory. Baramulla thus became an abode of Hindus, Muslims and Sikhs living in fraternity and contributing to a rich composite culture.
Baramulla has appropriately been called the “PANIPAT” of Kashmir. As the gate way to the valley and right upto 1947 the inhabitants of this place would frequently become the victims to internal and external invasions. The city was a regular battle field for the kings of Kashmir. The Tribal raid of 1947, however, proved fatal for the city of Baramulla. As a result of this Tribal raid this historical city, which had steadily grown into an important trade centre, the valley lost all its glory in 1947 and has since reduced into the position of a small border town.
The present district of Baramulla is border district of the state. The district is bounded by Kupwara in the North, Budgam and Poonch in the South, parts of Srinagar and Bandipora in the East and has the line of control in West. There are presently 6 Tehsils in the district. The district consists of ten medical blocks namely, Sheeri, Boniyar, Uri, Pattan, Sopore, Tangmarg, Dangiwacha, Kreeri, Kunzer and Ruhama. The district headquarter is 56 kms away from summer capital of the State, Srinagar. The world famous tourist resort of Gulmarag is situated in the district. The Muzffarabad Srinagar road passes through the district.
The district of Baramulla which lies between 32o 55’ to 33o 50’north latitude and 73o 45’ to 75o 20’ east longitude is one of the 12 districts of the oval shaped Kashmir
25 valley which, commanding an average height of 1581 meters. But spread on a flat surface is famous throughout the world for its salubrious climate and scenic beauty. Nature has endorsed the district with a number of health resorts and places of tourist attracts. Mention may specially be made of Gulmarag, Watlab, Uri, etc.. Gulmarag in particular attracts large number of Indian and foreign tourists.
Baramulla is no different from other parts of Kashmir Valley. The food habits, dress pattern, customs and traditions are the same as followed in other parts of the valley. Kashmiri is the main language of the people in the District, Pahari and Gojari are also spoken in Uri. The people also speak Urdu..
The district experiences severe cold in winter and moderate temperature during summer. The areas like Mohra and Uri however do not experience much snow fall. Except for the hard tracts of Baramulla tehsil the district receives adequate rainfall. The average rainfall is 31 inches per annum and the average temperature varies between 19.6o to 7.06o Celsius. Majority of the district’s population lives in rural areas with agriculture as their primary occupation.
As per the “Facility Survey” in July 2007, Ninety seven percent SCs do not have electricity; eighty five percent SCs do not have water supply connection and 97 percent SCs are without toilets in the district which adversely impacts utilization of services. There are total 43 PHCs but water supply is available only in 57 percent and electricity in 51 percent. In order to increase institutional delivery attention has been given to functioning of 24x7 PHCs in phased manner. Under NRHM special focus has been given to Village Health and Sanitation Committee, Rogi Kalyan Samitis, up gradation of health facilities as per IPHS, selection and training of ASHAs, functioning of quality assurance committee, infrastructure development etc. In the absence of existence of Panchayati Raj institutions, there is a component on community action through village health and sanitation committees.
In the year 2006, International Institute of Population Sciences (IIPS) Mumbai ranked 593 districts in the country. This ranking is on children parity, contraceptive prevalence rate (CPR), under five child mortality and ANC. The overall ranking of the district Baramulla is 228. It is 574 on the basis of percentage of women having three
26 or more children; 504 on the basis of CPR; 377 for under five mortality rate and rank 15 for three or more ANC visits. In this ranking system, the lower is the rank, the better the district.
District Schedule For PART A of the schedule, most of the information was collected from the office of the District Programme Management Unit (DPMU) and office of the Chief Medical Officer. The DPMU is located in the same building where the Chief Medical Officer’s office is situated and in fact they are adjacent to each other. In Part A of the schedule the data shows that the district currently constitutes 10 medical blocks with 526 (excluding the villages which are now part of new district namely Bandipora) census villages as per 2001 census.
Population Baramulla District is the largest District in entire valley both with reference to the population and area. The District has a total population 8, 44,141(Census 2001 projection) out of which 4, 34,694 are male and 4, 09,447 are female which lives in 526 villages.
The projected population of 2008 ranks the district 2nd in Kashmir valley with population of 10.25 lakhs. The district is predominantly rural in character as 86 percent population is rural. As per census 2001 the district has recorded a sex ratio of 909, which is higher as compared to the state sex ratio of 892 females per 1000 males. The sex ratio of 0 6 year’s population as per the census 2001 is 818 for the district which is less than the state ratio of 937 for the same group. The overall literacy rate of the district as per census 2001 was 49 percent, which is less than that of the state average of 55 percent. The male literacy rate was higher (67 percent) in the district as compared to that of the females (48 percent). The district is way behind in terms of literacy rate both for males and females as compared to that of the state average. The district has Below Poverty Line (BPL) population of 27 percent (237068 persons) as on 1st October, 2007. Overall Scheduled Tribes (STs) account for six percent of the total population of the district as against 11 percent for the state. Total Scheduled Caste population in the district is only 92 persons. The
27 migrant labourers are also working not only in urban areas but in rural areas predominantly. The dominated pockets of the district are Uri & peripheral villages of the block Tangmarg, Kreeri & Sheeri because of severe impact of 8th October 2005 earth quack.
Health Infrastructure Facilities The Primary Health Care infrastructure has been developed as a three tier system with sub centre, primary health centre and community health centre. Besides, one district hospital at the district headquarter, there are other different types of health institutions both public and private in the district to cater the health needs of the people. There are 134 SCs, 43 PHCs including 15 PHCs which have been designated as 24x7; six CHCs, seven first referral units (FRUs), 31 ISM (AYUSH) dispensaries, 21 Allopathic Dispensaries (ADs) and 11 private health institutions in the district. Overall more than half of the private health intuitions have a bed capacity of 30 or more. The information collected from the CMO office shows that all the six CHCs and 15 PHCs are operational on 24x7 bases but during our visit to the selected CHCs/PHCs we could find as none of selected 24x7 PHC was operational after 4.00 p.m. and out of selected two CHCs, one of the CHC was also running the same way. It was reported by the CMO that in all the CHCs and first referral units’ facility survey as per Indian Public Health Standard have been completed but this statement was negated by the officials when we visited the selected intuitions during the survey.
Delivery Facilities Regarding the health institutions which were providing all types of maternity facilities in the district, the data shows that there are 26 health institutions that provide delivery services to the pregnant women. Besides the district hospital, all the CHCs in the district provide this service to the women while as 15 PHCs are also providing normal delivery facilities to the women. Facility for both normal and caesarean section deliveries is available at the district hospital and some CHCs. Complete BeMOC is available in the district hospital and some designated CHCs and old type PHCs. Besides the district hospital, atleast two CHCs provide complete CeMOC facilities to the needy women. Two private health institutions of the district have also been recommended for Public Private Partnership (PPP) and brought under the
28 scheme of JSY. The district hospital, three CHCs, five PHCs, and two public maternity homes have the facility of New Born Care Units.
Human Resource Both medical and Para medical staff is the backbone of any health facility. No health programme can run smoothly without the availability of trained and technical human resource. As per the data collected regarding the staffing pattern in the district, it shows that all the 28 positions of Medical Officers are filled in while as out of 7 sanctioned positions of Gynecologists only 3 are regular in position. Further, out of the six sanctioned posts, only one post of Pediatrician in the district is presently in position. Overall actual shortfall of the manpower of different positions in the district was 29 percent. The shortfall was 57 percent in case of gynecologists, 17 percent for Anesthetists, 83 percent for pediatricians, 24 percent for staff nurses, 11 percent for ANMs and 57 percent in case of other specialists. During the survey it was observed that this shortfall of the human resource has severely affected the functioning of various health institutions in the district. One of the CHC (Chandoosa) was without any specialist and permanent Medical Officer. The SCs at certain places are run by a nursing orderly. The information collected shows that three staff nurses and 32 ANMs have been engaged on contractual basis in the district.
Rogi Kalyan Samitis (RKS) The concept of community ownership in the NRHM has a direct reference to RKS and as per the guidelines CHCs/PHCs are to be brought under the community ownership through the system of RKSs. It would be a committee which would have members from the PRI, the civil society, health professionals, and NGOs. The RKSs are registered societies. The RKSs are envisaged at all levels such as district/CHC/PHC. Under NRHM it is envisaged that the hospital care system would move towards a fully funded universal social health insurance scheme. This system would obviously work only when the personnel working in the CHCs are not part of a State cadre but are recruited locally at the district level by the District Health Mission on contract basis. Since evolving such a system is likely to take some time at the first instance, it is proposed to give control of the budget of the PHCs/CHCs, and district hospitals to the Rogi Kalyan Samitis. Since all the RKSs at CHC and PHC levels get
29 a grant of Rs. One lakh and are authorized to retain the user fee for its day to day expenses. They are also supposed to generate funds for the use in various activities related to the development of the institution. The information provided by the DPMU Baramulla shows that RKSs have been constituted and registered for the DH, all the CHCs and PHCs. It was also observed during the field survey that RKSs are functional and meet regularly.
Janani Suraksha Yojna (JSY) The National Rural Health Mission is a statement of hope and conviction. The government is committed to achieve the goals laid down in National Population Policy and National Health Policy. For the underserved poor at the village level, the Mission spells hope in the form of a voluntary trained community health activist (ASHA) equipped with a drug kit. In many parts of the country, the public health system has not been in a satisfactory State; therefore, NRHM is to strengthen the public health institutions like as SCs/PHCs/CHCs and District hospitals so that all the health programmes may run smoothly and effectively. Such integration within the health department would make available more human resources with the same financial allocations and would also promote more effective interventions for health care. The Mission had to undertake suitable public private partnerships to meet the deficiencies in the public health delivery system. In the district, the district health society had identified and covered 2 private health institutions to provide the health facilities with regard to the JSY scheme. Other health related facilities were also covered under the partnership like as lab services, X ray, hiring of specialist services and providing transportation facility for delivery and referral cases but still the contract of partnership was not functional at the time of survey.
Under the Mission, Janani Suraksha Yojna (JSY) is an innovative scheme to universalize the utilization of maternal health services. Under the scheme, cash assistance is given to the women who receive ANC during pregnancy period, institutional care during delivery and immediate post partum period in a health facility. The basic aim of the scheme is to reduce the IMR to less than 30, MMR to 100 and increase institutional deliveries to 80 percent. JSY was made operational in April, 2007 in the state but most of the women who were registered under the scheme have not received any incentive. During the survey it was observed that
30 majority of women who were registered under the scheme complained of non receipt of incentives.
The information collected from the DPMU Baramulla shows that a total of 9752 women were registered under the JSY scheme during the year 2007 08 and all of them had opted for the institutional deliveries during the same period. Out of the total 9752 registered women, 47 belonged to Scheduled Caste and 213 belonged to Scheduled Tribe category. The break up of APL/BPL population of institutional deliveries was not available with the district programme management unit office. The private health facilities which were identified and accredited for health services were non functional and no records were maintained in this regard at DPMU.
Financial Mechanism There are a large number of schemes running in the health sector interventions. Many of these programmes pertaining to disease specific control programme. Many other related to family welfare. Special programmes have been initiated as per need for diseases like TB, Malaria, Filaria, HIV/AIDS etc, The NRHM has to strengthen the public health institutions for all health programmes and to bring all of them within the umbrella of a health plan so that preventive, promotive and curative aspects are well integrated at all levels. The intention of convergence within the health department is also to recognize human resource in a more effective and efficient way under the umbrella of the Common District Health Society. The purpose of the health society is to improve outreach of health services for common people through convergent action involving all health sector interventions. As per the information provided by the Finance Manager of the district programme management unit, all the health societies created under different programmes have been merged into a District Health Society (DHS) which has been registered in the district and there is a common bank account for all health programmes in the district health society. The District Action Plan (DAP) of the current year was prepared and approved by the DHS. Though the first DAP was prepared by a private agency in 2006 07 but later the district was bifurcated into two districts and it was only at that time the new DAP was made for both the districts separately by the DPMU.
31 DPMU reported that the funds are being received from the state under two major heads Activity Wise and Flexi Pool Funds. All the funds are transferred electronically from State to the district. All the 134 SCs functioning in the district have functional joint bank account of ANM and Sarpanch. Further it was also reported that all the 134 SCs, six CHCs and selected PHCs have received the untied grant for the financial year 2008 09.
District Hospital
District Hospital is the apex health facility in the health care system in a district and provides almost all the specialized health care services to people on subsidized cost. The District Hospital Baramulla is one of oldest district hospital in the state and perhaps among the first ones’. Major units of the hospital are still in the old building and few units have been shifted to the new hospital building which is still under construction. District Hospital Baramulla not only caters to the health care needs of its own population but also a large population from adjoining districts of Kupwara and Bandipora also get the specialized services from this hospital. The hospital is located in the heart of the town on the banks of river Jhelum and is hardly half a kilometer away from the general bus stand. The nearest CHC is at a distance of 20 Kms from the DH and it takes about 45 minutes to reach the destination by public transport. The farthest CHC is 50 Kms away from DH and it takes 2 hours to reach the CHC by public transport. The Medical Superintendent of the DH reported that the facility survey was carried out in the district as per Indian Public Health Standard.
Physical Infrastructure Part B presents information regarding physical infrastructure of the hospital. A new hospital building for the DH is in the final stage of completion and one or two units have already been shifted there but still the Hospital is fully functional in its old building. Therefore, the information collected from the DH pertains to the current building only. The hospital is situated on the bank of river Jhelum which has an area of one and half hectare of land (30 kanals, 4185 sq. meters). There are 11 big and small structures in the hospital premises where different types of health services are being provided to the people. These buildings have covered an area of 369 sq. meters. The description of these buildings is given separately as under:
32
Table 1: Description of buildings at District Hospital S.No Buildings Indentified Area of Building Area of Building (Sq.Feet) (Sq.Meter) 01 Registration building 25x40=1000 92.9 02 OPD building 30x50=1500 139.4 03 IPD building 35x160=5600 520.2 04 Administration building 25x20=500 46.4 05 Drug store 25x20=500 46.4 06 Blood bank (ICTC centre) 30x20=600 55.7 07 V.D clinic 20x20=400 37.2 08 Nursing school (office) 30x25=750 69.6 09 Nursing school 50x20=1000 92.9 10 Doctors quarter 40x40=1600 148.6 11 Para medical staff quarter 30x30=900 83.6
Most of the buildings are concrete and well maintained. These buildings are neat, well furnished and well equipped with almost all the modern facilities. The hospital has a bed capacity of 110 bed and is located in the residential area. The necessary environmental clearance has been obtained from the Pollution Control Board by the hospital authority. There are Ramps and Wheel chairs for disabled persons and they are always in ready position for use. There is no lift in any of the hospital blocks as most of them are two storied.
Space for Administrative/Main Block No doubt the administrative block is an old type of building but it was observed that the rooms are well decorated and well furnished. It is a double storied building located in the centre of the hospital premises. Though all the consultations/treatment rooms in any hospital need to have a waiting space adjacent to each room but it was found that there was no such space in the hospital but there is a common waiting room for patients in the building which does not cater to the needs as there is a heavy rush at OPD and most of the patients are seen in the main corridor in long queues waiting for the consultation. However registration counter, blood bank/blood
33 storage unit are available. Doctor’s duty room, isolation room, treatment room, pharmacy/dispensary, ICU, emergency services and examination and preparation room are available with main administrative block.
Hospital Services Under NRHM, the district hospitals are to be strengthened so as to provide quality health services. In addition Rogi Kalyan Samitis have been established at the district hospitals so as to utilize the untied fund for the development of the hospital to make them more effective in terms of better delivery of services to the people. This part of the information deals with the general amenities and facilities available at the district hospital. The information collected shows that surprisingly the kitchen facilities are not available in the hospital. Most of the facilities like the Central Sterile and Supply Department (CSSD), hospital laundry, medical and general stores, ventilation in the wards both natural or exhaust, water coolers/refrigerators, round the clock water supply, and overhead water storage tank with pumping and boosting arrangements were available in the hospital. The facilities like the engineering and provision for fire fighting in case of any emergency were not available in the hospital.
The State Pollution Control Board (SPCB) and the State Directorate of Health Services have issued strict orders to all the Government and Private Hospitals/ Nursing Homes to strictly comply with the norms laid down for the disposal of the bio medical waste and in this background such directions were followed in the district hospital and mostly the bio medical waste is either outsourced to the agency or buried. It was observed by the survey team that Bio Medical Waste was segregated in three different bins placed outside the rooms in the hospital. The proper drainage and sanitation system for waste water, surface water, sub soil water and sewerage was found in place in the District Hospital.
Staff Quarters Some residential quarters for both medical and Para medical staff in the hospital premises were available but they were not found sufficient in numbers to cater to the demand of the accommodation. There are six quarters for the medical staff and all of them were occupied by the doctors while as two sets meant for Para medical staff were also occupied. There is sufficient space for parking within the hospital
34 premises. The Medical Records Section is also available in the hospital. Further the Medical Superintendent reported that disease classification is being carried out as per the specified protocols. There is a telephone in the hospital placed in the chamber of the Medical Superintendent and the hospital is without a fax machine and internet facility. The computer is available in the hospital.
Obstetrics and Gynecology Section The information provided regarding the Obstetrics and Gynecology section by the Medical Superintendent and the Staff Nurse shows that there is a separate ward for women having a bed capacity of 24 beds. Though the requisite information for calculation of bed occupancy rate was not available with the record section of the hospital and as such some direct estimates shows that the bed occupancy during the year 2007 08 was 100 percent which means that all the beds remain occupied round the clock throughout the year. The data provided by the concerned sister was verified from the registers regarding the number of patients who have sought treatment from the OPD during the last three months prior to the survey. A total of 55,000 patients visit the OPD during the last 3 months prior to the survey and a total of 646 deliveries took place in the hospital during the same period. There is a separate Operation Theater for Gynecology and Obstetrics section available in the hospital.
Procedures Carried Out In Obstetrics and Gynecology Section In this part of section, the information was collected from the records of the hospital for the year 2007 08 (period of one year that is 1 4 2007 to 31 3 2008). The information collected shows that 2751 deliveries were conducted during the above mentioned period in the hospital. Of these deliveries, 313 (11 percent) were carried through caesarean section. None of the JSY case has undergone caesarean section. The concerned officials reported that there were some assisted and forceps deliveries also during the same period but they have not maintained the records for them. Medical Termination of Pregnancy (MTP) was carried out in 281 cases while as information regarding mid trimester abortion, Ectopic pregnancy, Retained placenta, Eclampsia, PPH, and Suturing Cervical Tear was not available in the Gynecology section. Overall 30 cases of sterilization were also done during the year 2007 08. There is no facility available for treatment for infertility in the hospital. As
35 reported by one lady doctor, the hysterectomy was not being conducted in the hospital because of non availability of the special beds for the same.
Surgical Facilities The data regarding different type of surgeries done in the hospital was also complied by the hospital administration. The information in this regard was collected from the Incharge sister of the surgical ward and the Medical Superintendent. During last three months a total of 11,000 patients had visited the hospital OPD for consultations and during the same period 552 surgeries were performed. The information regarding the number of patients visiting the OPD for surgical problems and the number of surgeries performed in the surgical section in the hospital by their sex was not available and in fact the hospital does not maintain the records in that manner. Out of the 552 surgeries carried out at the DH, 120 were conducted in emergency cases, and 40 for abdominal surgeries. Facilities for Pancreas surgery, Spleen and Portal Hypertension, and Breast surgery are also available in the hospital and some Breast surgeries have also been carried in the hospital.
Medical Section The information pertaining to Medical Section of DH Baramulla was collected from the Medical Superintendent and the concerned MPW of the section. The total number of patients who attended the OPD of the Medical Section during 2007 08 was 16,500. The total number of patients admitted to the Medical Ward during the last three months was 828. The sex wise break up for both OPD and IPD was not maintained by the said unit of the hospital. A total of 5, 500 patients were treated for Skin, Venerological diseases, and RTI/STI during the last three months prior to the survey. Services under National Leprosy Eradication Programme (NLEP) are also available in the hospital but no patient had received the treatment during the reference period. Services like Pleural Aspiration, Lumber Puncture and Psychiatry services were also available in the hospital and records were not maintained for these services by the hospital administration. Important procedures like Bronchoscopy, Pericardial tapping, Skin scrapping for fungus, Bone Marrow Biopsy, and Specialized Endoscopic procedures were not being conducted in the district hospital. Therefore, such patients are referred to the State Hospital.
36 Pediatric Section The data regarding the pediatric section of the hospital shows that 46,575 children have received the OPD services during the year 2007 08. Separate ward for children with a bed capacity of 10 beds was available in the hospital and such beds are normally used for newborns. In the year 2007 08, 2,418 children were admitted in the hospital for different types of ailments. The age wise break up of the children who had availed the services at OPD or IPD was not available. The Medical Officer of the unit reported that services like Asphyxia management, management of malnourished children, management of neo natal sepsis, management of dehydration and diarrheal cases and management of respiratory tract/pneumonia were available in the Pediatric section.
Equipment and Drugs in Pediatric Section Information on the availability of equipment and drugs in the Pediatric Section was also collected from the Incharge of the section and it was found that Cradle was not available there. The other equipment like Radiant heat warmer, Phototherapy unit, bag with mask, Laryngoscope, Oxygen mask, Suction machine and Thermometer were available and all the mentioned equipment was functional. Further the information collected regarding the availability of drugs for Pediatric use shows that ORS was not available in the hospital. Vitamin A solution, Iron Folic Acid Syrup, and Pediatric Antibiotics were available in good numbers. The Incharge of the concerned unit reported that usually the supply of drugs is regular and satisfactory.
Diagnostic Section While visiting the Radiology Section of the Hospital, it was found that all the necessary and basic machinery was available and operational. As per the records available it was found that 4,511 patients have visited the hospital for different type of diagnostics during the last three months prior to the survey. X ray, USG, and ECG facilities are available in the diagnostic section of the DH. Ultrasound guided Biopsy is not available in the Hospital. A total of 3,097 X Rays, 657 Ultrasounds, and 757 ECGs have been carried out during the last three months.
37 Laboratory Services DH Baramulla has a well established laboratory where almost all the basic and important tests are being carried regularly. Further all the technical staff of the laboratory was found fully trained in their technical knowhow. As many as 4,484 patients have undergone for different type of investigations in the hospital laboratory during the last three months prior to the survey. The break up of some of the tests is given as follows: Hematology test were conducted for 1,727 patients, Urine analysis for 604 patients, Stool analysis for 13 patients, Semen analysis for 4 patients, Sputum tests for 172 patients, Serology analysis for 747 patients and tests pertaining to Biochemistry were done for 1,217 patients. Besides, Microbiology and Histopathology analysis other tests like CSF analysis (cell count, culture sensitivity etc., gram staining) and Aspirated fluids (cell count cytology) test facility was not available in the hospital.
Human Resource of DH This particular block represents the information about the staffing structure both medical and Para medical staff available at the district hospital. For this purpose a latest detailed copy of the staff strength was collected from the office of the Medical Superintendent. The information collected shows that almost all the sanctioned positions of medical staff in the hospital (over 92 percent) were filled up. There is one sanctioned position each of Medical Superintendent, Orthopedic Surgeon, ENT specialist, Pediatrician, Eye Specialist and Blood Bank Officer in the hospital and all of them were in position. One each position of the Pathologist and Junior Anesthetist were lying vacant. Further two positions each of Physician specialist, Surgeon specialist, Anesthetist, Radiologist and Medical officer (homeopathy) were sanctioned and filled up. Similarly, among the three each sanctioned positions of Gynecologist and Dental surgeons, only two each of them were filled up. There are also 29 sanctioned posts of Assistant surgeons and all are working in the hospital. Besides, two more doctors (Assistant surgeons) were also working on contractual basis in the hospital.
The information regarding the vacant positions of the Para medical staff of the hospital shows that 12 percent of the positions were lying vacant. The information collected shows that there is one each of the sanctioned posts of Section officer,
38 Senior Assistant, Tahvildar, Junior Assistant, Senior Theatre Assistant, Female Theatre Assistant, Dental Technician, Dental Assistant, Senior Laboratory Technician, Microscopic Assistant, Blood Bank Technician, Ophthalmic Assistant, Senior Para medical Assistant (PMA), Electrician, Plumber, X Ray Technician, X Ray Assistant, Lady Health Visitor, Dental Boy, Theatre Boy, X Ray Boy, Choakidar and Chest Carrier are filled up. Further, out of 19 sanctioned Nursing posts, 15 were in position. Other positions like 4 cooks, 11 Nursing Orderlies, nine helpers and 17 Safaiwalas were also working in the DH. In addition to the above mentioned permanent staff of the hospital, the hospital authority furnished one more list of 20 such Paramedical officials who have managed to remain at the district hospital though they are actually posted at various health institutions of the district. It was also observed that such employees are drawing their salaries from their respective places of posting and have instead made a mess of all and have left their original places on the mercy of nursing orderlies.
Other Framework and Structure Related Issues This section deals with the Rogi Kalyan Samiti of the district hospital. Actually the RKSs under NRHM have been constituted for all the PHCs/CHCs/sub district hospitals of the district. RKS for DH Baramulla has also been constituted and is registered. As reported by the Medical Superintendent of the hospital the patients belonging to BPL/SC/ST are exempted from the user fee only on need basis and it was found that there was no proper criterion in place regarding the same. It was also reported that some additional resources have been generated by RKS in the shape of user fee. The user fee is retained within the facility and is used for local use. Further it was found that DH has not put up any display board showing details regarding RKS or number of meeting held by RKS. The feedback for grievance redressal by the RKS was done through public scrutiny.
39 CHAPTER 4 COMMUNITY HEALTH CENTRE (CHC)
The CHCs are currently provided on the population norm of 1 per 1, 20,000 population in general areas and 1 per 80,000 population in tribal/desert areas. Under the Mission, the CHCs are conceived as the first major curative health service providers addressing 80 percent of all ailments requiring out patient services or hospitalization. Since the credibility of any health institution is generally determined by the standard of curative services it provides as benchmarked to the best institutions, the Mission attaches utmost importance to strengthen the existing CHCs and build up new ones to bring the number of CHCs broadly in conformity to the ratio of one per one lakh population. Lack of accountability in the CHCs has been the main reason for patients preferring private facilities over them. To bring in quality accountability in the health services, Indian Public Health Standards (IPHS) have been set up for the CHCs. IPHS is a novel concept to fix benchmarks of infrastructure including building, manpower, equipments, drugs, quality assurance through introduction of treatment protocols. This chapter presents the status of the 2 CHCs surveyed in Baramulla district with respect to the availability of selected infrastructure, staff, equipment and supplies, training of medical and para medical staff besides service outcome. The CHCs studied are Chandoosa in Sheeri Block and Pattan in Pattan Block.
Coverage and Infrastructure (Table C1) As mentioned above that a CHC is expected to serve a population of 80,000 in states like ours. It was observed that such norms were still non existent in Baramulla as Chandoosa CHC covers a population of 22,000 only while as CHC Pattan (one of the oldest CHC) covers a large population of 1, 50,000. The distance to the nearest PHC from CHCs ranges from 9 Kms for Chandoosa to 7 Km in Pattan. The time taken by the public transport to reach nearest PHC from the respective CHCs ranges between 30 to 45 minutes. The distance to the farthest PHC from CHC was reported to be 25 Kms in Chandoosa and 8 Kms in Pattan. The time taken to reach the farthest PHC from a CHC by public transport is about 75 minutes in Chandoosa and 30 minutes in Pattan. Further the distance from CHC to District Hospital was 28 kms
40 for CHC Pattan and 18 Kms for Chandoosa. Pattan has a bed capacity of 30 (15 male and 15 female) while as Chandoosa had 15 beds (8 for male and 7 for female) only. Thus only one CHC had a bed capacity of 30 or more beds. Both the CHCs were functioning in their own government buildings. For CHC Chandoosa a new building has been constructed as per the latest NRHM specifications while as Pattan is still operating from the old building as the new building for the CHC is presently under construction.
In the present day life communication has assumed high significance as this is the means to remain connected with the rest of the world but it has yet to pickup in our state as none of the CHCs had a telephone or internet facility available. Computer was available in Pattan CHC only. Table C1 further presents the distribution of CHCs with selected infrastructural facilities such as vehicles, labs, various testing facilities, OT, labour room, drug store, toilets, waiting room, drinking water etc. In the context it was found that generator set was available in Pattan only while as Laboratory, ECG, USG, X Ray, general OT, Labour room, pharmacy for drug dispensing and drug storage, OPD room, Emergency room separate wards for males and females and prominent display boards regarding the availability of services were found available in both the CHCs in the district. Further the data shows that the OT used for Gynecology was available in Pattan only while as new born care corner was not available in any of the CHCs. Only CHC Chandoosa has maintained the JSY beneficiary records. No suggestion/complaint box was found in any of the CHCs while as counter at the entrance for getting contraceptives/ORS packets/Vitamin A and medicines, waiting room for patients, and availability of drinking water in waiting room were found available in Chandoosa only. In Pattan waste material was buried in a pit while it was thrown open in Chandoosa. In CHCs where women are expected to get services like antenatal and postnatal check ups including internal examination and IUD insertions, and where women are admitted for delivery, sterilization or MTP, it is crucial to have at least one toilet and in this regard it was found that both the CHCs had separate public utilities for males and females and they were connected to soak pit. Further it was observed that cleanliness of the OPD was good at Chandoosa but poor in Pattan while cleanliness of premises and rooms/wards was good at CHC Chandoosa and fair in Pattan.
41 All the CHCs are supposed to prominently display outside A Charter of Citizen’s Health Rights that would include the services to be given to the citizens and their rights in that regard, information regarding grants received, medicines and vaccines in stock etc. would also be exhibited. Similarly, the outcomes of various monitoring mechanisms would be displayed at the CHCs in a simple language for effective dissemination. The transparency would help the community to better monitor the health services. In this background it was found that prominent display boards regarding the availability of services and other information in the local language were seen at both the CHCs.
Staff Position (Table C2) The availability of at least four Specialists/Medical Officers is a prerequisite at the CHC as per the norms which were in practice before the NRHM and as per the revised norms under NRHM each CHC is supposed to have 7 Specialists/Medical Officers. During the survey it was found that government has sanctioned many positions of Specialists/Medical Officers at CHC level. Both the CHCs have sanctioned posts of General Surgeon, Physician, Gynecologist and Anesthetist but none of the specialist post was currently in position in Chandoosa while in Pattan except the Anesthetist all these specialists were currently in position. Besides, a post of Pediatrician and one post of general duty medical officer was also sanctioned and in position in Pattan. In Chandoosa a total of 6 general duty medical officers were currently working and out of these 3 were working on sanctioned posts while as three more were working on contractual basis. It is strange to mention that the post of Eye specialist was not sanctioned in any of the CHC. It was reported that the short term obstetric course was attended by the concerned doctor in Pattan.
As per the revised norms under NRHM each CHC is supposed to have one sanctioned post of Public Health Nurse (PHN) and 10 posts of Staff Nurses but it was found that Chandoosa had no sanctioned post of PHN while as seven such posts were sanctioned and were presently in position in CHC Pattan. In CHC Chandoosa currently only three Staff Nurses were working (two Staff Nurses were appointed on contractual basis and one was in position out of the sanctioned posts). There was one sanctioned post of LHV in Pattan and that was presently in position.
42 Further every CHC is supposed to have one sanctioned post each of computer clerk, Dresser, Pharmacist, Lab. Technician, Block Extension Educator (BEE), and Radiographer. It was found that in CHC Pattan the above mentioned Para medical staff was surplus and in gross violation of the norms laid down from time to time. The number of sanctioned posts of BEE, Dresser, and Pharmacist was three each and most of them were in position while in Chandoosa there was no sanctioned post of BEE and computer clerk as reported by the in charge MO. Two posts each of Theater attendant, Driver and Registration clerk were sanctioned in Pattan and were in position while Chandoosa had one Driver working on contractual basis as they have not filled the two sanctioned posts of Drivers. . Pattan had also one sanctioned post each of ANM and Ophthalmic Assistant and both were in position. Thus the above information clearly shows that Pattan CHC is well equipped as far as the staff strength is concerned while as Chandoosa is yet in complete infancy and need a lot to be done to call it as CHC or FRU.
Availability of Specific Services (Table C3) Process is underway for the up gradation of CHCs as FRUs in order to provide basic Emergency Obstructive Care for women and ARI treatment for children. It will also have an AYUSH clinic with an AYUSH doctor and medicines, AYUSH practitioners can be appointed on contractual basis so that AYUSH becomes a part of primary health care. Over the Mission period, the Mission aims at bringing all the CHCs at par with the IPHS in a gradual manner. In the process, all the CHCs would be operationalized as FRUs. Table C3 shows that both the CHCs were functioning on 24x7 basis and none of them has yet been designated as FRU. The AYUSH services have not yet been started in any of the CHCs and no emergency care of sick children, VCTC, cataract surgery is provided in these CHCs. Both the CHCs have treatment facility for STI/RTI while Dots is also provided in both the CHCs. The full range of family planning services are provided in CHC Pattan only. This shows that not much has been done by the state government to bring them at least nearest to the NRHM norms.
