1.District Calicut Major observations of Regional Evaluation Team, Chennai about the Evaluation work in Calicut District of Kerala State in October, 2009.

I. Details of the visited Institutions: District Visited GH, PHCs and CHCs visited HSCs and Scan Centres visited Calicut GH: Quilandy HSCs: Paranur, Avilora, Pannur, CHCs: Narikkuni and Palazhi, Iringallur and Poolenkara Olavanna Sarada Hospital Scan Centre- PHC :Kizhakothu Quilandy, Appollo Scan Centre- Quilandy

II. Major Observations: 1. Human Resources: Staff position at various Institutions in the district was satisfactory as very few sanctioned posts were vacant. In spite of sufficient staff and manpower very few deliveries were conducted in Govt. Hospital Quilandy. In CHC Narikkuni the post of Gynecologist was found vacant, In PHC Kizhakothu the post of male health supervisor (HI) was vacant.

2. Functioning of Rogi Kalyan Samiti(RKS) and Village Health & Sanitation Committee(VHSC): a. Rogi Kalyan Samitis were reported to be formed in all the 87 institutions in the district. b. RKS meetings at the visited GH, PHC and CHCs were being held regularly once in two months. c. 1466 VHSCs were formed in the district. d. It was observed that the meetings of VHSCs under GH Quilandy were being conducted regularly. e. Utilisation of funds in the visited CHCs was being done as per norms. f. ASHA is a member in the VHSCs 3. ASHA Scheme:

a. Out of total 2592 ASHAs selected in the district, as many as 2568 were given 7 days induction training but only 657 ASHAs were provided with drug kits. b. Drug kits were supplied to the ASHAs at GH Quilandy after validity date expired. The performance of the ASHAs at GH was poor, only one delivery case was motivated. c. In the visited PHCs, ASHAs were trained upto second module. 4. Untied Funds: a. As per information received from the district, Rs.16.97 crores were received under various financial heads from the state HQ to the district office during 2007 and September 09. Out of it, Rs.16.5 lakhs were sanctioned as untied funds to CHCs, and Rs.14.26 lakhs were spent for the above period. As Regards, untied funds to PHCs, in totality Rs.31.0 lakhs were received. But spent more by adjusting from the flexi pool to the tune of Rs.40.6 lakhs. Similarly, the district has spent Rs.71.58 lakhs for strengthening of various HSCs under the head but only 53.8 lakhs were sanctioned initially. b. It was observed that the funds were being utilized at the visited centres. 5. Services of JSY: a. The details of functioning of JSY Scheme in the district were not made available to the team at the district office. However, it was reported that the district had received a total of Rs.3.06 crores under JSY, out of which Rs.2.96 crores were spent for the period 2007-08 to 2009-10 (up to September 2009). b. In the visited CHCs and PHCs, the beneficiaries were covered for providing the services and cash incentives. 6. 24 Hour Service: In the district, 8 PHC/CHCs were functioning as 24 hours delivery care centres but very few deliveries conducted by these centres. In the visited Institutions at Narikkuni, Olavanna & Kizhakothu not a single delivery has been conducted in the current year even though the required facilities were available. 7. Physical infrastructure: (i) Sub Centres: a. Visiting team observed that basic equipments like essential furnitures, drugs and some equipments were not available in HSC Palazhi. b. As there was no labor room, delivery was not being conducted in the visited 6 HSCs during last few years.