Status of Specific Interventions (Table C4) The launching of National Rural Health Mission (NRHM) has provided the opportunity to streamline the functioning of CHCs and to make them more effective
43 and answerable by recommending a set of standards for CHC called Indian Public Health Standards (IPHS) for CHCs. The objectives of IPHS for CHCs are well defined and focused on enhancing and equipping CHCs in all fields to make them more effective and cater to the needs of the people. As already mentioned other interventions include the incorporation of AYUSH services, make the CHC 24x7 practically, formation of Rogi Kalyan Samiti / Hospital Management Committee, proper notice displaying wings of the centre, available services, names of the doctors, users’ fee details and list of members of the Rogi Kalyan Samiti etc.
Under NRHM, funds are being provided to CHCs for conducting IPHS facility surveys; however it was found that none of the CHCs in Baramulla has yet initiated any action to conduct IPHS facility survey. In fact many officials at the CHCs have no idea about the terminology of IPHS facility survey.
As already mentioned both the CHCs reported that they are working on 24x7 basis but the research team could not find any such arrangement in place for the same (particularly in Chandoosa) and there was no patient admitted (IPD) in these CHCs during the days of our visit, the reason mentioned by the officials at both the CHCs was that due to cold conditions no patient is admitted for nights during the winters.
Rogi Kalyan Samitis have been constituted and registered in both the CHCs and display boards showing the number of members and number of meetings organized by RKSs were seen at the selected CHCs. Both the CHCs reported that electronic transfer of funds has not yet been initiated in the district. RKS of CHC Pattan was generating some resources through user fees. RKS are also supposed to have a mechanism to redressal of grievances and it was found that such mechanism was not in place in any of the CHCs. CHCs are also supposed to display the Citizen’s Charter publically and it was found that Citizens Charter was displayed in both the CHCs with some limited information. Further the MOs of both the CHCs were asked to report whether all standard treatment guidelines and protocols are available in their CHCs it was reported that such standard treatment guidelines and protocols are not available in their respective CHCs.
44 Residential Facilities (Table C5) Another important component for making any health institution functional on 24x7 basis is the residential quarters for medical and Para medical staff and in this regard it was found that in Chandoosa no staff quarter was available for doctors or other staff though two residential quarters have been constructed during 2006 07 but have not been handed over to the department at the time of survey by the concerned agency. In Pattan residential quarters were available for doctors and were currently occupied by them. No residential quarter was available for other staff at Pattan.
Laboratory Facilities and Performance (Table C6 and C7) In the context of provision of RCH services, the availability of laboratory in CHC to test blood and urine of the women seeking antenatal care as well as for the diagnosis of RTI/STI among men and women is critical. Table C6 gives the detailed information regarding the availability of laboratory testing facility in selected CHCs. The information collected shows that all the basic tests such as blood grouping, haemoglobin, BT CT, blood sugar, urine test, rapid pregnancy test, test for syphilis, and blood smear is done at both the CHCs while as test for RTI/STI and Malaria parasite is done in Pattan only.
Information regarding the number of tests conducted during the last 3 months prior to survey was collected from each CHC and the same is presented in Table C7. CHC Pattan has outnumbered Chandoosa as far as the average number of tests conducted per month for diagnosis of various diseases is concerned. In Pattan on an average 260 tests for hemoglobin were conducted as compared to 96 in Chandoosa. Blood sugar test was conducted for 180 patients in Pattan as compared to 41 in Chandoosa. Further it was found that 827 urine tests were conducted in Pattan while the number for Chandoosa was 179 and this shows that at the people are getting some benefit of lab facilities at their respective CHCs.
Performance of Surgeries (Table C8 and C9) CHCs are expected to do some basic surgical procedures and in this regard the information regarding the number of surgeries under different categories and reason for not conducting any surgeries was collected from both the CHCs for the year
45 2007 08 and is presented in table C8 and C9. In CHC Chandoosa none of the surgeries was conducted and the reason for not conducting any surgery mentioned by the in charge MO at the CHC was non availability of specialist (Surgeon)/ anesthetist there. In Pattan CHC 1400 caesarean section deliveries for JSY beneficiaries were conducted during 2007 2008 while during the same period 78 Tubectomy and 24 NSV surgeries were conducted in Pattan.
Performance of Labour Room (Table C10) Since one of the important goal of the National population policy, 2000 is to achieve eighty percent institutional deliveries; the availability of labour room is a critical facility for a CHC. It was found that the labour room was available at both the CHCs. The total number of institutional deliveries conducted in Pattan was 311 during 2007 2008 while as in Chandoosa 35 institutional deliveries were performed during the same period. All the institutional deliveries at both the CHCs had a JSY card. None of CHCs has conducted any delivery from 8 PM to 8 AM and none of the neonates was resuscitated by any of the CHCs during 2007 2008. Table C10
Status of Equipment and Drugs (Table C12) Availability of equipments and drugs assume great importance for smooth functioning of any health instution and in this regard various steps have been initiated under NRHM and there is a provision to equip CHCs with the latest equipments to make them functional FRUs. In this background the information collected and presented in table C12 shows that most of the equipments mentioned in the table like Boyles apparatus, Cardiac monitor for OT, Defibrillator for OT, Horizontal/vertical high pressure sterilizer, OT care fumigation, Gloves dusting machine, Oxygen cylinder, Resuscitation trolley, Phototherapy unit, MVA syringes and Baby incubator were not available/supplied to CHC Chandoosa as the only two apparatus which the Chandoosa had were ECG machine and Hydraulic operation table. On the other hand, CHC Pattan had almost all the above mentioned equipments available and in working condition. Pattan was without a ventilator for OT, horizontal high pressure sterilizer, resuscitation trolley, phototherapy unit and baby incubator. This shows that there is still a long way to go and achieve the minimum possible in terms of equipment and it needs some immediate attention from the policy makers and programme implementing agencies.
46
The information on whether CHCs are supplied with necessary drugs, contraceptives, kits and other necessary material with data on stock out and regularity of supplies during the last six months prior to the survey is presented in Table C12. It was found that Tab. Nefidipine, injection Magnesium Sulphate, Tab. Progestrone, Injection Pentazocine Lactate, Silver Sulphadiazine ointment, Injection Prociane Pencillin, and IFA Syrup are not supplied at all to the CHCs in the district. Both the CHCs reported stock out of ORS during the last 6 months and also reported its irregular supply. The position with regard to the availability of oral pills and IUD 380 was satisfactory as both the CHCs have never been out of stock and the supplies have been regular during the last six months for these spacing methods. Further the data shows that CHC Chandoosa was out of stock for most of the drugs and complained of irregular supplies of almost all the drugs while as CHC Pattan had never been out of stock for majority of the drugs and had regular supplies during the last six months prior to the survey. Overall CHC Pattan, was not out of stock for any of the mentioned drugs (other than those for whom they said that they are not supplied at all) in the table and had regular supplies for most of them while as Chandoosa CHC was found out of stock for almost all the drugs (except spacing methods, and few other drugs) mentioned in the table and were found with irregular supplies during the last 6 months.
Availability of Specific Services (Table C13) CHCs are supposed to provide various services both at OPD and IPD level. These include specialized medical services such as medicine, surgery, obstetric, pediatrics, communicable diseases, ophthalmology etc., emergency services for 24 hours, neo natal care, full range of FP services, safe abortion, counseling, testing centre, AYUSH facility, primary management of wounds, factures, RTI/STI, MTP services and management of poisoning etc. Though there are specific guidelines under NRHM for fully functional FRU in terms of minimum services to be provided by them. Table C13 shows that in CHC Chandoosa, none of the specialized services like medicine, surgery, obstetric, pediatrics, communicable diseases management, and ophthalmology were provided to the clients. On the other hand except for pediatrics and ophthalmology CHC Pattan was providing all the above mentioned specialized services to the patients. Further the data shows that leprosy diagnosis management
47 and referral services, full range of family planning services (except laparoscopic ligation), and safe abortion services were also available in Pattan while as Chandoosa was lacking behind in most of the specific services. Services like Mobile medical unit, separate neo natal care unit, emergency care for sick children, blood storage facility, counseling on HIV/AIDS, voluntary counseling and test centre, and AYUSH facility were not available in any of the selected CHCs. Both the CHCs provide services for management of wounds, primary management of burns, primary management of fracture, and management of poisoning, snake/scorpion bites and treatment/management of RTI/STIs. out of the listed 24 services, CHC Pattan reported availability of 15 services while as Chandoosa reported availability of only eight services and this clearly indicates that in order to make these CHCs as FRUs as per the standards mentioned in the NRHM, there is still long way to achieve it and as such it looks that not much has been done in this regard.
Service Outcome (Table C14) CHCs are expected to provide various services of maternal and child health care, family planning and treatment of RTI/STI. They are also expected to manage surgeries, burns, fractures, and provide services to TB, leprosy and malaria patients. Information was collected regarding the service outcome of various services that are provided at the CHCs for the last three months.
The number of antenatal care (ANC) visits and the timing of the first visit are important for the health of the mother and the outcome of pregnancy. Therefore, CHCs are required to identify pregnant women and register them for ANC services soon after the pregnancy is confirmed. The average number of ANC cases per month registered at CHC Pattan was 330 during the last three months and all of them were registered under JSY. The monthly average number of cases registered by CHC Chandoosa was 11 and all had been registered for JSY. All the registered cases for ANC in the above mentioned CHCs belonged to ‘Other’ caste.
Under RCH, efforts are to be made by the health institutions to register pregnant women for ANC as early as possible. It was found that on an average in a month 87 women in Pattan and 11 in Chandoosa were registered for ANC in the first trimester during the last three months while as three ANC checkups as per RCH schedule
48 were done for 82 women in Pattan and two in Chandoosa during the same period and all of them were JSY beneficiaries. One of the important elements of ANC is to provide two doses of tetanus toxoid vaccine and iron and folic acid (IFA) tablets to pregnant women to prevent nutritional anemia, in this regard all the PHCs where pregnant women were registered for ANC had received TT1 and completed IFA Prophylaxis. The number of women who had received the TT was less than the registered number due to the fact that they were still registered for the ANC at their respective CHCs while as IFA was not available in CHC Pattan and none of the women was given IFA.
Further it was found that in CHC Pattan none of the pregnant woman was identified with any obstetric complication while as in CHC Chandoosa four such women were identified and treated. No such woman was referred from PHC/SHC.
As far as institutional deliveries are concerned, the performance of CHC Chandoosa is very poor as on an average in a month only three deliveries were conducted there during last three months prior to the survey as compared to 25 deliveries in CHC Pattan during the same period. All the deliveries conducted in these CHCs were JSY beneficiaries (though no money under JSY was provided due to non availability of funds) and belonged to ‘others’ as far as their caste is concerned.
Though all the CHCs are actively engaged in implementing the Universal Immunization Programme for children but their performance gets affected due to non availability of para medical staff. On an average in a month the number of infants who have been given the BCG at the selected CHCs ranges between as low as 12 for Chandoosa to the high of 42 in CHC Pattan. DPT3 has been provided to 12 infants in Chandoosa and 59 in Pattan while vaccination against measles has come down sharply in Pattan (from 59 for DPT3 to only two for measles) while as 11 infants have been vaccinated against measles in Chandoosa during the same time. As has already been mentioned that Vitamin A and IFA syrup was not supplied to both the CHCs, therefore, none of the children was either given Vitamin A first dose or IFA syrup.
49 CHCs are also supposed to provide family planning services to the clients and in this regard the more emphasis is given on spacing methods. CHCs are also expected to organize camps for providing family planning services like IUDs, female sterilizations and Non Scalpel vasectomies (NSVs) etc. But the information collected from the two selected CHCs revealed that the performance in this regard is not good in both the CHCs. The only family planning service provided by two CHCs is insertion of IUDs. The two CHCs on an average during the last 3 months have provided IUD services to 2 women in Chandoosa and 13 in Pattan in a month.
Since all the CHCs are supposed to provide IPD services to the patients but it was found that mostly and particularly during the winters only day care is provided to such patients due to non availability of heating system at CHC level. In CHC Pattan on a average per month 146 patients were provided the indoor services during the last three month while as in CHC Chandoosa only 13 patients were provided with IPD services. In Chandoosa six patients were referred beyond CHC with different ailments while as in Pattan no such patient was referred. None of the leprosy patient was currently under treatment in either of the CHCs. Three new cases of TB for Dots were enrolled at CHC Pattan while no such case was enrolled in Chandoosa
Since CHCs are supposed to work round the clock and act as FRUs and therefore it is expected from CHCs to provide assured services to the community in line with the IPHS standards to cover all the essential elements of preventive, promotive, curative and rehabilitative primary health care. This implies a wide range of services that include IPD, OPD, emergency, and other related services. The data collected regarding the average monthly number of patients by sex and age attended by each of the CHC during last three months prior to the survey show that CHC Pattan treated about 350 patients (150 each male and female and 40 children) while as the average number of patients treated on monthly basis in Chandoosa were 45 male and 35 each female and children during the same period. Further the data shows that out of the total OPD attendance there was no referred patient from PHC/SHC in Pattan while in Chandoosa the referred patients from PHC/SHC was five during the last three months prior to the survey. Though the needed information regarding the calculation of bed occupancy rate was not available at any of the CHC and still some
50 direct indicators were taken for the calculation of the same and the Bed Occupancy Rate for CHC Pattan was calculated to be 29 (about 100 percent) and for CHC Chandoosa it was five (34 percent).
Table C1. Coverage and Availability of Infrastructure in Baramulla Name of CHC Coverage Chandoosa Pattan Population Served by the CHC Numbers 22,000 150,000 Nearest PHC Coverage Area Distance 9 7 Nearest PHC Coverage Area: Time 45 30 Farthest PHC Coverage Area: Distance 25 8 Farthest PHC Coverage Area: Time 75 30 District Hospital Area: Distance 18 28 District Hospital Area: Time 60 45 No of Beds: Male 8 15 No of Beds: Female 7 15 Status of Building Own Government Building 1 1 Rented Premises Other Rent Free Building Electricity in all parts: No Regular electricity supply 1 Regular electricity supply in all parts 1 30 or more beds Yes No 1 1 Generator Yes 1 No 1 Cont...
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Table C1. Coverage and Availability of Infrastructure in Baramulla CHC Coverage (Yes=1, No=0) Chandoosa Pattan Telephone 0 0 Computer 0 1 Internet Connection 0 0 Running Vehicle/Ambulance 1 1 Laboratory 1 1 ECG Facilities 1 1 X Ray Facilities 1 1 Ultrasound Facilities 1 1 Operation Theatre 1 1 OT used for Gynecology 0 0 Labour Room Available 1 1 Separate Areas for Septic and Aseptic Deliveries 0 0 New Born Care Corner 1 1 JSY Beneficiaries Maintained in Record 1 0 Pharmacy for Drug Dispensing and Drug Storage 1 1 Counter Near Entrance of CHC to Obtain Contraceptives, ORS Packets, Vitamin A and Medicines 1 0 Separate Public Utilities (Toilets) for Males and Females 1 1 Suggestion / Complaint Box 0 0 OPD Rooms / Cubicles 1 1 Waiting Room for Patients 1 0 Waiting Room have Adequate Sitting Place 1 0 Drinking Water Available in the Waiting Area 1 0 Emergency Room / Casualty 1 1 Separate Wards for Males and Females 1 1 Type of Sewerage System Soak Pit 1 1 Waste Material is Being Disposed Buried in a Pit 0 1 Thrown in Open 1 0 Status of Cleanliness of OPD Good 1 Poor 1 Status of Cleanliness of Compound /Premises Good 1 Fair 1 Status of Cleanliness of Room / Wards Good 1 Fair 1 Prominent Display Boards Regarding Service Available in Local Language 1 1 JSY Beneficiaries Maintained in Record 1 0 Pharmacy for Drug Dispensing and Drug Storage 1 1 Counter Near Entrance of CHC to Obtain Contraceptives, ORS Packets, Vitamin A and Medicines 1 0
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Table C2: Position of Medical Staff and Paramedical Staff in Baramulla Numbers in Position Type of Staff Chandoosa Pattan General Surgeon: Sanctioned 1 1 Regular in Position 0 1 Contractual Recruited 0 0 Total in Position 0 1 Physician: Sanctioned Sanctioned 1 1 Regular in Position 0 1 Contractual Recruited 0 0 Total in Position 0 1 Obstetrician / Gynecologist: Sanctioned 1 1 Regular in Position 0 1 Contractual Recruited 0 0 Total in position 0 1 Medical Officer Trained with Short Term Obstetrics Course: Sanctioned 0 1 Regular in position 0 1 Contractual Recruited 0 0 Total in position 0 1 Pediatrician: Sanctioned Sanctioned 1 Regular in Position 1 Contractual Recruited Total in Position 1 Anesthetist: Sanctioned Sanctioned 1 1 Regular in position Contractual Recruited Total in Position 0 0 Medical Officer Trained with Short Term Anesthesia Course: Sanctioned 0 0 Regular in position 0 0 Contractual Recruited 0 0 Total in Position 0 0 General Duty Medical Officer: Sanctioned 3 1 Regular in Position 3 1 Contractual Recruited 3 0 Total in Position 6 1 Eye Surgeon: Sanctioned 0 0 Regular in Position 0 0 Contractual Recruited 0 0 Total in Position 0 0 Public Health Nurse: Sanctioned 0 7 Regular in Position 0 7 Contractual Recruited 0 0 Total in Position 0 7
53 Table C2: Position of Medical Staff and Paramedical Staff in Baramulla CHC (Yes=1, No=0) Chandoosa Pattan Lady Health Visitor (LHV): Sanctioned 0 1 Regular in Position 0 1 Total in Position 0 1 Block Extension Educator (BEE): Sanctioned 0 3 Regular in Position 0 1 Total in Position 0 1 ANM: Sanctioned 1 1 Regular in Position 0 1 Contractual Recruited 1 0 Total in Position 1 1 Staff Nurse: Sanctioned 7 1 Regular in Position 1 1 Contractual Recruited 2 0 Total in Position 3 1 Dresser: Sanctioned 0 3 Regular in Position 0 2 Total in Position 0 2 Pharmacist / Compounder: Sanctioned 2 3 Regular in Position 1 2 Total in Position 1 2 Lab. Technician: Sanctioned 1 1 Regular in Position 0 1 Contractual Recruited 1 0 Total in Position 1 1 Radiographer: Sanctioned 1 1 Regular in Position 0 1 Total in Position 0 1 Ophthalmic Assistant: Sanctioned 0 1 Regular in Position 0 1 Total in Position 0 1 Statistical Assistant / Data Entry Operator: Sanctioned 0 1 Regular in Position 0 1 Total in Position 0 1 OT Attendant: Sanctioned 0 2 Regular in Position 0 2 Total in Position 0 2 Ambulance Driver: Sanctioned 2 2 Regular in Position 0 2 Contractual Recruited 1 0 Total in Position 1 2 Registration Clerk: Sanctioned 0 2 Regular in Position 0 2 Total in Position 0 2
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Table C3. Availability of Specific Services in CHC in Baramulla Availability of Specific Services (Yes=1, No=0) Chandoosa Pattan Functioning on 24 x 7 Basis 1 1 Functioning as FRU 0 0 Emergency Care for Sick Children 0 0 Full Range of Family Planning Services 0 0 AYUSH Services 1 1 VCTC 0 0 Cataract Surgery 0 0 Treatment of STI/RTI 1 1 Dots 1 1
Table C4. Status of Specific Interventions in Baramulla CHC (Yes=1, No=0) Chandoosa Pattan IPHS Facility Survey been Carried out 0 0 Funds Being Electronically Transferred from District 0 0 Registered Rogi Kalyan Samiti 1 1 RKS Generate Resources: User Fees 0 1 Money generated by RKS being used 1 0 Display board showing no. of meetings & members of RKS 1 1 Feedback mechanism in place for grievances redressed by RKS 0 0 Citizen Charter Been Publically Displayed 1 1 All Standard Treatment Guidelines and Protocols Available 0 0
Table C5: Status of Residential Facilities for Doctors and Other Staff in Baramulla CHC (Yes=1, No=0) Chandoosa Pattan Residential Facility for Doctors 0 1 Non Occupied Residential Quarters 0 0 Residential Facility for other staff 0 1 Non Occupied Residential Quarters 0 0
Table C6. Availability of Laboratory Facilities in Baramulla Laboratory Testing (Yes=1, No=0) Chandoosa Pattan Blood Grouping 1 1 Hemoglobin 1 1 Bleeding Time Clotting Time 1 1 RTI/STIs 1 1 Blood Sugar 1 1 Malaria Parasite 0 1 Urine Test 1 1 Rapid Test for Pregnancy 1 1 RPR Test for Syphilis 1 1 Rapid Test for HIV 1 0 Blood Smear: 1 1
55 Table C7: Number of Lab. tests done in CHC in last 3 calendar months in Baramulla Type of tests done Chandoosa Pattan Hemoglobin Numbers 96 260 Blood Sugar Numbers 41 180 Blood Grouping Numbers 9 110 Blood Smear Numbers 25 65 Bleeding Time Clotting Time Numbers 96 125 RTI/STIs Numbers 144 Malaria Parasite Numbers 15 Rapid Test for Pregnancy Numbers 83 215 RPR Test for Syphilis Numbers 38 52 Rapid Test for HIV Numbers Urine Test Numbers 179 827
Table C8: Number of surgeries performed during 2007 2008 in Baramulla CHC Type of surgeries Chandoosa Pattan Caesarean Sections Numbers 0 0 No of C Section Deliveries for JSY Numbers 0 1,400 Surgical Cases Numbers 0 0 Cataract Numbers 0 0 Tubectomy Numbers 0 78 Laparoscopic Sterilization Numbers 0 0 NSV Numbers 0 24 Conventional Vasectomy Numbers 0 0 MTP Numbers 0 0 Laprotomy Numbers 0 0
Table C9: Reasons for not conducting surgeries in Baramulla CHC (Yes=1, No=0) Chandoosa Pattan Non availability of doctor/anesthetist/staff 1 0 Lack of equipment/poor physical state of the operation theatre 0 0 No power supply in the OT 0 0 Other 1 0
56 Table C10. Status of performance of Labour Room during 2007 2008 in Baramulla CHC
Chandoosa Pattan Total Institutional Deliveries Numbers 35 311 Deliveries Carried Out from 8.PM to 8 AM Numbers 0 NA Institutional Deliveries for JSY Card Holders Numbers 35 311 No of Neonates Resuscitated Numbers 0 0
Table C11: Reasons for not conducting deliveries in Baramulla CHC (Yes=1, No=0) Chandoosa Pattan Non availability of doctor / anesthetist/staff Yes No Poor condition of the labour room Yes No No power supply in the labour room Yes No
Table C12: Status of availability of Equipments & drugs in Baramulla CHC (Yes=1, No=0) Chandoosa Pattan Boyles Apparatus : Available 0 1 Boyles Apparatus : Working 1 ECG Machine : Available 1 1 ECG Machine : Working 1 1 Cardiac Monitor for OT : Available 0 1 Cardiac Monitor for OT : Working 1 Defibrillator for OT : Available 0 1 Defibrillator for OT : Working 1 Ventilator for OT : Available 0 0 Horizontal High Pressure Sterilizer : Available 0 0 Vertical High Pressure Sterilizer : Available 0 1 Vertical High Pressure Sterilizer: Working 1 OT Care Fumigation Apparatus : Available 0 1 OT Care Fumigation Apparatus: Working 1 Gloves Dusting Machines : Available 0 1 Gloves Dusting Machines: Working 1 Oxygen Cylinder : Available 0 1 Oxygen Cylinder: Working 1 Hydraulic Operation Table : Available 1 1 Hydraulic Operation Table: Working 1 0 Resuscitation Trolley : Available 0 0 Phototherapy Unit : Available 0 0 MVA Syringe : Available 0 0 Baby Incubator : Available 0 0 Cont..
57 Table C12: Status of availability of Equipments & drugs in Baramulla CHC (Yes=1, No=0) Chandoosa Pattan Iron Folic Acid :Stock Out 0 1 Iron Folic Acid: Irregular Supply 0 1 Oral Pills : Stock Out 0 0 Oral Pills: Irregular Supply 0 0 IUD 380 : Stock Out 0 0 IUD 380: Irregular Supply 0 0 ORS : Stock Out 1 1 ORS : Irregular Supply 1 1 ORS with Zinc Adjutant as Per Policy : Stock Out 1 1 ORS with Zinc Adjutant as Per Policy : Irregular 1 1 Vitamin A : Stock Out 1 1 Vitamin A : Irregular Supply 1 1 Tab Fluconazole : Stock Out 1 0 Tab Fluconazole : Irregular Supply 1 0 Tab Metronidazole : Stock Out 0 0 Tab Metronidazole : Irregular Supply 0 0 Tab Co Trimoxazole : Stock Out 0 0 Tab Co Trimoxazole : Irregular Supply 0 0 Tab Nefidipine : Stock Out 1 1 Tab Nefidipine : Irregular Supply 1 1 Inj Oxytocin : Stock Out 0 0 Inj Oxytocin : Irregular Supply 0 0 Inj Gentamycin : Stock Out 1 0 Inj Gentamycin : Irregular Supply 1 0 Inj Magnesium Sulphate : Stock Out 1 1 Inj Magnesium Sulphate : Irregular Supply 1 1 Tab Misoprostal : Stock Out 1 0 Tab Misoprostal : Irregular Supply 1 0 Tab Progestrone : Stock Out 1 1 Tab Progestrone : Irregular Supply 1 1 Inj Lignocaine Hydrochloride : Stock Out 0 0 Inj Lignocaine Hydrochloride : Irregular Supply 0 0 Inj Pentazocine Lactate : Stock Out 1 1 Inj Pentazocine Lactate : Irregular Supply 1 1 Inj Adrenaline : Stock Out 0 0 Inj Adrenaline : Irregular Supply 0 0 Cap Doxycycline : Stock Out 0 0 Cap Doxycycline : Irregular Supply 0 0 Silver Sulphadiazine Oint :Stock Out 1 1 Silver Sulphadiazine Oint : Irregular Supply 1 1 IV Fluids : Stock Out 0 0 IV Fluids : Irregular Supply 0 0 Inj Procaine Penicillin : Stock Out 1 1 Inj Procaine Penicillin : Irregular Supply 1 1 Inj Atropine : Stock Out 0 0 Inj Atropine : Irregular Supply 0 0 Syp Amoxicillin : Stock Out 0 0 Syp Amoxicillin : Irregular Supply 0 0 IFA Syrup : Irregular Supply 1 1 IFA Syrup : Stock Out 1 1
58 Table C13. Availability of Specific Services in Baramulla CHC (Yes=1, No=0) Chandoosa Pattan Medicine 0 1 Surgery 0 1 Obstetric Gynae 0 1 Pediatrics 0 0 Dots 1 1 Cataract Surgery 0 0 Leprosy Diagnosis Management and Referral Services 0 1 Emergency Services (24 Hrs) 1 1 Mobile Medical Unit 0 0 Separate Neo Natal Care Unit Available 0 0 Emergency Care for Sick Children 0 0 Full Range of F.P Services & Laparoscopic Ligation 0 1 Safe Abortion Services 0 1 Treatment of STI/RTI 1 1 Blood Storage Facility 0 0 Counseling Facility on HIV / AIDS / STD etc 0 0 Voluntary Counseling and Testing Centre 0 0 AYUSH Facility 0 0
Table C13. Availability of Specific Services in Baramulla CHC (Yes=1, No=0) Chandoosa Pattan Primary Management of Wounds 1 1 Primary Management Fracture 1 1 Primary Management of Cases of Poisoning Snake Insect or Scorpion Bite 1 1 Primary Management of Dog Bite 1 1 Primary Management of Burns 1 1 Management of RTI/STI 1 1
Table C14. Service out come in Baramulla CHC
Chandoosa Pattan Total ANC Registration: Others 11 330 Total 11 330 Total JSY Cases Registration: Others 11 330 Total 11 330 1st Trimester Registration Others 3 87 Total 3 87 ANC Given 3 Checkups as Per RCH Schedule: Others 2 82 Total 2 82 Out of Above the No of JSY Beneficiaries: SC ST Others 11 82 Total 11 82 ANC Given TT :SC Others 2 103 Total 2 103
59 Table C14. Service out come in Baramulla CHC
Chandoosa Pattan No of JSY Beneficiaries :SC SC 0 0 ST 0 0 Others 2 103 Total 2 103 ANC Completed IFA Prophylaxis :SC SC 0 0 ST 0 0 Others 8 0 Total 8 0 Out of No of JSY Beneficiaries :SC SC 0 0 ST 0 0 Others 8 0 Total 8 0 No of Pregnant Women Identified and Attended with Obstetric Complications :SC SC 0 0 ST 0 0 Others 4 0 Total 4 0 How Many have Been Referred from PHC / SHC :SC SC 0 0 ST 0 0 Others 0 0 Total 0 0 Total Institutional Deliveries: SC SC 0 0 ST 0 0 Others 3 25 Total 3 25 No of JSY Cases (Out of Total Institutional Deliveries):SC SC 0 0 ST 0 0 Others 3 25 Total 3 25 No of Infants Given BCG:SC SC 0 0 ST 0 0 Others 12 42 Total 12 42 No of Infants Given DPT3:SC SC 0 0 ST 0 0 Others 12 59 Total 12 59 No of Infants Given Measles: SC SC 0 0 ST 0 0 Others 11 2 Total 11 2 No of Infants Given Vit A First Dose: SC ST 0 0 Others 0 0 Total 0 0
60 Table C14. Service out come in Baramulla CHC
Chandoosa Pattan Children Given IFA Syp: SC SC 0 0 ST 0 0 Others 0 0 Total 0 0 IUD Inserted: SC SC 0 0 ST 0 0 Others 2 13 Total 2 13 Total Indoor Patients: SC SC 0 0 ST 0 0 Others 13 146 Total 13 146 No of Cases Referred Beyond CHC:SC SC 0 0 ST 0 0 Others 6 0 Total 6 0 No of Leprosy Cases Currently Under Treatment CHC:SC SC 0 0 ST 0 0 Others 0 0 Total 0 0 No of New TB Cases Enrolled For Dots : SC 0 0 ST 0 0 Others 0 3 Total 0 3
Table C14. Service out come in Baramulla CHC
CHC1 CHC2 No of Cases Given Blood Transfusion in Last 3 Months Numbers 0 0 Bed Occupancy Rate in the Last 12 Months Rate 5 29 OPD Attendance Male Average 45 150 OPD Attendance Female Average 35 150 OPD Attendance Children Average 35 40 Out of the Total OPD Attendance Specify the Referred Cases from PHC / SHC Average 5
(-): represents either 0 or information not available
61 CHAPTER 5 PRIMARY HEALTH CENTRE (PHC)
The concept of Primary Health Centre (PHC) is not new to India. The Bhore Committee in 1946 gave the concept of a PHC as a basic health unit to provide as close to the people as possible, an integrated curative and preventive health care to the rural population with emphasis on preventive and promotive aspects of health care. PHCs are the cornerstone of rural health services a first port of call to a qualified doctor of the public sector in rural areas for the sick and those who directly report or referred from Sub centres for curative, preventive and promotive health care. It acts as a referral unit for 6 sub centres and refer out cases to Community Health Centres (CHCs 30 bedded hospital) and higher order public hospitals at sub district and district hospitals. It has 4 6 indoor beds for patients.
PHCs are not spared from issues such as the inability to perform up to the expectation due to (i) non availability of doctors at PHCs; (ii) even if posted, doctors do not stay at the PHC HQ; (iii) inadequate physical infrastructure and facilities; (iv) insufficient quantities of drugs; (v) lack of accountability to the public and lack of community participation; (vi) lack of set standards for monitoring quality care etc.
Standards are a means of describing the level of quality those health care organizations are expected to meet or aspire to. Key aim of these standards is to underpin the delivery of quality services which are fair and responsive to client’s needs, which should be provided equitably and which deliver improvements in the health and wellbeing of the population. Standards are the main driver for continuous improvements in quality. The performance of health care delivery organizations can be assessed against the set standards. The National Rural Health Mission (NRHM) has provided the opportunity to set Indian Public Health Standards (IPHS) for Health Centres functioning in rural areas.
Setting standards is a dynamic process. Since the IPHS for Primary Health Centres has been prepared keeping in view the resources available with respect to functional
62 requirement for PHCs with minimum standards such as building, manpower, instruments, equipments, drugs and other facilities etc.
Coverage (Table P1) Therefore, in order to ascertain the overall impact of NRHM on various services/facilities/infrastructure/manpower available at the PHC level a well structured questionnaire was canvassed in Baramulla district to get information from the selected PHCs. A total of four PHCs (2 each from Sheeri and Pattan Blocks) were covered. Two of them were designated as 24x7 (Fathegrah from Sheeri block and Wanigam from Pattan block) PHCs. Table P1 shows that the total number of SCs in a particular PHC varies from three in PHC Singhpora to six in PHC Wanigam. The population covered by each of the PHC ranged between 14,000 and 16,000 persons. The distance to the nearest SC was highest (5 kms) for Fathegrah PHC and it takes one hour (by foot) to reach this SC while in case of PHC Singhpora, the SC was located within the PHC. The farthest SC was 12 kms away in PHC Wanigam and it takes one hour (by local transport) to reach there. The distance to the nearest CHC from PHC was seven kms for Wanigam and G.K. Qasim while this distance was 23 kms for Fathegrah CHC and the time taken to reach there by the local transport was two hours. All the selected PHCs had beds notified for male and female patients and the highest number (seven) of beds was in PHC Fathegrah. Though PHCs Fathegrah and Wanigam have been designated as 24x7 PHCs but it was found that none of them was presently functional as 24x7. Further all the PHCs reported that they are equipped with the basic obstetric services. Except for PHC Singhpora all other PHC had bed strength of 4 6.
Infrastructure (Table P2) Table P2 gives the information about the availability of basic infrastructure in the selected PHCs. The data collected shows that all the PHCs were functioning in the designated government buildings. The labour room was available in only two PHCs and surprisingly it was not available in those PHCs which have been designated as 24x7. Boards displaying the availability of services in the local language were found in all the PHCs except in PHC Singhpora. It was found that only two PHCs (Fathegrah and Singhpora) have maintained the records pertaining to the names of the JSY beneficiaries. Separate public utilities for males and females, suggestion/
63 complaint box and pharmacy for drug dispensing and drug storage were found available in half of the selected PHCs while OPD rooms and piped water supply was available in all the PHCs. Further the data shows that none of the selected PHCs had the facility of computer, telephone or internet.
It was found that the sewerage system was connected with a soak pit in all the PHCs while the waste material is buried or thrown open by the selected PHCs. It was further found that separate areas for septic and aseptic deliveries were available in two of the selected PHCs only while new born care was not available in any of the PHCs. Further, the cleanliness of OPD, Compound of PHCs and room/wards was found to be satisfactory in all the PHCs.
Staff Position (Table P3) Availability of human resource and infrastructure at any health facility is a prerequisite for delivery of services to the public. Therefore, the information with regard to the staffing pattern at the selected PHCs was also collected. It shows that except for PHC Wanigam (24x7 PHC) all the sanctioned posts of Medical officer were filled in at the time of survey. In PHC Wanigam, besides, one Medical officer working on regular basis there were two Medical officers (one each for Gynaecology and Dental section) working on the contractual basis while all other selected PHCs have not engaged any Medical officer on contractual basis. Table P3 further shows that except for PHC Fathegrah all the sanctioned posts of Pharmacist were filled in and in PHC G. K. Qasim, besides one regular pharmacist there was one Pharmacist recruited on contractual basis. One post of Nurse was sanctioned to all the PHCs in the district but only half of the selected PHCs had a Nurse in position at the time of survey. It was found that one post each of Laboratory Technician, Driver and ANM was sanctioned to all the selected PHCs and in most of them they were in position.
Training (Table P4) Table P4 gives the information regarding the training of the personnel at PHCs and it shows that IMNCI training has been received by the health personnel in two PHCs (Wanigam and G. K. Qasim) while the trainings regarding safe abortion methods,
64 skill birth attendant training and new born care training has not been received by any health personnel in any of the selected PHC.
Labour Room (Table P5 and P6) Labour room was found available in half of the selected PHCs (Singhpora and G. K. Qasim) and was currently in use in only one PHC (Singhpora) while in PHC G. K. Qasim it was not in use due to non availability of the staff, poor conditions of the labour room and non availability of power supply in the labour room. It was observed during our visit to the PHC Fathegrah that they have temporarily specified one room for the normal deliveries during the day hours though the money has been sanctioned by the authorities for the construction of the labour room/operation theatre but the money (Rs. Three lacs in the form of a cheque) is pending with the concerned BMO as reported by the Medical officer of the PHC. Further table P6 shows that the total number of institutional deliveries conducted during 2007 2008 in PHC Singhpora was 14 and all of them were JSY card holders and were conducted during the day time while in PHC G. K. Qasim, no delivery was conducted due to non availability of the requisite staff.
Testing Facilities (Table P7) Table P7 gives the detailed information regarding the availability of laboratory testing facility in selected PHCs. The information collected shows that in PHC Singhpora none of the laboratory testing facility was available and the patients had to suffer and go to private labs for different basic tests while in comparison PHCs Fathegrah, Wanigam and G. K. Qasim had all the basic testing facilities like haemoglobin, urine RE, Blood sugar, Blood grouping, Blood smear, BT CT, Rapid test for pregnancy etc. Tests for detection of RTI/STI and rapid test for HIV was not done in any of the selected PHCs. Further table P8 shows that in PHC Wanigam where the basic test facilities are available and the officials reported that they have conducted theses tests during the last three month prior to the survey have not maintained the records for the same while in PHCs Fathegrah and G. K. Qasim such records were found updated and these records show that a good number of patients have utilized the testing facilities in these PHCs.
65 Tests Conducted (Table P8) The average number of Urine tests conducted by PHCs Fathegrah and G. K. Qasim was 175 and 158 respectively during the last three months prior to survey while during the same period the number of haemoglobin tests was done to 60 and 35 patients. Blood sugar, blood grouping and blood smear tests were conducted in only PHC Fathegrah while BT CT was done for 22 patients in Fathegrah and 2 in G. K. Qasim PHC during the last three months prior to the survey.
Specific Interventions (Table P9) The launching of National Rural Health Mission (NRHM) has provided the opportunity to streamline the functioning of PHCs and to make them more effective and answerable by recommending a set of standards for Primary Health Centre to be called Indian Public Health Standards (IPHS) for PHCs. The objectives of IPHS for PHCs are: To provide comprehensive primary health care to the community through the Primary Health Centres, to achieve and maintain an acceptable standard of quality of care, and to make the services more responsive and sensitive to the needs of the community. Further the other interventions include the incorporation of AYUSH services as per local people’s preference (Mainstreaming of AYUSH), make the PHC 24x7, formation of Rogi Kalyan Samiti / Hospital Management Committee, proper notice displaying wings of the centre, available services, names of the doctors, users’ fee details and list of members of the Rogi Kalyan Samiti etc. Under NRHM funds are being provided to PHCs for conducting IPHS facility surveys; however it was found that none of the PHCs in Baramulla has yet initiated any action to conduct IPHS facility survey. In fact almost none of the officials at the PHCs were aware about the terminology of IPHS facility survey.
As already mentioned out of the four PHCs selected, PHCs Fathegrah and Wanigam have been designated as 24x7 PHCs but it was found that none of them was presently functional as 24x7. Though AYUSH doctors were providing services at all the 4 PHCs but AYUSH doctors complained of non availability of AYUSH drugs. Besides, they suggested that each PHC should have a post of AYUSH Pharmacist because the Pharmacists who are currently posted in PHCs are not trained to handle AYUSH drugs. Further they complained that they are not being allowed to function
66 properly by the regular staff as they say that they belong to NRHM quota and are harassed on one pretext or the other.
Rogi Kalyan Samitis have been constituted and registered in all the PHCs. However, we could not see any display board showing the number of members and number of meetings organized by RKSs in any of the PHCs. It was found that all the RKSs in PHCs were currently allowed to use the user fee for their day to day activities. RKS are also supposed to have a mechanism to redressal of grievances and except for PHC Singhpora all the PHCs reported that feedback mechanism is in place for grievances redressal by RKSs. PHCs are also supposed to display the Citizen’s Charter publically. It was found that MOs generally at the PHCs were not fully aware what the Citizens Charter is and what is to be displayed in the charter. Some sort of Citizens Charter was seen to be displayed in PHCs Fathegrah, Singhpora and G. K. Qasim. When the MOs were asked to report whether all standard treatment guidelines and protocols are available in the PHCs it was reported by almost all the MOs that all standard treatment guidelines and protocols are available in their respective PHCs. (Table P9).
PHCs are supposed to provide some general services like primary management of wounds, factures, malnourishment of children, minor surgeries, RTI/STI, MTP services and management of poisoning etc. Table P9 shows that all the selected PHCs provide services for management of wounds, primary management of burns and management of RTI/STIs. AYUSH doctors are in place in all the PHCs but services are available at only PHC Wanigam and G. K. Qasim while in other two PHCs due to lack of drugs and other paramedical staff AYUSH services are in shambles. Facilities for MTP are provided in three out of four selected PHCs in the district. Facilities for the primary management of fracture, management of neonatal asphyxia, sepsis, and management of malnourished children are available in PHC G. K. Qasim only. Two PHCs reported that facilities for the primary management of poisoning/snake/insect or scorpion bites are available in the PHCs. Of the 4 PHCs, out of the listed 11 services, PHC G. K. Qasim reported availability of 10 services, and Fathegrah reported 7 services while as only 6 facilities were reportedly to be available in PHCs Wanigam and Singhpora.
67 Availability of Equipment (Table P10) Equipments are essential for the delivery of primary health services at the PHC level. In this regard the information was collected from all the PHCs regarding the status of PHCs with respect to the availability of these equipments as well as their working condition. The information collected shows that except for PHC G. K. Qasim all other PHCs had a Patient trolley and was in working condition. Examination table, Delivery table, Stretcher, Oxygen cylinder, sterilization equipment, Oxygen mask, and Thermometers, were found available in all the PHCs in working condition. Wheel chair, suction apparatus, suction machine, and Microscope were found available in two PHC (Fathegrah and Wanigam).
Wheel chair, Cradle, Autoclave, Laryngoscope, and Auto Analyzer, in working condition was available in PHC Fathegrah only while as Infant warmer, Radiant warmer and Resuscitation equipment was not available in any PHC. Of the 23 items discussed above, PHC Fathegrah has 18 items in working condition, PHC Wanigam has 14 and PHC G. K. Qasim has 13 while PHC Singhpora had 9 equipments in working condition. Thus it shows that the two 24X7 PHCs are comparatively better equipped than other two PHCs. (Table P10)
Supplies and Availability of Drugs (Table P11) The information on whether PHCs are supplied with necessary drugs, contraceptives, vaccines, kits and other necessary material with data on stock out and regularity of supplies during the last six months prior to the survey is presented in Table P11. It was found that Vitamin A, Iron syrup, Magnesium Sulphate, and Partograph, are not provided to the PHCs. Both the PHCs in Pattan block reported stock out of IFA Tablets during the last 6 months and three PHCs reported its irregular supplies. In fact it was found that IFA tablets available with the PHCs were at the verge of expiry as most of the pregnant women say that it creates stomach problem. The position with regard to the availability of Oral Pills was somewhat satisfactory as only one PHC had the experience of stock out and two were satisfied with the regularity of supplies of Oral Pills. Further the data shows that none of the PHCs had any shortage or irregularity in the supplies of measles vaccine. Of the four PHCs, two(both 24x7 PHCs) reported that they were out of stock of ORS for some time during the last 6 months and the supplies of ORS were also irregular. In all the
68 PHCs Methergine tablets, Albendazole tablets, IUDs, Ringers Lactate, Disposable gloves, and Bandages were available have never been out of stock during the last six months. Injection Oxytocin was out of stock in 2 PHCs while 2 PHCs mentioned that they are regularly receiving them. Fluconzole was reported to be out of stock at during the last 6 months by 3 PHCs and supply was also reported to be irregular by these 3 PHCs. Similarly three fourth of the PHCs experienced stock out and irregular supplies of MVA syringes, DOTs drug and MDT blister packs. One of the PHCs (PHC Singhpora) has witnessed stock out of AD Syringes, however, its supply was reported be regular by most of the PHCs. Overall two PHCs reported that they were short of AYUSH drugs for some time during the last 6 months due to irregular supply.
Service Outcome (Table P12) PHCs are expected to provide various services in the area of maternal and child health care, family planning and treatment of RTI/STI. They are also expected to manage minor surgeries, burns, fractures, and provide services to TB, leprosy and malaria patients. Information was collected regarding the service outcome of various services that are provided at the PHCs for the last three months. Though the research team tried to collect detailed information on service outcome by caste and tribe but such information was not available at all in PHC Wanigam and as such we could not find any records there in this regard.
The number of antenatal care (ANC) visits and the timing of the first visit are important for the health of the mother and the outcome of pregnancy. Therefore, PHCs are required to identify pregnant women and register them for ANC services soon after the pregnancy is confirmed. On an average during the last three months prior to survey, PHC G. K. Qasim had registered 13 ANC cases in a month and all of them were registered under JSY. PHC Fathegrah had registered five ANC cases and all had been registered for JSY. The mean number of ANC cases registered in a month during the last three months in PHC Singhpora was 4 and all these women had been issued JSY cards while in PHC Wanigam no records were available in this regard. All the registered cases for ANC in the above mentioned PHCs belonged to ‘Other’ caste. Under RCH, efforts are to be made by the ANMs to register pregnant women for ANC as early as possible. It was found that all the pregnant women registered in Fathegrah had been registered for ANC in the first trimester while in G.
69 K. Qasim only three women were registered in first trimester of their pregnancy. One of the important elements of ANC is to provide two doses of tetanus toxoid vaccine and iron and folic acid (IFA) tablets to pregnant women to prevent nutritional anemia, in this regard all the PHCs where pregnant women were registered for ANC had received TT1 and completed IFA Prophylaxis. The number of women who had received the TT2 + Booster was less than the registered number due to the fact that they were still registered for the ANC at their respective PHCs.
As far as institutional deliveries are concerned, the performance of PHCs is very poor. PHC Singhpora and Wanigam currently do not handle institutional deliveries. In PHC Fathegrah out of all the cases registered for ANC none of the deliveries was conducted there while in G. K. Qasim 3 institutional deliveries had taken place and all had a JSY card. Needless to say that none of them was paid any financial incentives under JSY because of non availability of funds under the scheme.
Though all the PHCs are actively implementing the Universal Immunization Programme for children but their performance is not so good. On an average in a month the number of infants who have been given the BCG at the selected PHCs ranges between as low as three for PHC Fathegrah to the high of 14 in PHC Wanigam. DPT3 has been provided to 65 infants in Wanigam followed by 11 in G. K. Qasim, 10 in Singhpora and eight in PHC Fathegrah. Further the data shows that on an average in a month vaccination against measles was administered to 50 infants in Wanigam followed by 10 in G. K. Qasim and nine each in two other PHCs. As has already been mentioned that Vitamin A and IFA syrup was not in the supply of the PHCs, therefore, none of the children was either given Vitamin A or IFA syrup.
PHC are also supposed to provide family planning services. They are also expected to organize camps for providing family planning services like IUDs, female sterilizations and Non Scalpel vasectomies (NSVs). But the information collected from the PHCs revealed that the PHCs are not involved in providing family planning services to the couples who need them. The only family planning service provided by two PHCs is insertion of IUDs (Copper T). The two PHCs on an average during the last 3 months have provided IUD services to 3 or 4 women in a month.
70 All the PHCs have been provided beds to admit patients and treat them. But it was found that none of the PHCs has a regular IPD facility available and patients are not admitted in any of the PHCs for night stay. The PHCs normally admit patients during day time for 2 3 hours for administration of IV fluids and for the treatment of minor sickness. Those patients who need further medical supervision are referred to District Hospital. The average number of day care IPD patients in a month in G. K. Qasim is nine and in Wanigam it is one. None of them belonged to SC or ST. Medical Officers mentioned that due to the shortage of doctors and paramedical staff, irregular electricity, lack of any heating arrangement they are unable to provide regular IPD services.
Minimum Requirements (Assured Services) at the Primary Health Centre for meeting the IPHS cover all the essential elements of preventive, promotive, curative and rehabilitative primary health care. This implies a wide range of services that include OPD services: 4 hours in the morning and 2 hours in the afternoon /evening. Time schedule will vary from state to state. Minimum OPD attendance should be 40 patients per doctor per day. The data collected regarding the average monthly number of patients attended by each of the PHC during last three months prior to the survey show that 600 patients were treated at the OPD in PHC Wanigam followed by 567 in Fathegrah and 561 in G. K. Qasim PHC. The average monthly number of patients treated at Singhpora PHC in the OPD was 169. Though all the PHCs reported that they do manage the patients with RTI/STI but it was found that PHC Fathegrah, Singhpora and Wanigam have not treated any case of RTI/STI during the last three months while as PHC G. K. Qasim have on an average have treated 12 cases of RTI/STI during the same period. None of the PHCs reported of any Maternal death in their respective PHCs during 2007 2008 and it is because of the fact that these PHCs conduct very limited number of deliveries. Table P12 further shows that two cases each from Wanigam and G. K. Qasim PHCs were referred to higher health institution with obstetric complications. .
All PHCs are supposed to function as DOTS Centres to deliver treatment as per RNTCP treatment guidelines through DOTS providers and treatment of common complications of TB and side effects of drugs, record and report on RNTCP activities
71 as per guidelines. In this regard the data collected shows that on an average only one new TB case was enrolled at PHC Fathegrah while no case of TB, Leprosy was reported by any of the selected PHCs. Further the data shows that none of the PHCs have done any Cataract surgery during last three months mainly due to non availability of requisite infrastructure and Staff (Ophthalmologist and Technician).
Maintenance of Records (Table P13) Record keeping and its maintenance is very important as every health institution is supposed to forward it to the concerned quarters periodically for the review. In this regard the information was collected from all the PHCs in district Baramulla which is presented in table P13. It shows that except for PHC Wanigam all the PHCs had updated register of ANC while as eligible couple register was maintained by only one PHC (Fathegrah). Further PNC register was maintained by half of the PHCs, Family Planning register and Birth/Death register by Singhpora only, immunization register and Untied Fund register by all the PHCs while as meeting register was maintained by G. K. Qasim PHC only. The JSY register was maintained by 75 percent PHCs.
72 Table P1. Coverage and facilities of Primary Health Centre in Baramulla Coverage and facilities, SHEERI PATTAN (Yes=1, No=0) FATHEGRAH SINGHPORA WANIGAM G. K. QASIM Number of SC Under the PHC Numbers 5 3 6 4 Population Covered 15,000 16,000 16,000 14,000 Nearest SC in the Coverage Area: Distance in kms 5 0 2 1 Nearest SC in the Coverage Area: Time 60 0 30 15 Farthest SC in the Coverage Area: Distance 9 4 12 4 Farthest SC in the Coverage Area: Time 30 45 60 40 Nearest CHC : Distance 23 16 7 7 Nearest CHC: Time 120 90 40 20 No of Beds : Male 4 2 3 2 No of Beds : Female 3 1 2 3 PHC Functioning on 24 x 7 Basis 0 0 0 0 PHC Equipped to Provide Basic Obstetric Services 1 1 1 1 PHC with 4 6 Beds 1 0 1 1
Table P2. Primary Health Centers by Infrastructure in Baramulla SHEERI PATTAN Infrastructure (Yes=1, No=0) FATHEGRAH SINGHPORA WANIGAM G. K. QASIM PHC functioning in Designated Government Building 1 1 1 1 Labour Room 0 1 0 1 Prominent Display Boards Regarding Service Availability in Local Language 1 0 1 1 Names of JSY Beneficiaries Maintained in Record 1 1 0 1 Pharmacy for Drug Dispensing and Drug Storage 1 1 0 1 Separate Public Utilities for Males and Females 1 0 0 1 Suggestion / Complaint Box 1 0 0 1 OPD Rooms / Cubicles 1 1 1 1 Piped water supply 1 1 1 1 No Regular electricity 0 0 1 0 Regular Electric Supply in all Parts 1 1 0 1 Telephone Computer 0 0 0 0 Internet 0 0 0 0
73 Table P2. Primary Health Centers by Infrastructure in Baramulla SHEERI PATTAN Infrastructure (Yes=1, No=0) FATHEGRAH SINGHPORA WANIGAM G. K. QASIM Type of Sewerage System Soak Pit 1 1 1 1 Connected to Municipal Sewerage Open Drain Other How Waste Material is Being Disposed Buried in a Pit Collected by an Agency Incarnation 1 1 1 Thrown in Open 1 Standby Facility Available 0 1 0 1 Separate Areas for Septic and Aseptic Deliveries Available 0 1 0 1 New Born Care Available 0 0 0 0 Status of Cleanliness of OPD Good 1 1 Fair 1 1 Poor Status of Cleanliness of Compound / Premises Good 1 1 Fair 1 1 Poor Status of Cleanliness of Room / Wards Good 1 1 Fair 1 1 Poor
74 Table P3: Staff Position of in Primary Health Centre in Baramulla SHEERI PATTAN Type of Staff FATHEGRAH SINGHPORA WANIGAM G. K. QASIM Medical Officer : Sanctioned 1 1 2 2 Regular in Position 1 1 1 2 Contractual Recruited 2 Total in Position 1 1 2 2 Pharmacist : Sanctioned 1 1 1 1 Regular in Position 1 1 1 Contractual Recruited 1 Total in Position 1 1 2 Nurses : Sanctioned 1 1 1 1 Regular in Position 1 1 Contractual Recruited Total in Position 1 1 ANM : Sanctioned 1 2 1 Regular in Position 1 Contractual Recruited 1 Total in Position 1 1 Lab Technician : Sanctioned 1 1 1 1 Regular in Position 1 1 Contractual Recruited 1 Total in Position 1 1 1 Driver : Sanctioned 1 1 1 1 Regular in Position 1 Contractual Recruited 1 1 Total in Position 1 1 1
Table P4: Status of training of personnel at Primary Health Centre in Baramulla PHC having personnel trained Training (Yes=1, No=0) SHEERI PATTAN FATHEGRAH SINGHPORA WANIGAM G. K. QASIM Pre Service IMNCI 0 0 1 1 Safe Abortion Methods 0 0 0 0 Skill Birth Attendant Training 0 0 0 0 New Born Care 0 0 0 0
Table P5: Availability of Labour Room in Primary Health Centre in Baramulla SHEERI PATTAN Labour Room (Yes=1, No=0) FATHEGRAH SINGHPORA WANIGAM G. K. QASIM Availability of Labour Room 0 1 0 1 Labour Room Currently in Use 0 1 0 1 Reasons for Deliveries Not Conducting in Labour Room: Non Availability of Doctors/ Staff 0 0 0 1 Poor Condition of the Labour Room 0 0 0 1 No Power Supply in the Labour Room 0 0 0 1 Other 0 0 0 1
75
Table P6: Status of performance of Labour Room during 2007 2008 in Baramulla Number of deliveries performed in PHC Number of Deliveries SHEERI PATTAN FATHEGRAH SINGHPORA WANIGAM G. K. QASIM Total Institutional Deliveries Numbers 14 Deliveries Carried Out from 8 Pm 8 am Numbers Institutional Deliveries for JSY Card Holders Numbers 14 No of Neonates Resuscitated Numbers
Table P7: Availability of Laboratory Testing in PHC in Baramulla Availability Laboratory Testing SHEERI PATTAN (Yes=1, No=0) FATHEGRAH SINGHPORA WANIGAM G. K. QASIM Hemoglobin 1 0 1 1 Urine RE 1 0 1 1 Blood Sugar 1 0 1 0 Blood Grouping 1 0 1 1 Blood Smear 1 0 1 1 Bleeding Time, Clotting Time 1 0 1 1 Diagnosis of RTI / STIs with Wet Mounting, Grams Stain Etc 0 0 0 0 Blood Smear Examination for Malaria Parasite 0 0 0 0 Rapid Test for Pregnancy 1 0 1 0 RPR Test for Syphilis 0 0 1 0 Rapid Test for HIV 0 0 0 0
Table P8: Number of tests done in PHC in last three calendar months in Baramulla Number of tests done in last 3 calendar months Type of Test SHEERI PATTAN FATHEGRAH SINGHPORA WANIGAM G. K. QASIM Hemoglobin :Number 60 0 INA 35 Urine RE Number 175 0 INA 158 Blood Sugar Number 60 0 INA 0 Blood Grouping Number 95 0 INA 0 Blood Smear Number 25 0 INA 0 Bleeding Time, Clotting Time Number 22 0 INA 2 Diagnosis of RTI / STIs with Wet Mounting, Grams Stain Etc Number 0 0 INA 0 Blood Smear Examination for Malaria Parasite Number 0 0 INA 0 Rapid Test for Pregnancy Number 9 0 INA 0 RPR Test for Syphilis Number 0 0 INA 0 Rapid Test for HIV Number 0 0 INA 0
76
Table P9: Status of specific Interventions in Baramulla Status of Specific Interventions SHEERI PATTAN (Yes=1, No=0) FATHEGRAH SINGHPORA WANIGAM G. K. QASIM IPHS Facility Survey done 0 0 0 0 PHC Functioning on 24 x 7 Basis 0 0 1 0 AYUSH Doctor Providing Services 1 1 1 1 Registered Rogi Kalyan Samiti 1 1 1 1 RKS generating resources through user fees 0 0 0 0 Money generated by RKS being used 1 1 1 1 Display board showing no. of meetings & members of RKS 0 0 0 0 Citizen Charter Publically Displayed 1 1 0 1 All Standard Treatment Guidelines and Protocols Available 1 0 0 1 Feedback mechanism in place for grievances redressed by RKS 1 0 1 1 Primary Management of Wounds 1 1 1 1 Primary Management Fracture 0 0 0 1 Management of Neonatal Asphyxia, sepsis 0 0 0 1 Management of Malnourished Children 0 0 0 1 Minor Surgeries Like Draining of Abscess etc 1 1 1 1 Primary Management of Cases of Poisoning / Snake Insect or Scorpion Bite 1 0 1 0 Primary Management of Dog Bite Cases 1 1 0 1 Primary Management of Burns 1 1 1 1 Facility for MTP Available 1 0 1 1 Management of RTI/STI 1 1 0 1 AYUSH Services 0 0 1 1
77 Table P10: Availability of selected equipments in PHC in Baramulla Equipments available/ working SHEERI PATTAN (Yes=1, No=0) FATHEGRAH SINGHPORA WANIGAM G. K. QASIM Patient Trolley: Available 1 1 1 0 Patient Trolley: Working 1 1 1 Examination Table: Available 1 1 1 1 Examination Table: Working 1 1 1 1 Delivery Table: Available 1 1 1 1 Delivery Table: Working 1 1 1 1 Wheel Chair: Available 1 0 1 0 Wheel Chair: Working 1 0 0 Stretcher / Trolley: Available 1 1 1 1 Stretcher / Trolley: Working 1 0 1 1 Oxygen Cylinder: Available 1 1 1 1 Oxygen Cylinder: Working 1 1 1 1 Suction Apparatus: Available 1 0 1 0 Suction Apparatus: Working 1 1 Infant Warmer: Available 0 0 0 0 Radiant Warmer: Available 0 0 0 0 Cradle: Available 1 0 0 0 Cradle: Working 1 Autoclave: Available 1 0 0 1 Autoclave: Working 1 0 0 1 Sterilization Equipment: Available 1 1 1 1 Sterilization Equipment: Working 1 1 1 1 Bag and Mask: Available 0 0 1 0 Bag and Mask: Working 1 Laryngoscope: Available 1 0 0 0 Laryngoscope: Working 1 Oxygen Mask: Available 1 1 1 1 Oxygen Mask: Working 1 1 1 1 Thermometer: Available 1 1 1 1 Thermometer: Working 1 1 1 1 Suction Machine: Available 1 0 1 0 Suction Machine: Working 1 1 0 Water Purifier: Available 0 1 0 1 Water Purifier: Working 1 1 Microscope: Available 1 0 1 1 Microscope: Working 1 0 1 Haemoglobinometer: Available 1 0 1 1 Haemoglobinometer: Working 1 1 1 Auto Analyzer: Available 1 0 0 0 Auto Analyzer: Working 1 Autoclave: Available 1 0 0 1 Autoclave: Working 1 1 Resuscitation Equipment: Available 0 0 0 0
78
Table P11: Status of Availability of Drugs in Baramulla Type of Drugs SHEERI PATTAN (Yes=1, No=0) FATHEGRAH SINGHPORA WANIGAM G. K. QASIM IFA Tablets: Stock Out in Last 6 Months 0 0 1 1 IFA Tablets: Irregular in Last 6 Months 0 1 1 1 Iron Syrup: Stock Out in Last 6 Months 1 1 1 1 Iron Syrup: Irregular in Last 6 Months 1 1 1 Oral Pills: Stock Out in Last 6 Months 1 0 0 0 Oral Pills: Irregular in Last 6 Months 0 1 1 0 Vitamin A:Stock Out in Last 6 Months 1 1 1 1 Vitamin A:Irregular in Last 6 Months 1 1 1 1 Measles Vaccine: Stock Out in Last 6 M 1 1 1 1 Measles Vaccine: Irregular in Last 6 M 0 0 0 0 ORS: Stock Out in Last 6 Months 1 0 1 0 ORS: Irregular in Last 6 Months 1 1 1 0 Tab Maethergin: Stock Out in Last 6 M 0 0 0 0 Tab Maethergin: Irregular in Last 6 Months 0 1 0 0 Tab Albendazole : Stock Out in Last 6 M 0 0 0 0 Tab Albendazole / Mabendazole: Irregular in Last 6 Months 0 0 0 0 IUDs: Stock Out in Last 6 Months 0 0 0 0 IUDs: Irregular in Last 6 Months 0 0 0 0 Inj Oxytocin: Stock Out in Last 6 M 1 0 1 0 Inj Oxytocin: Irregular in Last 6 M 1 0 1 0 Magnesium Sulphate: Stock Out in Last 6 Months Magsium Sulphate: Irregular in Last 6 M
Cont......
79 Table P11: Status of Availability of Drugs in Baramulla Type of Drugs SHEERI PATTAN (Yes=1, No=0) FATHEGRAH SINGHPORA WANIGAM G. K. QASIM Tab Fluconazole: Stock Out in Last 6 Months 1 1 0 1 Tab Fluconazole: Irregular in Last 6 Months 1 1 0 1 Partograph: Stock Out in Last 6 M 1 1 1 1 Partograph: Irregular in Last 6 M 1 1 1 1 MVA Syringe: Stock Out in 6 M 1 1 0 1 MVA Syringe: Irregular in Last 6 Month 1 1 0 1 Tab Ciprofloxacin: Stock Out in Last 6 Months 0 0 1 0 Tab Ciprofloxacin: Irregular in Last 6 Months 0 0 1 0 Syp Cotrimoxazole: Stock Out in Last 6 Months 1 1 0 0 Syp Cotrimoxazole: Irregular in Last 6 Months 1 1 0 0 Syp Paracetamol: Stock Out in Last 6 Months 0 1 1 0 Syp Paracetamol: Irregular in 6 M 0 1 1 0 Ringers Lactate: Stock Out in Last 6 0 0 0 0 Ringers Lactate: Irregular in Last 6 M 0 0 0 0 Haemoccele: Stock Out in Last 6 M 0 0 1 0 Haemoccele: Irregular in Last 6 M 0 0 1 0 AD Syringes: Stock Out in Last 6 Months 1 0 0 0 AD Syringes: Irregular in Last 6 Months 1 0 0 0 Disposable Gloves: Stock Out in Last 6 Months 0 0 0 0 Disposable Gloves: Irregular in Last 6 Months 1 0 0 0 Bandages: Stock Out in Last 6 Months 0 0 0 0 Bandages: Irregular in Last 6 Months 0 0 0 0 AYUSH Drugs: Stock Out in Last 6 Months 1 1 0 0 AYUSH Drugs: Irregular in Last 6 Months 1 1 0 0 Dots Drugs: Stock Out in Last 6 Months 1 1 1 1 Dots Drugs: Irregular in Last 6 Months 1 1 1 0 MDT Drugs Blister Packs: Stock Out in Last 6 Months 1 1 1 1 MDT Drugs Blister Packs: Irregular in Last 6 Months 1 1 1 1
80 Table P12 : Service Outcome (based on data for last three months) in Baramulla SHEERI PATTAN Indicator FATHEGRAH SINGHPORA WANIGAM G. K. QASIM Total ANC Registration : SC 0 0 INA 0 ST 0 0 INA 0 Others 5 4 INA 13 Total 5 4 INA 13 Total JSY Case Registered : SC 0 0 INA 0 ST 0 0 INA 0 Others 5 0 INA 13 Total 5 0 INA 13 1st Trimester Registration : SC 0 0 INA 0 ST 0 0 INA 0 Others 5 1 INA 3 Total 5 1 INA 3 ANC Given 3 Checkups : SC 0 0 INA 0 ST 0 0 INA 0 Others 1 1 INA 13 Total 1 1 INA 13 ANC Given TT1 : SC 0 0 INA 0 ST 0 0 INA 0 Others 5 1 INA 13 Total 5 1 13 ANC Given TT2+ Booster : SC 0 0 INA 0 ST 0 0 INA 0 Others 4 1 INA 3 Total 4 1 INA 3 ANC Completed IFA Prophylaxis : INA ST 0 0 0 Others 5 1 13 Total 5 1 INA 13 Total Institutional Deliveries : SC 0 0 INA 0 ST 0 0 INA 0 Others 0 0 INA 3 Total 0 0 INA 3 No of JSY Cases : SC 0 0 INA 0 ST 0 0 INA 0 Others INA 3 Total 0 0 INA 3 No of Infants Given BCG : SC 0 0 0 0 ST 0 0 0 0 Others 3 7 14 9 Total 3 7 14 9 No of Infants Given DPT3 : SC 0 0 0 0 ST 0 0 0 0 Others 8 10 65 11 Total 8 10 65 11
81 Table P12 Service Outcome (based on data for last three months) in Baramulla SHEERI PATTAN Indicator FATHEGRAH SINGHPORA WANIGAM G. K. QASIM No of Infants Given Measles : Others 9 9 50 10 Total 9 9 50 10 No of Infants Given Vit A First Dose : SC 0 0 0 0 ST 0 0 0 0 Others 0 0 0 0 Total 0 0 0 0 Syp IFA : SC 0 0 0 0 ST 0 0 0 0 Others 0 0 0 0 Total 0 0 0 0 IUD (Copper T) Inserted : SC 0 0 0 0 ST 0 0 0 0 Others 0 0 4 3 Total 0 0 4 3 Male Sterlisation Carried Out : SC 0 0 0 0 ST 0 0 0 0 Others 0 0 0 0 Total 0 0 0 0 Female Sterlisation Carried Out : SC 0 0 0 0 ST 0 0 0 0 Others 0 0 0 0 Total 0 0 0 0 Total Indoor Patients : SC 0 0 0 0 ST 0 0 0 0 Others 0 0 1 9 Total 0 0 1 9 Total Out Patients : SC 0 0 0 0 ST 0 0 0 0 Others 567 169 600 561 Total 567 169 600 561 RTI / STI Cases Treated : SC 0 0 0 0 ST 0 0 0 0 Others 0 0 0 12 Total 0 0 0 12 No of Maternal Deaths in 2007 2008 : SC 0 0 0 0 ST 0 0 0 0 Others 0 0 0 0 Total 0 0 0 0 No of Cases of Obstetric Complications Referred Beyond PHC : Total 0 0 2 2
82 Table P12 Service Outcome (based on data for last three months) in Baramulla SHEERI PATTAN Indicator FATHEGRAH SINGHPORA WANIGAM G. K. QASIM No of Cataract Surgeries Carried Out : SC 0 0 0 0 ST 0 0 0 0 Others 0 0 0 0 Total 0 0 0 0 No of New TB Cases Enrolled For Dots : 0 0 0 0 SC ST Others 1 0 0 0 Total 1 0 0 0 No of New Leprosy Cases Registered for MDT : SC 0 0 0 0 ST 0 0 0 0 Others 0 0 0 0 Total 0 0 0 0 No of Leprosy Cases Completed Treatment for Leprosy : SC 0 0 0 0 ST 0 0 0 0 Others 0 0 0 0 Total 0 0 0 0
Table P13: Status of record maintenance in Baramulla Type of Records SHEERI PATTAN (Yes=1, No=0) FATHEGRAH SINGHPORA WANIGAM G. K. QASIM Ante Natal Register 1 1 0 1 Eligible Couple Register 1 0 0 0 Post Natal Care Register 1 0 0 1 Family Planning Register 0 1 0 0 Birth and Death Register 0 1 0 0 Immunization Register 1 1 1 1 Meeting Register 0 0 0 1 JSY Register 1 1 0 1 Untied Funds Register 1 1 1 1
83 CHAPTER 6 SUB CENTRE
Sub health Centre (Sub centre) is the most peripheral and first contact point between the primary health care system and the community. As per the population norms, one Sub centre (SC) is established for every 5000 population in plain areas and for every 3000 population in hilly/tribal/desert areas at the national level. It is the lowest rung of a three tier set up consisting of the Sub centre with referral linkage to the Primary Health Centre (PHC), and the Community Health Centre (CHC).