c. Essential equipments and drugs like delivery table, mclntsh sheets, Ambut bag/suction, IUD insertion kit, DDKs, Oxytocin Tab, Metranidazole, cap ampicillin, gentamycin injection and kits A&B were not available in almost all the HSCs visited. d. SBA training was not provided to the ANMs in 4 out of 6 visited HSCs. (ii) GH/CHCs/PHCs: GH Facility: a. In GH Quilandy, out of 159 sanctioned bed strength only 122 were available at present. The space in the building is not sufficient in view of large number of IP & OP strength. b. Blood Storage unit and USG facility were not functional due to want of skilled manpower. c. Residential quarters were not provided to MOs and Staff. d. The hospital needs orthopedics and anesthesiology specialists. Considering the facilities and manpower availability, the performance of the delivery was not upto the mark in this hospital. There were only 11deliveries during the past 3 months. It was 316 in 2005, 151 in 2006, 72 in 2007 and 24 in 2008 showing steeply declining trend. CHCs Facility: a. CHC Narikkuni has all the necessary infrastructure, equipments and medicines except Jeep & IFA supply. Blood storage facility was not available there. Labour room and OT were not functioning from last 2 years. b. CHC Olavanna had shortage of IFA Tablets. c. Both the visited CHCs and GH did not have incinerator facility. PHC Facility: In PHC Kizhakothu, facilities of vehicle, driver, lab technician, oxygen cylinder, OT, surgical equipment, labour room and quarters for MOs and staffs were not available. 8. Community knowledge and opinion on health services: a. The visited team had contacted 54 mothers having child upto one year old in the area of visited HSCs in the district for evaluating their knowledge, health awareness and ANMs activities. b. 18(33.4%) mothers did not get PNC checkup by the field staff and only 17(31.5%) were mothers visited by the health personnel within 24 hours of their delivery. c. ARI danger sign was not known to 35(64.8%) mothers. d. 30(55.6%) mothers were not put to any contraceptive methods and knowledge about side effect of contraceptive method was not known to 38(70.3%)mothers.

e. For assessing the services that were being provided in the PHCs/CHCs, the team contacted different category of the peoples like ANC, PNC and 2 year old child’s mothers, AWW, ASHA, Village leaders etc. and observed that the mother care services need more attention during ANC and PNCs. f. Some of the villagers informed that they are utilizing the health care services of PHCs and CHCs and instead like to visit District level Hospital as well as private hospitals. 9. Reconciliation of the performance report: a. Performance reported by the district Office under sterilization, IUD, OP and Nirodh methods for the year 2008-09 did not tally with the figures reported by CHC/GH and recorded in the service registers. The following table gives the details as reported by the team. Centres verifi Sterilisation IUD

Reported by Reported by Recorded in Reported byReported byRecorded in Distt. CHC service registe Distt. CHC service register 1.CHC Narikku 1376 70 70 676 670 x 2.CHC Olavann 346 304 x 319 270 115* x Service register was not maintained * Incomplete register even after more than one and half year passed. Name of the centres verifie Oral Pills Cycles Nirodh Pieces Reported by Dis Reported by Reported by Reported by GH/CHC Distt. GH/CHC 1.GH Quilandi 200 180 6650 60400 2.CHC Narikkuni - - 13515 73810 3.CHC Olavanna 888 736 28458 24550 c. Team reported that even after prior intimation to the district authority, the district report (PHC wise) of F.W. programme was not made available as such no reconciliation could be taken up in the visited PHCs.

10. Maintenance of Records and Registers: a. Maintenance of registers and records needs lot of improvement in the district.

b. No service register for IUD was maintained in the visited CHCs and PHC. c. There was no service register for sterilisation maintained in GH Quilandy. d. MCH registers were not maintained with full particulars in some of the visited centres. e. Case cards for sterilization cases were also not maintained in any of the visited centre. f. Eligible Couple Registers were not updated at the centres visited in CHCs area and it was not maintained at GH Quilandy. 11. Miscellaneous Observations: a. In Kizhakothu PHC, IUD performance for 2008-09 was just only 1 and for the currently year it was Nil. District authority needs to monitor the cases for improving services in this regard. b. The team found lot of unimmunized and partially immunized children in the visited area. In HSC Pannur there were 8 such cases. The district authority can improve the situation by paying regular visits to such areas in all the centres. c. Citizen charter containing details of facilities available, phone numbers and mechanism of referral should be exhibited in all the health institutions as it was observed to be very poor at the visited centres. d. Steps may be taken to provide emergency 108 services by pooling all the ambulances available in the district. 2. District Trichur

Major observations of Regional Evaluation Team, Chennai about the Evaluation work in Trichur District of Kerala State in October, 2009.

I. Details of the visited Institutions:

District Visited CHCs and GH visited HSCs visited Trichur GH: HSCs : , Valliyanagara, CHCs: Mattathur, Vatanappally, Koothambakkam, , Chirakal, Alappad, and Vellanikkara and Vellakkarithadam and St. Antony’s Hospital Scan Centre- Pazhuvil and Samjose Hospital Scan

Centre-

II. Major Observations: 1. Human Resources: a. The Staff position in respect of MOs, ANMs and Male health workers was found satisfactory in the district. b. Though there were total 4 field staff in the PP unit but their contribution to record maintenance and field work was found nil. c. In CHC Alappad the staff position was satisfactory with 6 MOs out of which 2 were specialists and 5 staff nurses with essential facilities but no delivery was conducted for the past several years. d. In CHC Pazhanji the contribution towards delivery was found zero despite the fact that out of 7 MOs, only 1 specialist and 2 staff nurses were laying vacant. e. In CHC Mattathur, not even a single delivery case was conducted for the past several years inspite of all the required staff strength. 2. Constitution of Rogi Kalyan Samiti(RKS) and Village Health & Sanitation Committee(VHSC). a. RKSs have been set up in all the 44 institutions in the district. It was functioning in all the visited centers. b. In Kerala VHSCs were known as ward health committees. 1703 committees were formed in the district. ASHA is a member of VHSC. 3. Services of ASHA: a. In the district, 1770 ASHAs were selected out of them, 1615 were given with 7 days training. Drug kits were provided to 880 ASHAs. b. In GH Kunnamkulam out of 12 ASHAs, only 7 got 1st module training and 5 had completed second module training. The details regarding drug kit was not made available to the team. c. 123 ASHAs were selected in CHC Vatanappaly, out of which only 37 had completed second module of training and the rest first module training. d. In CHC Mattathur shortage of drug kits was found. e. In CHC Alappad requirement of ASHA is 103, but only 53 ASHAs were selected. Out of them, 24 received 2nd module and the rest of them have received first module of training.

f. In CHC Vellanikkara, out of the requirement of 34 ASHAs only 23 were selected. Out of which only 13 were given with 1st module of training and 6 were given with 2nd module of training and the rest didn’t receive any training. g. In CHC Pazhanji, all the 150 selected ASHAs were trained and only 33 were given drug kits. 4. Untied Funds: a. in the visited centres, funds were mostly utilized. However, the fund for 2009-10 was not received so far. b. It was observed that the funds were not utilized for purchase of very basic and necessary items for the sub centre. 5. Services under JSY: a. Janani Surakha Yojna was not functioning properly in the district. b. In the district 19073 mothers were identified for JSY in 2008-09 but the details of number of beneficiaries and the number of JSY pending cases were not available in the district. c. During 2008-09, out of total 51396 deliveries, 38288 were conducted in Private Sector; no effort was taken to provide JSY benefit to the BPL eligible mothers. However, 60 private hospitals were recently accredited for JSY in the district. d. In GH Kunnamkulam and CHC details of JSY were not made available to the visited team. e. In CHC Mattathur there were 120 eligible mothers for JSY payments out of which 104 received JSY incentive money during 2008-09. During current year, out of 100 eligible mothers only 46 were paid. f. In CHC Alappad, out of 30 eligible mothers only 20 were paid during current year. g. In CHCs Vellanikkara and Vatanapply, the year wise details of JSY beneficiaries were not available. 6. 24 Hours delivery care services: a. There were 11 PHCs functioning as 24 hours delivery care centres in the district but it was found that out of 6 institutions visited by the team, 5 CHCs had not conducted any delivery for the last several years inspite of required number of doctors and para medical staff were available there. b. In the GH Kunnamkulam, the performance of deliveries for 2008-09 was only 390 and for the current year till September 2009 it was 288; inspite of 22 staff nurses and 3 DGOs, the night deliveries were only 53 and 32 for the above period.