A Sub centre (SC) provides interface with the community at the grass root level, providing all the primary health care services. Of particular importance are the packages of services such as immunization, antenatal, natal and postnatal care, prevention of malnutrition and common childhood diseases, family planning services and counselling. They are also supposed to provide elementary drugs for minor ailments such as ARI, diarrhoea, fever, worm infestation etc. and carryout community needs assessment. Besides the above, the government implements several national health and family welfare programmes which again are delivered through these frontline workers.
As sub centres are the first contact point with the community, the success of any nationwide programme would depend largely on well functioning SCs providing services of acceptable standard to the people. This would also have an impact on the reduction of maternal and infant mortality. Recent studies have shown that ensuring their accessibility and availability of quality primary health care services to the community through these SCs are major concerns. The launch of National Rural Health Mission has provided the opportunity to have a fresh look at their functioning. In this background the data was also collected regarding the functioning of SCs during this survey and information was collected from 12 SCs falling under selected four PHCs in district Baramulla. The Sub Centres selected were Laridora, Malpora, Kahwara from PHC Fathegrah, Kanispora, Singhpora, and Uplina, from PHC Singhpora. Similarly Andergam, Yatipora and Resripora SCs were selected from PHC Wanigam and Archanderhama, Agrikalan and Matipora from PHC G. K. Qasim.
84 Therefore, this chapter provides us the information covered under different heads regarding the functioning of the selected SCs in district Baramulla.
Coverage (Table S1) As mentioned above, every SC of the plain area has to cater a population of 5,000 and of the hilly area a population of 3,000 as per the norms set by government of India but the state government has made it uniform for both rural and urban areas and in a SC in the state is supposed to cater a population of 4,000. Table S1 gives the information about the coverage of population and number of villages under each SC. The data shows that on an average, the sub centre caters three villages with a population of 3,272.6 persons. It is worth to say that one hilly SC namely Kanispora of the Singhpora PHC covers a population of 9,800 while as another SC of the plain area namely Resripora of the Wanigam PHC covers only population of 573 persons. The table further shows that on an average the distance from the SC to farthest village is 4.5 kilometers. Further the data shows that the average distance from the SC to PHC is 6 kilometers though SC Kanispora was 15 kilometers away from the PHC (that caters it) as compared to SC Uplina which is only two kilometers away from to PHC Singhpora. The table shows that on an average the distance between the SC to CHC is 15 kilometers. The distance between the SC Singhpora to CHC Chandoosa was 31 kilometers. While, as in case of SC Resripora it was 4 kms away from CHC Pattan. Table further shows the average time taken to travel by public transport from farthest village to SC was estimated to be 28 minutes. The maximum time taken to travel from the farthest village to SC was 45 minutes while, as the minimum time taken to travel from the village to SC was only 12.5 minutes. On an average the time taken to travel from SC to PHC was calculated to be 32.1 minutes and the maximum time taken to travel from SC Andergam to PHC Wanigam and SC Archanderhama to PHC G.K Qasim was 52.5 minutes, and the minimum time taken to travel from SC Malpora to PHC Fathegrah was 15 minutes. The average time taken to travel from SC to CHC was 57.9 minutes. The time taken to travel from SC Laridora to CHC Chandoosa and SC Kanispora to CHC Chandoosa was estimated to be 90 minutes while in case of SCs Resripora and Matipora it was 20 minutes. On an average three ASHAs are working in each of the selected SC and the SC Andergam had the highest (eight) number of ASHAs while as SCs Kahwara and Agrikalan had only one working ASHA.
85 Infrastructure (Table S2) Table S2 gives the information about the availability of infrastructure in SCs. Out of 12 Sub centers only two (18 percent) SCs namely Kanispora and Singhpora have a government building. Since all the SCs are supposed to carry out the Indian Public Health Standard (IPHS) survey in their but it was found that none of the Sub centers has undergone IPHS facility survey. SC Agrikalan under PHC G. K. Qasim was the only SC which has labour room facility. But, it was observed that the same room is being used for other activities of the SC as another room has been converted into a store. Except for SCs Kahwara and Singhpora, none of the SCs have piped water supply. Further the data shows that except in SC Matipora, none of the Sub centers have regular electric supply. Four SCs had telephone facility, but this facility was not provided to them by the government and as such they could use their own mobile sets for communication purposes. Only Singhpora Sub centers had a soakage pit facility. In none of the SCs the toilet is connected to the sewerage line. In most of the SCs there is open drainage system while as in Singhpora this facility does not exist. The disposal of the waste material is buried in pit in most of the SCs. In none of the SCs the waste was collected by any agency. The garbage was thrown in open by some of the SCs in the district.
Residential status of ANM (Table S3) The presence of ANM in the SC village is essential for the local population to avail the emergency services round the clock and much focus has been given by the government to construct residential accommodation for ANMs near the SC. Table S3 shows that none of the SCs is provided with ANM quarter facility. It has been seen that the Sub centers are located in a single rented room and how it is possible to have a residential quarter facility in it. In only one SC namely Malpora, the ANM was staying within the SC village in a rented accommodation.
Staff Structure (Table S4) For the smooth functioning of a government health facility, it is necessary to have a full fledged staff in position and particularly at gross root level. As per the government guidelines a SC is supposed to have one ANM, a Pharmacist and a nursing orderly. Besides, there is a provision of appointment of ANM on contractual basis under NRHM. So for as the position of sampled SCs of the district is
86 concerned, it was observed that due to non availability of the requisite staff, the functioning of these centers has severely affected. As the data shows that about 58 percent of the SCs did not have the male health worker. Similarly, half of the SCs did not have FHW/ANM. These posts are sanctioned but are not in position from years together. One SC namely Matipora in CHC Pattan has engaged an additional ANM on contractual basis. It was found that those SCs where the ANM was not in position were either run by the Male Health worker (If available) or by Nursing Orderly. The residents of such SCs also complained that the SCs remain mostly closed in the absence of a trained ANM. It was observed by the research team that atleast two SCs namely Kahwara in Fathegrah PHC and Resripora in Wanigam PHC were presently run by nursing orderly as the Sanctioned ANMs have been attached to some other places for their personal convenience.
Availability of Labour Room (Table S5) In order to achieve a goal of 80 percent institutional deliveries set by the National Population Policy 20000, the availability of labour room is a prerequisite for all the health facilities. It has been observed that ANMs are capable to conduct atleast normal deliveries but due to lack of basic infrastructure (labour room and delivery kit) at the SC it has not picked up and a good number of women prefer to deliver at home in the remote and far flung areas. In this background the information collected shows that except of one SC (Agrikalan in PHC G. K. Qasim) none of the SC had a labour room. This labour room is used for the conduct of normal deliveries only.
Number of Deliveries and Arrangement for Deliveries (Table S6A and S6B) During the year 2007 2008 three normal deliveries were conducted by SC Agrikalan and no pregnant women from this SC has been referred to higher health facility for delivery. The ANM of the SC informed that only those women with high risk pregnancy are referred to higher health facility for delivery purposes.
Availability of Equipment and Use (Table S7a and b) Information was collected about the availability of equipments in various subcenters on the day of survey as the availability of certain basic equipment for service delivery is a pre requisite. The table S7a and S7b shows that out of twelve SCs only four SCs (33 percent) had a sterilizer and was currently used by all these SCs. None of the
87 SCs had a haemoglobinometer at the time of survey while as only one (eight percent) SC had bag/mask, suction machine and regent strips for urine tests available at the time of survey. Thermometer was found to be available at 83 percent SCs and was also functional. Overall, it was found that BP apparatus and weighing machine were available in almost all (eleven) the SCs and were functional. None of the SCs had a height measuring scale or mucus extractor. Overall, only three (25 percent) SCs had a Cuscus speculum available and was found to be functional. More than one half (58 percent) of the SCs reported the availability of a functional Fetoscope.
Status of Availability of Drugs (Table S8) The information collected on the status of availability of various drugs which include Iron/ Folic Acid, Disposable Delivery Kit, contraceptives (Oral Pills, Emergency Contraceptive, Condoms, and IUDs) ORS, Tab. Flucanazole, Vaginal, Tab. Misoprostal, Partograph, Pregnancy Test Kit, Syrup Cotrimoxazole, Syrup. Paracetamol, Vitamin A, Tab Ciprofloxacin, and Disposable Gloves at SC level are shown in table S8. In Baramulla the information collected on availability of various contraceptive methods shows that half of the SCs had the stock of Oral Pills, 42 percent had Condoms, while as IUD and emergency contraceptive were available in only one (eight percent) SC. Only SC Kanispora reported that they have a pregnancy test kit.
Overall one half the SCs reported the availability of IFA and at most of the places it was almost at the verge of expiry. Further Vitamin A was available in 42 percent SCs and it was reported that it has been supplied very recently. Three fourth of the SCs had some stock of ORS available. ORS packets were found available in all the selected SCs of PHCs Singhpora and Wanigam.
One fourth of the selected SCs in the district reported the availability of Disposable Delivery Kit (DDK). In CHC none of the SCs was supplied with this kit while as some SCs in Pattan CHC had the DDK. None of the SCs reported the availability of Partograph while as only two (17 percent) SCs reported the availability of disposable gloves.
88 Since a SC is supposed to get the supplies of some basic drugs for management of various infections and diseases related to RTI but it was found that none of the selected SCs in the district had the availability of the drugs like Tablet Flucanazole, Vaginal, Tablet Misoprostal, and Syrup Cotrimoxazole. In fact most of the SCs reported that such items are not being supplied to them at all. Further it was found that Ciprofloxacin tablets were available in only 42 percent of the SCs while as Paracetamol syrup was available in only one SC at the time of survey in the district. ,
Status of Specific Skills and Procedures (Table S9) As mentioned earlier all the SCs are supposed to provide some basic services like maternal and child health, family planning, and other curative services in their respective areas. Information on these activities carried out by the SCs during last three months preceding the survey was collected and is presented in table S9.
Overall only half the SCs in Baramulla have registered pregnant women within the three months of their pregnancy. As per the RCH schedule a pregnant woman is supposed to get three ANC checkups, first is given in 6th month, 2nd in 7th month, and 3rd in 9th month but the data shows that only one third of the SCs carry out three ANC visits as per the above mentioned schedule. Two SCs each in PHC Singhpora and G .K. Qasim mentioned that they do carry out 3 ANC visits while as none of SCs in other two selected PHCs made any mention in this regard.
As ANM is trained in carrying out certain specific examinations to pregnant women but it was found that only one third of the SCs could carry examinations like checking of blood pressure, hemoglobin and urine test in district Baramulla. It is mainly because of the fact that these SCs either do not have the requisite infrastructure or trained manpower available. Overall three fourth of the SCs in the district reported that they do provide IFA and TT injections to all the pregnant women free of cost. Further the data collected shows that half of the SCs used to identify the high risk pregnancies within their given areas and all the selected SCs in G. K. Qasim were doing this practice while as in PHC Wanigam none of the SC was following this activity.
89 The data shows that only two (17 percent) of the ANMs reported that they have received any training in the insertion/removal of IUD and they were also carrying out this service at their respective SC to the needy women but as a whole majority of the ANMs have not been trained for insertion of IUD and thus this service is defunct at most of the SCs as they do not get the supplies also. As per the RCH guidelines all the ANMs should be trained for the management of syndromic treatment of RTI/STI but it was found that only one third of the ANMs have only received any training in this regard. The immunization activity is being carried out by all the SCs either at their respective SCs are at AWCs by SC Staff. This activity has been part of SCs even before the RCH and it looks that there is not any marked change in the working of the SCs over the years. Thus it appears that majority of the ANMs in Baramulla have not been trained fully to implement various key components of RCH programme.
Services Outcome (Table S10) In order to ascertain the performance of SCs, some information was collected regarding the number of women registered for ANC during last three months prior to the survey, number of high risk pregnancies identified, number of deliveries conducted at the SC, number of pregnant women referred for delivery and number of neonate infections identified and referred during the same period. The information was also collected regarding the number of IUD insertions at the SC during 2007 08. Overall half of the SCs have registered some cases of ANC during the last three months and the average number of women registered for ANC services in Baramulla is eight. One of the SC (Matipora in G. K. Qasim PHC) has alone registered 46 women during the same time while as none of the SCs in Wanigam PHC has registered any woman for the same. The average number of women registered for ANC services during their 1st trimester was three. Less than half of the SCs have made any identification of high risk cases and the average number of women in this regard for the district was one. Though some SCs have referred some cases of pregnant women for delivery at next higher health facility but none of SCs has conducted any delivery at the SC. Further, none of the SCs had identified any case of neonate infections for referral services. IUD insertion activity is almost non existent in all the SCs of the district as except for SC Kanispora (five cases of IUD insertion during 2007 08); none of the SCs have made any IUD insertion.
90 Record Maintenance (Table S11) Record keeping is an important activity for any individual or group for ready reference. Under the NRHM guidelines, record keeping is an essential part and all the SCs are supposed to keep updated records pertaining to number of households, under the SC (Household Survey Register), number of eligible couples (eligible couple register), number of women registered for ANC/PNC (Ante Natal Register, Post Natal Care Register), distribution of various contraceptives (Family Planning Register), records of Birth and Death in the area, Immunization Register, Meeting Register, number of JSY beneficiaries registered, records of Untied Funds and Cash Book. In order to keep uniformity in the maintenance of records ten registers are being provided to all the SCs to maintain the above mentioned records. The data was collected in this regard which shows that record keeping for many aspects was very poor and at many SCs most of the records were not maintained at all. Overall only one fourth of the SCs each have maintained the updated household survey register and eligible couple register. None of the SCs in Wanigam PHC has maintained these two registers. ANC register was maintained by 58 percent SCs while as PNC register was maintained by only 25 percent SCs in the district. None of the SCs in Pattan CHC has any records of PNC. Further the data shows that one third of the SCs each have maintained the Family Planning and Birth/Death register. Three fourth of the SCs have maintained the Immunization register while as only one SC (Archanderhama) in PHC G. K. Qasim has maintained the meeting register. None of the SCs in CHC Pattan has maintained the JSY register and in this regard most of the ANMs reported that such records are maintained at PHCs and CHCs. Overall the Untied Funds register has been maintained by 83 percent (10 out of 12) SCs and Cash Book was maintained by 42 percent SCs in the district. The data collection team observed that at most of the SCs the registers for the maintenance of these records were not supplied to SCs and some of the ANMs could get some registers from the market out of their own pocket (as reported by ANMs). ANMs also reported that not much training has been provided to them for record keeping under the IPHS and there is a need to improve this important aspect so that records at the SC level can be maintained properly with a uniform pattern.
91 ANM’s Awareness about JSY (Table S12A and S12B) All the ANMs are supposed to be aware about the JSY scheme, its eligibility criterion, and the amount payable under different activities for the beneficiary. Overall three fourth (nine out of 12 ANMs) ANMs were found aware about the JSY Scheme in Baramulla. As per the guidelines of the scheme every JSY beneficiary is supposed to get Rs. 1400/= but there the information collected shows that the mean amount paid to a JSY beneficiary is Rs. 1144/= and ANMs attributed this confusion to the modifications made in the guidelines from time to time by the state government. There is a provision that every women who during her pregnancy utilizes full ANC but delivers at home is eligible to get Rs. 500/= under the JSY Scheme and in district Baramulla the mean amount given to the beneficiaries who delivered at home was Rs. 425/=. The mean amount given to the women for transport facility for the delivery was calculated to be Rs. 208/=
One of the basic objective of the introduction of JSY Scheme was to increase the demand for the institutional deliveries, therefore, all the nine ANMs who had knowledge about the scheme were asked to report whether they have observed any increase in the demand for institutional delivery after implementation of JSY. In this regard Seven ANMs (78 percent) could answer in affirmative and said that there has been increased demand in this regard. Though it was observed that the non payment of incentives under the scheme have disappointed all and has also severely affected the working of ANMs/ASHAs in their respective areas as they are now hardly being taken seriously by the community. Further all the ANMs reported that the amount under JSY scheme is being given through Cheques to the beneficiaries within a two weeks time after the delivery. Eleven percent ANMs reported that there is a register for the maintenance of expenditure incurred on account of JSY beneficiaries.
Performance of ANM under JSY Scheme (Table S13) In order to assess the performance of ANM with regard to JSY Scheme, the data was collected from all the selected SCs regarding the number of JSY cases registered during the last three months prior to the survey. On an average a SC has registered four such cases during last three months. SC Singhpora has registered the highest (11 cases) number of cases while as SC Kahwara has not registered any
92 such case. None of the SCs under Wanigam PHC has registered any JSY case during the same time. The average number of JSY cases resulted in an institutional delivery for a SC was three though some cases could not be tracked down as they go to their parental home for delivery as reported by the concerned ANMs. None of beneficiaries had received any incentives under the scheme as it has been stopped by the authorities for reasons best known to them.
Status of Untied Grant (Table S14) As part of the National Rural Health Mission, each SC is provided a grant of Rs.10, 000 as an untied fund to facilitate meeting urgent yet discrete activities that need relatively small sums of money. The guidelines for the use of untied funds suggest that the fund shall be kept in a joint bank account of the ANM and the Sarpanch. Decisions on activities for which the funds are to be spent will be approved by the Village Health Committee (VHC) and be administered by the ANM. The funds can be used for any of the villages, which are covered by the SC. As per the guidelines Untied Funds are to be used only for the common good and not for individual needs, except in the case of referral and transport in emergency situations. Suggested areas where Untied Funds may be used include: Minor modifications to SC curtains to ensure privacy, repair of taps, installation of bulbs, other minor repairs, which can be done at the local level, Adhoc payments for cleaning up SC, especially after childbirth, Transport of emergencies to appropriate referral institutions, Transport of samples during epidemics, Purchase of consumables such as bandages in SC, Purchase of bleaching powder and disinfectants for use in common areas of the village, Labour and supplies for environmental sanitation, such as clearing measures for stagnant water, and Payment/reward to ASHA for certain identified activities. Untied funds shall not be used for any salaries, vehicle purchase, and recurring expenditures or to meet the expenses of the Gram Panchayat. Keeping this in view information was collected regarding the receipt of Untied Funds under NRHM from all the selected SCs in the district. The table S14 shows that overall 92 percent of SCs (11 out of 12 SCs) have received untied grant of Rs. 10,000 during 2007 08. Except for SC Kahwara in PHC Fathegrah, all the SCs have received the untied funds. All the SCs who have received the untied funds reported to have utilized them. All the SCs in both the blocks have a joint account with the village head/any functionary of GP/Chairman VHSC or any respected person of the area. All the SCs
93 have maintained the register to record about the decisions taken to spend the untied funds, and register regarding amount transactions carried out on untied funds. All the ANMs reported that the review by the GP members/VHSC people of these records is a regular feature at the SCs. None of the SCs have spent any amount on purchase of drugs, arrangement of transport or paying of power/telephone bills in the district. Overall three SCs (27 percent) have purchased or arranged facilities like Water Cooler etc. for patients. All the SCs who have received the untied funds have mostly used this fund for purchasing furnishing, furniture, curtains etc. some of the SCs have also purchased some instruments out of this grant.
94
Table S1: Sub Centers Coverage in Baramulla, J & K Name of CHC Chandoosa Pattan Fateh Grah 24x7 Singh Pora Wanigam 24x7 G K Qasim
Coverage of Sub Centre
Average per Sub Centre Centre Sub per Average laridora laridora Malpora Kahwara Kanispora Singhpora Uplina Andergam Resripora Archanderhama Agrikalan Matipora Yatipora Yatipora Population coverage 2,000 4,000 9,800 3,000 3,000 3,028 1,600 573 4,500 2,047 2,451 3,272.6 Number of villages covered by SC 2 3 4 3 2 5 2 3 3 2 2 2 3 Distance between PHC &SC (in kms) Farthest village to Sub Centre 1.0 7.0 2.0 2.0 3.0 1.0 2.0 5.0 1.0 2.0 22.0 6.0 4.5 Sub Centre to PHC 8.0 7.0 6.0 15.0 0 2.0 6.0 4.0 12.0 3.0 5.0 5.0 6.1 Sub Centre to CHC 6.0 28.0 24.0 22.0 31.0 20.0 7.0 7.0 4.0 7.0 12.0 7.0 14.6 Time Taken (In minutes) to travel in public transport/available mode from
Farthest village to Sub Centre 30.0 30.0 12.5 30.0 30.0 12.5 30.0 21.0 45.0 30.0 21.0 45.0 28.1
Sub Centre to PHC 45.0 15.0 22.5 45.0 15.0 22.5 52.5 22.5 35.0 52.5 22.5 35.0 32.1
Sub Centre to CHC 90.0 75.0 45.0 90.0 75.0 45.0 67.5 50.0 20.0 67.5 50.0 20.0 57.9 No. of ASHAs working in the SC 2 2 1 2 2 3 8 2 2 3 1 2 3
95
Table S2: Sub Centers Infrastructure in Baramulla Name of CHC Chandoosa Pattan Fateh Grah 24x7 Singh Pora Wanigam 24x7 G K Qasim Availability of Infrastructure in Sub Centres (Yes:1; No:0)
respective facility facility respective % of Sub Centre having having Centre Sub % of laridora laridora Malpora Kahwara Kanispora Singhpora Uplina Andergam Resripora Archanderhama Agrikalan Matipora Yatipora Yatipora Functioning in designated government building (Govt. / Rented by Govt.) 1 1 1 1 1 1 1 1 1 1 1 1 100.0 IPHS Facility Survey Done 0 0 0 0 0 0 0 0 0 0 0 0 Labour Room 0 0 0 0 0 0 0 0 0 0 1 0 8.3 Piped water supply 0 0 1 0 1 0 0 0 0 0 0 0 16.7 Regular electricity supply 0 0 0 0 0 0 0 0 0 0 0 1 8.3 Telephone 0 0 0 1 1 0 0 1 1 0 0 0 33.3 Type of Sewerage System Soak Pit 1 8.3 Connected to any Sewerage Line Open Drain 1 1 1 1 1 1 1 1 1 1 1 91.7 Waste Material is Being Disposed Buried in Pit 1 1 1 1 1 1 1 1 1 75.0 Collected by Agency Incarnation Thrown in Open 1 1 1 25.0
96
Table S3: Sub Centers with ANM staying with or away from SC village by distance from Sub Centre and reasons for not staying in Sub Centre quarter in Baramulla Sub Centre Name of CHC Chandoosa Pattan Fateh Grah 24x7 Singh Pora Wanigam 24x7 G K Qasim
Residential status of ANM (Yes:1;
No:0)
% of Sub Centres Centres Sub % of Uplina Uplina Andergam Resripora Archanderhama Agrikalan Matipora laridora laridora Malpora Kahwara Kanispora Singhpora Yatipora Yatipora Sub Centre with ANM quarter 0 0 0 0 0 0 0 0 0 0 0 0 Sub Centre with ANM staying in SC's quarter 0 0 0 0 0 0 0 0 0 0 0 0 Sub Centre with ANM staying within SC's village 0 1 0 0 0 0 0 0 0 0 0 0 8.3 Sub Centre with ANM staying outside SC's village 1 1 1 1 1 1 1 1 1 1 1 91.7 Reason for ANM not staying in SC quarter: Quality of quarter Family related reasons Security reasons Education and other facilities for children not available Water/ Power facility not available Own residence is nearby
97
Table S4: Sub Centers with Staff in Position in Baramulla Name of CHC Chandoosa Pattan Fateh Grah 24x7 Singh Pora Wanigam 24x7 G K Qasim
Availability of Staff (Yes:1; No:0)
available available % of Sub Centres Centres Sub % of with specific staff staff with specific laridora laridora Malpora Kahwara Kanispora Singhpora Uplina Andergam Resripora Archander hama Agrikalan Matipora Yatipora Yatipora Health worker male in position 0 0 0 1 0 1 0 1 0 1 0 1 41.7 Health worker female in position 0 1 0 1 1 0 1 0 0 1 1 0 50.0 Additional ANM contractual 0 0 0 0 0 0 0 0 0 0 0 1 8.3
Table S5: Availability of Labour Room in Sub Centre in Baramulla Name of CHC Chandoosa Pattan Fateh Grah 24x7 Singh Pora Wanigam 24x7 G K Qasim Labour Room (Yes:1; No:0)
% of Sub Centres Centres Sub % of Uplina Uplina Andergam Resripora Archander hama Agrikalan Matipora laridora laridora Malpora Kahwara Kanispora Singhpora Yatipora Yatipora Availability of Labour Room 0 0 0 0 0 0 0 0 0 0 1 0 8.3 Labour Room currently in use 1 100.0 Reasons for not using Labour Room ANM not staying Poor condition No power supply No electric supply Other
98 Table S6A: Number of deliveries performed during 2007 08 in Baramulla Name of CHC Chandoosa Pattan Fateh Grah 24x7 Singh Pora Wanigam 24x7 G K Qasim
Centre Centre Average delivery delivery Average conducted per Sub Sub per conducted Matipora Matipora laridora laridora Malpora Kahwara Kanispora Singhpora Uplina Andergam Resripora Archanderhama Agrikalan Yatipora Yatipora Total deliveries conducted 0 0 0 0 0 0 0 0 0 0 3 0 3
Table S6B: Sub Centers with arrangement for deliveries in Baramulla Name of CHC Chandoosa Pattan Fateh Grah 24x7 Singh Pora Wanigam 24x7 G K Qasim Arrangement for deliveries (Yes:1;
No:0)
% of Sub Centres Centres Sub % of Uplina Uplina Andergam Resripora Archanderh ama Agrikalan Matipora laridora laridora Malpora Kahwara Kanispora Singhpora Yatipora Yatipora Deliveries conducted at Sub Centre Itself if required referred to higher facility 0 0 0 0 0 0 0 0 0 0 1 0 100.0 Deliveries not conducted at Sub Centre but referred to higher facility 0 0 0 0 0 0 0 0 0 0 0 0 Referred to Private/NGO facility 0 0 0 0 0 0 0 0 0 0 0 0
99 Table S7 A: Sub Centers with availability of equipments in Baramulla Name of CHC Chandoosa Pattan Fateh Grah 24x7 Singh Pora Wanigam 24x7 G K Qasim
Availability of the equipments (Yes:1; No:0)
equipment available available equipment % of Sub Centres with with Centres Sub % of Matipora Matipora laridora laridora Malpora Kahwara Kanispora Singhpora Uplina Andergam Resripora Archanderhama Agrikalan Yatipora Yatipora Sterliser 0 0 0 0 1 0 0 0 1 0 1 1 33.3 Haemoglobinometer 0 0 0 0 0 0 0 0 0 0 0 0 Bag & Mask 0 0 0 0 0 0 0 0 1 0 0 0 8.3 Suction Machine 0 0 0 0 0 0 0 0 0 1 0 0 8.3 Thermometer 1 1 0 1 1 1 1 1 0 1 1 1 83.3 BP Apparatus 1 1 0 1 1 1 1 1 1 1 1 1 91.7 Weighing Machine 1 1 0 1 1 1 1 1 1 1 1 1 91.7 Height Measuring Scale 0 0 0 0 0 0 0 0 0 0 0 0 Reagent Strip for Urine Test 0 0 0 1 0 0 0 0 0 0 0 0 8.3 Cuscos Speculum 0 0 0 1 0 0 0 0 0 0 1 1 25.0 Mucus Extractor 0 0 0 0 0 0 0 0 0 0 0 0 Fetoscope 0 1 0 1 1 0 1 0 0 1 1 1 58.3
100
Table S7 B: Percentage of SCs with functional equipments in Baramulla Name of CHC Chandoosa Pattan Fateh Grah 24x7 Singh Pora Wanigam 24x7 G K Qasim
Functional equipments (Yes:1; No:0) functional equipment equipment functional % of Sub Centres with with Centres Sub % of laridora laridora Malpora Kahwara Kanispora Singhpora Uplina Andergam Resripora Archanderhama Agrikalan Matipora Yatipora Yatipora Steriliser 1 1 50.0 Haemoglobin meter Bag & Mask 1 100.0 Suction Machine 1 100.0 Thermometer 1 1 1 1 1 1 1 1 1 1 100.0 BP Apparatus 1 1 1 1 1 1 1 1 1 1 90.9 Weighing Machine 1 1 1 1 1 1 1 1 1 1 1 100.0 Height Measuring Scale Reagent Strips for Urine Test 1 100.0 Cuscos Speculum 1 1 1 100.0 Mucus Extractor Fetoscope 1 1 1 1 1 1 1 100.0
101
Table S8: Status of availability of drugs in Baramulla Name of CHC Chandoosa Pattan Fateh Grah 24x7 Singh Pora Wanigam 24x7 G K Qasim
Type of Drugs Available (Yes:1; No:0) % of Sub Centres Centres Sub % of drug on date of survey of date on drug reporting availability of of availability reporting laridora laridora Malpora Kahwara Kanispora Singhpora Uplina Andergam Resripora Archanderhama Agrikalan Matipora Yatipora Yatipora Iron/ Folic Acid 0 0 1 1 0 1 1 0 1 0 0 1 50.0 Disposable Delivery Kit 0 0 0 0 0 0 1 1 0 0 0 1 25.0 Oral Pills 1 1 0 1 1 0 0 0 0 1 0 1 50.0 Emergency Contraceptive 0 0 0 0 0 0 0 1 0 0 0 0 8.3 Condoms 1 1 0 1 1 0 0 1 0 0 0 0 41.7 IUD 0 0 0 0 0 0 0 1 0 0 0 0 8.3 ORS 1 1 0 1 1 1 1 1 1 0 0 1 75.0 Tab. Flucanazole Vaginal 0 0 0 0 0 0 0 0 0 0 0 0 0 Tab. Misoprostal 0 0 0 0 0 0 0 0 0 0 0 0 0 Partograph 0 0 0 0 0 0 0 0 0 0 0 0 0 Pregnancy Test Kit 0 0 0 1 0 0 0 0 0 0 0 0 8.3 Syp Cotrimoxazole 0 0 0 0 0 0 0 0 0 0 0 0 0 Syp. Paracetamol 0 1 0 0 0 0 0 0 0 0 0 0 8.3 Vitamin A 0 0 0 1 0 0 1 1 0 1 1 0 41.7 Tab Ciprofloxacin 0 0 0 0 0 1 0 1 1 0 1 1 41.7 Disposable Gloves 0 0 0 0 1 0 0 0 0 0 0 1 16.7
102
Table S9: Status of Specific Skills and Procedures in Baramulla Name of CHC Chandoosa Pattan Fateh Grah 24x7 Singh Pora Wanigam 24x7 G K Qasim Type of Skills/ Procedure (Yes: 1; No: 0) procedure
of specific skills/ skills/ of specific % of Sub Centres Centres Sub % of reporting availability availability reporting laridora laridora Malpora Kahwara Kanispora Singhpora Uplina Andergam Resripora Archanderha ma Agrikalan Matipora Yatipora Yatipora Register pregnancy within three month 1 1 0 1 1 0 0 0 0 0 1 1 50.0 Carry out 3 ANC visits as per the RCH schedule (1st: 6th month, 2nd: 7th month, 3rd: 9th month) 0 0 0 1 1 0 0 0 0 1 1 0 33.3 Carry out specific examinations like Blood Pressure, Hemoglobin, and Urine 0 0 0 1 1 0 1 0 0 0 1 0 33.3 Provision of TT, IFA etc. 1 1 0 1 1 0 1 1 0 1 1 1 75.0 Identification of High Risk Pregnancies 0 1 1 0 1 0 0 0 0 1 1 1 50.0 Is the ANM carrying out IUCD insertion/ removal 0 0 0 1 0 0 0 0 0 0 1 0 16.7 Is IUCD insertion being carried out using IUD A380 0 0 0 0 0 0 0 0 0 0 0 0 0 Is the supply of IUD A380 regularly available 0 0 0 0 0 0 0 0 0 0 0 0 0 Has the ANM been trained on the insertion/ removal of IUD A380 0 0 0 0 0 0 1 0 0 0 1 0 16.7 Is the ANM trained in syndromic treatment of RTI/ STI 0 0 0 0 1 0 1 0 0 1 1 0 33.3 Immunization services 1 1 1 1 1 0 1 1 1 1 1 1 91.7
103
Table S10: Service Outcome (Based on the data for last 3 months) in Baramulla Name of CHC Chandoosa Pattan Fateh Grah 24x7 Singh Pora Wanigam 24x7 G K Qasim
Indicator
Average per Sub Centre Sub per Average laridora laridora Malpora Kahwara Kanispora Singhpora Uplina Andergam Resripora Archanderhama Agrikalan Matipora Yatipora Yatipora Total ANC registered 2 9 0 7 11 0 0 0 0 0 16 46 8 Out of total ANC, number registered in 1st trimester 0 6 0 2 4 0 0 0 0 0 15 3 3 No. given 3 ANC visits as per the RCH schedule 0 0 0 3 4 0 0 0 0 0 5 0 1 No. of High Risk Cases identified 0 3 4 0 1 0 0 0 0 0 3 1 1 Deliveries conducted by ANM at Sub Centre 0 0 0 0 0 0 0 0 0 0 0 0 0 Pregnancies referred and attended by the next higher facility 0 0 0 2 1 0 4 0 0 0 1 1 1 No. of neonate infections identified and referred 0 0 0 0 0 0 0 0 0 0 0 0 0 No. of IUCD insertions in 2007 2008 0 0 0 5 0 0 0 0 0 0 0 0 5
104
Table S11: Status of Record Maintenance in Baramulla Name of CHC Chandoosa Pattan Fateh Grah 24x7 Singh Pora Wanigam 24x7 G K Qasim
Type of Records maintained (Yes:1; No:0)
% of SCs reporting reporting SCs % of maintenance of record of maintenance laridora laridora Malpora Kahwara Kanispora Singhpora Uplina Andergam Resripora Archanderhama Agrikalan Matipora Yatipora Yatipora Household Survey Register 0 1 0 1 0 0 0 0 0 1 0 0 25.0 Ante Natal Register 1 1 0 1 1 0 0 0 0 1 1 1 58.3 Eligible Couple Register 0 1 0 1 0 0 0 0 0 1 0 0 25.0 Post Natal Care Register 0 1 0 1 1 0 0 0 0 0 0 0 25.0 Family Planning Register 0 0 0 1 1 0 0 0 0 0 1 1 33.3 Birth and Death Register 0 0 0 1 1 0 0 0 0 1 1 0 33.3 Immunisation Register 0 1 1 1 1 0 1 1 0 1 1 1 75.0 Meeting Register 0 0 0 0 0 0 0 0 0 1 0 0 8.3 JSY Register 0 1 0 1 1 0 0 0 0 0 0 0 25.0 Untied Funds Register 1 1 0 1 1 1 1 1 0 1 1 1 83.3 Cash Book 0 1 0 1 1 1 0 0 0 0 1 0 41.7
105 Table S12 A: Status of Awareness of ANM about JSY Scheme in Baramulla ANM's awareness about JSY Value Aware about JSY Number of ANMs interviewed 12 Number of ANMs reporting awareness 9 Percent reporting awareness 75.0 Aware about average amounts to be given to beneficiaries for A. Institutional Delivery 1,143.8 B. Home Delivery 425.0 C. Transport Facility 208.3 ANM reporting increase in demand for Institutional delivery after implementation of JSY Scheme Number of ANMs interviewed 9 Number of ANMs reporting awareness 7 Percent reporting awareness 77.8
Table S12 B: Status of procedure under JSY Scheme in Baramulla ANM's awareness about JSY % of ANMs according to response Funds being paid to beneficiaries by Cash Cheque 100.0 Vouchers Average time taken after birth for JSY payment to beneficiary Less than 1 Week 1 : 2 Weeks More than 2 Weeks 100.0 Transport for shifting of cases available from Sub Centre to PHC/ CHC Register available for recording of JSY expenditure 11.1 Total no. of ANMs interviewed 12
106 Table S13: Status of performance of ANM under JSY Scheme in Baramulla Name of CHC Chandoosa Pattan Fateh Grah 24x7 Singh Pora Wanigam 24x7 G K Qasim
Performance of ANM under JSY Scheme Average per Sub Centre Centre Sub per Average Matipora Matipora laridora laridora Malpora Kahwara Kanispora Singhpora Uplina Andergam Resripora Archanderhama Agrikalan Yatipora Yatipora Total cases of JSY registered in last 3 calendar months 0 8 0 7 11 0 0 0 0 0 3 5 4 Total number of JSY cases resulted in Institutional deliveries in last 3 months 8 7 1 3 3 3 Total cash disbursed in last 3 calendar months for JSY cases (Rs.) 0 0 0 0 0 Out of total amount disbursed, the amount disbursed on the following Home Deliveries (Rs.) Institutional Deliveries (Rs.) Transport Costs (Rs.) Amount given to ASHA (Rs.)
107 Table S14: Status of Untied Grants in Baramulla Name of CHC Chandoosa Pattan Fateh Grah 24x7 Singh Pora Wanigam 24x7 G K Qasim % of SCs % of Status of Untied Grants (Yes:1; No:0)
Agrikalan Agrikalan Matipora laridora laridora Malpora Kahwara Kanispora Singhpora Uplina Andergam Resripora Archanderha ma Yatipora Yatipora Sub Centre received Untied Grant 1 1 0 1 1 1 1 1 1 1 1 1 91.7 Sub Centre reported expenditure from Untied Grant 1 1 1 1 1 1 1 1 1 1 1 100.0 ANM having a joint account with the Sarpanch/ any other GP functionary 1 1 1 1 1 1 1 1 1 1 1 100.0 Sub Centre reporting maintenance of register to record the decisions taken to spend this amount 1 1 1 1 1 1 1 1 1 1 1 100.0 Sub Centre reporting written record of transactions being carried out on Untied funds 1 1 1 1 1 1 1 1 1 1 1 100.0 SC reporting that Sarpanch/ others ever reviewed the expenditure records 1 1 1 1 1 1 1 1 1 1 1 100.0 Sub Centre reporting expenditure from Untied Grant on the following: Spent on Purchase of Drugs 0 0 0 0 0 0 0 0 0 0 0 Arranging Transport 0 0 0 0 0 0 0 0 0 0 0 Paying of Power/ Telephone bills 0 0 0 0 0 0 0 0 0 0 0 Arranging facilities like Water Cooler etc. for patients 1 0 1 0 0 0 0 0 0 1 0 27.3
Other (like white wash, maintenance.) 1 1 1 1 1 1 1 1 1 1 1 100.0
108 CHAPTER 7 CLIENT PERSPECTIVE
Household Characteristics
The present chapter presents the demographic and socio economic characteristics of the households interviewed during the study “Concurrent Evaluation of NRHM”. The total number of households surveyed in Baramulla district was 1200 rural households comprising two CHC’s (Sheeri and Pattan), four PHC’s (Fathegrah, Singhpora, G. K. Qasim, and Wanigam), twelve sub Centers (Laridora, Malpora, Kahwara, Kanispora, Singhpora, Uplina, Andergam, Yatipora, Resripora, Archanderhama, Agrikalan, and Matipora) and twenty four villages (Laridora, Malpora, Kahwara, Kanispora, Singhpora, Uplina, Andergam, Yatipora, Resripora, Archanderhama, Agrikalan, and Matipora, Dangerpora, Wanchal, Kahwara Bala, Check Kanispora, Kalampora, Dardpora, Khambyar, Bon Mohalla, Seeru, Purni Sadarshah, Dangerpora, and BoniChakal). The general characteristics of the sample population were collected from the reasonable person of the concerned household mainly from a woman in her reproductive age. The questionnaire consisted of five different sections. Part (A) of the schedule deals with the basic identification details of the respondent. Part (B) constitutes the details of the household and the amenities available to the household. Part (C) collects the information from the household respondents about the awareness of ASHAs who were selected from the local villages to deliver the message of health related issues. Part (D) gathers the information from the households about the awareness of Janani Suraksha Yojna (JSY) scheme in which a pregnant women gets a compensation from the health department in the form of cash incentive and finally Part (E) of the questionnaire comprises the feedback from the household respondents about the kind of services availed by them from a public health facility, quality of care provided and level of satisfaction from the services provided. It also includes the information of knowledge about HIV/AIDS.
109 Identification of the Households (Table H.1)
Table H.1 presents the percentage distribution of the household respondents by their age. The proportion of respondents decreases from 42 percent in the age group of below 30 years to two percent in the age group of 60 years or more. This indicates that full consideration has been taken in the field to collect the information of the household from the person who was mostly of the reproductive age group. Overall 95 percent respondents were aged up to 49 years. Among the interviewed households, 86 percent were female respondents and 14 percent were male respondents. The distribution of respondents with regard to their level of education shows that 57 percent were illiterate and 43 percent had received some years of schooling in which 16 percent had received schooling up to 10 years or more. Among the household respondents, 86 percent were currently married whereas about 12 percent respondents were unmarried. Two percent of the respondents were widowed.
Table H.2 shows the caste composition of the sample households. The data shows that three percent were scheduled tribes, 44 percent were from other backward classes and majority of the household respondents (53 percent) belonged to the other castes. The Hindu constitutes only one household, Muslim households 92 percent and Sikhs households about 8 percent. The household status reveals that 45 percent of surveyed households were living below poverty line (BLP). The rate of BPL households is high because of the fact that one CHC was selected from far flung backward area with low performance and the other CHC was selected with good performance. The distribution of households by type of house shows that about 61 percent of the households had a Pucca house and 39 percent had semi Pucca or Kutcha house.
Household Amenities (Table H.2)
Table H.2 throws light on different household amenities available with them. Almost all the households contacted, (99 percent), were electrified. About three fourth (73 percent) of the households have their own separate toilet facility within the house or
110 in the premises. Major source of supply of drinking water for the sample households was the piped water (66 percent) and other source was available to about 27 percent. This indicates that all these 27 percent of the households were not having access to portable water in the district. The percentage of households who were using LPG/biogas for cooking purposes was 59 percent. Further the data shows that 89 percent households had their own agricultural land. The percentage of households having luxury/durable goods by type of goods shows that 65 percent were having a mobile phone while as 63 percent households had their own colour/B.W television. The distribution of households by standard of living index (SLI) shows that about 21 percent of the households had low SLI and more than three fourth (79 percent) households had high or medium SLI.
The table further provides the information regarding total living children born in the selected households in a health facility. It is very much clear that out of the 1200 households, 760 children were born during the last five years and were alive at the time of survey (January, 2004 December, 2008). A healthy trend was observed for institutional deliveries as out of these 760 children, 618 (81 percent) were born in different health institutions.
Preferred System of Medicine (Table H.3)
Table H.3 provides the information regarding the cleanliness of the households and their preferred treatment of medicines. In this regard, the data shows that the majority of the households, more than two third (69 percent) either of the sub centre village or without the sub centre village used to throw the waste in the open area. Almost with the same proportion of households of the sub centre or without the sub centre village buried the waste in a pit and burnt the waste that is 16 percent and 14 percent respectively. It is still a dream to have a well planned drainage system in the rural areas. As such, 41 percent of the sample households of the district were surrounded with the waste water which is the root cause of spreading the bacterial infections and diseases. The instance of mosquito breeding is prevalent among 90 percent of the households which is similar in both types of villages that is sub centre/ without sub centre village.
111 The research team also tried to know from the household respondents the system of medicine they mostly preferred for the treatment for their general illness. Multiple responses were recorded in this regard. It was found that almost all the households (99.5 percent) give priority to allopathic type of treatment. Not even a single household had gone for Ayurvedia, Yoga and Naturopathy type of treatment. Only a single household mentioned of utilizing the services of homeopathy type of treatment. Besides allopathic, Sidha is also utilized by a meager percentage of households that is two percent. However, Unani type of treatment is preferred by five percent of the households and traditional type of healing is utilized by nine percent of the households in the district.
Knowledge of Health Personnel (Table H.4)
For seeking any type of treatment, one should have the knowledge about the health personnel and the place of availability. The respondents were asked whether they have heard the name of ANM (locally known as sub centre/dispensary nurse) and in this regard Table H.4 shows that 81 percent replied in affirmative. The same respondents were told whether they have heard about the male health worker and it was reported by above 83 percent that they know the health personnel. There is not much variation about the knowledge of the health personnel between sub centre and without sub centre village. The household respondents were further asked whether any health worker visited their house in last one month prior to the survey and only one fourth of the respondents said that a male health worker visited them during this time period and provided some health related information. The data shows that only 71 percent of the respondents reported that the health workers are available at the time when they needed. It was further probed to the respondents to mention the place of availability of the health personnel and in this regard 19 percent mentioned the place of availability as Registered Medical Practitioner (RMP), 16 percent each mentioned as private clinic/NGO and sub centre. The primary health centre (PHC) was mentioned by nine percent and the community health centre (CHC) by 35 percent as the place of availability of the health personnel. The other places of health personnel available constitutes by 30 percent. Again there is not much variation among the SC and without a SC village.
112 Table H.4 also presents the information regarding the place of treatment for serious patients and their mode of transport for the same. Overall it was found that majority (51 percent) of the respondents sought their treatment from the district/sub divisional hospital, about one fourth (24 percent) from CHC, 10 percent from RMP/private clinic, and two percent from PHC. Besides a large number of households (39 percent) had visited for treatment to other service providers which include traditional methods. The information collected from the respondents regarding the mode of transport used for serious patients to reach the health facility shows that four percent used the cot to reach the destination; while as large proportion of households (69 percent) used their own private vehicle. Further, 52 percent households utilize the public transport (bus service) to reach the health facility. Government ambulance was used by two percent of the households. Other sources as a means of transportation were also utilized by 14 percent of the households. Still there is no variation among the villages which have SC and the villages which have not the SC.
Knowledge about NRHM and its Components (Table H.5)
Since the NRHM was introduced late by one year in the State of Jammu & Kashmir in the year early 2006. The aim of the mission is to bring about improvement in the health system and the health status of the people, especially those who live in the rural areas. Since the popularity of any programme is based on its awareness among the different stakeholders, therefore in order to do so the Information, Education and Communication (IEC) has been one of the basic components of the Mission to familiarize the community regarding the NRHM and its various schemes so that they will be benefited from the programme. In this regard the information was collected from the selected households regarding the knowledge and source of knowledge about NRHM. Overall more than one half (53 percent) of the respondents have heard about the NRHM (Table H.5). Among the knowledgeable households, 56 percent of them belong to the villages where SC is located and 50 percent of households belong to the villages where there was no SC. The table further shows the distribution of respondents having knowledge about the NRHM by source of knowledge. The data shows that 16 percent of the households have heard about the programme from the Accredited Social Health Activist (ASHA) who is actually
113 chosen and accountable to the Panchayat but in the district it was found that these ASHA’s are working under the guidance of the village SC. Majority of the households, about two third (64 percent) came to know about the programme from Radio/Television, four percent from newspapers, two percent from community members and over one fourth (27 percent) have heard about NRHM from other sources like other household members, relatives etc. However, there is not much difference regarding source of knowledge among the SC villages or non SC villages.
The table further throws light on the functioning of the ASHA worker. The ASHA is a trained female voluntary Community Health Worker. ASHA’s would reinforce community action for universal immunization, safe/institutional delivery, other reproductive and health related services, newborn care, prevention of water borne and other communicable diseases, nutrition and sanitation. Though she would not be paid any salary, she would be entitled for performance linked incentives under different programme. These ASHA’s are supposed to work in close coordination with the ANM and AWW and there would be always with them a basic drug kit including AYUSH drugs. She would also be considered as a depot holder for contraceptives and IEC materials developed for villages. It has been seen and observed in the field that these ASHA’s had been selected almost in all the villages. But at some places she has been assigned more than 1,000 population which is against the IPHS norm. ASHA worker has the key role in the society by promoting universal immunization, referral and escort services for RCH, construction of household toilets and other healthcare delivery programmes. Keeping in view the heavy responsibilities of ASHA in the village, the research team tried to know from the respondents that to what extent these ASHA’s are active in their villages in performing their duties. The data shows that overall 81 percent of the household respondents in the district have heard the name ‘ASHA’. The knowledge about ASHAs is more in villages where the SCs are located as compared to those where there is no SC. Eighty five percent of household respondents knew about the ASHAs from the village where the SC is located as only three fourth (76 percent) of the respondents from non SC village knew about ASHAs. Since ASHA is supposed to have a drug kit (with basic specified drugs) always with her and the data shows that large proportion of respondents, 62 percent, reported that they have never seen the ASHA with the medical kit while
114 performing her duties. Regarding providing free medicines, a little more than one fourth (29 percent) of the respondents said that she gave the medicine free of cost while as 71 percent say that she had charged the money for the medicine. ASHA is also supposed to provide knowledge about general hygiene and in this connection hand washing knowledge was provided only to 30 percent of the respondents, knowledge about construction of household toilets to 23 percent and knowledge about safe drinking water to 29 percent respondents. The table further gives the percentage distribution of household respondents about the information of village health nutrition day (VHND) organized in the village and presence of village health sanitation committee (VHSC) and it was reported by only 16 percent and four percent of the respondents that the nutrition day is organized and VHSC is formed in their village respectively. The data regarding the frequency of celebration of VHND shows that majority (49 percent) of the respondents did not know about the programme while as another 24 percent reported that it is being held annually and seven percent said that it is held weekly.
Knowledge about Janani Suraksha Yojna (JSY) Scheme (Table H.5)
The Janani Suraksha Yojna (JSY) Scheme aims to promote institutional deliveries amongst all pregnant women in the state and it links cash assistance with delivery and post delivery care. In availing institutional delivery services, the client is usually escorted, provided transport to reach the institution and in case of complications, referred to higher health institution. The special focus of the JSY scheme is on a) Maternal care through micro- planning of birth b) Cash assistance to all eligible mothers for delivering care c) Cash assistance for referral transport d) Cash assistance to institutions for hiring specialists for caesarean section or for the management of obstetric complications and e) Cash benefit to ASHA for facilitating institutional delivery. In this regard all the respondents were asked about the knowledge and source about the JSY scheme. The information presented in table H5 shows that overall three fourth (74 percent) of the respondents had full knowledge about the JSY scheme. The level of information about JSY was slightly more in villages were the SCs are located as compared to those villages where there is no SC. As far as source of information about the JSY is concerned, 41percent of
115 the respondents have heard it from Radio/T.V, 40 percent from ASHA, 11 percent each from Anganwadi centre (AWC) and Doctor, six percent from ANM and 23 percent of household respondents have heard the scheme from other source which include family members, relatives, newspapers etc.
Further the information was sought from also those households who had knowledge of the JSY scheme, about the number of beneficiaries in the household irrespective of the fact that whether they have received any incentive or not. The data collected shows that out of the total 888 households having knowledge about the JSY scheme, only 271 (31 percent) women were registered as JSY beneficiaries since the implementation of the scheme.
Background Characteristics of JSY Beneficiaries (Table H.6)
This section presents briefly various socio economic and demographic characteristics of the beneficiary women under JSY scheme. The information collected and presented in Table H.6 shows that all the beneficiaries were of the reproductive age group of 15 49 years. The age distribution of the beneficiaries shows that about two percent of them were below 20 years of age, 29 percent were aged 20 24 years, 36 percent women were in the age group of 25 29 years. Further 21 percent were aged 30 34 years, about nine percent aged 35 39 years and three percent belonged to age group 40 44 years. At the time of survey, the parity of children of the beneficiaries shows that majority (43 percent) of the respondents had two living children, 41 percent had 3 or more and 16 percent had one living child. Large proportion of the beneficiaries 59 percent belonged to other backward class category, two percent to ST and 39 percent to other castes. The composition of the beneficiaries by religion shows that majority (98 percent) beneficiaries belonged to Muslim community while as two percent beneficiaries belonged to Sikh community. As far as economic status of the beneficiary households is concerned, it was found that 21 percent women belonged to households with low standard of living index (SLI), one half (51 percent) with medium SLI and 28 percent with high SLI. Overall more than one half (53 percent) beneficiaries belonged to BPL families. All the JSY beneficiaries were asked to report the place of last delivery and the data collected
116 shows that 90 percent of these deliveries took place in various health institutions. It was observed that during the last few years the number of institutional deliveries has increased and besides other reasons one of the reasons in this regard seems to be the introduction of JSY where the women are being provided incentives for the same. This health trend among women will help to reduce the infant mortality rate and maternal mortality rate in the years to come and fulfill the core issue under NRHM.
Registration for JSY its Timing, Place and Person (Table H.7)
Table H.7 presents the data regarding the timing, place and person for registration of beneficiaries under JSY. Only 15 percent of the beneficiaries had heard about the scheme well before they were pregnant while majority (85 percent) heard about the JSY after they became pregnant. Distribution of the women by the stage of pregnancy, when registered for JSY scheme shows that over three fourth (76 percent), were registered during their 5th month or later, 10 percent each in the 4th and 3rd month of their pregnancy while as two percent each were registered in the 2nd or first month. Further the information was collected from all the respondents who were registered as JSY beneficiaries about the person who registered them. The data in this regard shows that ASHA has been instrumental in this regard and has alone registered more than one half (57percent) of the beneficiaries. Doctors have registered 19 percent, ANM/FHW 15 percent and Anganwadi worker AWW) eight percent. Overall more than one third (38 percent) women were registered at the SC, 13 percent at district/ sub district hospital, 10 percent at community health centre, seven percent at PHC, five percent at (AWC) and eight percent at other places. The Table also shows that 19 percent beneficiaries were registered at their homes (mostly registered by ASHAs or AWWs).
Role of ASHA in Getting JSY Card and Difficulties Faced (Table H.8)
Table H.8 presents the data regarding the receipt of JSY card, role of ASHA in this regard and the difficulties faced by beneficiaries in getting the card. Since majority of the beneficiaries have received their cards but about three percent have not received
117 the card and the main reason as ascertained from the health officials was non availability of cards at that time. Majority (57 percent) of the beneficiaries had sought the help of ASHA in getting the card while as another 43 percent had sought the help from other sources in securing their cards. A few beneficiaries (four percent) reported that they faced some difficulties while procuring their JSY cards. Among these, 30 percent reported that at the time of registration cards were not available while 40 percent said that the formalities for making the cards are cumbersome and surprisingly another 40 percent beneficiaries reported that they were asked to pay money for the same.
Role of ASHA During the Pregnancy of Beneficiaries (Table H.9)
As mentioned earlier ASHA has the key role in the field. She is supposed to identify and enroll all the pregnant women in her area and is supposed to provide them help during their pregnancy period and aware them about the pregnancy complications. In this regard the information collected from the beneficiaries shows that only 29 percent of them have received any specific help from ASHA during their last pregnancy. Table H.9 further shows that 31 percent beneficiaries had received some advice on diet from ASHA’s, 17 percent about danger signs during pregnancy, 24 percent about breast feeding, 18 percent about delivery care, 15 percent about newborn care, and 10 beneficiaries were given some information about family planning methods by ASHA’s. Overall 11 percent women reported that they had no ASHA working in their respective villages and as such did not receive any help or advice from them. Usually a pregnant woman needs a lot of information regarding the pregnancy care so that the risks of pregnancy could be avoided. The ASHA worker is supposed to provide such information to the pregnant women during the whole pregnancy period (during antenatal care). Therefore, the information was collected from all the beneficiaries regarding the type of information they received from ASHAs. The data shows that 86 percent of pregnant women had received the information from the ASHAs regarding the visit to the health centre for the next check up. Two third (67 percent) were also informed about the place of next check up, 54 percent regarding the Expected Date of Delivery (EDD) and 39 percent were told about the place of delivery by the ASHA. Further one third of the pregnant
118 women were told about the place of referral centre if they face any complications during their pregnancy.
Place of Delivery and Reasons Thereof (Table H. 10)
The place of delivery of a pregnant woman is closely associated with the survival status of mother and the child. The information provided in Table H. 10 gives the information regarding the place of delivery of all the JSY beneficiaries and reasons thereof opting for institutional delivery. Overall 88 percent deliveries among the beneficiaries had taken place in different health institutions while as 12 percent beneficiaries had their last delivery at home. Most of the institutional deliveries had taken place at government health facilities (71 percent at district/sub district hospital, nine percent at CHC, and one percent at PHC). Further around seven percent of the deliveries had taken place in private institutions.
Since it was expected that all the beneficiaries under JSY would get some monetary benefit if they deliver at the health institution but it was found that this has not been the major driving force for beneficiaries to opt for institutional delivery as only five percent beneficiaries reported that the availability of money under JSY was one of the reasons for opting institutional delivery. The main reasons mentioned by beneficiaries for institutional delivery were better access to institutional delivery by 82 percent, better care for mother and new born by 47 percent and 34 percent beneficiaries had their previous delivery also at the health institution. Further four percent mentioned that facility is nearby in the area while as the role of ASHA in this regard has been very limited as only three percent beneficiaries had got her support.
Transport Facilities for Beneficiaries (H. 11)
Under the norm of NRHM, every JSY beneficiary is entitled to receive the money for transport expenses to reach the health facility for delivery purposes. In this regard some information was collected from the beneficiaries and it was found that only seven percent beneficiaries had received the referral slips from ASHA or any other health worker to access the delivery services. Overall 35 percent of the beneficiaries
119 mentioned that they faced some difficulty in reaching health facility at the time of delivery. Out of the beneficiaries who had faced some problems in reaching to health institution for delivery, 41 percent mentioned that it was late at night, 33 percent had no sufficient money, 67 percent reported that transport was unavailable at the need of the hour, four percent had no male member at home to accompany them and one percent reported that ASHAs were reluctant to accompany them to health institution. The average distance from the house to the health facility where they were supposed to deliver was calculated to be about 23 kilometers.
There is a provision of arrangement of transport facility to the beneficiaries under JSY scheme from their respective places to the place of delivery and ASH/ANM has a vital role in this regard but it was seen that most (80 percent) of the beneficiaries had arranged and used private vehicle while as 16 percent had arranged some other transport to reach the health facility. Government ambulance was utilized by only four percent beneficiaries. The data collected further shows that in only five percent cases the transport was arranged by ASHA/ANM or VHSC to the beneficiaries to reach the health instution for delivery while as most (95 percent) of the beneficiaries had made the transport arrangements at their own for this purpose. It is here to mention that 13 percent beneficiaries had no money for transport to reach the health facility for delivery and had to arrange it from various sources or preferred to go by foot where the distance was too short.
Though all the beneficiaries under JSY are entitled for the assistance for transportation but it was found that the average amount received by a beneficiary for transportation was rupees 1.5 while as the average amount spent by a beneficiary in this regard was calculated to be rupees 560. This clearly indicates that the various incentives provided under JSY scheme have not reached to the gross root level and there is a serious need to streamline the scheme in this regard. There is a provision of incentive for the ASHA if she accompanies the pregnant woman to the health facility where she is supposed to deliver the child but it was found that in only eight percent cases the ASHA has accompanied the pregnant women for delivery while as most (91 percent) women were accompanied by their relatives.
120 Type of Delivery, Level of Satisfaction and Amount Spent (Table H.12)
Table H.12 gives the information regarding the type of delivery at the health instution, level of satisfaction, and the amount spent at the health facility by the beneficiaries. The average time taken by the health personnel to attend the beneficiary (when she reached the health institution) was estimated to be 23 minutes. Further more than one half (53 percent) of the beneficiaries delivered a baby through normal process while as one fourth of births were assisted by using forceps/vacuum and another 22 percent births were delivered through the caesarian section. A beneficiary on an average spent three days at the health facility. Overall 89 percent beneficiaries reported that they paid the expenses incurred (mostly on medicines). The average amount spent by a beneficiary was Rs. 2927.5. Majority (91 percent were satisfied and seven percent somewhat satisfied) beneficiaries were satisfied with the services provided to them at the health facility.
Reasons for Home Delivery (Table H.13)
It was observed in the field that the reasons behind the higher rate of institutional deliveries were a) Incentives to the beneficiaries and b) hard toil of the ASHA to motivate the beneficiary. But we could also find that some beneficiaries preferred to deliver at home and our research team tried to get the information from these women regarding the reasons for home deliveries in spite of being the beneficiaries under the JSY scheme. Multiple responses were recorded in this regard from the beneficiaries. The data shows that 46 percent beneficiaries disclosed the fact that they could not afford the institutional delivery because of the heavy expenses, 32 percent mentioned that home delivery is more convenient and 36 percent reported that the transport facility was not available in time. Further seven percent each reported that they had fear of stitches/ caesarean and cultural social conditions, four percent were of the view that the attitude of medical and Para medical staff of the health centre is always indifferent.
121 Cash Incentive (Table H.14)
One of the major components of the JSY Scheme under NRHM is the cash incentive for all those women who deliver at a government health facility or any other private health facility accredited by the government. In this regard there is a provision of incentive for both the beneficiary women and the ASHA. The beneficiary woman is supposed to get Rs. 1400 while as ASHA is paid an amount of Rs. 600 for each delivery at the health instution. During the field work it was observed that the incentive was limited only up to the papers and in the actual practice, this major and attractive part was almost non existent. Table H.14 shows that among the eligible beneficiaries, only six percent had received some amount of incentive during last two years while as majority (94 percent) have not received any incentive. On an average these beneficiaries received an amount of Rs. 688 mostly in one installment. All those respondents who had received the incentive were further asked about the timing of its receipt but most (65 percent) of them have not received the full amount. Six percent of the beneficiaries mentioned that they received the incentive before one week of their delivery, 12 percent had received within one week after delivery and another 18 percent said that they received it much later after their delivery. Further the distribution regarding the disbursement of the incentive shows that majority (47 percent) of the beneficiary had received this amount through the doctor, over 35 percent received it from ASHA worker, six percent from ANM/FHW and 12 percent had received from other health personnel. The distribution of beneficiary by place of receipt of amount shows that three fourth (76 percent) of them had received the incentive amount at government health centre while as six percent at AWC and another 18 percent were given the amount by ASHAs/ANMs at home. Overall 24 percent beneficiaries reported that they faced some difficulty in getting the payments and most of them said that it was paid by cheque/draft while as one of them mentioned that she was asked to pay the bribe
Client Satisfaction
This section pertains to the quality and care in Government health facilities and their level of satisfaction among the clients who visited them during last six months prior to the survey. This section also includes the information about knowledge of different diseases, HIV/AIDS and family planning methods among the respondents.
122
Utilization of Government Health Facility (Table H.15)
The information was collected from that person of the sample household who availed health services in any Government health facility at any time during last 6 months prior to survey for any type of ailment. The data given in Table H.15 shows that out of the total interviewed households a little less than one half (42 percent) of them had availed health services in Government health facility. Out of these, 41 percent belonged to subcentre villages and 44 percent were from other villages.
Background Characteristics of Respondents (Table H.16)
Table H.16 presents various socio economic and background characteristics of those respondents who availed any health service from the Government health facility during the last six months prior to the survey. Overall more than two third (67 percent) respondents belonged to age group 16 49 years while as 14 percent were below the age of 16. More than three fourth (79 percent) of the respondents were females. The educational qualification of the respondents shows that 60 percent of them were illiterate, 10 percent had studied upto primary standard and 19 percent upto middle standard. Further it was found that 10 percent respondents had their education level upto matric or above. Overall 83 percent of the interviewed respondents were currently married. As far as the caste of respondents is concerned it was found that three percent respondents belonged to ST category, 49 percent to other backward caste and 48 percent respondents were from general caste (others). The data regarding the religion of the respondents shows that majority, (94 percent) of them were Muslim and six percent were Sikh. Further the data collected shows that a little less than one half (47 percent) respondents belonged to below poverty line (BPL) category. The distribution of households by standard of living index shows that 20 percent of the households had low standard of living index and more than three fourth (43 percent with medium SLI and 37 with high SLI) households had high or medium standard of living index. Overall 21 respondents were either expired or were not available during the repeated visits of our research team to their respective household and thus the information regarding them was not available.