7. Physical infrastructure: (i) Sub Centres: a. Out of 7 HSCs visited, Cheruthuthi and Chirakkal did not have any basic facilities like building, furniture and equipments. Only HSC Mattathur has labour room. b. Drugs and Equipments like Tab Oxytoxin, Tab Ampicillin, Inj. Gentamycin, EC Pills, IUD, DDK, IUD insertion kit, Delivery kit, Steam sterilizer, Ambu bag, Delivery table and Mclntosh sheet were not available in most of the HSCs visited (ii) CHC: a. In CHC Mattathur, facilities like Microscope, Lab equipments, X-ray, blood storage, Neo-natal resuscitation equipment, Boyles apparatus, incinerator, functional OT and table were not available. Though there were seven MOs but no delivery was conducted since 2001. b. In CHC Alappad facilities of USG, X-ray, blood storage, the posts of DGO and Anesthetist were vacant. The OT and labour room were not functioning for several years. There bio medical waste available in the CHC and only burning of waste was being done. c. In CHC Pazhanji out of 30 beds sanctioned, 16 were available at present. Facilities of OT, X-ray, blood storage, Boyles apparatus, neo-natal resuscitation equipment, and incinerator were not available there. Out of 7 MOs only one was a specialist. d. In CHC Vatanappalli the ambulance and Auto clave were not found in working condition. Labour room, tables, resuscitation equipment were not available. There was no supply of EC pills in the CHC. e. In CHC Vellanikkara, all the facilities were available except X-ray, USG. IFA small and EC Pills were not available in the centre. iii. GH Kunnamkulam The GH building was very old & not maintained properly. The wards were congested and there was insufficient space for IP & OP. There was no space for store room for medicine also. Out of 2 OTs, only one was in working condition. Oxygen cylinder and autoclaves were insufficient. The BP apparatus was not in working condition. There was no residential quarters for MOs and staffs. 8. Community Satisfaction: a. The team had selected and contacted groups and village leaders to know their opinion about the services being rendered at the visited CHCs. Mothers who had received ANC

services informed that they did not get IFA tablets from the CHC and HSC for want of stock for the past one year. b. Some of the contacted mothers were not aware of referral transport and its mechanism. All the contacted ASHAs informed that there was no supply of EC pills in their kits. c. All the contacted public informed that staffs are coming regularly in the area and some of the MOs were staying at the HQs. d. 69 Mothers who were contacted in the area of the sub centres told that ANMs of their area were available at the time of need. All mothers informed that their delivery were conducted by trained personal and their babies were weighted after birth. Only 45 (65.3%) mothers had given breast feeding within half an hour and the rest 23 (33.3%) within one hour or more. All the contacted mothers were aware of the use of ORS, exclusive breast feeding and complimentary feeds. ARI awareness found in 37 (53.6%) mothers. 42(60.9% mothers have contraceptive awareness and knowledge. 30(43.5%) mothers were not given three PNC checkups. 9. Discrepancies in FW Figures: PHCs were not made available to the team. In the district, there was no system of keeping cumulative individual centerwise FW figures for any specific period/ year. In the visited CHCs also, there was no proper system of keeping any consolidated service register for FW activities. Hence, the team could not cross check the FW figures. 10. Maintenance of Records and Registers: a. Visited team observed that at the CHC level there was no consolidated service register for IUD and other activities. The printed register for IUD and Sterilization were not available. b. Case cards were not maintained for any methods. c. JSY register and account of funds were not updated in some centres. d. in some centres, ANC and PNC registers were not maintained as per guidelines. 11. Observations and Suggestions: a. There is no proper monitoring of individual PHCs and CHCs at the district level. The details of individual PHC achievement of FW and other activities were not even available at the district level. b. ASHA kit should include more ORS. c. More PHCs/CHCs could be made operational for 24X7 deliveries. d. Record maintenance needs lots of improvements.

e. The skills and practices of LHS of CHC Alappad and JPHN of CHC Pazhanji need improvement especially on danger symptoms of ARI and ANC check up. f. Even though the untied fund and annual maintenance grant at Pazhuvil HSC was spent but, no attempt has been made by the ANM to utilize these funds for procuring most essential items for the patients welfare. g. printed register for sterilization and IUD not made available to the centres visited. h. No FW or ANC cases referred by any of the JPHNs or ASHAs in the centres visited. The very purpose of ASHA scheme is defeated in this respect. i. No citizen charters seen exhibited in the district about the services, OPD timings, facility for delivery, user charges, contact number etc. Since the people were not aware of the nearest public facility, they were approaching costly private hospitals.