123
Type of Health Facility and Purpose of Visit (Table H.17)
Table H.17 gives the distribution of respondents who visited any Government health facility by its type, purpose of visit and the level of satisfaction regarding the behaviour of health workers, privacy and availability of medicines. The data shows that about one half (49 percent) of the respondents had visited district/Sub district hospital, one third (34 percent) to CHC, about 10 percent to PHC and eight percent had visited to SC for the treatment of different ailments. Majority (67 percent) of the respondents who visited the health facility had gone for minor ailments, five percent for ANC service, over seven percent for child care, two percent for immunization and another 21 percent had visited for other major or chronic diseases. Overall 39 percent of these respondents were of the view that the behavior of staff at health facility was indifferent or causal. Further It was found that in 88 percent cases, the doctor/staff listened to the complaints of the patients while as 12 percent respondents were not satisfied in this regard. More than three fourth (79 percent) of the woman patients were treated in privacy while as 16 percent patients reported that the privacy was not maintained. Further the data shows that one fourth of the respondents mentioned that the patients with chronic diseases get the medicines regularly at the health facility and one third mentioned that they do not know about it. Overall 29 percent patients mentioned that the doctors do private practice during and after duty hours while as 38 percent patients could not answer to this question as they were not aware about it. The overall satisfaction of respondents towards the services and staff indicates that the level of satisfaction was high as 72 percent of them were fully satisfied, 19 percent somewhat satisfied and only nine percent were not satisfied. Again the overall satisfaction of the respondents towards the behavior of staff indicates that 79 percent were satisfied, 17 percent somewhat satisfied and six percent were not satisfied.
User Fee and Extra Charges (Table H.18)
In order to get the consultation/services for any ailment in any type of government health facility, the patient is supposed to pay a nominal registration fee and the government has also fixed concessional charges for other type of facilities being
124 availed by the patients in these health facilities. In this regard the information was collected from all the respondents who visited any health facility during the last six months prior to the survey. Table H.18 shows that overall, 89 percent respondents were charged with the user fee on different accounts. Almost all the respondents had paid the registration fee, user fee for X Ray was charged from 15 percent respondents, 11 percent were charged user fee for Ultrasound, and 31 percent for other laboratory tests. Overall 94 percent were given the receipt for any user fee which they had paid. Further seven percent respondents were charged extra money for other service/test.
Services for BPL Patients (Table H.19)
Every CHC and PHC had to constitute a committee that is called Rogi Kalyan Samiti (RKS). There is a provision in this committee to help the needy and poor people at the health facility especially the BPL people. In this regard the research team tried to ascertain about the facilities which are being provided to BPL patients at different government health facilities. Table H.19 shows only 17 percent respondents reported that BPL patients are provided free/subsidized services at the health centre while as some of patients reported that they (BPL patients) faced any problem in paper work for free/subsidized services. The role of RKS was not found much satisfactory as only two percent of BPL patients were facilitated by them for the preparation of paperwork.
Outbreak of specific Diseases (Table H.20) In order to make the Disease Surveillance more effective, NRHM has given a framework in this regard and it is proposed to change Vertical programmes for communicable diseases to the Horizontal integration of programmes through VHSCs, SCs, PHCs, and CHC, Initiate and Integrate IDSP at all levels and Build district/ Sub district level epidemiological capabilities. Further one of the important goals in the NRHM is the Prevention and control of communicable and non communicable diseases, including locally endemic diseases. In this backdrop the information regarding the prevalence of different communicable diseases during last six months prior to the survey was collected from all the respondents. Table H.20
125 shows the prevalence of different diseases in sample area of the district were almost negligible and none of the major disease had taken the shape of an epidemic. Malaria was non existent in all the areas of the district while as the outbreak of measles was reported by seven percent respondents. Further two waterborne diseases namely Gastroenteritis outbreak was reported by three percent and Jaundice by 10 percent respondents. The outbreak of other disease (mostly localized and not serious) was reported by six percent respondents.
Action Be Taken for Different Diseases (Table H.21) In order to ascertain the knowledge of respondents about the selected diseases and their prevention, multiple responses were collected and analyzed. In the first instance all the respondents were asked to mention the measures that could be taken for the prevention of diarrhea and in this regard one fourth of the respondents mentioned that diarrhea can be prevented by washing the hands regularly. More than one half (59 percent) reported that it can be prevented by using safe food and water, over 20 percent give the opinion that the water which is used for drinking and cooking should always be covered fully in a container, and 13 percent were of the view that the diarrhea can be prevented if the daily garbage of the household could be properly disposed. More than one third (37 percent) of the respondents could not answer to this question as they were unaware regarding the safety measures for the prevention of diarrhea. Therefore, there is a need to strengthen the IEC campaign and provide awareness to the people regarding various health programmes and related issues to them.
Further, all the respondents were asked as what they do when any of their family members suffer with high fever for more than a week. The information collected in this regard is presented in Table H.21 which shows that three percent of the respondents go immediately for blood test for malaria, more than one third (35 percent) go to registered medical practitioner (RMP), more than one half (58 percent) rush to the nearest government health facility, 12 percent try some home remedies and 34 percent of the respondents utilize other sources (which include
126 private specialist doctors, Unani doctors etc.) at the time when any family member has persistent high fever.
The information regarding the management of persistent cough for more than two weeks to any family member was also collected from all the respondents and it shows that only seven percent respondents go for immediate sputum testing, 31 percent visit to RMP and majority (58 percent) of the respondents prefer to go to nearest government health facility, 10 percent try home remedies in this regard and another 42 percent use other sources (private doctor) for its treatment.
Further the information collected regarding the management of loose motion to a family member lasting for more than 24 hours show that more than one fourth (27 percent) respondents stop giving the oral fluids etc, one third start giving ORS, about 30 percent visit to RMP, more than one half (54 percent) utilize the services of nearest government health facility, and 15 percent try the home remedies. Further 31 percent respondents prefer specialized private doctors for the treatment in this regard.
Information regarding the management of persistent cough and breathing problem among children was also collected from the households which shows that more than one half (55 percent) of the households take the child to nearest government health facility while as more than one third (37 percent) consult private doctor. Further about 10 percent prefer to give the home remedy and 29 percent take to RMP for consultation.
Knowledge about Spacing Methods (Table H.22)
Since lot of emphasis has been given on family planning methods right from the beginning and most of the programmes have been named after it to reduce the fertility rate and check the population growth. Of late spacing methods have assumed great significance due to the fact that most of them do not need any
127 medical procedure and one can use these methods at any point of time either to space between the children or limit the family size. NRHM has also put the goals regarding the population stabilization. The information was collected from all the respondents regarding their awareness about family planning methods and it was found that 88 percent respondents were aware about it. Further the research team tried to get the information from all the respondents regarding the ideal gap between the first and the second child, the information collected shows that 10 percent respondents were of the view that there should be a gap of two years between the children while as majority (90 percent) said that it should be atleast three years or more. Further the knowledge regarding spacing methods among respondents shows that half of the respondents were aware about intra uterine device (IUD), Oral pills were known to 65 percent, Nirodh/Condom to only 20 percent and another 20 percent of the respondents said that they were aware about other methods of spacing like periodic abstinence, withdrawal and injection etc. Still there were over 18 percent of respondents who do not know any of the spacing method.
Knowledge about HIV/AIDS (Table H.23)
Table H.23 gives the information regarding the awareness about HIV/AIDS, its mode of transmission, source of knowledge, awareness about HIV/AIDS counseling centre, and its location. Overall more than two third (66 percent) of the respondents have heard about HIV/AIDS. The main sources by which it can transmit from one person to other as mentioned by the respondents were: sexual contact 80 percent, blood transfusion 51 percent, sharing needles/syringes 53 percent, from mother to child over 16 percent, and by shaking hands about two percent. Further main source of knowledge of the respondents about HIV/AIDS were: Radio with 76 percent, TV 60 percent, health workers seven percent, by posters eight percent and other means 20 percent. The counseling centre of HIV/AIDS was known to 30 percent of the respondents in which 42 percent said that it is located at district hospital/sub district hospital, 12 percent reported at CHC, three percent told at private hospital and 42 percent identified some other places.
128 H1. Characteristics Table of the respondents of HHs in Baramulla, JK Characteristics of the respondents Number Percent Age < 30 years 498 41.5 30 39 years 429 35.8 40 49 years 214 17.8 50 59 years 34 2.8 60 years or more 25 2.1 Sex Male 173 14.4 Female 1,027 85.6 Years of Schooling IIiterate 681 56.8 1 5 Years 108 9.0 5 9 years 217 18.1 10 years of more 194 16.2 Marital status Unmarried 141 11.8 Currently Married 1,029 85.8 Divorced/Separated 6 0.5 Widowed 24 2.0 Total number of respondents 1200 100.00
Table H2. Characteristics of the household in Baramulla, J&K Characteristics of the household (1=Yes, 0=No) Number Percent Social category Scheduled caste Scheduled tribe 40 3.3 OBC 523 43.6 Others 637 53.1 Religion Hindu 1 0.1 Muslim 1,106 92.2 Sikhs 93 7.8 Households having BPL status 542 45.2 Household living in Pucca house 726 60.5 Households with electricity 1,191 99.3 Households with toilet facility 872 72.7 Households with piped water supply 789 65.8 Households using LPG/Biogas for cooking 713 59.4 Household with own agricultural land 1,070 89.2 Households have a mobile phone 784 65.3 Households own a colour/B&W television 757 63.1 Households with low standard of living index 248 20.7 Total number of respondents 1200 100.00
129
Table H2. Characteristics of the household in Baramulla, J&K Characteristics of the household Number Number of living children born in last five years: 760 Total Institutional delivery: Total Total 618 % of children born in Health Institutions during last 5 years 81
Table H3: Percent distribution of households by their waste disposal, stagnation of waste water and mosquito breeding around the house and system of medicine preferred by them in Baramulla, J&K Households located Households in Sub Centre HQ located in other All Village village (1=Yes, 0=No) No % No % No % Method of waste disposal by the household
Thrown in the open 407 67.8 423 70.5 830 69.2 Buried in a pit 98 16.3 88 14.7 186 15.5 Burnt 88 14.7 80 13.3 168 14.0 Other 7 1.2 9 1.5 16 1.3 Stagnation of waste water around the household 242 40.3 251 41.8 493 41.1 Instance of any mosquito breeding 215 88.8 226 90.0 441 89.5 System of medicine preferred: Allopathic 598 99.7 596 99.3 1,194 99.5 Ayurveda 0 0 0 Yoga and Naturopathy 0 0 0 Unani 32 5.3 31 5.2 63 5.3 Siddha 5 0.8 14 2.3 19 1.6 Homeopathy 1 0.2 1 0.1 Traditional healing 45 7.5 58 9.7 103 8.6 Any other 4 0.7 1.3 12 1.0 None 0 0 0 Total Number of Households 600 100.0 600 100.0 1,200 100.0
130 Table H 4. Percent distribution of household respondents by their information about availability of health worker, health facilities and transport used to take serious patients in Baramulla, J&K
Households (1=Yes, 0=No) located in Sub Households Centre HQ located in other Village village All No % No % No % Heard about ANM 491 81.8 478 79.7 969 80.8
Heard about male health worker 504 84.0 497 82.8 1,001 83.4 Visited by a Health Worker in last one month 144 24.0 153 25.5 297 24.8 Health worker available at the time of need 429 71.5 419 69.8 848 70.7 Available health facility in need: RMP 112 18.7 116 19.3 228 19.0 Private clinic/NGO 90 15.0 96 16.0 186 15.5 Sub Centre 132 22.0 58 9.7 190 15.8 PHC 47 7.8 56 9.3 103 8.6 CHC 174 29.0 243 40.5 417 34.8 Other 179 29.8 168 28.0 347 28.9 Cont...
Table H 4. Percent distribution of household respondents by their information about availability of health worker, health facilities and transport used to take serious patients in Baramulla, J&K
(1=Yes, 0=No) Households Households located in Sub located in other Centre HQ Village village All
No % No % No % Facilities where serious patients taken:
RMP/Private clinic 59 9.8 55 9.2 114 9.5 NGO hospital/clinic 1 0.2 2 0.3 3 0.3 PHC 11 1.8 9 1.5 20 1.7 CHC 123 20.5 161 26.8 284 23.7 District/ Sub Divisional hospital 315 52.5 295 49.2 610 50.8 Other 229 38.2 244 40.7 473 39.4 Mode of transport for serious patient: Bullock cart 27 4.5 25 4.2 52 4.3 Bus 311 51.8 313 52.2 624 52.0 Private vehicle 428 71.3 400 66.7 828 69.0 Ambulance 11 1.8 9 1.5 20 1.7 Other 72 12.0 100 16.7 172 14.3 Total number of household respondents 600 100 600 100.0 1,200 100.0
131 Table 5. Percent distribution of household respondents by their knowledge about NRHM, ASHA and her activities, VHND, VHSC and JSY in Baramulla, J&K Households located Households (1=Yes, 0=No) in Sub Centre HQ located in other Village village All No % No % No % Have heard of NRHM Yes 38 56.3 297 49.5 635 52.9 No 262 43.7 303 50.5 565 47.1 Source of information about NRHM: ASHA 53 15.7 50 16.8 103 16.2 Radio/television 228 67.5 181 60.9 409 64.4 Newspaper 18 5.3 7 2.4 25 3.9 Panchayat Community member 9 2.7 2 0.7 11 1.7 Other 82 24.3 92 31.0 174 27.4 Number of respondents heard about ASHA 510 85.0 457 76.2 967 80.6 ASHA carries a kit 168 38.7 111 36.9 279 38.0 ASHA provides medicine free of cost 138 31.7 74 24.6 212 28.8 ASHA held discussion about: Hand washing 139 31.9 83 27.6 222 30.1 ASHA held discussion about: Construction of household toilets 112 25.7 55 18.3 167 22.7 ASHA held discussion about: Safe drinking water 139 31.9 77 25.6 216 29.3 VH Nutrition Day being organized in the village 90 15.0 103 17.2 193 16.1 Presence of VHSC in the village 36 6.0 13 2.2 49 4.1
Frequency of Village Health and Nutrition Weekly 7 7.8 7 6.8 14 7.3 Monthly 14 15.6 25 24.3 39 20.2 Quarterly 21 23.3 25 24.3 46 23.8 Annual 48 53.3 46 44.7 94 48.7 Don't know Number of respondents aware about the JSY scheme Yes 454 75.7 434 72.3 888 74.0 No 146 24.3 166 27.7 312 26.0 Radio/Television 191 42.1 172 39.6 363 40.9 Pamphlets 2 0.4 2 0.5 4 0.5 Hoardings at SC/PHC etc 3 0.7 3 0.7 6 0.7 ASHA worker 164 36.1 110 25.3 274 30.9 Anganwadi Centre/Worker 49 10.8 49 11.3 98 11.0 ANM 22 4.8 29 6.7 51 5.7 Doctor 58 12.8 35 8.1 93 10.5 Gram Panchayat 1 0.2 1 0.1 NGOs/SHGs Others 85 18.7 121 27.9 206 23.2 JSY beneficiary in HH 143 31.5 128 29.5 271 30.5 Total 454 100.0 434 100.0 888 100.0
132 Table H6. Percent distribution of JSY beneficiaries by their background characteristics in Baramulla, J&K Total number of JSY beneficiaries Number Percent Total 271 100.0 Age < 20 years 5 1.9 20 24 years 77 28.5 25 29 years 98 36.3 30 34 years 57 21.1 35 39 years 24 8.9 40 44 years 8 3.0 45 49 years 1 0.4 Parity 0 1 43 15.9 2 116 42.8 3 & 3+ 112 41.3 Social category SC ST 6 2.2 OBC 159 58.7 Others 106 39.1 Religion of the household Hindu Muslim 267 98.5 Christian Sikhs 4 1.5 Other SLI of the household Low 58 21.4 Medium 137 50.6 High 76 28.0 BPL household Yes 144 53.1 No 127 46.9 Place of last delivery Household 27 10.0 Health Institution 244 90.0
133
Table H7. Timing, person place of registration for JSY scheme in Baramulla, J&K Timing, place of registration for JSY card Number Percent Timing of hearing about JSY scheme Before being pregnant 40 15.3 During pregnancy 221 84.7 Whether know about the stage of pregnancy when beneficiary registered under JSY scheme Yes 243 89.7 No 28 10.3 Stage of pregnancy when beneficiary got registered for JSY scheme 1st month 7 2.9 2nd month 4 1.6 3rd month 23 9.5 4th month 25 10.3 5th month or later 184 75.7 Person who registered the beneficiary for JSY scheme Doctor 52 19.2 ANM/FHW 41 15.1 Anganwadi worker 22 8.1 ASHA worker 153 56.5 Others 3 1.1 Place where the beneficiary was registered for JSY scheme District/Sub District Hospital 36 13.3 Community Health Centre 28 10.3 PHC 19 7.0 Sub Centre 103 38.0 Anganwadi Centre 13 4.8 Pvt. Hosp. accredited by the Govt. At home 50 18.5 Other places 22 8.1 Total number of JSY beneficiaries 271 100.0
134 Table H8. Receipt of JSY card, role of ASHA in getting JSY card and difficulties faced by the beneficiary in getting the JSY card in Baramulla, J&K JSY Card (1=Yes, 0=No) Number Percent JSY card received by the beneficiary Yes 264 97.4 No 7 2.6 Total number of JSY beneficiaries 271 ASHA worker helped the beneficiary in getting JSY card Yes 150 56.8 No 88 33.3 Not applicable 26 9.8 Beneficiary faced difficulty in procuring JSY card Yes 10 3.8 No 254 96.2 Problem faced in procuring JSY card: Cards were not available 3 30.0 Formalities in making card were too cumbersome 4 40.0 Asked to pay money for card 4 40.0 Other
Table H 9. Role of ASHA during the pregnancy of the beneficiaries in Baramulla, J&K (1=Yes, 0=No) Number Percent ASHA worker provided any specific help to beneficiary in last pregnancy Yes 78 28.8 No 164 60.5 Not Applicable 29 10.7 Beneficiary received advice from ASHA Diet 66 24.4 Danger signs 45 16.6 Delivery Care 48 17.7 Breastfeeding 66 24.4 Newborn care 40 14.8 Family Planning 27 10.0 Not applicable (ASHA not appointed in the village) 29 10.7 Information given to the beneficiary Date of next check up 233 86.0 Place of next check up 181 66.8 Date of expected delivery 146 53.9 Place of delivery 106 39.1 Place of referral, if complications arise 88 32.5 Total number of JSY beneficiaries 271 100.0
135 Table H 10. Place of delivery and reason for opting institutional delivery in Baramulla, J&K Place of delivery and reason for opting Number institutional delivery (1=Yes, 0=No) Percent Place of delivery District/Sub District Hospital 162 71.1 Community Health Centre 21 9.2 PHC 2 0.9 Sub Centre Trust/NGO Hospital 4 1.8 Private Hospital 11 4.8 Pvt. Hosp. accredited by the Govt. At home 28 12.3 Total number of JSY beneficiaries 228 100.0 Reasons for opting Institutional Delivery Money available under JSY scheme 9 4.5 Better access to institutional delivery 164 82.0 Better care for mother and new born child 94 47.0 Services in the area 7 3.5 Support provided by ASHA 5 2.5 Previous child was born in an institution 69 34.5 Others 13 6.5 Total number of JSY beneficiaries 200 100.0
136 Table H 11. Transport of the beneficiaries to reach the Health Institution in Baramulla, J&K Process of Transport (1=Yes, 0=No) Number Percent Received referral slip from ASHA/health personnel to access delivery services 13 6.5 Faced difficulty in reaching Health Institution 70 35.0 Faced difficulty in reaching Health Institution: It was late in the night 29 41.4 Did not have sufficient money 23 32.9 Transport was not immediately available 47 67.1 Male members in the household were not present 3 4.3 ASHA was not readily available 1 1.4 Others 1 1.4 Average distance to the ultimate place of delivery from the beneficiary residence Average 22.5 Mode of transport used by the beneficiary to reach the ultimate place of delivery Government Ambulance 8 4.0 Private Vehicle 159 79.5 Vehicle arranged by Local Health Committee Others 33 16.5 Persons facilitated in arranging the transport ASHA 8 4.0 ANM 1 0.5 Village Health Committee 1 0.5 Others 190 95.0 Beneficiary had money to pay for the transport 175 87.5 Average amount spent on transport (in Rs.) 560.3 Average amount of transport assistance received under JSY scheme 1.5 Person accompanied beneficiary to the health institution ASHA 15 7.5 Relatives 182 91.0 Others 3 1.5 Total number of JSY beneficiaries 200 100.0
137 Table H 12. Waiting time at the health facility, type of delivery, amount spent at the health facility and satisfaction regarding services available in the health facility in Baramulla, J&K (1=Yes, 0=No) Number Percent Average waiting time at the facility until someone attended the beneficiary (in minutes) Average 23.2 Type of delivery beneficiary Normal 106 53.0 Assisted (Forceps, Vacuum) 50 25.0 Caesarean 44 22.0 Average number of days spent in the facility till discharge Average 3.2 Percent beneficiary who have to pay at the health centre Yes 178 89.0 No 22 11.0 Average amount paid at the health centre (Rs.) Average 2,927.5 Satisfied with the services at health centre Satisfied 182 91.0 Somewhat satisfied 13 6.5 Not satisfied 5 2.5 Reason for non satisfied Staff was rude 2 40.0 Facility was not clean Poor quality of services 2 40.0 Others 1 20.0
Table H13. Reason for the JSY beneficiary to opt home delivery, in spite of cash incentives being available under the JSY in Baramulla, J&K (1=Yes, 0=No) Number Percent Reasons for home delivery: Home delivery is more convenient 9 32.1 Fear of stitches/caesarean 2 7.1 Indifferent behaviour of medical/paramedical staff 1 3.6 Cultural/social reasons 2 7.1 Transport not being available 10 35.7 Can't afford 13 46.4 Others 2 7.1 Total number of JSY beneficiaries under Home 28 Delivery 100.0
138 Table H.14 Cash incentive received by the beneficiary under JSY scheme in Baramulla, J&K (1=Yes, 0=No) Number Percent Beneficiary received cash incentive under JSY scheme Yes 17 6.3 No 254 93.7 Total number of JSY beneficiaries 271 Average amount received by beneficiary as cash incentive Average 688.2 Received the cash incentive In one go 16 94.1 In 2 3 installments 1 5.9 Timing of the receipt of the cash incentive by beneficiary
Much before delivery Within a week before the EDD 1 5.9 Immediately after the delivery Within a week of delivery 2 11.8 Much later 3 17.6 Not revived yet in full 11 64.7 Person who delivered the cash incentive to the beneficiary Doctor 8 47.1 ANM/FHW 1 5.9 ASHA worker 6 35.3 Other 2 11.8 Place where the cash incentive received by the beneficiary District/Sub District Hospital 4 23.5 Community Health Centre 4 23.5 PHC 3 17.6 Sub Centre 2 11.8 Anganwadi Centre 1 5.9 At home 3 17.6 Faced any difficulty in getting money Yes 4 23.5 No 13 76.5 Type of difficulty faced Was asked to pay the bribe 1 25.0 Was paid by cheque/draft 2 50.0 Others 1 25.0 Total number of JSY beneficiaries 4 100.0
139 Table H 15. Utilization of government health facility in last 6 months in Baramulla, J&K Percent of household who availed Households Households health services in government health located in Sub located in other facility in last 6 months Centre HQ Village village All Yes 244 40.7 263 43.8 507 42.3 No 356 59.3 337 56.2 693 57.8 Total number of households 600 100.0 600 100.0 1200 100.0
Table H. 16 Characteristics of the respondents who have availed the services in government health facility in last 6 months in Baramulla, J&K Number Percent Age <16 years 68 14.0 16 19 years 24 4.9 20 29 years 130 26.7 30 39 years 112 23.0 40 49 years 59 12.1 50 59 years 32 6.6 60 years or more 61 12.6 Sex Male 101 20.8 Female 385 79.2 Years of schooling completed Illiterate 293 60.3 1 5 years 51 10.5 6 9 years 91 18.7 10+ years 51 10.5 Marital status Unmarried 50 10.3 Currently married 401 82.5 Divorced/Separated 2 0.4 Widowed 33 6.8 Social category of the household ST 16 3.2 OBC 246 48.5 Others 245 48.3 Religion of the household Muslim 479 94.5 Sikhs 28 5.5 BPL Household Yes 240 47.3 No 267 52.7 Standard of Living Index Low 99 19.5 Medium 219 43.2 High 189 37.3
140 Table H.17 Type of health facility visited, purpose visit and client satisfaction regarding behaviour of health worker, privacy and availability medicines in Baramulla, J&K Number Percent Type of health facility where service availed District/ Sub district hospital 239 49.2 CHC 163 33.5 PHC 46 9.5 Sub Centre 38 7.8 AYUSH Purpose of visit to health facility Treatment of minor ailment 311 64.0 ANC care 25 5.1 Child care 36 7.4 Immunisation 10 2.1 Other 104 21.4 Behaviour of staff at health facility Courteous 295 60.7 Causal/Indifferent 188 38.7 Insulting/Derogatory 3 0.6 Listening of complaints by Doctor/staff Listened to complaints 428 88.1 Somewhat listened 48 9.9 Not listened 9 1.9 Cannot say 1 0.2 Women patient were treated in privacy Yes 385 79.2 No 78 16.0 Do not know 23 4.7 Patients with chronic disease get regular medicines from health facility Yes 125 25.7 No 202 41.6 Do not know 159 32.7 Private practice of the doctors during and after the duty hours Yes 140 28.8 No 161 33.1 Do not know 185 38.1 Satisfied with overall services and staff of Govt Health Facility Satisfied 350 72.0 Somewhat satisfied 93 19.1 Not satisfied 43 8.8 Satisfied with the behaviour of staff at Govt. Health Facility Satisfied 378 77.8 Somewhat satisfied 80 16.5 Not satisfied 28 5.8
141 Table H.18 User fees and extra charges in Baramulla, J&K (1=Yes, 0=No) Number Percent Total respondents who have availed the services in government health 507 facility in last 6 months User fees charged from the users Yes 430 88.5 No 56 11.5 If user fees charged, type of user fees: Registration 421 97.9 X ray 63 14.7 ultrasound 46 10.7 lab test 133 30.9 other 3 0.7 Receipt given for the user fees Yes 405 94.2 No 25 5.8 Extra money charged for any services Yes 28 6.5 No 373 86.7 Do not know 29 6.7 Total respondents 430
Table H19. Services for the BPL patients in Baramulla, J&K (1=Yes, 0=No) Number Percent BPL patients provided free / subsidized services Yes 32 16.5 No 148 76.3 Do not know 14 7.2 BPL patients faced any problem in paper work for free/subsidized services Yes 6 3.1 No 167 86.1 Do not know 21 10.8 RKS facilitated the paperwork for BPL patients Yes 3 1.5 No 165 85.1 Do not know 26 13.4 Total BPL respondents 194 100.0
142 Table H 20. Outbreak of selected diseases in the respondents' area in the last six months in Baramulla, J&K Number Percent Malaria in last six months in the area Yes 1 0.1 No 1,155 96.3 Do not know 44 3.7 Measles in last six months in the area Yes 78 6.5 No 1,080 90.0 Do not know 42 3.5 Gastroenteritis in last six months in the area Yes 33 2.8 No 1,111 92.6 Do not know 56 4.7 Jaundice in last six months in the area Yes 114 9.5 No 1,036 86.3 Do not know 50 4.2 Other disease in last six months in the area Yes 72 6.0 No 1,046 87.2 Do not know 82 6.8 Total number of HH respondents 1200 100.0
143
Table H 21. Action to be taken for selected diseases in Baramulla, J&K Number Percent Prevention of diarrhoea: Hand washing 295 24.6 Use of safe food and water 713 59.4 Use of covered container 244 20.3 Proper disposal of garbage 161 13.4 other 61 5.1 Don't know 447 37.3 Action for high fever: Blood test for malaria 31 2.6 Taken to RMP 417 34.8 Taken to nearest govt health facility 696 58.0 Consult ASHA 9 0.8 Try home remedies 149 12.4 Other 406 33.8 Don't know 7 0.6 Action for persistent cough: Taken for sputum testing 82 6.8 Taken to RMP 372 31.0 Taken to nearest govt health facility 702 58.5 Consult ASHA 9 0.8 Try home remedies 116 9.7 Other 504 42.0 Action for loose motions: Stop giving oral fluids/food etc 328 27.3 Start giving ORS 400 33.3 Taken to RMP 354 29.5 Taken to nearest govt health facility 653 54.4 Consult ASHA 8 0.7 Try home remedies 181 15.1 Other 375 31.3 Don't know 6 0.5 Action for persistent cough and breathing problem: Try home remedies 117 9.8 Taken to RMP 350 29.2 Taken to nearest govt health facility 665 55.4 Consult ASHA 6 0.5 Other 442 36.8 Don't know 7 0.6 Total number of HH respondents 1200 100.0
144 Table H 22. Awareness about spacing methods and ideal gap between 1st and 2nd child in Baramulla, J&K (1=Yes, 0=No) Number Percent Aware of family planning methods 1,058 88.2 Total number of household respondents 1,200 Ideal gap between 1st and 2nd child 1 year 9 0.9 2 year 102 9.6 3 and more year 947 89.5 Spacing method: IUD 527 49.8 Oral Pills 682 64.5 Nirodh/Condom 189 17.9 Any other 224 21.2 Don't know 191 18.1 Total number of HH respondents 1,058
Table H23. Awareness about modes of getting AIDS, source of information about AIDS and awareness about VCTC in Baramulla, J&K (1=Yes, 0=No) Number Percent Heard about HIV/AIDS Yes 787 65.6 No 413 34.4 Total number of HH respondents 1200 100.0 Mode of HIV/AIDS: Sexual contact 627 79.7 Blood transfusion 398 50.6 Sharing needles/syringes 415 52.7 From mother to child 129 16.4 Shaking hands 12 1.5 Sneezing 1 0.1 Insect bite 2 0.3 Kissing 2 0.3 Other 30 3.8 Source of information on HIV/AIDS: Radio 598 76.0 TV 471 59.8 Health workers 54 6.9 Posters 62 7.9 News papers 63 8.0 Other 158 20.1 Aware of HIV/AIDS counseling centre/VCTC nearby 233 29.6 Location of counseling centre PHC 2 0.9 CHC 27 11.6 District Hospital 90 38.6 Sub District Hospital 8 3.4 Private Hospital 8 3.4 Other 98 42.1 Total household respondents 233 100.00
145 CHAPTER 8 STATUS AND PERFORMANCE OF ASHA
The Government of India launched the National Rural Health Mission (NRHM) throughout the country to improve the access of people, especially the poor women and children to quality primary health care services. It was a general perception under earlier programmes that the ANM was heavily overworked, which used to affect the delivery of quality services and also used to affect out reach of services in the rural areas. In order to ease the working of ANMs a new band of Community based functionaries, named as Accredited Social Health Activist (ASHA) has been introduced under the NRHM as the trained women Community Health Volunteer. Besides, helping the ANMs in her activities ASHA is supposed to provide a minimum package of curative care, make timely referrals, reinforce community action for universal immunization, safe delivery, new born care, prevention of water borne and communicable diseases, improved nutrition and promotion of household toilets. ASHA is also supposed to inform, interact, mobilize, and facilitate improved access to preventive and promotive health care and also provide basic health care through her drug kits.
Under the National Rural Health Mission which was launched in Jammu and Kashmir from February, 2006. The state government has selected and made functional all the ASHAs in the state. These ASHAs have also been given some basic training regarding their role and responsibilities. Now these ASHAs are working for the last one year and it would be fruitful at this stage to have an evaluation on the working of the ASHA, so that it may be possible to assess their performance and impact on the objectives laid down under NRHM. This concurrent evaluation exercise may also help the policy makers and programme managers to take appropriate corrective measures if the workers are not functioning as per the NRHM guidelines.
The data was collected during the field survey in Baramulla district of Jammu and Kashmir regarding the working of ASHAs. The following paragraph gives us the detailed information on various aspects related to ASHAs (28 ASHAs) covered during the survey.
146 Coverage (Table A1) Table 1 gives us the detailed information regarding the status of ASHA in district Baramulla. It shows that overall 28 ASHAs were interviewed (all the ASHAs) in the two selected blocks of Baramulla district. It was estimated that the average population served by each ASHA in the district was 1,117 and average number of villages/habitations served by her was 1.5.
Selection of ASHAs (Table A1) The Mission Statement of NRHM states that every village/large habitat will have a female Accredited Social Health Activist (ASHA) chosen by and accountable to the Panchayat to act as the interface between the community and the public health system. ASHA must be a woman resident of the village married/divorced, preferably in the age group 25 45 years. She should be a literate woman with atleast educated upto middle standard. In this regard the Information was also collected from the selected ASHAs regarding their mode of selection. It was found that majority (93 percent) of ASHAs were selected on the recommendations of Gram Pradhan while about four percent were selected on the recommendations of Village Health and Sanitation Committee (VHSC). Further four percent ASHAs reported that they were selected on the recommendations of local ANM. The information thus collected in this regard shows that the selection procedure of ASHAs as per the guidelines under NRHM has been followed.
Training (Table A1) Since there is a provision for Induction training of ASHA for 23 days in all, spread over 12 months. The job training would continue throughout the year as capacity building of ASHA is seen as a continuous process. Prototype training material needs to be developed at National level subject to State level modifications. Cascade model of training proposed through Training of Trainers including contract plus distance learning model. Training would require partnership with NGOs/ICDS Training Centres and State Health Institutes. The information collected in this regard shows that 93 percent ASHAs have received the training under different modules. Overall all the ASHAs have received training under the first module while more than three fourth (77 percent) reported that they have received the training under module
147 2 also. Only eight percent ASHAs have reported that they have received any training under module 3 while none of the ASHAs has received any training under module 4.
Role and Performance (Table A2) Accredited Social Health Activist (ASHA) has been introduced under NRHM as the trained women Community Health Volunteer. Besides, helping the ANMs in her activities, ASHA is supposed to provide a minimum package of curative care, make timely referrals, reinforce community action for universal immunization, safe delivery, new born care, prevention of water borne and communicable diseases, improved nutrition and promotion of household toilets. ASHA is also supposed to inform, interact, mobilize, and facilitate improved access to preventive and promotive health care and also provide basic health care through her drug kits. In this regard Table 2 gives us the detailed information regarding the role and performance of ASHAs in Baramulla district. Overall it was found that 32 percent ASHAs were DOTS providers. Further the data in Table 2 reveals that the average monthly number of JSY cases facilitated by ASHA in last three months prior to the survey was estimated to be 2.5 cases. The information was also collected on the performance of ASHA during the last three months prior to the survey and the information collected shows that on an average 4 cases of diarrhea were given ORS during the last three months prior to the survey while 2 cases were accompanied for institutional delivery by ASHAs during the same period. Similarly on an average 2 cases were distributed with oral pills by ASHAs during the last three months. The new cases of pregnancies identified by ASHAs during the same time was one while hardly any group meetings or health and nutrition day was arranged by the ASHAs during the last three months prior to the survey.
Incentives Received (Table A2) ASHA is supposed to receive performance based compensation for promoting universal immunization, referral and escort services for RCH, construction of household toilets, and other healthcare delivery programmes.The information was also collected from all the selected ASHAs about the average money incentive received by an ASHA each month under different heads admissible to her. Table 2 shows that total average money received by an ASHA per month was Rs. 317. The average money received on JSY was Rs. 119 while for sterilization it was Rs. 5.4.
148 The data further revels that under the head ‘others’ (which mostly include immunization and Pulse Polio immunization) the money received by an ASHA on an average per month was around Rs. 193. The information clearly shows that the money which ASHA is supposed to receive under different components is not distributed on regular basis with any uniform pattern mainly due to the fact that incentive money under JSY was not available during 2007 08.
Problems Faced by ASHAs (Table A3) The ASHAs were further asked to report the types of difficulties which they face in performing their duties and what type of further support is required to them to perform in more effective way. In this regard majority of the ASHAs (96 percent) reported that the funds for various activities are not available in time while 11 percent have not received adequate training and seven percent reported for delayed supply of drugs. Further four percent ASHAs reported that there are no adequate facilities available for institutional deliveries.
Suggestions Made (Table A3) Regarding the support they require for the implementation of the programme more effectively, 82 percent ASHAs reported that payments under different heads should be released in time while 43 percent ASHAs reported that more training should be arranged for them and for the community members. Eleven percent ASHAs wanted to have fixed remunerations for them.
Technical competence (Table A4) Since most of the ASHAs have been provided the basic training for performing their duties and in order to see the impact of the training and awareness about different aspects related to women and children, all the selected ASHAs were asked to report about their awareness on different aspects related to their job. The Table 4 shows that all the ASHAs were asked to report the important steps for prevention of diarrhea and multiple responses were recorded. Most of the ASHAs (93 percent) reported that use of safe drinking water is very important for prevention of diarrhea while one fourth of ASHAs reported that washing the hands is important. Further seven percent ASHAs reported that in order to prevent diarrhea the containers which
149 are used for storage should be covered. About four percent ASHAs had no idea as to how the diarrhea can be prevented.
All the selected ASHAs were asked to report for the awareness about the ideal time for initiation of breast milk to infants after their birth. In this regard majority of the ASHAs (82 percent) reported that the child should be given the breast milk within the first hour of his birth while four percent were of the view to initiate it within six hours and another four percent reported that the breast milk should be given within the first 24 hours of the birth. About 11 percent could give other options for the same while four percent ASHAs had no knowledge as to when the breast milk should be initiated. Further 96 percent ASHAs reported that exclusive breastfeeding to the child should be continued up to first six months.
150
Table A1. Status of ASHA in Baramulla district of J&K Status of ASHA Value A. Number of ASHA interviewed in the district 28 B. Average population served by ASHAs interviewed 1,117.2 C. Average number of village/habitations served by ASHAs covered 1.5 D. Percentage of ASHAs by method of selection Selected on recommendation of ANM 3.6 Selected on recommendation of Gram Pradhan 92.9 Selected on recommendation of Anganwadi worker Selected on recommendation of Village Health Committee 3.6 Previously worked as Dai Other E. Percentage of ASHA undergone training 92.9 F. Percentage of ASHAs undergone training by modules Module 1 100.0 Module 2 76.9 Module 3 7.7 Module 4 G. Percentage of ASHAs issued ASHA kit 82.1
Table A2: Role and Performance of ASHA in Baramulla district of J&K Role and Performance of ASHA Percent A. Percentage of ASHAs who are DOTS provider 32.1 B. Average monthly no. of JSY cases facilitated in last 3 months by ASHA 2.5 C. Average number of cases handled in last 3 months Children with diarrhoea given ORS 4.0 Number of cases 28 Accompanied institutional delivery cases 2.0 Number of cases 28 Number of Oral Pills distributed 2.4 Number of cases 28 Number of Malaria Patients given drugs Number of cases 28 Number of new pregnancies identified 1.1 Number of cases 28 Number of group meetings like Mahila Mandals arranged 0.1 Number of cases 28 Number of Health and Nutrition day arranged 0.1 Number of cases 28 D. Average money incentive received by an ASHA on an average per month JSY 119.1 Sterilization 5.4 VHND Other 192.9 Total 317.4 Number of ASHA interviewed in the district 28
151 Table A3: Distribution of ASHAs by reported types of difficulties faced and kind of support required in Baramulla district of J&K Reported types of difficulties faced and kind of support required Percent A. Percentage of ASHAs by types of difficulties faced in implementing programme activities under NRHM Funds not available in time 96.4 Adequate training is not provided 10.7 Delayed supply of drugs 7.1 Behaviour of staff in health facilities is not appropriate Inadequate facilities for institutional deliveries 3.6 B. Reported kind of support require to ASHA to enable her to implement the programme more effectively More training is to be arranged for ASHA & Community members 42.9 ASHA should be paid a fixed remuneration 21.4 Payments should be made timely 82.1 Other 7.1 Number of ASHA interviewed in the district 28
Table A4: Distribution of ASHAs by reported awareness on different aspects in Baramulla district of J&K Reported awareness on different aspects Percent A. Percentage of ASHAs reporting important steps for prevention of diarrhoea Hand washing 25.0 Use of safe water 92.9 Use of covered container 7.1 Proper disposal of garbage Other 3.6 Don't know 3.6 B. Percentage of ASHAs reporting ideal time for initiating breastfeeding Within 1 hour of delivery 82.1 Within 6 hours of delivery 3.6 Within 24 hour of delivery 3.6 After child has given water, honey ghutti etc Other 10.7 Don't know 3.6 C. Percentage of ASHAs reporting exclusive breastfeeding months for a child 2 months 3 months 6 months 96.4 Number of ASHA interviewed in the district 28
152 CHAPTER 9 GRAM PANCHAYATS To train and enhance capacity of Panchayati Raj Institutions (PRIs) to own, control and manage public health services is one of the core strategies of the Mission and in this background the role of Village Health and Sanitation Committee (VHSC) has been well defined in the NRHM. The Mission envisages that the Village Health Committee of the Panchayat would prepare the Village Health Plan, and promote inter sectoral integration, Each sub centre will have an Untied Fund for local action @ Rs. 10,000 per annum. This Fund will be deposited in a joint Bank Account of the ANM & Sarpanch and operated by the ANM, in consultation with the VHSC.
In order to look into the role of Gram Panchayats (GPs), in all the selected village, Gram Panchayat schedule was also canvassed. Overall in district Baramulla 17 Gram Panchayats were covered during the survey. Since the Panchayats in the district were not functioning and elected at the time of survey and thus it was difficult to get the requisite information. It was ultimately decided to interview the Chairman of the VHSC who mostly was the village head/Ex Gram Pradhan/community Head /School Teacher or any other responsible person of the village. Therefore, the information was mostly collected from Chairman VHSC in a particular village.
Coverage (Table G1) Table 1 gives us the information about the status of Gram Panchayats covered during the survey. Overall on an average a Gram Panchayat in Baramulla covered a population of 2,929 persons in which the Scheduled Tribe population constituted for 190 persons. The average number of households covered by a Gram Panchayat was 336 in which there were 12 households that belonged to Schedule Tribe population. Further the data shows that the average number of BPL families covered during the survey was 108 and out of these 12 families belonged to ST.
Awareness and Involvement (Table G2) The attempt was also made to get the information from the Gram Panchayats/village committees about the awareness of various activities conducted under the NRHM. In this regard Table 2 shows that more than two third of Gram Panchayats each
153 reported the regular availability of ANM at the Sub Centre (SC) and timely services provided by the SCs to the patients. Only 12 percent GPs reported for their role in conducting/finalizing IEC programme in their respective areas. Further the data collected shows that, two third of the GPs each reported that VHSC has been established in their respective villages and they conduct the meetings regularly. All the surveyed GPs have neither prepared any Village Health Plan nor have they received any Untied Fund for the VHSC. More than three fourth (82 percent) GPs reported that the ASHA worker is in position in their GP and only 41 percent GPs have awareness about the benefits under JSY. More than one half (59 percent) GPs were satisfied with the NRHM and they reported that NRHM brought about some improvement in their respective areas.
I n order to ascertain the level of improvement due to the intervention of NRHM at the grass root level all the selected GPs were asked to report about the type of improvement which has taken place in their respective areas due to intervention of NRHM, overall 70 percent GPs reported that the availability of funds for maintenance of SCs has improved while 60 percent reported that community support to ASHA is available. Regarding the availability of funds/facilities under JSY, less than one fourth (20 percent) of the GPs were satisfied and this level of satisfaction among GPs decreases further to only 10 percent with regard to availability of better facilities for CHCs/PHCs where the patients are referred.
All the GPs were further asked to mention the difficulties they face in the implementation of various activities under NRHM. In this regard table 2 shows that about two third (65 percent) of the GPs have not received any funds till date or the funds are not available in time. Overall, more than one half (53 percent) GPs reported that ASHAs have not been trained adequately while 18 percent reported that they do not have the availability of adequate facility for institutional deliveries.
Further all the GPs were asked to mention for the type of support they need to implement the NRHM more effectively. Overall 59 percent GPs reported that more training programmes should be arranged for ASHAs and community members for effective implementation of the programme while 41 percent each reported that there
154 is a need that more funds should be released for maintenance and as such funds for VHSCs. Table G1: Status of Gram Panchayats Covered in Baramulla, J&K Status of Gram Panchayat Covered Value A. Number of Gram Panchayats covered in the district 17 B. Average population of the Gram Panchayat covered Scheduled Tribe 189.7 Total 2,929.1 C. Average number of Households in the Gram Panchayat covered Scheduled Caste Scheduled Tribe 11.8 Total 336.0 D. Average number of BPL families in the Gram Panchayat covered Scheduled Caste Scheduled Tribe 12.0 Total 107.8 Table G2: Level of awareness and involvement of Gram Panchayats in Baramulla, J&K Level of awareness and involvement of Gram Panchayats Percent A. Percentage of Gram Panchayat reporting regular availability of ANM 66.7 B. Percentage of Gram Panchayat reporting timely services provided by Sub 64.7 Centre to the patients C. Percentage of Gram Panchayat reporting role of Gram Panchayat in 11.8 conducting/finalizing IEC programme in Gram Panchayat D. Percentage of Gram Panchayat reporting existence of VHSC in their Gram 64.7 Panchayat E. Percentage of Gram Panchayat reporting regular meetings of VHSC 63.6 H. Percentage of Gram Panchayat reporting ASHA worker in position 82.4 I. Percentage of Gram Panchayat reporting awareness of the benefits under JSY 41.2 scheme J. Percentage of Gram Panchayat reporting that NRHM brought about any 58.8 improvement in their area Distribution of G Ps covered by type of improvement reported due to NRHM Funds available for maintenance of Sub Centres 70.0 Community support is available as ASHA worker 60.0 Funds/facilities are available under JSY 20.0 Better facilities are available for CHCs/PHCs for referred patients 10.0 Distribution of GPs by type of difficulties faced in implementing programme activities under NRHM Funds not available in time 29.4 Decision making with community leaders are difficult 5.9 ASHA has not been adequately trained 52.9 Adequate facility for institutional deliveries are not available 17.6 Other 35.3 M. Distribution of Gram Panchayats by kind of support required to implement programme more effectively More funds are required for maintenance/ effective functioning 41.2 Gram Panchayat should be given direct control over funds 5.9 More training is to be arranged for ASHA and Community members 58.8 Any other 41.2 Number of Gram Panchayat covered in the district 17
155 CHAPTER 10 EXIT INTERVIEWS FOR IPD AND OPD PATIENTS
In Patient Department (IPD) In order to assess the quality of services provided to clients (patients) at different health institutions and their satisfaction level with them, two types of questionnaires were canvassed, one for the out patients and another for those patients who were admitted in different type of health facilities. This chapter deals with the perception of the beneficiaries with the utilization of the services availed from government health institutions in Baramulla district. It also presents their opinion regarding the quality of services delivered by these health institutions. Though at the beginning it was decided to interview 10 patients each from the selected PHCs, CHCs and District Hospital, but due to non availability of IPD patients at CHCs and PHCs the IPD interviews were ultimately restricted to DH Baramulla. Interviews were conducted with both male and female respondents aged 16 years or more. However, if the patient was less than 16 years, interviews were conducted with the adult member accompanying the patient.
Background Characteristics (Table IP1) Overall almost all the IPD patients who were interviewed during the survey were admitted in district hospital Baramulla and none of the patients was found admitted at any CHC or PHC. This clearly indicates the state of facilities which are available for IPD at these health centres. Table 1 provides the information about the background characteristics of all the 11 patients who were interviewed during the survey. Overall more than one third (36 percent) patients belonged to age group 40 49 years, 18 percent each for age groups 60 years or more and less the 20 years. Another 18 percent belonged to age group 20 39 years while nine percent belonged to 50 59 years age group. About three fourth (73 percent) were male and the same percentage was also married. Further 18 percent of the IPD patients were unmarried while nine percent were widowed. As far as residence of IPD patients is concerned, 91 percent of the patients belonged to rural areas while nine percent were from urban areas.
156 Purpose of Admission (Table IP2) All the selected patients who were admitted to the health institution were asked for purpose of their admission. Table 2 shows that about three fourth (73 percent) of the patients reported that they had some serious complication (kidney, stomach, chest, reproductive tract infection, liver, high sugar level etc.) while 18 percent had minor illness and another nine percent had their child admitted for his/her illness.
Waiting Time and Satisfaction level (Table IP3 and IP4) Table 3 and 4 pertains to the information about the average waiting time for availing different services during the patients were admitted in the health facility and their satisfaction with it. On an average the time taken for the registration for IPD was 38 minutes and more than one third (36 percent) of the patients reported that it was too long. Further it was found that on an average the Doctor’s first call was after 51 minutes and more than one fourth of the patients were dissatisfied with this as it was after long time. The average time taken by the Doctor for indoor examination of the patient was calculated to be nine minutes about three fourth of the patients were satisfied in this regard while 18 percent reported that it was too short. The tables further show that average time taken for admission to the ward was 27 minutes and 91 percent patients were satisfied with this time as they said it was appropriate. For getting the services in the indoor the average time taken in this regard was 38 minutes and most of the patients were found satisfied. The average time taken for getting discharged from the health facility was 38 minutes and 91 percent patients were satisfied in this regard while nine percent IPD patients said that it was too long.
Behaviour of Staff, Measures Taken, and Privacy (Table IP5, IP6, and IP7) The behaviour of the staff at different levels for the patients who were admitted to the health facility for various illnesses was found highly satisfactory. The level of satisfaction regarding the behaviour of the staff for IPD patients ranged from 90 percent to 100 percent as shown in Table 5. Eighty two percent patients reported that they could not find that any unique/innovative measure was taken to improve the behaviour of the staff (Table 6). Further Table 7 shows that 82 percent IPD patients reported that privacy was maintained during their examination by the Doctor.
157 Patient Doctor Communication (Table IP8) Since communication skill by the Doctors has assumed significant importance in medical science now and therefore the research team tried to look into this aspect also. In this regard it was found that all the surveyed IPD patients were satisfied with the patient hearing by the Doctor for description of the ailment the patient had. Ten percent of the patients reported that they were not allowed to ask any question to the Doctor. Overall 80 percent of the Doctors replied to the questions which were asked to them by the patients. Further more than 80 percent of the Doctors discussed about the ailment to the patient and its recovery. Seventy percent Doctors gave other advice to the patients as well. (Table 8)
Cleanliness and Level of Satisfaction (Table IP9 and IP10) All the interviewed IPD patients were asked to report about the cleanliness of the facilities which they used during their stay at the IPD and their level of satisfaction with them. In this regard table 9 shows that 70 percent IPD patients reported that floor was cleaned only once in a day while 30 percent reported that it was cleaned twice a day. In this regard it was found that one half the patients were not satisfied. Similarly cleaning of the toilet/bathroom once a day was reported by 70 percent and 10 percent reported that it was not cleaned even once. Table 10 shows that 60 percent of the patients were not found satisfied with the cleaning of toilet/bathroom. None of the patient’s uniform was changed during the time they were admitted in the hospital. The bed sheet was changed once a day in case of 60 percent patients while 40 percent reported that it was not changed. The satisfaction level with regard to the changing of uniform and the bed sheets was 33 and 60 percent respectively.
Crowding in Wards (Table IP11) In order to see the adequacy/availability of different facilities for IPD patients it was found that all the patients were provided the cot immediately at the time of admission while 20 percent had no cot till the time of their discharge from the hospital. Overall 10 percent patients were not satisfied with the arrangements in the ward. Further 20 percent IPD patients reported that there was not adequate space in the IPD while 80 patients reported that the space was adequate. (Table 11)
158 Amenities at Health Facilities (Table IP12) Table 12 gives us the detailed information with regard to the various amenities provided by the hospital to the IPD patients during their stay at the health facility. The data collected shows that only one patient (10 percent) reported that television was available in the ward while as all the patients said that the Ambulance, Canteen and Medical shop facility was available there. None of the IPD patients reported any facility of telephone or accommodation for relatives during their stay at the hospital. All the patients who had enjoyed any facility were found satisfied.
Continuity of Treatment (Table IP13) As far as the overall satisfaction of the IPD patients during their stay in the hospital is concerned it was found that 20 percent were dissatisfied and reported that the hospital has poor quality of basic services. Further all the patients were asked to report that would they come again to this hospital if they fell sick? 90 percent reported in affirmative and said that they will also recommend this hospital to others.
Table IP1: Background characteristics of the in patients in Baramulla Background Characteristics of the In Patients Percent Age < 20 years 18.2 20 29 years 9.1 30 39 years 9.1 40 49 years 36.4 50 59 years 9.1 60 years or more 18.2 Sex Male 72.7 Female 27.3 Marital status Unmarried 18.2 Currently married 72.7 Divorced/Separated Widowed 9.1 Residence Rural 90.9 Urban 9.1 Type of Health Facility District Hospital 90.9 CHC PHC 9.1 Total no. of in patients interviewed 11
159 Table IP2: Purpose of the admission in the Health Institution in Baramulla Purpose of admission in Type of Health Facility (Percent) Health Institution District Hospital CHC PHC All Minor illness 10.0 100.0 18.2 FP surgery Delivery Child admitted 10.0 9.1 Other 80.0 72.7 Total no. of in patients interviewed 10 1 11
Table IP3: Waiting time in Baramulla Type of Health Facility (Average waiting time in minutes) Average waiting time for: District Hospital CHC PHC All Registration 41.0 3.0 37.5 Doctor's call 55.5 10.0 51.4 Doctor's examination 8.7 15.0 9.3 Admission to ward 29.5 3.0 27.1 Getting services 41.5 4.0 38.1 To get discharged 40.5 15.0 38.2 Total IPD interviewed 10 1 11
Table IP4: Satisfaction regarding waiting time in Baramulla Waiting time Type of Health Facility for/Satisfaction District Hospital CHC PHC All Registration Too long 40.0 36.4 Appropriate 60.0 100.0 63.6 Doctor's call Too long 30.0 27.3 Appropriate 70.0 100.0 72.7 Doctor's examination Appropriate 70.0 100.0 72.7 Too short 20.0 18.2 Can't say 10.0 9.1 Admission to ward Too long 10.0 9.1 Appropriate 90.0 100.0 90.9 Too short Can't say Getting services Too long 10.0 9.1 Appropriate 90.0 100.0 90.9 To get discharged Too long 10.0 9.1 Appropriate 90.0 100.0 90.9 Total no. of in patients interviewed 10 1 11
160
Table IP5: Behaviour of Staff in Baramulla Type of Health Facility (Percent) Staff Behaviour District Hospital CHC PHC All Doctor greet in a friendly manner Yes 90.0 100.0 90.9 Somewhat 10.0 9.1 No Behaviour of Doctor Rude 10.0 9.1 Reasonable Good Very kind 90.0 100.0 90.9 Behaviour of Nurse Rude Reasonable Good 10.0 9.1 Very kind 90.0 100.0 90.9 Behaviour of Technical Staff Rude Reasonable 14.3 14.3 Good 42.9 42.9 Very kind 42.9 42.9 Behaviour of Ayah Negligent Arrogant Indifferent Good 100.0 100.0 Behaviour of Ward Boys Negligent Arrogant Indifferent 10.0 10.0 Good 90.0 90.0 Behaviour of Counter Clerk Negligent Arrogant Indifferent Good 100.0 100.0 100.0 Total no. of in patients interviewed 10 1 11
161 Table IP6: Unique/ innovative measure taken to improve the staff behaviour in Baramulla Type of Health Facility (Percent) Staff Behaviour District Hospital CHC PHC All Unique/innovative measure taken to improve the staff behaviour 10 1 11 Yes 20.0 18.2 No 80.0 100.0 81.8 Total in patients interviewed 10 1 11
Table IP7: Privacy in Baramulla Type of Health Facility (Percent) Privacy District Hospital CHC PHC All Patients reporting presence of privacy at the place of examination 80.0 100.0 81.8 Total in patients interviewed 10 1 11
Table IP8 : Patient Doctor/ Provider Communication in Baramulla Patient Doctor/ Provider Type of Health Facility (Percent) Communication District Hospital CHC PHC All Doctor listened to description of ailment patiently Yes, somewhat 10.0 9.1 Yes, always 90.0 100.0 90.9 Doctor allowed to ask question Yes, somewhat 30.0 27.3 Yes, always 60.0 100.0 63.6 No 10.0 9.1 Doctor responded to question Yes, somewhat 10.0 9.1 Yes, always 70.0 100.0 72.7 No 20.0 18.2 Doctor discussed about ailment Yes 80.0 100.0 81.8 No 20.0 18.2 Doctor talked about the recovery Yes 80.0 100.0 81.8 No 20.0 18.2 Doctor gave 'other advice' Yes 70.0 100.0 72.7 No 30.0 27.3 Total in patients interviewed 10 1 11
162 Table IP9: Cleanliness of the facility in Baramulla Type of facility/ Type of Health Facility (Percent) Frequency of cleaning District Hospital CHC PHC All Floor Twice a day 30.0 27.3 Once a day 70.0 100.0 72.7 Less than once a day Not applicable Toilet/ Bathroom cleaning Twice a day 20.0 18.2 Once a day 70.0 63.6 Less than once a day 10.0 100.0 18.2 Not applicable Changing patient's uniform Less than once a day Not changed 33.3 30.0 Not applicable 66.7 100.0 70.0 Changing bed sheets Twice a day Once a day 60.0 54.5 Less than once a day 40.0 100.0 45.5 Not applicable Total in patients interviewed 10 1 11
Table IP10: Satisfaction of patients regarding cleanliness of the facility in Baramulla Type of facility/ Type of Health Facility (Percent) Satisfaction District Hospital CHC PHC All Floor cleaning Satisfied 40.0 100.0 45.5 Somewhat satisfied 10.0 9.1 Not satisfied 50.0 45.5 Toilet/ Bathroom cleaning Satisfied 30.0 27.3 Somewhat satisfied 10.0 9.1 Not satisfied 60.0 100.0 63.6 Changing patient's uniform Satisfied 33.3 33.3 Somewhat satisfied Not satisfied 66.7 66.7 Changing bed sheets Satisfied 30.0 27.3 Somewhat satisfied 30.0 100.0 36.4 Not satisfied 40.0 36.4 Total IPS interviewed 10 1 11
163 Table IP11: Crowding in the facility in Baramulla Crowding in the Type of Health Facility (Percent) facility District Hospital CHC PHC All Availability of cot Immediately 100.0 100.0 100.0 Availability of cot/bed till the time of discharge Yes 80.0 100.0 81.8 No 20.0 18.2 Adequacy of space in the ward Adequate 70.0 100.0 72.7 Somewhat adequate 30.0 27.3 Satisfaction with the ward arrangement Satisfied 70.0 100.0 72.7 Somewhat satisfied 20.0 18.2 Not satisfied 10.0 9.1 Adequacy of space in IPD Adequate 70.0 100.0 72.7 Somewhat adequate 10.0 9.1 Not adequate 20.0 18.2 Total no. of in patients interviewed 10 1 11
Table IP12: Amenities provided by the hospital in Baramulla Percentage of in patients Type of Health Facility reporting availability/ % reporting satisfaction % DH % CHC % PHC % All Availability of amenities Television 10.0 1 9.1 1 Canteen 100.0 10 90.9 10 Medical shop 100.0 10 90.9 10 Telephone Ambulance 100.0 10 100.0 1 100.0 11 Satisfaction among those who said the amenity available Television 100.0 1 100.0 1 Canteen 80.0 8 80.0 8 Medical shop 100.0 10 100.0 10 Telephone Accommodation for relatives 100. Ambulance 100.0 10 0 1 100.0 11
164 Table IP13: Continuity of treatment in Baramulla Type of Health Facility (Percent) Continuity of treatment District Hospital CHC PHC All Overall satisfaction on visiting to facility Dissatisfied 20.0 18.2 Somewhat satisfied 20.0 18.2 Satisfied 60.0 100.0 63.6 Reason of dissatisfaction Lack of facilities Bad experience with doctor Poor quality of services 100.0 100.0 Charges are exorbitant Other Would like to come again in case fell sick Yes 90.0 100.0 90.9 No May come/unsure 10.0 9.1 Whether recommend this hospital to other Yes 90.0 100.0 90.9 No 10.0 9.1 Total in patients interviewed 10 1 11
165 Out Patient Department (OPD)
Background Characteristics (Table OP1) Overall 67 exit interviews were conducted to the patients who had come for consultation at the OPDs of District Hospital Baramulla, two selected CHCs (Chandoosa and Pattan), and four selected PHCs (Fathegrah, Singhpora, G. K. Qasim and Wanigam) in district Baramulla. Table 1 gives the background characteristics of the interviewed respondents. Overall more than one half (58 percent) interviewed patients belonged to age 20 39 years, 13 percent in 40 49 years and 22 percent in 50 years and above. Further six percent respondents were less than 20 years of age. Fifty two percent of the respondents interviewed were male and the rest 42 percent female. As far as the marital status of the respondents is taken into account, about three fourth (72 percent) were currently married while 19 percent were young and unmarried. Most of the respondents (96 percent) interviewed belonged to rural areas while only five percent belonged to urban areas.
The distribution of the respondents with regard to the type of health facility where they were interviewed shows that out of the total of 67 respondents interviewed, 55 percent were taken from the selected PHCs while 30 percent from their respective CHCs and another 15 percent were interviewed at the district hospital.
Purpose of Visit (Table OP2) All the respondents were asked to report for the purpose of the visit to the health facility. In this regard the information collected in Table 2 shows that overall more than one half (54 percent) respondents had gone for the treatment of minor illnesses, 22 percent child illness, 10 percent for antenatal care and three percent for eye check up. Further 10 percent had gone for other illnesses which include some serious diseases like liver, lung, stomach, heart, and kidney problems. The follows of patients for minor illnesses and child illness was seen more at CHCs and PHCs while most of the patients with some serious problems had opted for district hospital, Table 2.
166 Waiting Time and Satisfaction level (Table OP3 and OP4) In order to ascertain the waiting time at a health facility for different facilities availed by the patients, all the respondents were asked to report for the time which they spent at the health facility for availing different services and whether they were satisfied with it or not. Table 3 and 4 shows that overall the average waiting time for registration was 6.9 minutes in the district and 85 percent respondents were satisfied with it and said it was appropriate. The average waiting time for registration decreases from 11.5 minutes at district hospital to 4.2 minutes at PHC level. At district hospital only half of the patients were satisfied with the waiting time for the registration while another half of the patients reported that it was too long. The average waiting time for Doctor’s examination in the district was 12.6 minutes and it varies from 17.2 minutes at the district hospital to 10.8 minutes for the PHCs. Eighty two percent patients were satisfied with the time for consultation by the Doctor while 12 percent patients were not satisfied and said it was too short. In this regard the satisfaction level was highest at district hospital level as all the patients were satisfied and it was lowest for CHCs. Overall 32 patients reported that they were given the injection at their respective health facility and the average waiting time for getting the injection was 5 minutes in the district and almost all the patients (97 percent) were satisfied with it. Further the average time spent on getting the medicines from the health facility in the district was estimated to be 8 minutes and 87 percent patients were satisfied in this regard. Overall six patients reported that they had to go for dressing in the health facility and the average time taken for it was 7.7 minutes in order to pay their bill, on an average it took them about 2 minutes for paying it. All the patients interviewed were found satisfied in this connection in the district (Table 3 and Table 4)
Behaviour of Staff (Table OP5) In order to ascertain the attitude and behaviour of the doctors and other Para medical staff, all the respondents were asked to mention about the behaviour of the staff at the OPD. Table 5 shows that overall 97 percent patients reported that Doctors greet them in a friendly manner/somewhat friendly while three percent reported that they were not friendly at all. Similarly another 97 percent patients reported that behaviour of the Doctor at the OPD was satisfactory (Reasonable/ good/ very kind). All the respondents in district Baramulla who had any interaction
167 with the Para medical staff reported that the behaviour of the Nursing staff, Dispenser, and Technicians at the health facilities was satisfactory (Reasonable/ good/very kind). Only three percent of the respondents were not satisfied with the behaviour of Technicians at the PHC level.
Privacy (Table OP6) Table 6 shows that overall 91 percent patients reported that the privacy was maintained at the OPD during consultation. All the patients who had gone to CHC reported that privacy was maintained while at District hospital and PHC the percentage was 80 and 89 respectively.
Communication (Table OP7) Since patient Doctor communication is one of the important components for the satisfaction of the patient, therefore all the patients were investigated for the same and in this regard Table 7 shows that all the respondents reported that Doctor listened to their description of ailment patiently. Further 97 percent respondents were allowed by the Doctor to ask questions with regard to their illness. All the patients at district hospital OPD were given a chance to ask questions to the Doctor while in case of CHC, five percent patients reported that they were not allowed to ask any question and for PHC OPD this percentage was three. Almost all the respondents (99 percent) reported that they were answered by the Doctors for their questions regarding their illness and discussed about their ailment. Table 7 further shows that overall 87 percent Doctors talked about the recovery of the ailment with the patient while 13 percent respondents reported in negative for the same. Only 37 percent Doctors could provide ‘other advice’ to patients for their ailment and majority (63 percent) Doctors did not provide any advice to the patients in this regard.
Cleanliness and Satisfaction level (Table OP8) Table 8 gives us the detailed information for satisfaction of OPD patients regarding the cleanliness of various facilities at the health facilities they visited for the treatment in district Baramulla. All the interviewed OPD patients were found satisfied with the cleanliness of the OPD and Examination rooms. Further two percent patients who visited the dispensary reported that it was not clean and this was reported by 10 percent patients in case of district hospital. Overall 96 percent patients who visited
168 laboratory during their visit to OPD were also satisfied with the cleanliness their while four percent said that the laboratory was not clean and all these patients had visited to CHC. All the patients who had visited to injection room and dressing room were found satisfied with the cleanliness.
Crowding and Satisfaction level (Table OP9) As far as the satisfaction of the selected OPD patients regarding the crowding in the health facility is concerned, table 9 shows that overall 97 percent patients were satisfied with the management of crowding in the OPD room of the health facility they visited for their illness while three percent reported that it was very crowded at the time they visited the OPD of the health facility. Further 98 percent patients reported that they were satisfied with the management of crowd in the examination room while about three percent found it very crowded in the examination room of the PHC they visited. Ninety two percent patients who availed the services in the dispensary of the health facility found no crowd at the dispensary while 20 percent found it crowded at the PHC level. The laboratory of the health facility was found crowed by eight percent of the patients who had availed the services of laboratory during their visit to OPD. The dressing room was also found crowded by four percent OPD patients and they were not satisfied with the management of crowd in dressing room.
Satisfaction level regarding Health Facility (Table OP10) In order to ascertain the overall level of satisfaction with the visit to health facility by the OPD patients all the respondents were asked to report if they were satisfied with the visit to health facility? Table 10 shows that overall 97 percent patients reported in affirmative while three percent patients were found dissatisfied and all of them reported that the health facility (CHCs and PHCs) they visited lack the basic facilities for OPD patients. Further 96 percent patients reported that they will visit the health facility again if they fell ill while two percent were not sure about the visit. Overall 91 percent respondents reported that they will recommend the health facility (which they visited) to others also while nine percent said that they will not recommend the health facility (which they visited) to others for OPD services.
169 Table OP1: Background characteristics of the out patients in Baramulla Background Characteristics of the Out Patients Percent Age < 20 years 6.0 20 29 years 19.4 30 39 years 38.8 40 49 years 13.4 50 59 years 7.5 60 years or more 14.9 Sex Male 52.2 Female 47.8 Marital status Unmarried 19.4 Currently married 71.6 Divorced/Separated Widowed 9.0 Place of residence Rural 95.5 Urban 4.5 Type of Health Facility District Hospital 14.9 CHC 29.9 PHC 55.2 Total no. of out patients interviewed 67
Table OP2: Purpose of visit to the Health Institution in Baramulla Type of Health Facility (Percent) Purpose of visit in the District Health Institution Hospital CHC PHC All Minor illness 40.0 60.0 54.1 53.7 FP services Antenatal care 10.0 5.0 13.5 10.4 PNC Eye check up 10.0 2.7 3.0 MDT DOTs Child illness 20.0 25.0 21.6 22.4 Other 20.0 10.0 8.1 10.4 Total no. of out patients interviewed 10 20 37 67
170 Table OP3: Waiting time in Baramulla Type of Health Facility Waiting time for District Hospital CHC PHC All Registration Number of patients availed the service 10 20 37 67 Average waiting time (in minutes) 11.5 9.6 4.2 6.9 Doctor's examination Number of patients availed the service 10 20 37 67 Average waiting time (in minutes) 17.2 13.6 10.8 12.6 Injection Number of patients availed the service 9 12 11 32 Average waiting time (in minutes) 6.2 4.8 4.2 5.0 Getting medicines Number of patients availed the service 10 9 19 38 Average waiting time (in minutes) 12.2 6.9 6.6 8.1 Dressing Number of patients availed the service 1 1 4 6 Average waiting time (in minutes) 20.0 5.0 5.3 7.7 Paying bill Number of patients availed the service 5 14 27 46 Average waiting time (in minutes) 4.2 2.4 1.1 1.8
171
Table OP4: Satisfaction regarding waiting time in Baramulla Type of Health Facility (% of patients) Satisfaction District Hospital CHC PHC All Registration Too long 50.0 10.0 8.1 14.9 Appropriate 50.0 90.0 91.9 85.1 Too short Can't say Number of patients availed the services 10 20 37 67 Doctor's examination Too long 10.0 5.4 6.0 Appropriate 100.0 75.0 81.1 82.1 Too short 15.0 13.5 11.9 Can't say Number of patients availed the services 10 20 37 67 Injection Too long 8.3 3.1 Appropriate 100.0 91.7 100.0 96.9 Too short Can't say Number of patients availed the services 9 12 11 32 Getting medicines Too long 40.0 11.1 13.2 Appropriate 60.0 88.9 100.0 86.8 Too short Can't say Number of patients availed the services 10 9 19 38 Dressing Too long Appropriate 100.0 100.0 100.0 100.0 Too short Can't say Number of patients availed the services 1 1 4 6 Paying bill Too long Appropriate 100.0 100.0 100.0 100.0 Too short Can't say Number of patients availed the services 5 14 27 46
172 Table OP5: Behaviour of staff in Baramulla Type of Health Facility Staff Behaviour DH CHC PHC All Doctor greet in a friendly manner Not friendly 5.0 2.7 3.0 Yes, somewhat 10.0 5.0 10.8 9.0 Yes 90.0 90.0 86.5 88.1 Did not interact/ Not applicable Behaviour of Doctor Rude 5.4 3.0 Reasonable 10.0 3.0 Good 30.0 25.0 32.4 29.9 Very kind 70.0 65.0 62.2 64.2 Did not interact/ Not applicable Behaviour of Nursing Staff Reasonable 40.0 15.0 8.1 14.9 Good 50.0 45.0 56.8 52.2 Very kind 10.0 13.5 9.0 Did not interact/ Not applicable 40.0 21.6 23.9 Behaviour of Dispenser Rude Reasonable 30.0 10.0 5.4 10.4 Good 70.0 30.0 48.6 46.3 Very kind 5.0 5.4 4.5 Did not interact/ Not applicable 55.0 40.5 38.8 Behaviour of Technician Rude 2.7 1.5 Reasonable 20.0 3.0 Good 30.0 15.0 18.9 19.4 Very kind 25.0 7.5 Did not interact/ Not applicable 50.0 60.0 78.4 68.7 Total no. of out patients interviewed 10 20 37 67
Table OP6: Privacy in Baramulla Type of Health Facility (Percent) Privacy DH CHC PHC All Patients reporting presence of privacy at the place of examination 80.0 100.0 89.2 91.0 Total no. of out patients interviewed 10 20 37 67
173
Table OP7: Patient Doctor/Provider Communication in Baramulla Type of Health Facility (Percent) Patient Doctor Communication District Hospital CHC PHC All Doctor listened to description of ailment patiently Yes, somewhat 5.0 8.1 6.0 Yes, always 100.0 95.0 91.9 94.0 No Did not interact/Not Applicable Doctor allowed to ask questions Yes, somewhat 20.0 5.0 4.5 Yes, always 80.0 90.0 97.3 92.5 No 5.0 2.7 3.0 Did not interact/Not Applicable Doctor responded to questions Yes, somewhat 5.0 1.5 Yes, always 100.0 90.0 97.3 95.5 No 5.0 2.7 3.0 Did not interact/Not Applicable Doctor discussed about the ailment Yes 90.0 95.0 94.6 94.0 No 10.0 5.0 5.4 6.0 Did not interact/Not Applicable Doctor talked about the recovery Yes 90.0 90.0 83.8 86.6 No 10.0 10.0 16.2 13.4 Did not interact/Not Applicable Doctor gave 'other advice' Yes 20.0 45.0 37.8 37.3 No 80.0 55.0 62.2 62.7 Did not interact/Not Applicable Total no. of out patients interviewed 10 20 37 67
174 Table OP8: Satisfaction of OPD patients regarding cleanliness of the facility in Baramulla Satisfaction Type of Health Facility (Percent of patients) regarding cleanliness in the District facility Hospital CHC PHC All OPD Room Not clean Partially clean 10.0 10.0 8.1 9.0 Clean 90.0 90.0 91.9 91.0 No. of patients availed the services 10 20 37 67 Examination Room Not clean Partially clean 30.0 15.0 2.7 10.4 Clean 70.0 85.0 97.3 89.6 No. of patients availed the services 10 20 37 67 Dispensary Not clean 10.0 1.9 Partially clean 10.0 15.4 3.3 7.5 Clean 80.0 84.6 96.7 90.6 No. of patients availed the services 10 13 30 53 Laboratory Not clean 11.1 4.2 Partially clean Clean 100.0 88.9 100.0 95.8 No. of patients availed the services 5 9 10 24 Injection Room Not clean Partially clean 25.0 7.1 9.1 Clean 75.0 100.0 92.9 90.9 No. of patients availed the services 8 11 14 33 Dressing Room Not clean Partially clean 80.0 16.0 Clean 20.0 100.0 100.0 84.0 No. of patients availed the services 5 9 11 25
175 Table OP9: Satisfaction of OPD patients regarding crowding in the facility in Baramulla Satisfaction Type of Health Facility (Percent of patients) regarding crowding District in the facility Hospital CHC PHC All OPD Room Not adequate 10.0 5.0 3.0 Somewhat adequate 20.0 25.0 24.3 23.9 Adequate 70.0 70.0 75.7 73.1 Not applicable No. of patients availed the facility 10 20 37 67 Examination Room Not adequate 2.7 1.5 Somewhat adequate 30.0 25.0 24.3 25.4 Adequate 70.0 75.0 73.0 73.1 No. of patients availed the facility 10 20 37 67 Dispensary Not adequate 6.7 3.8 Somewhat adequate 20.0 23.1 13.3 17.0 Adequate 80.0 76.9 80.0 79.2 No. of patients availed the facility 10 13 30 53 Laboratory Not adequate 20.0 8.3 Somewhat adequate 11.1 4.2 Adequate 100.0 88.9 80.0 87.5 No. of patients availed the facility 5 9 10 24 Injection Room Not adequate Somewhat adequate 16.7 7.1 8.8 Adequate 100.0 83.3 92.9 91.2 No. of patients availed the facility 8 12 14 34 Dressing Room Not adequate 8.3 3.8 Somewhat adequate 20.0 11.1 8.3 11.5 Adequate 80.0 88.9 83.3 84.6 No. of patients availed the facility 5 9 12 26
176 Table OP10: Continuity of treatment in Baramulla Type of Health Facility (Percent) Continuity of District treatment Hospital CHC PHC Total Satisfaction with the visit to the health facility Dissatisfied 5.0 2.7 3.0 Somewhat satisfied 30.0 15.0 13.5 16.4 Satisfied 70.0 80.0 83.8 80.6 Reason of dissatisfaction, if dissatisfied Lack of facilities 100.0 100.0 100.0 Bad experience with doctors Poor quality of services Charges are exorbitant Other Visit again to the facility (if fell sick) Yes 100.0 90.0 97.3 95.5 No 5.0 2.7 3.0 May come/unsure 5.0 1.5 Recommend this hospital to others Yes 90.0 85.0 94.6 91.0 No 10.0 15.0 5.4 9.0 Total no. of out patients interviewed 10 20 37 67
Note: Various websites of the Ministry of Health and Family Welfare, Government of India, State website, District websites and other related websites containing the information about various Components of NRHM were used during the write up of this report. The Census Handbook of Baramulla was also used during the study
177 SCHEDULE (S): STATE SCHEDULE
Block A. Identification Details (Information to be collected from State Health Department) Q. No. Questions S101. Name of the State Jammu and Kashmir S102. Total Number of Districts 22 (Twenty two) S103. Total Number of Census Villages (2001 census) 6652 S104. Name of the Respondent Irshad Mir S105. Designation of the Respondent SPM
Block B. (I) Population of the State (As on 2001 as per Population Census) Rural Urban Total Q. No. Category Male Female Male Female Male Female S106. Scheduled Caste 331380 304636 71876 62263 403256 366899 770155 S107. Scheduled Tribe 550329 504159 28620 22871 578949 527030 1105979 S108. Others 3095943 2840615 1282778 1048230 4378721 3888845 8267566 S109. 3977652 3649410 1383274 1133364 5360926 4782974 10143700 Total Block B. (II) Population of the State (As on March, 2008) (Information to be collected from State Health Department) Rural Urban Total Source Code (Population Projection – Q. No. Category Male Female Male Female Male Female 1; State Estimate – 2; Not Available-3) S110. Scheduled Caste 397656 365563 86251 74715 483907 440278 924186 S111. Scheduled Tribe 660394 604990 34344 27445 694738 632436 1327174 S112. Others 3715131 3408738 1539333 1257876 5254465 4666614 9921079 S113. 4773182 4379292 1659928 1360036 6433111 5739568 12172440 Total
Block C. Infrastructure (Information to be collected from Programme Manager in State Programme Management Unit (SPMU)) S114. Name of the Respondent S115. Designation of the Respondent SPMU Public Health Infrastructure Total Existing New Buildings Total Number No. of facilities where IPHS (In Nos.) (As on Under Construction where IPHS facility Upgradation completed 30.6.2008) (In Nos.) (As on survey completed (As on 30.6.2008) 30.6.2008) (As on 30.6.2008) S116. Sub Centre 1907 INA 1907 S117. PHC 375 375
178 S118. 24x7 PHC 85 85 85 S119. CHC 85 85 15 S120. First Referral Units(FRU) S121. Mobile medical unit 02 S122. Sub Divisional Hospital S123. District Hospital 14 14 14 S124. AYUSH Private Health Total Existing Infrastructure (In Nos.) (As on 30.6.2008) S125. Hospitals (More than 30 INA bedded) S126. Nursing Homes (Less than INA 30 bedded) Block D. Rogi Kalyan Samitis (RKS)(Information to be collected from Programme Manager in State Programme Management Unit (SPMU)) Q. No. How many facilities have Rogi Kalyan Samitis (RKS) Registered? Total Functioning No. with Registered RKS S127. District Hospital 14 14 S128. Sub Divisional Hospital S129. CHC 85 85 S130. PHC 375 375 S131. Block PHC Not existing
S132. Addl. PHC Not existing
Block E. Janani Suraksha Yojana(JSY)(Information to be collected from Programme Manager in State Programme Management Unit (SPMU)) Q. No. Response Category Skip S133. Whether any PPP initiative Yes undertaken in the state for the implementation of JSY > Q. S135 Scheme? S134. If yes, number of private 07 health facilities accredited for JSY scheme
Q. No. Total Institutional Total number of Out of total number of Registered JSY Deliveries Reported Registered JSY Women Women, number of women opting for during 2007-08 during 2007-08 Institutional Delivery during 2007-08 At Govt. Facilities S135.SC INA INA INA S136.ST INA INA INA S137.General INA INA INA
179 S138.BPL INA INA INA S139.APL INA INA INA S140.Total 151144 151144 INA At Private Facilities (Wherever accredited for services) S141.Scheduled INA INA INA Caste S142.Scheduled INA INA INA Tribe S143.General INA INA INA S144.BPL INA INA INA S145.APL INA INA INA S146.Total INA INA INA
Block F. Financial Mechanisms (Information to be collected from Finance Manager in State Programme Management Unit (SPMU)) Q. No. Response Category Skip
S147. Name of the Respondent S148. Designation of the Respondent S149. Have all the vertical health societies Yes created under different programmes > Q. S151 merged in to State Health Society under NRHM? S150. How many districts have merged 14 registered health societies? S151. Is there a common bank account for No all programmes in State Health Society S152. Has the perspective State Health Yes Plan been prepared for 2008-09? > Q. S155 S153. How many districts have District Health action Plans have been Action Plans for the current year prepared in 2007-2008 (2008-09)? S154. Have these plans been approved by Yes the state society? S155. How are the funds being allocated Activity wise to the districts Flexi pool funds Size of district (Encircle all applicable options) Previous years expenditure S156. Are the funds being transferred Yes electronically by the State to the >Q S158 district?
180 Block F. Financial Mechanisms (Information to be collected from Finance Manager in State Programme Management Unit (SPMU)) Q. No. Response Category Skip
S157. If yes, then to how many districts is 22 it being transferred electronically? S158. How many Sub Centres have 1907 Operational Joint Bank Account of ANM and Sarpanch? No. of centres for which Untied Grant for the current year has been transferred? S159. CHC 85 S160. PHC 375 S161. Sub Centre 1907
181 SCHEDULE (D): DISTRICT SCHEDULE
Part A Block A. Identification Details (Information to be collected from District NRHM Society) Q. No. Questions D101. Name of the District Baramulla D102. Total Number of Blocks in the District 10 (Ten) D103. Total Number of Census Villages (2001 census) in 526 the District D104. Name of the Respondent M. Ashraf D105. Designation of the Respondent DPM
Block Population of the District (As on 2001 as per Population Census) B. (I)
Rural Urban Total Total Population Q. No. Categor Femal Male Female Male Male Female y e D106. SC 282 18 77 359 18 377 D107. ST 43744 39340 449 363 44193 39703 83896 D108. Others 509182 464276 105634 90688 614816 554964 1169780 D109. 553208 503634 106160 91051 659368 594685 1254053 Total Population of the District (As on March, 2008) (Information to be collected from Block State Health Department) B. (II) Rural Urban Total Source Code (Population Q. No. Category Male Female Male Female Male Female Projection –Estimate – 2; D110. SC INA INA INA INA Total =92 2 D111. ST INA INA INA INA Total = 62608 2 D112. Others INA INA INA INA Total =1023887 2 D113. INA INA INA INA Total= 1086587 2 Total
182 Block Infrastructure [Information to be collected from Chief Medical Officer (CMO) Office] C. D114. Name of the Respondent D115. Designation of the Respondent CMO Public Health Infrastructure Total Existing New Buildings Total Number No. of facilities where (In Nos.) (As on Under where IPHS IPHS Upgradation 30.6.2008) Construction facility survey completed (As on (In Nos.) (As on completed (As 30.6.2008) 30.6.2008) on 30.6.2008)
D116. Sub Centre 134 00 00 00 D117. PHC 28 00 00 00 D118. 24x7 PHCs 15 00 00 00 D119. CHC 06 00 06 02 D120. First Referral Units 07 00 07 02 (FRUs) D121. Mobile medical units 00 D122. Sub Divisional Hospitals 00 00 00 00 D123. District Hospitals 01 01 01 00 D124. AYUSH 00 00 00 00
Private Health Infrastructure Total Existing (In Nos.) (As on 30.6.2008) D125. Hospitals (More than 30 bedded) 06 D126. Nursing Homes (Less than 30 bedded) 05
Facilities available in the district for delivery Number of Facilities Facility Total Operational Providing With CeMOC With New Born Care existing in 24x7 BeMOC (having Blood Unit the District Storage, (As on Anesthetist and 30.6.2008) Gynecologist) D127. DH 01 01 00 01 01 D128. SubDH 00 00 00 00 00 D129. CHC 06 06 00 00 03 D130. PHC 28 15 00 00 05 D131. Public 02 02 00 02 02 Maternity Homes D132. Others Public 00 00 00 00 00 (ESI, Railways etc.) D133. Others 00 00 00 00 00 Private D134. Private 02 02 00 00 02 accredited for JSY
183
Block D. Human Resources Available in the District (Information to be collected from Chief Medical Officer (CMO) Office) Q. No. Category No. Regular in Contractual Total in sanctioned Position Recruits Position D135. Medical Officer 28 28 00 28 D136. Gynecologist 07 03 00 03 D137. Anesthetist 06 05 00 05 D138. Pediatrician 06 01 00 01 D139. Other Specialists 14 06 00 06 D140. Staff Nurses 63 45 03 48 D141. ANM 186 133 32 165
Block E. Rogi Kalyan Samitis (RKS) Information to be collected from District Programme Management Unit (DPMU) Q. No. D142. Name of the Respondent D143. Designation of the DPMU Office Respondent Number of facilities having Rogi Kalyan Samitis (RKS) Registered? Total functioning No. with Registered RKS D144. District Hospital 01 01 D145. Sub Divisional Hospital 00 00 D146. CHC 06 06 D147. PHC 28 28
Block Janani Suraksha Yojana(JSY) (Information to be collected from District F. Programme Management Unit (DPMU)) Q. No. Response Category Skip D148. Whether any PPP initiative being Yes > Q D151 undertaken in the district for the implementation of JSY Scheme?
184 Block Janani Suraksha Yojana(JSY) (Information to be collected from District F. Programme Management Unit (DPMU)) Q. No. D149. If yes, number of private 02 health facilities accredited for JSY scheme D150. Which of the following A,B,Fand H areas are covered under PPP initiatives (Encircle all applicable options)
Q. No. Total Total number of Out of total Institutional Registered JSY number of Deliveries Women during Registered JSY Reported during 2007 08 Women, number of 2007 08 women opting for Institutional Delivery during 2007 08 At Govt. Facilities D151. Scheduled Caste 47 47 47 D152. Scheduled Tribe 213 213 213 D153. General 9492 9492 9492 D154. APL INA INA INA D155. BPL INA INA INA D156. Total 9752 9752 9752 At Private Facilities (Wherever accredited for services) D157. Scheduled Caste NIL NIL NIL D158. Scheduled Tribe NIL NIL NIL D159. General NIL NIL NIL D160. APL NIL NIL NIL D161. BPL NIL NIL NIL D162. Total NIL NIL NIL
Block G. Financial Mechanisms (Information to be collected from Finance Manager in District Programme Management Unit (DPMU)) Q. No. D163. Name of the Respondent D164. Designation of the DPMU Office Respondent
185 Response Category Skip D165. Have all the vertical health societies created under different Yes >Q D167 programmes merged in to a District Health Society? D166. Whether the merged district Yes health society is registered? D167. Is there a common bank Yes account for all programmes in District Health Society D168. Whether the district has Yes prepared District Action Plan for >Q D170 the current year? 2008 09 D169. If yes, has the plan been Yes approved by the district society? D170. How are the funds being received from the State in the district (Encircle all applicable options) A & B
D171. Are the funds received were transferred electronically by the Yes State D172. How many Sub Centres have Operational Joint Bank Account 134 of ANM and Sarpanch? No. of centres for which Untied 134 Grant for the current year transferred? 2008 09 D173. CHC/SDH 6 D174. PHC 28 D175. Sub Centre 134
186 DISTRICT SCHEDULE Part B District Hospital
Block A. Identification Details (Information to be collected from the Office Of Medical Superintendent of the Hospital) Q. No. Questions (for both Male/Female) D176. Name of District Hospital Distt. Hospital Baramulla D177. Name of the Respondent Dr. M. Shafi D178. Designation of the Respondent Med. Superintendent Distance & Time Taken to travel to District Hospital in Distance (in Time (in public transport from Kms.) Hrs.) D179. Nearest CHC in the coverage area 20 45 D180. Farthest CHC in the coverage area 50 02 D181. Distance of District Hospital from the nearest bus < 0.5 Km. .A stop (in Kms.) D182. Has the IPHS facility survey been carried out in the Yes District Hospital Block B. Physical Infrastructure (Information to be collected from the Office Of Medical Superintendant of the Hospital and supplemented by observation) Q. No. Questions Response Category 15161.8 D183. Area of the Hospital (in Sq. mtrs.) 110 D184. Number of indoor beds available Yes D185. Is the hospital located near residential area?
D186. Is necessary environmental clearance obtained Yes from Pollution Control Board by the Hospital? D187. Whether hospital building is disable friendly as per Yes provisions of Disability Act? (Ramp, Lift, wheel chair movement etc.) Administrative/ Main Block (Availability of following) D188. Waiting Space adjacent to each consultation and No treatment room D189. Registration Counter Yes Yes D190. Blood Bank/ Blood storage Unit
D191. Doctors' Duty Room Yes D192. Isolation Room Yes D193. Treatment Room Yes D194. Pharmacy (Dispensary) Yes
187 D195. Intensive Care Unit (ICU) Yes D196. High Dependency Wards No D197. Critical Care Area (Emergency Services) Yes Yes D198. Examination and Preparation Room
Hospital Services D199. Hospital Kitchen (Dietary Service) No D200. Central Sterile and Supply Department (CSSD) Yes D201. Hospital Laundry Yes Yes D202. Medical and General Stores
D203. Engineering Services Backup No Ventilation (Natural or mechanical exhaust) in the Yes D204. wards D205. Water coolers / Refrigerators Yes D206. Round the clock water supply Yes Overhead water storage tank with Pumping and Yes D207. boosting arrangements D208. Provision for fire fighting No Proper drainage and sanitation system for waste Yes D209. water, surface water, sub soil water and sewerage A,B and C How is the Bio Medical Waste disposed? D210. (Encircle all applicable options)
Is Bio Medical Waste segregated in three different D211. Yes bins? Number of Residential Quarters available for all medical No. No.
and Para medical staff Available Occupied D212. Medical Staff 06 06 D213. Para medical staff 02 02 D214. Parking place Yes D215. Medical Records Section Yes Is the disease classification being carried out as Yes D216. per protocols Yes D217. Availability of telephone
D218. Availability of Fax equipment No D219. Availability of Computers Yes D220. Availability of Internet services No
188
Obstetrics & Gynae Section (Information to be collected from the Sister In charge of Gynae ward & supplemented by Observation from records) D221. Name of the Respondent D222. Designation of the Respondent FMPW Response Category Skip D223. Is there a separate Ward for Yes Female Patients? >Q D224 D224. If Yes, the number of beds 24 D225. Bed Occupancy Rate in the last 100% 12 months (As on March 31, 2008) D226. Total OPD in last 3 calendar 55000 months D227. Total deliveries in last 3 calendar 646 months D228. Is there a separate OT available Yes for Gynecology & Obstetrics Procedures Carried Out Particulars Availability of Services If Yes, Numbers in 2007 2008 2751 D229. Total deliveries conducted D230. Caesarean section deliveries Yes 313 No D231. Caesarean section for JSY
Yes INA D232. Assisted Delivery
Yes INA D233. Forceps delivery
Yes 281 D234. MTP
D235. Mid trimester Abortion Yes INA D236. Ectopic Pregnancy Yes INA Yes INA D237. Retained Placenta D238. Eclampsia Yes INA Yes INA D239. PPH
Yes 30 D240. Sterlisation
189 D241. Suturing Cervical Tear Yes INA D242. Hysterectomy No D243. Infertility Treatment No Surgical Section (Information to be collected from the Sister In charge of Surgical ward & supplemented by Observation) D244. Name of the Respondent Dr. Qayum D245. Designation of the Respondent surgeon No. of Surgical OPD in last three months: 11000 D246. Female INA D247. Male INA No. of Surgical IPD in last three months: 552 D248. Female INA D249. Male INA
Availability of Services Response Category If Yes, Numbers in last 3 months D250. Emergency (Accident & other Yes 120 emergency) (Casualty) D251. Pancreas Surgery No D252. Spleen and Portal No Hypertension Surgery D253. Yes 40 Abdomen Surgery
D254. Yes 00 Breast Surgery
D255. Leprosy Reconstructive No surgery
Medical Section (Information to be collected from the Sister In charge of Medical ward & supplemented by Observation) D256. Name of the Respondent D257. Designation of the Respondent FMPW Medical OPD in last three months 16500 D258. Female INA D259. Male INA Medical IPD in last three months 828
190 D260. Female INA D261. Male INA Availability of Services Response Category If Yes, Numbers in last 3 months Dermatology and Venerology 5500 D262. Yes (Skin & VD) RTI / STI D263. Services under NLEP Yes 00 D264. Yes INA Pleural Aspiration
D265. Pleural Biopsy No D266. Bronchoscopy No D267. Lumbar Puncture Yes INA D268. Pericardial tapping No D269. Skin scraping for fungus / AFB No D270. Bone Marrow Biopsy No D271. Endoscopic Specialized No Procedures D272. Psychiatry Services Yes INA
Pediatric Section (Information to be collected from the Sister In charge of Pediatric ward & supplemented by Observation) D273. Name of the Respondent D274. Designation of the Respondent MHW Pediatric OPD in 2007 2008 Numbers: 46575 D275. Female INA D276. Male INA D277. Designated/identified Beds for Yes >Q D280 newborns available?
D278. If yes, no. of beds 10 Pediatric Patients admitted Numbers in 2007 2008
D279. Total Admitted 2418 D280. Neonates admitted INA D281. Other Infants (0 1 years) INA admitted
191 Pediatric Section (Information to be collected from the Sister In charge of Pediatric ward & supplemented by Observation) D282. Children under 5 yrs admitted INA Services Available
D283. Asphyxia Management Yes
D284. Management of severe Yes malnourished children D285. Management of Neo Natal Yes Sepsis D286. Management of Dehydration Yes and Diarrhoeal Cases D287. Management of Respiratory Yes Tract / Pnuemonia Cases Available? If available, Equipment Available whether working? D288. Cradle No D289. No Incubator
D290. Yes Yes Radiant Heat Warmer
D291. Yes Yes Phototherapy Unit
D292. Yes Bag with Mask
D293. Yes Yes Laryngoscope
D294. Yes Oxygen Mask
D295. Yes Yes Suction Machine
D296. Yes Yes Thermometer
Availability of drugs D297. No ORS (WHO new formula)
D298. Yes Vitamin A Solution
192 Pediatric Section (Information to be collected from the Sister In charge of Pediatric ward & supplemented by Observation) D299. Yes Iron folic Acid Syrup
D300. Yes Pediatric Antibiotics
Diagnostic Section (Information to be collected from Radiology Section & supplemented by Observation) D301. Name of the Respondent D302. Designation of the Respondent X ray Technician Diagnostic OPD in last 3 months 4511 D303. Female INA D304. Male INA Response Category If Yes, Number Availability of services carried out in last 3 months D305. X Ray Yes 3097
D306. Ultrasound Yes 657
D307. Ultrasound guided Biopsy No D308. ECG Yes 757
Lab Services (Information to be collected from the Lab Technician & supplemented by Observation) D309. Name of the Respondent D310. Designation of the Respondent Pathologist Number attended in last 3 months 4484 D311. Female INA D312. Male INA Response Category If Yes, Number Availability of services carried out in last 3 months CLINICAL PATHOLOGY D313. Hematology Yes 1727 D314. Urine Analysis Yes 604
193 Diagnostic Section (Information to be collected from Radiology Section & supplemented by Observation) D315. Stool Analysis Yes 13 D316. Semen Analysis (morphology, Yes 04 count)
D317. CSF Analysis (Cell count, Yes 00 culture sensitivity etc., gram
staining) D318. Aspirated fluids (cell count Yes INA cytology)
PATHOLOGY D319. PAP smear No D320. Split Skin Smear Examination for leprosy No D321. Sputum Yes 172 D322. Histopathology No D323. Microbiology No D324. Serology Yes 747 D325. Biochemistry Yes 1217 D326. Physiology (Pulmonary function No test)
Block C. Human Resource (Information to be collected from the Statistics Section of the Office of Medical Superintendent of the Hospital) D327. Name of the Respondent D328. Designation of the Med. Superintendent Respondent Category of Personnel Sanctioned Regular Contractual Total In In Position Position D329. Hospital Superintendent 01 01 00 01 D330. Medical Specialist 02 02 00 02 D331. Surgery Specialist 02 02 00 02 D332. Gynecologist 03 02 00 02 D333. Gynecologists (short term 00 00 00 00 trained MO) D334. Pediatrician 01 01 00 01 D335. Anesthetist 02 02 00 02
194 Block C. Human Resource (Information to be collected from the Statistics Section of the Office of Medical Superintendent of the Hospital) D336. Anesthetist (short term trained 01 00 00 00 MO) D337. Radiologist 02 02 00 02 D338. General Duty Doctor 29 29 02 31 D339. Public Health Manager 00 00 00 00 D340. AYUSH Physician 02 02 00 02 D341. Pathologists 01 00 00 00 D342. Psychiatrist 00 00 00 00 D343. Dermatologist / Venereologist 00 00 00 00 D344. ENT Surgeon 01 01 00 01 D345. Ophthalmologist 01 01 00 01 D346. Orthopaedician 01 01 00 01 D347. Microbiologist D348. Dental Surgeon 03 02 00 02 Para Medicals/ D349. Staff Nurse 19 15 00 15 D350. Hospital worker (OP/ward +OT+ blood bank) D351. Sanitary Worker 02 02 00 02 Category of Personnel Sanctioned Regular Contractual Total In Position In Position D352. Ophthalmic Assistant / 01 01 00 01 Refractionist D353. Social Worker / Counselor 00 00 00 00 D354. ECG Technician 00 00 00 00 D355. Audiometrician 00 00 00 00 D356. Laboratory Technician ( Lab + 03 03 00 03 Blood Bank) D357. Laboratory Attendant 03 03 00 03 (Hospital Worker) D358. Dietician 00 00 00 00 D359. ANM 05 05 00 05 D360. LHV 01 01 00 01 D361. PHN 00 00 00 00 D362. Radiographer 00 00 00 00 D363. Pharmacist 10 10 00 10
195 Block C. Human Resource (Information to be collected from the Statistics Section of the Office of Medical Superintendent of the Hospital) D364. Matron 00 00 00 00 D365. Physiotherapist D366. Medical Records Officer / 03 02 00 02 Technician Administrative Staff D367. Manager (Administration) D368. Junior Administrative Officer D369. Office Superintendent 01 01 00 01 D370. Accounts Manager D371. Driver 04 03 01 04 D372. Peon 09 09 00 09
Block D. Other Framework and Structure Related Issues (Information to be collected from the Office of Medical Superintendent of the Hospital) Response Category Skip D373. Whether the Rogi Kalyan Yes Samiti established for the >Q D374 Hospital D374. If Yes, whether Rogi Kalyan Yes Samiti Registered for the Hospital? D375. Are there any official charges for Yes consultation/ procedures? >Q D377 D376. If yes, are people belonging to Yes BPL/ SC/ ST exempted/ subsidized? >Q D377 D377. If yes, what is the procedure for Others (please specify) granting exemption (Encircle all Need Based E applicable options) D378. How do RKS generate additional User fees .. ..B None resources other than govt. grants? (Encircle all applicable options) D379. How is the money generated Retained within the facility used? (Encircle all applicable for local use .. .. A options)
D380. Is display board put up in Hospital No showing number of members, number of meetings of RKS etc?
196 Block D. Other Framework and Structure Related Issues (Information to be collected from the Office of Medical Superintendent of the Hospital) D381. How feedback is taken for Public Scrutiny of action None grievance redressal by RKS? taken .. ..2
D382. Any Other Special Ward/ Procedures not covered above Any other remarks by MS of the hospital/ Other members which have not been captured in the questions above but are relevant The medical superintendent of the hospital reported that there is urgent need in the improvement of the sanitation of the hospital so that proper care may be taken towards the hygienic conditions of the visitors of the hospital.
It was also reported that there is also need of additional staff of Para medicals, drivers and some sweepers for the smooth functioning of the hospital.
197